The Open Heart Club

by Gabriel Brownstein

  She revered him. Her devotion was to scientific medicine, her Parthenon was McGill, and Osler was the god of her temple. Now he stood before her, big, bearded, brilliant, authoritative, and taking care of her bleeding finger. He was interested in her work on his specimen collections. He invited her to his home for dinner. “I wonder, now,” he said, “if you realize what an opportunity you have?” He sent her a letter, urging her to look up an article, “Clinical Museum,” in the British Medical Journal. “Pictures of life and death together—wonderful,” wrote Osler. “Then see what you can do.” He set before her the prospect of building something that did not yet exist in North America, a great medical museum, a living resource of pathology.

  Back in Montreal, Abbott was overcome. The task ahead of her was stultifying. “Promising drudgery,” she called it. The sheer volume of work was overwhelming. Abbott suffered a nervous breakdown. She stopped working for six months. But then she began again—labeling and sorting every specimen in the McGill medical museum. The museum secretary had to remind Abbott of the end of the workday, and Abbott would apologize for holding the secretary and then stay there late into the night. She worked for hours on end, forgetting to eat, forgetting to sleep, completely consumed by her task. Maybe she had some of the same mania that possessed her murderer father and invalid sister.

  She traveled back and forth to Europe to learn about medical museums. At home in Montreal she lay in bed surrounded by letters from all over the world, writing furiously back to doctors, pathologists, and curators. She organized an international society of medical museum curators and became editor of its bulletin. In sorting out the McGill collections, Abbott was inventing a profession.

  The most intriguing of all the items in the collection, for Abbott, was a heart with one ventricle, the Holmes heart. In a letter, Osler explained to her that this was a rare congenital deformity, discovered at McGill in 1834. In 1901, Abbott wrote a biographical sketch of Andrew Holmes, the doctor who had first reported the heart, for the Montreal Medical Journal. This was her first contribution to the study of congenitally deformed hearts.

  At the turn of the century, the heart was beyond medicine’s reach. Understanding of it hadn’t advanced much since Steno’s time. Doctors had a poor sense of the organ and few tools for looking at it. For the most part, they thought of the heart in the same way that William Harvey had described it in 1618, when he coined the term “circulation.” In De motu cordis, Harvey wrote,

  The heart, consequently, is the beginning of life; the sun of the microcosm, even as the sun might be designated the heart of the world; for it is the heart by whose virtue and pulse the blood is moved, perfected, made apt to nourish, and is prevented from corruption and coagulation; it is the household divinity, which, discharging its function, nourishes, cherishes, quickens the whole body, and is indeed the foundation of life, the source of all action.

  Theodor Billroth, the most prominent European surgeon of his time, was reported to have said in 1883, “A surgeon who tries to suture a heart wound deserves to lose the esteem of his colleagues.” In 1886, Billroth’s British colleague Stephen Paget wrote, “Surgery of the heart has probably reached the limit set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a heart wound.” Osler himself, in 1892, described adult heart disease as “relatively rare.”

  The earliest recorded cardiac surgeries were not on the myocardium, the heart muscle, or the great blood vessels on the top of the heart but on the pericardium, the tough, triple-layered sac that surrounds the heart, and these first surgeries were practiced in obscure corners of the medical world and soon forgotten. In 1815, Francisco Romero, a Catalan doctor in the French army, described a technique for treating pericardial effusion, or fluid around the heart. Romero believed the cause of pericardial effusions were the south wind, gazpacho, and tobacco rolled in paper. For treatment, he made an incision at the curve of the sixth rib, then used a pair of small scissors to cut the pericardial sac and let the fluid drain. For the patient in recovery, Romero recommended a diet of partridge broth, wheat bread soaked in red wine and sugar, and small doses of absinthe to drink. Romero performed seven of these surgeries, without antibiotics or anesthetics, and remarkably only one of his patients died, but when he presented his findings before the society of medicine in Paris, the authorities did not receive his paper favorably, and his contribution to medicine was lost.

