The Open Heart Club

by Gabriel Brownstein

  At the baseball game, the Mets gave us our own section in the upper deck. We sat together happily and were announced to the crowd. They put up on the scoreboard the name of our hospital, and maybe Dr. Malm’s name too, and maybe “THE OPEN HEART CLUB.” The whole stadium stood and cheered.

  Did I worry about how long my heart would survive? Did I think of myself as a medical miracle? No. I asked my dad for a hotdog. I filled out my scorecard. I hoped that the Mets would win.

  7.

  THE OLDEST SURGEONS and cardiologists I interviewed for this book are now in their eighties and nineties, people who started their careers before Danny Spandau’s heart was repaired by Jim Malm at Babies Hospital. These doctors remembered the awful moral calculus they faced at the dawn of the age of open-heart surgery. Dr. Welton M. Gersony, who would later direct the program in pediatric cardiology at Columbia, was completing his medical residency at Boston Children’s Hospital in the late 1950s.

  “The early patients,” he told me, “paid a terrible price.”

  Tetralogy of Fallot patients in particular presented doctors with a difficult puzzle. The vascular surgical techniques that had been devised by Helen Taussig, Vivien Thomas, and Alfred Blalock in Baltimore in 1944 alleviated a great deal of the tetralogy kids’ suffering. By sewing a shunt between the pulmonary and subclavian arteries, doctors could extend children’s lives. Some of those kids, like Danny Spandau, saw little improvement, but the vast majority responded well to the treatment and were still going after surgery, living limited but productive lives.

  By the late 1950s, surgery to implant a Blalock shunt was a reasonably safe procedure, one that could grant an eight-year-old tetralogy kid another ten or twenty years of life, or more. Meanwhile, in 1958, if you put the same kid on the operating table and tried to fix her heart more permanently, the odds weren’t great that the child would make it through the week.

  The surgeons, confident in their technical expertise, usually wanted to operate. But for a doctor like Gersony, deciding when to prescribe a risky surgery and on which child was an awful decision.

  “It was a tremendous dilemma,” Gersony told me. In his mid-eighties, thin and vigorous when I met him, Dr. Gersony still sympathized with the patients and parents he’d seen all those years ago. “When you’re ten years old, adding decades to your life means living until you’re thirty. And that sounds great when you’re ten. The problem is, how much extra mortality do you accept at five or ten years old, or even in a newborn or neonate, to then get potentially another fifty years of life? Would you accept that even 5 percent die there—kids who could have lived another twenty years with the Blalock? How many of those kids would you be willing to sacrifice to do the operation so the next generation would live?”

  The early experimental surgeries being done in Minnesota were often performed in lieu of the Blalock. C. Walt Lillehei’s first bypass operations risked the life of the parent as well as the child, the two of them hooked up in a complex blood transfusion, the parent’s heart feeding the child’s body. In some cases, Lillehei performed these procedures when the Blalock shunt was still possible—when the child’s life could have been extended for a decade with a safe and simple operation. At Babies Hospital at Columbia Presbyterian, most of Aaron Himmelstein’s tetralogy patients died—seven of eleven. Some of these were no doubt desperate cases, but if Himmelstein was like the other heart surgeons in the country, some likely might have lived another decade or two with a safely implanted Blalock shunt. Mortality rates for early open-heart surgery were 25 percent, 50 percent, or more, depending on the defect and the hospital.

  But the doctors had to consider not just the patient in their hands but also the next generation of children. This is what made the calculus so awful. If they were too cautious, if they never tried bypass surgery on the blue babies, if they just stuck with the shunts in the great arteries, they’d only be extending sick lives. They’d never cure anyone. With the heart-lung machine, the Holy Grail stood before them. They could grant long, happy, healthy lives to the sick children of the future, but in their present state of expertise, the first open-heart surgeries were almost murderous.

