Realdo Colombo, Vesalius’s student and later his adversary (and, yes, the guy who discovered the clitoris), went further: “Between the ventricles of the heart… is the septum, through which nearly everyone thinks that there is a way open for the blood to pass.… But those who believe this err by a long way.” In his lectures, Colombo described the movement of blood from one ventricle to the other via the pulmonary artery and the lungs. “Blood is carried to the lung by the pulmonary vein… and in the lung it is refined, and then together with the air it is brought through the pulmonary vein to the left ventricle of the heart.”
In 1600, William Harvey arrived in Padua to study. Harvey was the son of a wealthy yeoman from Kent. He was short, fierce, ruddy, ambitious, and always well armed. In England as a young man, he had witnessed no public dissections of human corpses or vivisections of animals; his Cambridge anatomical education had focused on the classics, but he had read Vesalius and Colombo. Harvey’s professor in Padua, Girolamo Fabrizi, worked under the name Fabricus; he was an older man whose anatomy lessons were celebrations of the human body intended to “display the glory of nature no less than did the circus games and gymnastics of antiquity.”
Everyone came to the theater to see Fabricus perform: “teachers, tailors, shoemakers, sandal-makers, butchers, salted fish dealers, porters, basket-bearers… money-lenders, and barbers,” according to Harvey’s biographer, Thomas Wright. The rectors of the city and the university wore ceremonial gowns, as did the professors of anatomy. The body was dissected in a chamber underneath the anatomy theater and, at the appropriate time, raised up through a trap door, while musicians played on the lute. Fabricus, seated and wearing purple and gold robes, read from classical anatomical texts, while his assistant, his ostentor, pointed at the relevant body parts with a rod. The performances began in early morning and went on late into the day. No one was allowed to chat or laugh, especially not during demonstrations of female anatomy. Porters tried to keep the peace. After the body was examined, the lesson would continue with vivisections of animals, the howls of the dogs accompanied by music.
Harvey returned to England with his prestigious Italian medical education. He married rich and rose up the ranks of London doctors, becoming president of the College of Physicians and physician to the king—first James I, then Charles II. He was sworn to uphold Galen’s teachings and to prosecute physicians who contradicted them. Publicly, Harvey was intellectually conventional. Privately, he was something else.
He came home from days as a London doctor and performed experiments by candlelight. He brought home dogs and cats and deer and calves, tied them down to his dissection table in his library, gagged the animals, and cut them open to examine their naked beating hearts. In the candlelight, with the blood and the squirming of the panicked animal, it was hard to see. Harvey found that he was able to observe the heartbeat more closely when vivisecting cold-blooded animals, fish, snakes, and lizards. He was able to observe how the heart relaxed in diastole and squeezed in systole. He filled a right ventricle of a heart with water, squeezed it, and proved that no liquid could travel through the septum. In vivisections of mammals, he punctured the aorta, which burst like a balloon. With each contraction, he saw a massive, explosive spurt. By measuring the outflow, Harvey was able to calculate how much blood was moved by every heartbeat. He multiplied the quantity in each beat to determine how much blood moved each minute, each hour, and came up with a massive quantity of blood, too large to be produced by the liver every day. Where would all that blood come from? Where would it go?
Harvey had caves dug in his garden, and alone at night he crawled into these caves and meditated on the structure of the heart. He encountered a patient with a hole in his side—the young nobleman had had an accident as a child, and the wound had healed to leave a cavity in his ribcage. Harvey brought his patient to the king. He reached his fingers inside the young man and touched the beating heart. He had the king do the same. It shook them—the heart, the center of human feeling, the place where the soul resided, could be touched, just like a face or a hand.
Back home, he called his servants into his study and experimented on them, ligating their arms, watching their fingers and hands go bloodless. He saw that the blood could only run in one direction, away from the heart through the arteries and back to the heart through the veins. It became clear to him: there was a fixed amount of blood in the body, and it went around in a circle, from the heart to the lungs, back to the heart, out to the body through the arteries, then back to the heart through the veins.