  Nearly a hundred years later, in 1893 in Chicago, an African American doctor named Daniel Hale Williams III repaired a stab wound that had reached his patient’s pericardium. It was the summer of the World’s Fair. The original Ferris wheel rose above the city, and facsimiles of the Nina, the Pinta, and the Santa Maria floated in Lake Michigan. Exhibitors displayed new products: Pabst Blue Ribbon beer, Juicy Fruit gum, and Quaker Oats. In a bar on the south side, a railroad worker named James Cornish got into a brawl. Someone carved a hole in Cornish’s chest, and he was taken to Provident Hospital, a three-story, twelve-room, brick building on 29th and Deerborn, run and founded by Williams and the Chicago black community. (Frederick Douglass was one of the original supporters and fund-raisers.) Williams was one of just four African American doctors in the city.

  Pictures of Williams show a man with close-cropped hair, a big bushy beard, and the light skin and sharp features of his Shawnee ancestors. Many of his patients were workers from the nearby Armour Meatpacking Plant, who came to him bleeding and mangled by the slaughterhouse machinery. Cornish, drunk and dying, arrived at the row house hospital on the night of July 9. Dr. Williams felt his pulse, listened to his breathing, and put a long tubular wooden stethoscope to Cornish’s chest. Initially, Williams diagnosed the wound as superficial, sewed it up, and let the patient rest, but overnight Cornish’s condition worsened. The heartbeat got weak and slow. Williams could hardly feel a pulse in Cornish’s neck.

  In a hospital room hotter than one hundred degrees, six of his colleagues gathered around. They opened the windows to ventilate the space. Williams cut a six-inch incision into Cornish’s chest. He retracted the ribs and siphoned away the blood. There was the beating heart, something that no one in the room had ever seen. The hole in the muscle was tiny. Williams let the heart be and sewed up the rip in the pericardium with catgut. The patient recovered. It took two months, but Cornish left the hospital as a new kind of thing, a survivor of cardiac surgery. But the work of a black doctor at a small black-owned hospital didn’t get much attention at the time.

  The first person to demonstrate to the medical establishment that a wound to the heart muscle could be repaired was Ludwig Rehn, the chief surgeon at Frankfort City Hospital, already famous for his surgeries on cancer and his pioneering thyroidectomies. Rehn’s patient was (like Williams’s) stabbed in a bar fight. In the early morning of September 8, 1896, Wilhelm Justus, a gardener’s assistant, had been discovered behind a park bench, bleeding and clutching his chest. Blood was oozing from him when Justus was taken to the hospital, and in the morning Rehn found him lying in a corner, waiting to die. Rehn listened to Justus’s breathing and examined his skin. He palpated the chest wound. He opened the chest and found Justus’s pericardium swollen like a balloon, blown up to twice its normal size, stretching toward Justus’s armpit. Rehn picked up his scalpel and made his incision. There was an explosion of blood and then a trickle. When Rehn suctioned the mess away, he got a good look at the right ventricle and the blood that with each beat of the heart came leaking from a half-inch gash. He put his finger on the hole, and then he did something that no one had ever recorded doing before. He sutured the wound in the muscle, and the patient survived.

  Rehn expanded on this operation, recommending a surgery for pericardial effusions that was in many ways quite similar to Romero’s (less the partridge broth, etc.). Theodor Billroth, Rehn’s eminent colleague, called these repairs of pericardial effusions “prostitution of the surgical art” and “surgical frivolity.” Despite Rehn’s success, the heart
retained its holy aura in 1899 when Abbott went to Europe to do her postgraduate studies, but diagnostic technology was improving, and as it did, so did medical understanding.

  From a single wooden tube, the stethoscope became the two-ear device we know today. Early machines called sphygmomanometers traced and measured the movement of the pulse, and by the 1880s French physician and inventor Etienne Jules Marey had adapted these devices to measure systolic blood pressure. Wilhelm Röntgen invented the X-ray machine, and it became possible to picture the size and placement of a patient’s heart. The first electrocardiograph machine was Willem Eintoven’s string galvometer, invented in the Netherlands in 1901. The machine filled three rooms in Eintoven’s lab. The patient sat with a hand and a leg each in a separate bucket of water, and these buckets conducted the impulses of the heart to a tiny, sensitive filament—Eintoven’s first filaments were made of molten glass, spun fine by shooting a bolt from a crossbow and catching the trailing strings, then covering the strings with silver. The slight tremblings of these silvered glass threads were magnified by a Zeiss lens and made decipherable. It took decades after its invention for the EKG to become a commonplace clinical tool, and even with all these new technologies, heart disease remained mysterious.