  In the late 1950s Welton Gersony was working with one of the most eminent heart surgeons in the world, Dr. Robert Gross, the chief heart surgeon at Boston Children’s. For decades Gross had been among the top chest surgeons in the nation, a natty, pompous, strutting genius, the best surgeon at the best pediatric surgery program in the world. But he was having a terrible time with open-heart surgery—connecting children to heart-lung machines and cutting into their hearts while they were on bypass. Gross liked to invent his own equipment and his own procedures, and his results with kids with heart defects were not good. Children were dying. It was too much for Welton Gersony. Despite his junior status, he went to Alexander Nadas, the chief of pediatric cardiology at Boston Children’s. Full of trepidation, Gersony emplored Nadas to tell Gross to stop.

  “I thought he’d throw me out the window,” Gersony told me. “But he did listen.” They did stop the program, for a while at least.

  My own pediatric cardiologist, Dr. Sylvia P. Griffiths, came to Columbia Presbyterian in 1955. Dr. Griffiths was trained at Yale by Ruth Whittemore, who had been Helen Taussig’s assistant during the very first blue baby operation at Hopkins in 1944. Griffiths, along with Whittemore, attended some of the summer gatherings of the so-called Knights of Taussig at Taussig’s family summer home in Cotuit, Cape Cod. Griffiths was also a coauthor of Malm’s breakthrough 1963 paper on the treatment of tetralogy of Fallot, describing his unprecedented string of effective corrections.

  She was at Columbia for Himmelstein’s early ventures into open-heart surgery, watching patients before and after the operations, and she too struggled with the high mortality rates. The chief of her pediatrics program summoned her to his office and sent her on a mission to Minnesota, the cradle of open-heart surgery, to see what was happening there. Why were their results so much better than Columbia’s?

  If, in the 1950s, Minnesota was the fertile crescent of the heart bypass, the University of Minnesota at Minneapolis and the Mayo Clinic were heart surgery’s Tigris and Euphrates, the two great wellsprings. Dr. John Kirklin at Mayo was technically minded and reserved. Walt Lillehei at the University of Minnesota was a wild man, a flamboyant daredevil and risk taker in medicine and in life. Lillehei would stay out all night drinking and dancing and show up in the OR hungover to perform impeccable surgeries. It was Lillehei who had the first successful series of bypasses with his two-patient surgeries—using an adult in place of a heart-lung machine and using transfusion to oxygenate his patients’ blood—but by 1958 Kirklin’s procedures with a heart-lung machine had surpassed Lillehei’s, and Sylvia Griffiths was sent to Mayo to watch Kirklin at work.

  I visited Dr. Griffiths in her apartment on Manhattan’s Upper East Side, where classical music was playing and the windows looked out over the East River. In her nineties, Dr. Griffiths was tall, fit, and elegant, in a white shirt with a bow and a long, dark pleated skirt. We met on a Thursday. She had done rounds at Columbia’s pediatric cardiology wards that Wednesday. She still did rounds every week. Her feral cat curled at my feet. “That one’s not for petting,” she said. Her hair was neatly cut in a white Prince Valliant bob, and she asked after my health with the same concern and hopefulness that she had when I was a child and she was my doctor. Then she told me about her visit to Rochester, Minnesota.

  “It was my first time in an airplane,” she told me. “I was given a hundred dollars from each department. I don’t know how much that is in present dollars, but right then and there, you could make a telephone call for a nickel. That trip was the most significant experience of my medical life. The operating room was an almost intimate setting. Beside a central bed on which the patient lay and the surrounding equipment, a balcony was in the OR. You were masked, but you were not behind glass. It was like another century. It seemed so advanced to anything I had seen or really under
stood, but there was remarkable teamwork between Kirklin and the anesthesiologist who ran the heart-lung machine.

  “In one week, three children were operated on, each with a ventricular septal defect.” That is, a hole in the wall between the two main pumping chambers of the heart. “These were approximately six to ten years in age. The most significant part of the visit was my observation and seeing the children. There were only three—but of course in those days three was a lot to leave the OR and go to the recovery room. Of course, I was familiar with the recovery room, in terms of intravenous and support fluids. In terms of the constant monitoring of the EKG and blood pressure. It was all very orderly, there were no disasters, and all three were discharged from the recovery room and sent back to the ward.

