The Open Heart Club

by Gabriel Brownstein

  What was she thinking, marrying me, a man with a failing heart? What were we doing, having a baby when it was unclear how much longer I would live? The answers come back like vague X-ray shadows. I guess we were thinking what everyone thinks when they make those kinds of commitments. We were in love.

  On April 2, 1999, she woke me in the middle of the night to tell me that her water had broken. I was annoyed and said she was imagining things and really we should just go back to sleep. Then we were in the delivery room. Marcia was screaming in pain. She seemed both to want me near her and to want nothing to do with me at all. She was sweating and straining, and then she gave a push, and my daughter Eliza was out.

  “A girl!” I cried. “A purple girl!”

  I held my baby in my arms. She was so tiny and so frail in her hospital blanket. The whole world shifted on its axis, or my world got a new axis to revolve around, and the axis was Eliza Rose Brownstein.

  She was a difficult infant. She screamed all the time. When she wasn’t nursing or sleeping, she howled at the top of her lungs. She would wake two, three, four, five times a night. Marcia, sleep deprived and besieged by hormonal shifts, cried in the pediatrician’s office and cried when I came home from work. I climbed from the subway station as the sun set in May, and there was my beautiful wife looking shell-shocked and holding my gorgeous daughter, whose face was bright red, whose mouth was set in a perfect, yowling O. We tried everything to calm the baby. Sometimes singing helped. Holding her like a football, with my hand on her chest and her belly on my forearm, seemed to take some pressure off her gassy gut. Someone suggested the sound of a vacuum cleaner might help, so that was the scene in our apartment after work, Marcia running the vacuum, me jogging around the house with the baby on one arm, the two adults singing “This Land Is Your Land,” while the baby howled and howled and howled.

  25.

  WHEN I ASKED Vivien Thomas’s nephew, Dr. Koko Eaton, to describe his uncle for me, Dr. Eaton, the orthopedic surgeon for the Tampa Bay Rays Major League Baseball team, offered one word: “humble.”

  I said I was uncomfortable with the word. All his life, I said, the white world had wanted to humble Vivien Thomas. He had been treated as less than a human being, had lived through segregation and racism, had faced a life of humiliation without once losing his dignity, had accomplished so much when so many had tried to make him feel so small.

  Helen Taussig had proposed the surgery, and Alfred Blalock performed it, but Vivien Thomas was the one who—in his lab—invented the procedure, who figured out how to make heart surgery practicable. It was Thomas the lab technician, not Blalock the surgeon or Taussig the cardiologist, who performed the research for the blue baby procedures, built all the instruments, and designed the groundbreaking technique. I said I wanted to use a word other than “humble.”

  “What can I tell you?” said Dr. Eaton, who spoke to me from his work inside the Rays spring training facility. “That’s the word I’d use.”

  His uncle Vivien had built his own house and all his own furniture. When he hosted family barbecues, he used spatulas he’d made for himself out of surgical clamps. Vivien Thomas’s portrait hangs on the wall at Johns Hopkins, but if asked why it was there, Koko Eaton told me, Thomas said only, “I used to work here.”

  At Hopkins, Thomas was paid janitor’s wages. Maids refused to collect his garbage, and higher-ups refused to fill his supply orders. Blalock made him paint the walls of their lab. He was routinely demeaned. In his laboratory workshop, Thomas trained many of the great doctors who would dominate heart surgery for the next decades, but he had to supplement his income by working as a servant for Blalock. At Blalock’s parties, Vivien Thomas was the bartender, fixing drinks for his students and colleagues. At Blalock’s wedding, Thomas was the chauffeur.

  Vivien Thomas hadn’t ever wanted to move to Baltimore. He had grown up in Nashville, where he had a large, protective family and community. In Baltimore he was exposed to discrimination in a new way—alone—and he thought the city was dirty. But Thomas had little choice. When his boss, Alfred Blalock, moved from Vanderbilt University to Johns Hopkins, Thomas had to follow him from Nashville to Baltimore: no one else in the world other than Blalock would let Vivien Thomas pursue the work he loved.