  In 1901 doctors focused less on heart function than on morbid pathology of the heart—the scars on the valves left by syphilis, rheumatic fever, and diphtheria. Doctors weren’t interested much in the aging heart or how it worked. It wasn’t until the 1920s that doctors agreed on a clinical diagnosis for heart attack—acute myocardial infarction—and this came, according to the historian of medicine Roy Porter, “only after huge debate and negotiation over the meaning of clinical and machine-readable signs.” In the 1920s, “cardiology” was a newfangled word, and if adult heart disease wasn’t a real concern of the medical establishment, congenital heart disease was still more neglected. In Principles and Practices of Medicine, Osler discusses “congenital affections of the heart” briefly, and his section on the subject begins, “These have only a limited clinical interest, as in a large proportion of the cases, the anomaly is not compatible with life, and in others nothing can be done to remedy the defect or relieve the symptoms.”

  In 1904, Osler, now a British peer and an Oxford don, paid a visit to Maude Abbott at McGill. “I shall never forget him as I saw him walking down the old museum toward me,” Abbott wrote, “with his great dark shining eyes fixed full upon me.”

  They sat together, reviewing his collections. Based on her work on the Holmes heart, he invited her to write the section on congenital heart disease for his forthcoming A System of Medicine, an encyclopedic work on medical subspecialties. Of the 104 medical authors he selected, Abbott was the only woman. Her contribution would be a small essay in a huge encyclopedia, but, characteristically, Maude Abbott threw herself into the subject. She reviewed the records of 412 autopsies. She developed large charts of features and symptoms. She began to systematically imagine and organize the pathology of congenital heart disease. The writing took two years, and when she sent it to Osler, he was delighted. “I knew you would write a good article, but I did not expect one of such extraordinary merit. It is by far and away the best thing ever written on the subject in English—possibly in any language. I cannot begin to tell you how much I appreciate the care and trouble you have taken.”

  Abbott was now the world’s foremost medical museum curator and expert on deformed hearts. In 1910, McGill awarded her an honorary medical degree, but it turned down her application to join the medical faculty, even though the pathology courses she taught were now a compulsory part of medical education at McGill. As her colleague Dr. Harold Seagall later recalled, “The mood at McGill was rather provincial. In certain circles it was acceptable to regard Dr. Abbott as an inferior character, someone to be tolerated and humored—a ‘hen medic.’”

  Outside McGill, women were increasingly advocating for their own rights. As the historian Jill Lepore tells it, “The word ‘feminism,’ hardly ever used before 1910, was everywhere by 1913. It meant advocacy of women’s rights and freedoms and a vision of equality.” In 1911, Abbott delivered a lecture at Harvard titled “Women in Medicine.” The lecture is a sixteen-page epic, a tight little demonstration of erudition. It moves from the medical skills of “Antiochis, daughter of Diodotos,” for whom a statue was raised in the ancient city of Tlos, to “Fabiola, the founder of hospitals in Italy, AD 380,” to Allessandra Giliani of Periceta, a fourteenth-century anatomist, to the Countess of Cinchona, “who, in 1640, introduced the use of quinine bark” for the treatment of malaria, and Lady Mary Wortley Montagu, who brought vaccination to Europe in 1718. Abbott was claiming her place in history—asserting, contrary to her colleagues, that there was nothing extraordinary about her doing so, that women had always been a part of the development of medicine.

  In 1900, there were about 7,000 female doctors in the United States, comprising about 5.6 percent of American physicians. (England, by contrast, had just 258 women doctors, and France had only 95.) In Boston, the numbers were considerably better: almost a fifth of the doctors there were women. But at McGill, Abbott was still seen as something of a freak, like a dancing bear—the wonder not that she knew a great deal about medicine but that she knew anything about it at all. At the outbreak of World War I, McGill Medical School was reorganized, and administrators wanted to get rid of her and to dismiss her from her position at the museum. Threatened, she wrote to her superior, George Adami, in a panic, finally expressing her rage and asking McGill to take her seriously:

  The cure is surely to treat me with the decency that I deserve and that the facts demand. To acknowledge me as the museum expert, the one who really does know most about the work and its needs… to give me on the basis of my museum teaching, and my lectures on congenital cardiac disease, the Associate Professorship that is my due… to raise my salary to a real ‘part-time’ salary corresponding to what I do, or else a real ‘full-time’ one; and to give me an assistant at $1,500 a year.… I am on the breaking point financially and in other ways.