  “I went back to New York and said, ‘The problem is not one of management in the recovery room. The problem is in the operating room and what the surgeon’—Himmelstein—‘was doing.’”

  This was a remarkable thing, to have a part-time junior physician criticize the work of the senior surgical staff. But at Columbia at that time, with a whole new world of surgery being invented, they listened to Sylvia Griffiths. A significant part of her critique had to do with the Columbia surgeons’ understanding of congenital heart defects.

  “The people who started at Columbia weren’t schooled in anatomy of the heart,” she told me. “In Mayo, Kirklin and whoever was working with him was trained in pathology of the heart. One of the big liabilities of the early surgeries, say for ventricular septal defect, was creating heart block”—that is, destroying the heart’s electrical conduction system and thus its ability to beat. “At the Mayo Clinic, when I was there, none of the patients developed heart block. But our people weren’t schooled in the proximate location of the conduction system.”

  In other words, Himmelstein had trained as a chest surgeon. He hadn’t studied the complex workings of a child’s heart—the complicated interrelations of its muscular and electrical systems—and the hearts of his patients were consequently damaged in surgery. When Himmelstein died and Malm was preparing to take over the heart surgery program, he worked closely with Griffiths, studying congenital heart disease—women’s work, the field that Sylvia P. Griffiths was expert in and that Helen Taussig had pioneered.

  8.

  WHEN I CALLED Jim Malm in 2017 and said that I wanted to thank him for saving my life, the first thing he said was, “What took you so long?”

  I stammered. I said I wanted to interview him for a book I was writing. He gave me the phone number for the Babies Heart Fund and asked me to contribute. “Price of the phone call,” he said.

  I met him the next month at a gathering of Columbia heart surgeons, the fiftieth anniversary of cardiac surgery at Columbia Presbyterian. A number of eminent doctors were in the room—inventors of groundbreaking procedures like Dr. Jan Quaegebeur, who developed the current technique for repair of transposition of the great arteries, and Dr. Craig Smith, who had fixed Bill Clinton’s heart. These were men (the heart surgeons were all men, and the old ones were all white) of excessive self-confidence and achievement. Imagine a convention of retired, highly educated, highly decorated fighter pilots who have all made good money together. They were all conservatively turned out, and they all had a gentlemanly air that required no swagger. They had proven themselves. They had played with life and death, and they had won and won and won and won.

  In that crowd, the name I heard over and over again was Jim Malm’s. “Jim Malm is here!” “Is that Jim Malm?” At ninety-two, though his face was a little rounder than in the old photographs, he stood as tall as me, with a firm grip and a clever eye. His skin was strangely smooth for a man his age, and delicate, with very fine wrinkles.

  “Where’s that book you’re writing?” he said and smiled. “You’re going to have to finish it soon if I’m going to read it.”

  In 1959, when little blue Danny Spandau was awaiting surgery, Malm was a junior member of the Columbia team. His work was kept to closed-heart procedures—operations on the great arteries, like the Blalock shunt. Aaron Himmelstein still ran the program, and Malm didn’t have the opportunity to undertake the open-heart cases he yearned for.

  “In 1959, our program was floundering, not doing well, a high mortality rate, lots of complications,” Malm told me. “I spent much of the whole year waiting for my first patient.”

  Like Sylvia Griffiths, he traveled the country and looked at other programs.

  “I had the opportunity to visit and spend time in centers all over the US, to study techniques in open-heart surgery,” he told me. “I had the experience of seeing bad heart surgery, and I had the experience of seeing good heart surgery.”

  I asked him what the difference was.

  “You can’t have people shouting in the operating room. It can’t be hyperactive. You’ve got to have peace, quiet, concentration. I saw it. Demeanor in the operating room. It’s got to be a quiet environment. Orderly. Someone’s in charge. Like any business, you’ve got to have someone at the helm.” For Malm, it came down to the affect of the surgeon. “Not cocky. But confident. But you don’t achieve that without a good background and training and discipline.”

  So Malm educated himself in the anatomy of congenital heart defects. That way he would know what he was going to encounter when he opened his first little blue chest.