  When he was young, Thomas had wanted to be a doctor. He was the son of a carpenter, and he had worked ever since he was small. He had saved up money for his education, but when he was nineteen, all of it vanished in the 1929 stock market crash. Carpentry work dried up too. When Thomas first took a job in Alfred Blalock’s lab at Vanderbilt, he saw it as “a stop-gap measure to get me through the cold winter months.” He thought the economy would pick up, and he could work again, and save again, and make his way through college. But that’s not the way it happened.

  The work in Blalock’s Vanderbilt lab was gruesome at first, and Thomas performed it meticulously. In Nashville in 1929, Blalock was running animal experiments to measure the effect of shock. It was Thomas’s job to induce systemic shock in laboratory dogs and measure the effects of grotesque wounds on their bodies. This meant anesthetizing the dogs, whacking them on their hind legs with a hammer, and then seeing how their blood pressure shifted.

  “I soon overcame my reluctance to inflict the trauma,” Thomas wrote in his memoir.

  For a blood pressure gauge, Thomas used a U-shaped tube half filled with mercury. A rubber float lay on one side of the U, attached to an aluminum rod; as the dog’s blood pressure changed, the rod moved and etched the changes onto a piece of glazed, smoked paper that rotated around a slowly spinning drum. When it was all over, Thomas carefully amputated the dogs’ legs, sewing up the blood vessels and then weighing the legs against each other to see how much fluid had run to the injured leg relative to its mate. He was paid less than he would have been if he were working as a groundskeeper.

  Thomas’s skills grew and, with them, his responsibilities. He began to design tools and experiments. Vivien Thomas, at twenty years old, was tall and thin and handsome, with very dark skin, long limbs, and long, sensitive fingers. He was famously calm and polite almost to the point of being finicky.

  Blalock, by contrast, was a hard-drinking man, with what Thomas called a “reputation for prowess with the ladies and for being a great party man.” He kept a case of Coca-Cola in his laboratory fridge and a ten-gallon charred keg of whiskey in his storeroom. As Thomas wrote, “The profanity he used would have made the proverbial sailor proud of him.” Thomas warned Blalock not to use such language in front of him if he wanted him to stick around, and Blalock obliged, and so a partnership was formed.

  Over the years, the two men’s professional lives merged. “It was extremely difficult to tell,” recalled Dr. Allen Woods, “if Dr. Blalock had the original idea for a particular technique or if it was Vivien Thomas, they worked so smoothly together.” Their work on shock changed the way soldiers were treated on the battlefield. (In his later years, Blalock would say it was his work on shock, not on blue babies, that was the real triumph of his medical career.) When Blalock came to Hopkins, he accepted the job on the condition that he could bring his assistant with him.

  Thomas liked Helen Taussig as soon as he met her. “She was tall and slender with a pleasant personality and spoke with a distinct New England accent.”

  These two reserved professionals, both of them exiled from their colleagues’ full respect, seem to have worked very well together. That first day they met in the lab at Johns Hopkins, “she went into great detail about the problems of patients with cyanotic heart disease.” According to Thomas, “she was particularly interested in the tetralogy of Fallot.”

  When Thomas visited Helen Taussig’s museum of hearts, he was dumbstruck. He spent days looking over the deformed hearts, the tetralogies. First, he was amazed by the human problem: How could a child live even for a year with a heart like that? And then he was overwhelmed with the technical problems of the surgery Taussig proposed.

  Thomas’s first problem w
as to induce the conditions of tetralogy in a lab animal. He did all his work on dogs, just as he had in Nashville, operating on animals as he developed and refined his technique. Of course, he could not punch holes in the centers of the dogs’ heart without killing the animals, so he tried several methods of restricting their blood oxygenation: tying ligatures around the pulmonary arteries and excising parts of their lungs. Thomas worked fourteen- and fifteen-hour days, killing dog after dog after dog. Finally, he began to work on the great arteries, trying to redirect oxygenated blood back to the heart, where it would mingle with the venous blood. This worked: it allowed Thomas to build a set of cyanotic lab dogs.