Harvey’s conclusion verged on the unspeakable. As everyone had understood it to that point, the blood of the hand stayed in the hand, and the blood of the feet stayed in the feet. Harvey’s notion was almost as shocking as if he were arguing that the bones of the skeleton were slowly moving around in a circle, exchanging parts with each other. It was also illegal, a violation of the professional code Harvey had sworn to uphold. The statutes of the British College of Physicians explicitly forbade its members from contradicting Galen in any way—and Harvey was its president. He published his findings as Exercitatio anatomica de motu cordis et sanguinis in animalibus (An Anatomical Exercise on the Motion of the Heart and Blood in Living Beings, usually referred to as De motu cordis). He coined a term for this new movement of the blood, “circulation.” He said, “I do not believe that my theory destroys Galenic medicine, rather it enhances it.” His colleagues did not concur.
If the blood was circulating around and around in the body, then the humors would be confused all the time—and according to Galen the confusion of the humors was the essence of disease. Furthermore, if the body maintained a constant supply of blood, then bleeding as a medical treatment made little sense. To bleed an infected leg could cause no relief; the blood from the rest of the body would move there. Harvey was cautious. He insisted he was making no challenge to bloodletting at all: “Daily experience satisfies us that [bleeding] has a most salutary effect in many diseases.” Skeptics made larger, empirical challenges. Harvey could not explain how the blood got from the arteries to the veins; the capillaries would not be discovered until 1661, so there was a gap in his circulatory system. He also could not explain the purpose of circulation—what Aristotle called its “final cause.” In Harvey’s time, no one knew what oxygen was or what cells were.
For decades, his theory faced resistance. Doctors would not relinquish their devotion to Galen or to bloodletting. For 150 years after he died, Harvey’s vision of the heart and blood had little effect on the work of the ordinary physician. As Thomas Jefferson wrote in 1806, “Harvey’s discovery of the circulation of the blood was a beautiful addition to our knowledge of the animal economy, but on a review of the practice of medicine before and since that epoch, I do not see any great amelioration which has been derived from that discovery.” Doctors kept on bleeding their patients to cool fevers or reduce swelling or mitigate what was diagnosed as a plethora of blood. When in 1799 George Washington had a fever and a sore throat, he got the same kind of medical treatment that would have been delivered to a European patient in the time of Michael Servetus during the Middle Ages. Washington’s doctors blistered his throat with Spanish fly, and it swelled up so he couldn’t swallow or breathe. They drained two pints of his blood before bed and a quart more in the morning, taking out nearly half the blood in his body. They killed him. The great seventeenth-century anatomists mapped the heart and circulatory systems, but it would be years before doctors could learn to navigate these charts. The word “cardiologist” would not appear until the 1920s.
This book recounts my particular struggle to come to terms with my particular heart—my defect, my surgeries, and the risks to my life—but when I look at the history of medicine, my experience feels like the whole in miniature, a tiny, revealing example of a great historical reckoning. It seems human nature not to want to look too closely at the function of the heart.
12.
IN THE FALL of 2017, I saw Dr. Jamil Abou
lhosn, head of the UCLA adult congenital heart disease (ACHD) program, speak to doctors and medical students at New York–Presbyterian. He was there to talk about single-ventricle heart conditions, but very early in his talk he was careful to address what he called the psychosocial aspect of care for ACHD patients. Many of them, Dr. Aboulhosn cautioned, have undergone multiple open-heart surgeries before the age of ten, and so as adults they have developed a fear of medicine, what Aboulhosn called almost a posttraumatic stress disorder.
“This is the reason so many fall out of care,” he said.
Most adult congenital patients go years or even decades avoiding the care they require. In the first visit with such a patient, Dr. Aboulhosn warned the assembled doctors, “Don’t bring up the T-word, ‘transplant.’ That’s one way to make sure they won’t come back and see you.”