  The pathology lab at Columbia was run by Dr. Dorothy Hansine Andersen. Andersen had been trained as a surgeon at a time when there were no female surgeons, and the medical establishment had shoved her off into the less prestigious field of pathology. From her lab at Columbia, Andersen changed the medical world. She is best known as the discoverer of cystic fibrosis, but her interests were wide, and she maintained a collection of defective children’s hearts in her lab. Every week, Malm, Sylvia Griffiths, and another pediatric cardiologist, Sidney Blumenthal, attended seminars in Dorothy Andersen’s lab.

  “The focus,” Sylvia Griffiths told me, “was to learn anatomy, in mapping the cardiac conduction system, not simply in normal hearts, but looking at the conduction system, say, in the presence of a ventricular septal defect.”

  Dorothy Andersen was a large woman with a broad, strong-featured face. In photographs, she looks imposing and unsmiling, and she dresses in man-tailored clothes. She was an amateur carpenter and roofer. She did all the repairs on her own house. She was a hard drinker, and her hair and her lab were famously a mess. She seems to have been as much of an out lesbian as it was possible to be in 1959.

  It’s interesting to me that Malm, alone of the heart surgeons, attended these seminars. He emerged from a very traditional, white, Protestant, male-dominated environment, but he was perfectly happy working each week with a Jew, Sidney Blumenthal, and two women, Griffiths and Andersen, with the gay one, Andersen, running the show. I doubt this had anything to do with a commitment to liberal politics. Unlike the generation of chest surgeons who had come before him, Malm wanted to learn everything about a child’s heart’s workings. He was interested in only one thing: surgery on the human heart.

  James Malm was born in 1925 in Cleveland, Ohio, and grew up in Evanston, Illinois. His father, Royal, was the son of Swedish immigrants, and James was his parents’ first child. He suffered from childhood asthma and frequent lung infections, and he admired the local doctors who treated him. By the time he had recovered from those troubles, he knew what he wanted to do with his life.

  “It never occurred to me to be anything but a doctor,” he told me. “Somehow, I never wanted to be anything else.”

  By second grade, he had met Constance Martha Brooks, the girl he was going to marry. His purpose was absolutely clear. Young Jim had about as much uncertainty as a scalpel does. He set up a lab in his basement, with a microscope and slides, and prepared himself for his future profession. He did well in school. He was good with his hands. When the family went off to northern Michigan in the summers, he hired himself out to scale and clean the catch of summer fishermen. He finishe
d Princeton in two years, and in 1949 he graduated with honors from Columbia Medical School. “I excelled in clinical courses, particularly in surgery, so I elected to pursue a career in surgery,” he told me. With other interview subjects, I have had to edit their spoken grammar, to make it intelligible on the page. Not so with Jim Malm. Even his syntax was crisp and cutting.

  He interned at Pennsylvania Hospital in Philadelphia. “A wonderful clinical experience,” he told me. “Every possible wound, gunshot, abortion, alcoholism, drugs, poverty, which you really did not see at Columbia Presbyterian.” He was called to active duty in the Korean War. He served as the junior medical officer and the only surgeon on the aircraft carrier Philippine Sea. The planes took off and bombed Korean cities. The three hundred seamen were mostly healthy. The most common operations that Malm performed were circumcisions on sailors in whom venereal disease had resulted in infected foreskins. Once, he had to perform an appendectomy during a typhoon.

  “It was a big ship, and it was rocking and rolling. We had a whole flotilla, so forty boats had to slow down. That was my only moment of power in my two years at sea,” he remembered. “The entire 7th Fleet had to slow down to stabilize the operating table until I finished.”

  He returned to New York for his medical residency. One winter day, a terrible snowstorm blanketed Manhattan. The regular surgical resident on call for chest surgery could not make it in to work. Malm was technically on vacation, but he had stayed home for his break. His apartment was near the hospital, and he volunteered to help out in the OR, where he assisted on a lung operation.

  “I was introduced to chest surgery, and I became enchanted,” he said. “That was when I got a bee. I thought this was the greatest thing I’d ever seen. Then and there I decided to become a heart surgeon. It meant a couple of additional years of training, but my wife didn’t mind.”