You can call the heart “just a pump,” as the great cardiac surgeon Denton Cooley does in his memoir 100,000 Hearts, and that phraseology can give you a confident and macho feeling, but everyone knows you’re just shutting your eyes to the mystery of the strange beating within you. Some internal organs are silent. It’s easy to forget about the liver, the kidneys, or the spleen. Other organs make explicit demands. I’m hungry, says the stomach. The bladder says, I need to pee! The heart makes itself heard constantly, but it does not address you. It does its ba-boom, ba-boom, ba-boom thing on its own, like Miles Davis turning his back on the audience. In the middle of the night, you wake up, and you eavesdrop on that intrusive little tenant in your chest practicing its scales, and this is frightening because you know that the minute your tenant stops playing, you’re going to die.
Another memory from seventh-grade biology (which I experienced at the time as crushingly boring, my boredom relieved only by immature sex fantasies, but which seems in retrospect to have made a deep impression): Mrs. Sturbenz told us that respiration was not something we could control, and the whole room full of us twelve-year-old junior Nicolaus Stenos began to experiment, hyperventilating and holding our breath. The lungs are spooky—but the heart is spookier still. The heart has a mind of its own.
In the late nineteenth century, scholars of the heartbeat divided themselves into two camps: those who supported the neurogenic theory, that the heartbeat was controlled by the nervous system and ultimately the brain, and those who supported the myogenic theory, that the heartbeat originated in the organ itself. The myogenic theorists won. Your heart does its thing without you. Your brain is not really involved.
At the top of the heart, above the right ventricle, lies a cluster of cells, the sinus node, that sends out an electric impulse every second or so. This is the heart’s brain. The electric impulses from the sinus node travel through a network of beating muscle tissue. The heart doesn’t use nerves; heart cells are the only muscle cells that conduct their own electric impulses. The electricity travels through ionic exchange, countless molecules of sodium and potassium traveling across hundreds of thousands of cells. The electrical impulse routes first around the upper, smaller chambers, the atria, and, compelled by that impulse, the top chambers beat. Then the energy collects again at a second node—the atrioventricular node—that lies between the right atrium and ventricle. A second burst follows, down the septum of the heart, through pathways called the Purkinje fibers that run the outsides of the ventricles. The ventricles contract. The blood flows.
When we exercise or get excited, our heartbeat accelerates. When we sleep or relax, it slows. In the early nineteenth century, French physiologist François Magendie demonstrated through vivisection that all the sympathetic nerve connections could be cut from the heart and that the organ would continue to beat on its own. In contemporary transplant surgery, all the patient’s necessary blood vessels are attached to the new heart, but the nerves are not, so the sympathetic connection between heart and brain is severed—after transplant, the mind conveys excitement to the heart only through blood-borne hormones like adrenaline. Should the heart get damaged by infection, injury, or heart attack, the electrophysiological system can adapt. If a circuit is blocked, a new circuit will develop. If the sinus node fails, the atrioventricular node will take over. The broad outlines of this system are well understood by modern medicine, but the subtleties of molecular conduction and adaptation remain mysterious.
“No one knows,” Michael Freed once told me, “how the heart communicates with itself.”
The heart is its own creature, a second secret intelligence obscure to the one in the brain, and this is essential to the heart’s mystery and metaphorical import. This is why it makes you cry when W. B. Yeats writes, “I feel it in the deep heart’s core.” The deep heart’s core is unfathomable.
In researching this book I had the pleasure of talking with Dr. Abraham Rudolph, the first doctor to perform a cardiac catheterization on an infant. He did it at Boston Children’s Hospital in 1956, when most of his patients were babies, dying in the first year of their life, untreated. Rudolph began catheterizing babies in the hopes that they would be treated and cured. According to my sources, he is the most historically significant pediatric cardiologist still alive.