His audience laughed in recognition.
Why do so many patients fall out of care? This is the deep ocean of my subject. I asked Mark Roeder, president of the Adult Congenital Heart Association (ACHA), if there were some geographical, economic, or educational factors determining who stayed in care and who fell out, and he only shrugged. There’s little solid data. Most US numbers on patients lost to care are approximations based on statistics garnered in Canada, where because of the national health system, doctors can accurately keep track of patients with congenital heart disease. In the United States we can only project those ratios onto our population.
Some patients lose their medical insurance and simply can’t afford a hospital echocardiogram. Others are geographically distant from the right doctor. If you live in Idaho, you have to fly to the Mayo Clinic in Minnesota to reach the closest ACHD center. If you’re feeling well and money is tight, you might not want to pay for a ticket every year. But a lot of us avoid doctors because we simply don’t want to think of ourselves as sick.
“This is one of my interests as a physician, but also as a human being,” said Dr. Ali N. Zaidi, an adult congenital cardiologist working at Montefiore Hospital in the Bronx. “I see patients who haven’t seen a physician for twenty years, and I say, How are you feeling, and they say they’re feeling fine. They don’t grasp the gravity of the situation because they’ve been living like that for so long. That’s their normality.” Patients like me don’t know the meaning of the word “healthy.”
Dr. Zaidi is tall and thin, with a neat gray beard and a boyish, enthusiastic smile. He grew up in a family of physicians, moving from London to Karachi to the United States, and he works with pediatric and adult congenital heart disease patients. Dr. Zaidi has a particular concern for patients who are lost to care—who, as they grow up, stop seeing the appropriate cardiologist. I came to his office after meeting one such patient, Bridgette Ratliff, whose case Dr. Zaidi described as “adult congenital heart disease in a nutshell.”
Bridgette, a tall, glamorous, chocolate-skinned woman, is about my age but looks younger. A dean of a public middle school and the proud mother of a charming adult daughter, Bridgette plans to retire soon from the New York City public school system and start a faith-based nonprofit helping teenaged girls in the Bronx. She is a delightful person, and she is doing great. But when she met Ali Zaidi in March 2015, she was in florid heart failure and unaware of it, and she came to the doctor almost against her will.
The first time he met her, Dr. Zaidi told me, as soon as he walked into the examining room, he could see her deteriorated condition, the fluid buildup in her belly, the fluid buildup in her legs. He knew right away she was in right-sided heart failure. But Bridgette would have none of it.
“She was like, ‘I have ten minutes. My car is parked out there, and I’m going to get a ticket. I don’t know why I’m seeing you.’”
She was working full-time and raising her daughter, and though she was in heart failure, Bridgette kept up a rigorous exercise routine. Every day after a long day of work she walked up three flights of stairs to her apartment. When she got home, she put on a Jillian Michaels exercise tape and jumped up and down in front of her television and did leg lifts and thrusts and stretches.
“Working out,” Bridgette told me. “Working out hard.”
Her coworkers could see her health was in decline. Bridgette, usually vivacious and energetic, was lethargic and tired. One day she was so exhausted after work that she parked and fell asleep for two hours in the driver’s seat. But then she got up, climbed three flights of stairs, changed clothes, put on her Jillian Michaels exercise tape, and began her routine, her planks and her step aerobics.
She had fits of lightheadedness. Her memory became compromised. She could not think up words or phrases. She developed a cough typical of heart failure, a constant, wheezing cough like a smoker’s cough, a sign that she wasn’t getting enough oxygen, but when people asked her if she had a cold, Bridgette got angry.
“I got an attitude,” she told me. “Like, no, I do not have a cold.”
Ali Zaidi put a stethoscope to her chest. He could hear the top chambers of her heart running fast, way out of time with the bottom chambers.
“You’re in atrial flutter right now,” he told her.
Bridgette demurred. “No, I’m not.”
