Two physicians examine heart disease through a literary lens

Heart disease has topped mortality charts as the No. 1 killer of men and women for many decades, but a novel analysis of American literary fiction by two physicians finds the disorder's presence in great novels has remained relatively modest.

In a report of their findings, published online May 11 in the journal Perspectives in Biology and Medicine, the doctors suggest that great American storytellers may cede prime literary space to HIV, cancer and tuberculosis - less prevalent conditions with a decidedly stronger hold on novelists' imaginations.

The research, performed by Johns Hopkins physician Benjamin Oldfield, M.D., and David Jones, M.D., Ph.D., of Harvard University, examines 14 prominent works of American literary fiction, tracing the evolution of heart disease representation in masterpieces ranging from Edgar Allen Poe's The Tell-Tale Heart (1843) and Kate Chopin's The Story of an Hour (1894) to Vladimir Nabokov's Lolita (1955) and Philip Roth's Everyman (2006).

The findings of the research highlight several important themes with serious and not-at-all fictional implications for physicians and their patients struggling to cope with cardiovascular disease, the authors say.

Oldfield and Jones say their analysis follows the parallel trajectories of literary narratives and biomedical science, seeking to understand whether new and improved medical understanding of cardiovascular disease fueled changes in the literary representations of it. Their conclusion: Although fictional heart disease narratives accurately reflect advances on the medical front, biomedical imagery remains limited in its capacity to convey the full meaning of what it means to live with heart disease.

"Storytelling is the principal way in which people make sense of their lives and in which patients and physicians communicate about disease," says Oldfield, a narrative medicine specialist and resident in the pediatrics/internal medicine program at the Johns Hopkins University School of Medicine. "The experiences of the characters in some of the most influential works of American literature serve as a potent reminder that biomedical knowledge by itself is not enough for people to make full sense of their disease."

Physicians, the authors say, should be keenly aware of the deficiencies of biomedical narrative and attempt to take greater advantage of the possibilities that metaphor and language offer in their daily interactions with patients.

"As a historian I was amazed by the ways in which the fictional narratives so precisely - and revealingly - track the developments of cardiology and cardiac surgery in the United States," says Jones, who is a professor of the culture of medicine at Harvard. "Stories written in the 1920s, 1950s, or 1990s accurately reflect the changing meanings of coronary artery disease in America and the growing capabilities of physicians to intervene. But despite the tremendous progress that has been made, many of the protagonists - and too many patients even today - remain dissatisfied with the relief that medical technology can provide."

American literary narratives of heart disease, the authors say, can be roughly divided into two therapeutic eras: before the 1960s, a period marked by a scarcity of treatment options, and after the 1960s, which brought a proliferation of medical and surgical therapies. Characters from works written before the 1960s were resigned to the tyranny of the disease, facing untimely demise. By contrast, narratives of heart disease from the later period are rich in descriptions of cardiac bypass surgery, angioplasty and medications. Yet, despite the growing ability to diagnose and treat heart disease, the protagonists from this later period are often unsatisfied with or downright resentful of life-extending therapies.

"Advanced cardiac therapies emerge as a decidedly mixed blessing in these characters' lives, underscoring the often-complex relationship many patients - in fiction and in reality - have with treatments that force them to choose between a medicalized life and a life they deem worth living," Oldfield says.

Tracing the evolution of heart disease metaphors over the last 170 years, Oldfield and Jones identified four dominant tropes, or figures of speech, that reflected the popular understanding of heart disease at certain times.

• Broken hearts: Emotional turmoil, such as unrequited love, emerged as a prominent driver of heart disease in 19th century works, including Henry James' novella The Turn of the Screw (1897) and Chopin's The Story of an Hour (1894). The underlying theme in such works is that intense emotion, whether ignited by sadness, disappointment or joy, can destroy the heart.
• Laboring hearts: Ideas about the nature of heart disease and its treatment changed in the early 20th century. The number of people suffering from rheumatic heart disease - a highly lethal form of the condition - began to drop due to the advent of antibiotics that prevented the heart-damaging effects of bacterial infections. At the same time, more people developed modern-day coronary artery disease marked by fatty plaque buildup inside the vessels of the heart, the most prevalent form of heart disease today. Literary works from that time depict coronary heart disease as a malady affecting busy upper-crust professionals and common laborers alike. Willa Cather's Neighbour Rosicky (1928), which tells the story of a poor Czech immigrant felled by heart disease while struggling to farm his barren land, captures a common theme from the period: heart disease fueled by the fight for survival in a gloomy economy.
• Modern hearts: Books such as Nabokov's Lolita, Jhumpa Lahiri's The Namesake and Marilynne Robinson's Gilead capture a deepening modern understanding of heart disease, its myriad manifestations and its fickle, capricious behavior. Yet none delved extensively into the treatment aspect of heart disease, the authors say.

Treated hearts: The treatment theme is not only prominent but central to the narrative in works such as John Updike's Rabbit at Rest, Thom Jones' story "Ooh Baby Baby" and Roth's Everyman. In the last few decades, advances in heart disease treatment - both open-heart surgery and minimally invasive techniques - have nudged the public attitude away from a view of heart disease as a condition that spells imminent death to that of a serious but treatable illness that physicians and patients can conquer.

The character in Roth's Everyman slogs through life with heart disease, his existence punctuated by test after test, procedure after procedure, culminating in a quintuple heart bypass surgery. These advances in treatment come at a high personal price, leading to growing ambivalence among characters about therapy that saves one's life but, in the process, may alter it beyond recognition. One sentence from Roth's novel captures the paradox with blunt elegance, the authors note: "All these procedures and hospitalizations had made him a decidedly lonelier, less confident man."

These findings, the two investigators conclude, highlight that physicians who care for people with heart disease need not fear descriptive language and metaphor but embrace them as tools that help enrich communication, make them more attuned to the emotional dimensions of their patients' suffering and render them more sensitive, better clinicians.