Dr. Rudolph, in his mid-nineties, has thin, dark hair and a somber, lined face. His long fingers have swollen knuckles, and he gestures with them expressively as he speaks. His words are precise and measured out carefully with a bit of a South African accent (as in “heart etteck” or “cet sken”), and he tells wild stories with a charming, self-deprecating giggle. What were you thinking the first time you catheterized a baby? “Well,” Abe Rudolph said, “I was scared.” Why were you scared? “I was scared,” he giggled, “that I’d kill the baby with the catheter.”
I spoke with Dr. Rudolph about the history of pediatric cardiology, about the struggle to understand and to treat the heart and to grasp the effects of new treatments. We discussed the complex relationship between new technologies, new diagnoses, and new interventions—for instance, how his early catheterizations helped doctors to understand and operate on the heart. Sometimes his answers were opaque.
“There is unquestionably a relationship,” he explained to me regarding catheterization and surgery, “but it is not a direct relationship.”
I tried to get him to talk to me about the mid- and late 1950s, the birth of open-heart surgery, and the fears that Welton Gersony had described to me. My questions seemed to frustrate Dr. Rudolph.
How did he feel when he learned about C. Walt Lillehei’s two-patient bypass? “Oh, we were very excited,” he said, and there was that giggle again, “because now we could do ventricular septal defects.” As I pressed him more closely, his responses seemed to grow more general. “In those days we made our decisions based on poor information,” he told me. “You base your decisions on what current medical dogma is.” He turned rueful about what seemed historically some of his greatest successes. He wondered if some of the riskiest breakthrough heart surgeries he had participated in—in the 1950s, on atrial septal defects—had been necessary. Many atrial septal defects, he told me, close up on their own.
Not until our conversation was over, when I was typing up my notes and going over it in my mind, did I realize what he was trying to tell me. It was difficult for him to explain what those days in the 1950s and 1960s felt like—heady though they were, with their complex calculations of risk and reward, balancing current patients against future patients and developing new technology—because that’s what medicine is always like. There is always an area of well-established practice, and then, at the outskirts of that solid ground, an unlit, uncertain wilderness.
In an email exchange after our conversation, Dr. Rudolph surprised me by quoting something Salman Rushdie had originally said about the magic realism of his novel Midnight’s Children: “Facts are hard to establish, and capable of being given many meanings. Reality is built on our prejudices, misconceptions and ignorance, as well as on our perceptiveness and knowledge.” I couldn’t decide if Dr. Rudolph was quoting Rushdie to describe my bumbling attempts at history or his early attempts at treatments and diagnosis, and I decided in the end that he meant both.
It’s a cliché that medicine is as much an art as a science. (“If we wanted art, Doc,” says a character in that Lorrie Moore story, “we’d go to an art museum.”) But it’s important for patients to understand how much medicine, particularly experimental medicine, is a discipline of the imagination. “We work in the dark—we do what we can—we give what we have”: these are Henry James’s most famous words about novel writing. “Our doubt is our passion, and our passion is our task.” Apparently, Dr. Abraham Rudolph feels much the same about pediatric cardiology.
PART TWO
Etherized Upon a Table
19.
OCTOBER 1931. IMAGINE that you’re riding a southbound train from Montreal to New York City. The woman
across the aisle smells strange, a mix of rose water and formaldehyde. She has packages everywhere, on the seat beside her, in the rack above, bags, boxes, some wrapped in twine, some in brown paper. The paper looks stained, as though what’s inside is leaking. She’s got a portfolio full of prints and drawings. She keeps knocking over a big striped umbrella.
She’s an older woman, her hair bobbed like a boy’s. Her coat is a horrible shade of purple, its velvet patchy and worn. She never takes it off during the length of the ride. She wears a polka-dotted blouse with a stiff collar and a long black skirt with mustard stains from the sandwich you saw her eat at lunchtime. She has glasses and deep lines on either side of her mouth.
You would take her for an eccentric housekeeper or unemployed schoolteacher if not for her masses of papers: journals, manuscripts, and notebooks. She’s indefatigable and seems to spend the whole eleven-hour train ride at work. You have a drink, you take a nap, you wake up, and she’s still at it, brow furrowed, mouth set, pen working. You find yourself staring at her, and she catches you, and you’re embarrassed, but when she smiles, her face turns grandmotherly and childlike, and she makes an odd self-deprecating apology for all the space she’s taking up with her packages.
