2. Progress was slower abroad. John McMichael, a doctor in London, wanted to use catheterization in his own shock study. He contacted Cournand, who shared information on the technique. However, a colleague of McMichael’s warned him that the technique was dangerous and that he would not be defended in court if he was charged with manslaughter if a patient died.
7. Stress Fractures
1. The British were under no such delusions. When Churchill visited the White House in May 1943, he asked his own physician whether he had noticed that Roosevelt was “a very tired man.” He added, ominously, “The Americans here cannot bring themselves to believe that he is finished.”
2. Thirty years later, in 1884, Robert Koch, a German physician, isolated the pathogen Vibrio cholerae, which causes cholera.
3. In later years, Framingham investigators added about a thousand ethnic minority patients to their study to try to understand why heart disease occurs disproportionately in certain groups and to identify novel risk factors.
4. The National Institutes of Health has started such a study. Named Mediators of Atherosclerosis in South Asians Living in America, or MASALA, it has enrolled about nine hundred South Asian men and women in two large metropolitan areas, the San Francisco Bay Area and Chicago. Researchers are focusing on novel risk factors, including malignant forms of cholesterol (previous research has suggested that South Asians may have smaller and denser cholesterol particles that are more prone to causing hardening of the arteries), as well as other social, cultural, and genetic determinants.
5. Sterling’s theory, allostasis, is a new way to think about human physiology. The traditional theory taught in medical school, homeostasis, holds that organ systems work together to maintain physiological balance. For example, when blood pressure drops acutely, the heart speeds up and the kidneys retain sodium and water, propelling blood pressure back to normal. If body temperature falls, we shiver to generate heat, blood vessels constrict to conserve heat, and we warm up. Homeostasis is about preserving constancy in the face of changing conditions. As a model for explaining human physiology, it does pretty well.
However, there are aspects of the human condition that homeostasis cannot explain. For instance, blood pressure often fluctuates minute to minute. If the body is supposed to be maintaining an optimal set point, it doesn’t seem to be doing a very good job. Blood pressure also increases steadily throughout childhood and adulthood. It is often constant until about age six, when children enter school, but then it rises quickly as kids detach from their parents and must become vigilant at defending against real or perceived threats. By age seventeen, almost half of all boys have blood pressures in the pre-hypertensive range, and about 20 percent have full-blown hypertension. Why does the blood pressure set point drift upward? To explain these things, experts like Sterling have proposed an alternative theory to homeostasis: allostasis.
Allostasis is not about preserving constancy; it is about calibrating the body’s functions in response to external as well as internal conditions. The body doesn’t so much defend a particular set point as allow it to fluctuate in response to changing demands, including those of one’s social circumstances. Allostasis is, in that sense, a politically sophisticated theory of human physiology. Indeed, because of its sensitivity to social circumstances, allostasis is in many ways better than homeostasis for explaining modern chronic diseases.
8. Pipes
1. Obstructive plaque can stimulate “collateral circulation,” or the formation of new blood vessels. Oxygen-deprived cells downstream from the obstruction release chemical growth factors that signal primitive vascular cells to invade the hypoxic tissue, assembling into a plexus of new hollow tubes that link up into a complex network. This process, called angiogenesis, ensures that blood vessels permeate every region of the body. These new blood vessels—the heart’s attempt to repair itself—limit the damage caused by a heart attack.
2. A few years later, Sones said that the era of angioplasty was “the best time in medical history to have been alive, and I am deeply grateful for the privilege.”
9. Wires
1. Ventricular fibrillation was probably first described by Andreas Vesalius, who observed that animals deprived of oxygen develop a wavy, wriggling motion of the heart.
2. The idea that an excitable system can degenerate into chaos was first suggested by David Ruelle and Floris Takens in a 1971 paper titled “On the Nature of Turbulence.” They proved mathematically that a system containing three or more coupled oscillations is inherently unstable. Their predictions were experimentally confirmed in studies of fluid dynamics and later electronic materials. Their work showed that ventricular fibrillation is a form of spatial and temporal chaos.
11. Replacement Parts
1. This was the case in other countries as well. In 1968, a Japanese surgeon was charged with murder after removing a patient’s heart while it was still beating to harvest it for transplant. The charges were eventually dropped, after six years of litigation, but heart transplants were outlawed in Japan—indeed, the very term “heart transplant” was taboo—until 1997, when brain death was officially recognized.
2. Brain death as a legal definition of death wasn’t widely accepted in the United States until 1981, when a presidential commission issued a landmark report on the subject.
12. Vulnerable Heart
1. Some patients experience what they describe as a shock; however, device interrogation shows no record of a shock being delivered. This condition has been termed phantom shock.
14. Compensatory Pause
1. Stress tests cannot tell if a plaque is vulnerable. Even today, no test in medicine can do so reliably.
2. Women measuring higher on the hopelessness scale had more carotid thickening, equal to the amount caused by one year of aging.
Supplementary Reading
INTRODUCTION: THE ENGINE OF LIFE
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1. A SMALL HEART
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3. CLUTCH
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4. DYNAMO
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5. PUMP
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6. NUT
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7. STRESS FRACTURES
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8. PIPES
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9. WIRES
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