  Once he had rejiggered the blood flow in the dogs’ great arteries, he experimented with building the artificial ductus. The lab work continued for two years. He invented special instruments for pediatric cardiac surgery. He braided the thread. He cut down needles and sharpened them so they would work on the tiny arteries of a child. He built the special clamps that would thereafter be named for Blalock. As a surgeon, Thomas was a wonder—so precise, nimble, fast, and accurate that the Hopkins doctors assigned him (without paying him any more money) to teach their students how to operate.

  Blalock was skeptical that the surgery Thomas had designed would be effective. He thought it would just give the tetralogy patients a small measure of relief. Taussig, meanwhile, had identified a candidate for the operation: Eileen Saxon, fifteen months old, who had been born prematurely and attended to by Taussig since soon after birth.

  Eileen had been born in August. Initially, she had been diagnosed with a ventricular septal defect, a hole in the middle of her heart. But her condition had worsened. Taussig suspected that Eileen’s relatively good early health corresponded with a PDA, which after a few months had closed.

  By March, according to Taussig’s report, it had become clear that Eileen had a grave deformity. “After eating she would become deeply cyanotic, roll up her eyes, lose consciousness and appear extremely ill.” In June, Eileen was admitted to the Harriet Lane Home. “She was poorly nourished and poorly developed. She had a glassy stare. Her lips were cyanotic.… The baby was given oxygen and phenobarbital but remained very irritable and would become intensely cyanotic when taken out of the oxygen tent.”

  Eileen could not move on her own. She had to be carried everywhere. She failed to gain weight. She could only sleep with her knees drawn up under her chest. “During her recurrent spells,” wrote Taussig, “she breathed fast and deep and then suddenly went limp and lost consciousness.” By October 17, she was falling into a coma. Without intervention, Eileen was sure to die.

  Alfred Blalock had not yet performed the surgery, not on a person and not on a dog. Blalock had watched Thomas work, but he had never done the cutting and sewing. So in November he scheduled a date on which Thomas would teach him how to perform the surgery. On the appointed day, Thomas had everything ready for his boss—the dog on the table, the tools all prepared—but Blalock didn’t show. Thomas was getting impatient, when the phone rang. It was Blalock. Eileen Saxon was dying. If they were going to perform the surgery, it would have to be done now, without Blalock ever having performed it in the dog lab.

  The operation took place on the morning of November 29, 1944. Blalock was so nervous, he didn’t trust himself to drive to work and asked his wife to take him to the hospital. Thomas set up the room. “Suture material had been prepared, and supplies included additional bulldog clamps, a seven-inch straight Adson hemostatic forceps (which was useful as a needle holder), a blunt right-angle nerve hook and smooth bayonet-type forceps to pull up the continuous suture.” Having arranged it all, Thomas ducked out, too anxious to watch.

  Dr. Austin Lamont, head of anesthesia at Hopkins, examined Eileen Saxon and refused to take part in the surgery. She was too small, Lamont thought. If the anesthetic didn’t kill her, the surgery would. He thought it would be more humane to let her die on her own. Blalock turned to a junior anesthesiologist, Dr. Merel Harmel, just a year out of medical school, who agreed to help out.

  Blalock was assisted by his resident, Denton Cooley, and his chief surgical intern, William Longmire. Cooley would go on to found the Texas Heart Institute and to be the first man to implant an artificial heart in a human being. Longmire was one of the founders of the UCLA School of Medicine and in Los Angeles built one of the foremost heart surgery centers in the world. When Blalock got to the operating room, he didn’t look for either of these men. He looked for Vivien Thomas—who had trained both Cooley and Longmire in his dog lab.

  “I guess you better go call Vivien,” he said. Thomas came to the observation gallery, where he could look down on the surgery below.

  “Vivien,” Blalock said. “You’d better come down here.”

  There were seven people in the operating room that day: Blalock, Thomas, Taussig, Cooley, Longmire, Harmel, and a scrub nurse, Charlotte Mitchell. Rain fell against the big windows. The radiator hissed. The room was cold and damp.

  “Many of us thought this operation was going to be a big disaster,” Cooley remembered.