You both get out at Penn Station. She puts on an absurd wide-brimmed hat. She’s hardly able to manage her umbrella and handbag. The papers crammed into and protruding out of her briefcase threaten to fall everywhere, and you have no choice but to offer to help her. Even as her boxes clog the aisle of the train and the stairs down to the platform, she’s telling you and everyone else who is helping that their assistance is unnecessary. She blushes and stammers and apologizes.
You call her a redcap. The redcap straps it all down on a trolley, but there’s still one stinky, fragile box left for you to hold, and you walk with her to the Eighth Avenue cabstand. You accompany her through the packed crowds, and you’ve got that box in your hands, jars inside clanking, something sticky on the bottom—you wish you’d never picked it up. To relieve the awkwardness, you ask what she is bringing with her to New York, and she begins to talk fast and fluently about the history of the human heart, how it forms in the womb and how it can malform—you didn’t know that could happen!—and her eyes are watery and blue and super intelligent, and you’re trying to keep up as she discourses about lizards and turtles and ventricles. You walk under the station’s huge ironwork columns, the big cathedral ceiling with its enormous panes of glass, and she seems to pay no attention to what’s behind or in front of her. When she goes up or down stairs, it’s a miracle she doesn’t topple, and as you leave the station for the street, you try to get the answer to the first question you asked: What have you been carrying for her?
Oh, she says, laughing, “That box of fetal hearts!”
She snatches it from you. She tips the redcap in Canadian money. The cab door slams. She lowers the window to say something more. She introduces herself as Dr. Maude Abbott, and she invites you to see a display of her work at the Graduate Fortnight at the New York Academy of Medicine. She is still talking as the cab pulls away, and her words are swallowed up by the city.
The history of pediatric cardiology begins with Maude Abbott. She was the first doctor to devote her career to the study of congenital heart disease, the first to describe the varieties and pathologies of cardiac birth defects, and the first to publish a book on the subject.
In 1869, two hundred years after Steno, Abbott was born in a small town in Quebec, not far from Montreal. Her mother, Elizabeth Abbott, was the daughter of an Anglican priest and one of eight children, seven of whom ultimately died of tuberculosis. Her father, the Anglican clergyman, was a murderer. On a wintery night in 1866, Maude’s father, Jeremiah Babin, took his crippled sister Mary to the Du Lieve River and drowned her there in the icy water and snow. Jeremiah Babin fled Quebec before Maude was born, and seven months after Maude’s birth, Maude’s mother, Elizabeth, died of tuberculosis.
Maude and her sister Alice were raised in the rectory of the church in St. Andrew’s, a small town north of Montreal, by her grandmother, Frances Smith Abbott, a sixty-two-year-old widowed immigrant from Great Britain and a descendent of the Marquis of Hereford. The Abbotts were a prominent family, and the orphaned girls’ last names were changed from Babin to Abbott by an act of the Canadian parliament.
In the rectory at St. Andrew’s, Maude lived a childhood out of Anne of Green Gables. A penknife for Christmas was a wonderful gift; so was a bit of bright ribbon. She was a bookish girl. In her teenage diary she wrote, “One of my day-dreams, which I feel to be selfish, is that of going to school.… And here I go again: once begin dreaming of the possibilities and I become half daft of what I know will never come to pass. Oh, to think of studying with other girls!” Her grandmother, when Maude was seventeen, indulged her and sent her to a girls’ school in Montreal. That same year, McGill University opened its doors to women; Abbott applied a couple years later, and she was admitted. The university became the great love of her life. For the most part, that love was unrequited.
“Very enthusiastic we all were,” she wrote of those first classes of women to attend McGill. “But I think perhaps I, who was country-bred, and had not had my fill of school or directed study before I entered Arts, felt our new advantage most acutely of all. I was, literally, in love with McGill, and I have never really fallen out of love with her since.” This was Abbott’s lifelong romance, with a university that would never take her seriously. She entered McGill dreaming of a career in the arts but graduated with her heart set on medicine.