Atrial flutter, right-sided heart failure—this was, as Dr. Zaidi explained, her normal. She didn’t know what sick was because she had never experienced health. For Bridgette, this was the story of her life: trauma and denial and pushing through all her difficulties with willpower and faith in God.
She grew up in North Carolina, and for the first eight years of her life, Bridgette’s heart condition was a mystery. She lived with blue lips and heart palpitations but no diagnosis. She was attended to by pediatricians and family doctors who did not understand her heart and were afraid of it.
“The doctors I saw were always in panic mode,” she remembers. They were terrified when she got a cough; they feared that coughing would strain her heart. They didn’t want to give her shots and vaccinations for fear of breaking her skin. “They were afraid of infection,” she told me. “They said if she gets an infection, it’s going to go to her heart, and she’s going to die.”
Once as a kid she showed up for an appointment with earrings. The doctors were aghast and made her mother take the studs out of her ears. She was forbidden from exercising. At the park, she had to sit on a bench and watch the other children play. It wasn’t until her family moved to the Bronx that she started seeing a pediatric cardiologist.
“I had to go to the doctor twice a year,” Bridgette remembered. “They still didn’t know what was wrong. As I got older, I began to get really scared. Everyone else had a name for their disease. If they had asthma, they could explain it. But for me?” Her lips were dark. She got tired easily. She suffered palpitations. “The teachers would ask, What is it? And my mother would say, We don’t know. That was the roughest part.”
Finally, when she was ten years old, she got a name for her condition: Ebstein’s anomaly, a congenital heart defect in which the right side of the heart develops as if it were upside down. The big pumping chamber is at the top, and the little chamber is at the bottom. The valves are abnormal. In 1973, there was nothing that could be done for a heart like Bridgette’s. Her future, according to the doctors, would be one of slow, unavoidable decline. She learned to compensate for her condition and to do the best she could.
She lived in an apartment with her mother and her three older sisters. In the streets, kids played baseball, dodge ball, running bases, and volleyball. Bridgette joined them. When her heart went wonky, she’d take a break and sit on a stoop, and another kid would take her place in the game. Her friends would come over. They would touch her shirt to feel the panicked heart and call to the other children.
“Look! Look! Her heart is beating really fast!”
Bridgette could feel her heart beating in her ears, beating, she said, “like it was going to beat out.” She never called an adult. She never went upstairs to her mother. She knew that if she drew attention to her condition, s
he would not be allowed to play, and so she developed habits of stubbornness and secrecy.
“I got used to it,” she explained. “It became my identity. That’s who I was in the neighborhood. Like, there was the kid with glasses. And I was Bridgette, the skinny girl with the heart condition.” She did well in school. She was smart. She loved to read. And she was feisty. When other kids picked on her, she stood up for herself. She got in fights. “I had a bad heart,” she told me. “There was no way I was going to be weak on top of that.”
As she got older, her palpitations became more extreme. She had to stay home for college, when she really longed to go away. Though the doctors predicted that she would not live long, she pursued her career. She got a master’s degree and a teaching license. When she was getting near what the doctors described as the limit of her life expectancy, she got pregnant. Her physicians felt her pregnancy might kill her. They told her that even if she brought the child to term, she would not live long enough to see it grow. Bridgette defied them.
“I wasn’t going to let the doctors play God,” Bridgette told me. “I figured, I’d trust their medical expertise on certain things, but when it comes to what’s really important, I’m going to live my life. Twenty-eight years I’d been living with this heart condition. I’d been able to do a lot of things they said I wasn’t going to be able to do. I was going to have a baby. I trusted God.”
Bridgette’s was a high-risk pregnancy. She was monitored carefully by a medical team. She developed difficulty breathing and was admitted to the hospital. Her daughter, Rachel, was born by caesarian section, a five-pound, beautiful child. The baby was healthy. Bridgette, though she didn’t know it at the time, was not.
The Open Heart Club Page 8