  The response she got was dismissive: “Take the world cheerfully and do not worry.… I think every true friend of yours must see that your wisest policy is to ‘Do your duty in the state of life to which it has pleased God to call you.’”

  Abbott fell ill. She had major abdominal surgery for the removal of ovarian tumors. Soon after her recovery from that operation, Osler died. She undertook to edit a special Osler memorial volume of the Bulletin of the International Association of Medical Museums. It took her six years to put together and in the end ran to over six hundred pages. The year before it was published, Harvey Cushing came out with his two-volume biography of Osler, which won the Pulitzer Prize. Abbott’s memorial volume left her $1,000 in debt. She set out to write a history of her beloved institution, McGill’s Heroic Past, only to discover, just as she was about to publish, that the university had hired an art history professor to write a similar book. She was finally made assistant professor at McGill, but her museum was taken away from her.

  Maude Abbott was an eccentric woman. She looked at the ground as she walked and muttered to herself. She had trouble crossing streets and climbing stairs. She got lab samples all over her clothes. Friends called her “the beneficent tornado” and the “big chief of heart.” Enemies mocked her. She was offered jobs elsewhere, at the University of Texas and at the Women’s College of Pennsylvania. All she wanted was McGill, but McGill would not have her. By the time she came to New York City to present her work in a display at the Graduate Fortnight of the New York Academy of Medicine in the fall of 1931, her career seemed at a dead end.

  In the exhibition hall of the grand building on 103rd Street and Fifth Avenue, she set up a long piece of gray millboard, about four feet high by thirty-two feet long. Her exhibit gave an overview of 1,000 cases of congenital heart disease, set into three large categories and some dozen subcategories, illustrated by photographs, paintings, models, and EKG readings. The
re were fetal hearts and turtle hearts and lizard hearts. The exhibit reviewed the heart’s development in the womb and in evolutionary terms. It was huge, cluttered, and complex but a marvel of comprehensive study, and for the first time in her life, Abbott gained a wide audience for her work.

  English doctors invited her to include her exhibit in the centenary meeting of the British Medical Association in London. The display was praised by the British Medical Journal, and Abbott shipped it back across the Atlantic and showed it again in Atlantic City in 1935 at the joint meeting of the American and Canadian Medical Associations, and then again before the Ontario Medical Association in 1936. The American Medical Association published the exhibit’s contents in a single volume, The Atlas of Congenital Cardiac Disease. Abbott was nearly seventy.

  The volume is a large, thin, beautiful book, 110 pages long including its index, and the first comprehensive book ever published on the subject. The left-hand pages are dense with small type and Latinate phrases; the right-hand pages are cluttered with complex collages of line drawings, photographs, diagrams, and EKG prints.

  There’s something eccentric and homemade about the atlas. It’s a portrait of congenital heart disease but also of the mind of Maude Abbott. Each page has the concentrated force of a lifetime of intellectual labor crammed into a narrow space. Plate 1, a single 11- × 14-inch page, “Development of the Reptilian and Mammalian Heart,” has sixteen illustrations sorted into four subsets: a pig heart, the hearts of two turtles, a sand lizard heart in nine stages of development, and the developing human embryotic heart. A short paragraph gives a terse history of the evolution of the human heart, a summary of the development of the fetal heart, and a theory of the etiology of heart defects: “The critical period in the human subject lies between the fifth and eighth weeks of embryonic life, i.e., before the cardiac septa are formed, and while the complex processes of torsion, involution, readjustment and fusion are taking place at the base, interruption of which is the source of most of the graver anomalies.” All her expertise is boiled down into paragraphs short enough to fit on a wall of a traveling exhibit.