It was an exciting time to be a physician. Throughout Abbott’s childhood, medicine had been changing, emerging, and becoming increasingly rigorous, scientific, and professional. The English doctor Joseph Lister had published his first accounts of antiseptics in the Lancet in 1867, just two years before Abbott’s birth. Lister used carbolic acid on the dressings of his patients’ wounds, and he demonstrated statistically that infection rates dropped. When he came to the United States in 1876 to promote germ theory, his ideas faced doubt and resistance. “People say there are bacteria in the air,” said Alfred Loomis, president of the New York Academy of Medicine, “but I cannot see them.” Loomis and his colleagues worked in unwashed wool coats, going straight from operating rooms to morgues to delivery rooms, unwittingly spreading sepsis and death. Hospitals were as dangerous as battlefields. (The denial of germ theory among so many doctors, like the denial of blood circulation 250 years before, makes one wonder about how reflexive the denial of science is; no matter how seemingly obvious in retrospect, any new theory will face contradiction.) Germ theory changed medicine, and concordant with its advance, medical education changed.
The father of modern medical education, William Osler, taught at McGill from 1876 to 1884 and in 1893 helped found Johns Hopkins Medical School, the first medical school in America to require that its entering students have four-year college degrees. “The future belongs to science,” Osler said. For him, laboratory technicians were “essential to the proper equipment of the hospital.… They are to the physician just as the knife and the scalpel are to the surgeon.” Osler’s 1892 The Principles and Practice of Medicine was the modern, turn-of-the-century physician’s bible.
Abbott wanted to enter this new world of scientific medicine, but because she was a woman, she was not permitted. Though she graduated valedictorian of her class, McGill rejected Abbott’s medical school application. The idea of a woman doctor was laughable. Her application was a scandal covered by Montreal newspapers. “Can you think of a patient in a critical case,” wrote Dr. F. W. Campbell, a member of the McGill faculty, “waiting for half an hour while the medical lady fixes her bonnet or adjusts her bustle?” Abbott was forced to attend the much smaller Bishop’s College Medical School, which accepted women, Jews, and blacks from the Caribbean. There, she distinguished herself. She won prizes. She did postgraduate work in Europe. Abbott was the first woman ever to have her work read at the Montreal Medico-Chirugical
Society—the same paper was presented overseas in England in 1900, the first by a woman given before the Pathological Society in London. She had hoped, initially, to become a gynecologist, but her success in diagnosing rare conditions of the liver led her to consider a career in pathology.
She needed to stay in Montreal—her sister Alice was mentally ill; Maude had to take care of her. While Maude worked in Montreal, Alice rested in the rectory at St. Andrew’s. Abbott was offered a position at the Verdun Protestant Hospital for the Insane, a residency in neuropathology, but all she wanted was McGill. She petitioned Dr. George J. Adami, who ran the pathology lab there: “If you could do for me what you suggested, and allowed me to work in your laboratory on a scholarship in neuropathology… I would be extremely happy, which is nothing to the point, but I think I could do better work than I have been able to give evidence of yet.” He did not offer her a scholarship to work in his lab. The best he could offer her, Adami said, was the part-time job of assistant curator of the medical museum.
“I would infinitely prefer to work anywhere else,” Abbott wrote back.
She didn’t have an office. Her desk lay in a curtained space at the end of a hallway. The museum itself was a mess. It contained records of all Osler’s early work—he had performed some 750 autopsies there and kept everything that seemed interesting. Adami was devoted to expanding the collections, but his zeal for collecting was unmatched by any organizational genius. In 1900 there was no standardized way of cataloguing pathology specimens. All the material was boxed and bottled and shelved almost at random.
Abbott traveled to Washington, DC, to see how the Army Medical Museum sorted its specimen collections. While there, she went to Baltimore to see Osler lecture. When the great man left the hall, Abbott approached him, but the door closed on her hand and took off a fingernail. Osler himself attended to her wound.
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