  The patient was wheeled in. Weighing less than nine pounds, she was so small it was difficult to see her under the sterile, surgical drapes. Taussig calmed the patient, held her, and laid her down on the operating table. Harmel, the anesthesiologist, had some difficulty fitting his breathing tube into the little girl’s tiny windpipe, but once the oxygenation began, her color improved. Taussig stood by the girl’s head. Ether was comingled with the oxygen in Eileen’s breathing tube. The patient was so small, according to Thomas, that they didn’t take her blood pressure—they couldn’t find a cuff small enough.

  Blalock asked Thomas to stand where he could see the operation, and so Thomas found a footstool, stepped onto it, and stood looking down over Blalock’s shoulder. Photographs of the operation taken from the gallery show six people gathered around the operating table and Thomas, standing tall, just behind the surgeon, in a cap and surgical mask. Denton Cooley, low man on the totem pole, inserted a needle into a small vein in Eileen’s ankle, at the ready with fluids and blood for transfusion.

  Blalock entered the chest on the left side. He made an incision from the sternum all the way down the side of the chest. Blalock entered the chest cavity through the third interspace between the ribs. The light was inadequate. A common floor lamp had to be brought close to illuminate the cavity. The veins and arteries were so small they looked to Thomas like capillaries. There was more bleeding than expected, which made it difficult to find the great arteries. Blalock found the left pulmonary artery and cut it free of the surrounding tissue.

  The artery was “no bigger than a matchstick” to Taussig’s eyes. According to Thomas, “The patient’s vessels were less than half the size of the vessels of the experimental animals that had been used to develop the procedure.” Blalock applied one of the clamps that Thomas had developed to the pulmonary artery and paused to see if the patient tolerated it. Then he applied a second clamp. He asked Thomas if he thought the space was long enough for an incision in the pulmonary artery. Thomas thought it was long enough—in fact, the incision didn’t have to be that long.

  “Al Blalock’s tenacity was remarkable,” Longmire remembered. “The cuff of the vessel visible was a fraction of a millimeter, and the incision itself was only four or five inches. I remember watching him open the patient and just thinking it was impossible.”

  Blalock began to suture the left subclavian artery to the incision he had made in the pulmonary artery, creating a connection that mimicked a patent ductus and diverted more oxygen to the lungs. The sutures had to be less than a millimeter apart from each other and very close to the edge of the vessels. It was a slow, laborious process. As Denton Cooley remembered it, “Dr. Blalock would ask Vivien questions over his shoulder. He would say, ‘Vivien, should I do it this way or that way?’ Vivien would know the answers.”

  Thomas watched Blalock sew and corrected him when the stitches went in the wrong direction. �
�Well, you watch,” said Blalock impatiently, “and don’t let me put them in wrong.” A set of stay sutures went over the initial suture, and then a second set kept it all in place. The clamps were removed. There was practically no bleeding. The vessels were connected.

  From a technical point of view, Blalock wrote later, the connection he’d created, an anastomosis, seemed fine. But he was perturbed by the tiny size of the arteries. And he couldn’t hear a “thrill,” the sound of blood rushing through at adequate pressure.

  The anesthesiologist, Merel Harmel, whispered, “The color is improving. Take a look! Take a look!”

  Taussig and Longmire looked down at the baby, at the new, cherry-red color of her lips. “You’ve never seen something so dramatic,” Thomas said later. “It was almost like a miracle.” Blalock washed the cavity with sulfanilamide and closed it. The procedure took ninety minutes in all.

  As she lay in the recovery room, no pulse could be felt in little Eileen Saxon’s left wrist, and her left arm was much colder than her right. She was alive, but her circulation was poor. Dr. Ruth Whittemore, Helen Taussig’s young fellow, stayed by little Eileen all day and night through the tiny girl’s torturous recovery.

  “I had to stick needles into both sides of her chest to draw off air that was compressing her lungs,” Whittemore remembered. Several times, Eileen’s lungs collapsed and had to be aspirated. There was no intensive care unit and no ventilator. No monitor existed to measure the pressure on her lungs, so Whittemore had to invent one. Eileen remained under close watch for two weeks, going in and out of fever. She was given oxygen and penicillin. She didn’t leave the hospital for home until two months after she underwent surgery.