Quickened her step along Franklin Street towards home.
Ran up the steps onto the porch and in through the screen door, to tell Walter the news.
The Heart of Denis Noble
Alison MacLeod
Alison MacLeod is a British novelist, short story writer and essayist. She was awarded the Society of Authors’ Prize for short fiction in 2008 and was shortlisted for the BBC National Short Story Award in 2011 for ‘The Heart of Denis Noble’.
As Denis Noble, Professor of Cardiovascular Physiology, succumbs to the opioids – a meandering river of fentanyl from the IV drip – he is informed his heart is on its way. In twenty, perhaps thirty minutes’ time, the Cessna air ambulance will land in the bright, crystalline light of December, on the small landing strip behind the Radcliffe Hospital.
A bearded jaw appears over him. From this angle, the mouth is oddly labial. Does he understand? Professor Noble nods from the other side of the ventilation mask. He would join in the team chat but the mask prevents it, and in any case, he must lie still so the nurse can shave the few hairs that remain on his chest.
No cool-box then. No heart on ice. This is what they are telling him. Instead, the latest technology. He remembers the prototype he was once shown. His new heart will arrive in its own state-of-the-art reliquary. It will be lifted, beating, from a nutrient-rich bath of blood and oxygen. So he can rest easy, someone adds. It’s beating well at 40,000 feet, out of range of all turbulence. ‘We need your research, Professor,’ another voice jokes from behind the ECG. ‘We’re taking no chances!’
Which isn’t to say that the whole thing isn’t a terrible gamble.
The nurse has traded the shaver for a pair of nail-clippers. She sets to work on the nails on his right hand, his plucking hand. Is that necessary? he wants to ask. It will take him some time to grow them back, assuming of course he still has ‘time’. As she slips the pulse-oximeter over his index finger, he wonders if Joshua will show any interest at all in the classical guitar he is destined to inherit, possibly any day now. According to his mother, Josh is into electronica and urban soul.
A second nurse bends and whispers in his ear like a lover. ‘Now all you have to do is relax, Denis. We’ve got everything covered.’ Her breath is warm. Her breast is near. He can imagine the gloss of her lips. He wishes she would stay by his ear forever. ‘We’ll have you feeling like yourself again before you know it.’
He feels he might be sick.
Then his choice of pre-op music – the second movement of Schubert’s Piano Trio in E-Flat Major – seems to flow, sweet and grave, from her mouth into his ear, and once more he can see past the red and golden treetops of Gordon Square to his attic room of half a century ago. A recording of the Schubert is rising through the floorboards, and the girl beside him in his narrow student bed is warm; her lips brush the lobe of his ear; her voice alone, the whispered current of it, is enough to arouse him. But when her fingers find him beneath the sheet, they surprise him with a catheter, and he has to shut his eyes against the tears, against the absurdity of age.
The heart of Denis Noble beat for the first time on the fifth of March, 1936 in the body of Ethel Noble as she stitched a breast pocket to a drape-cut suit in an upstairs room at Wilson & Jeffries, the tailoring house where she first met her husband George, a trainee cutter, across a flashing length of gold silk lining.
As she pierced the tweed with her basting needle, she remembered George’s tender, awkward kiss to her collarbone that morning, and, as if in reply, Denis’s heart, a mere tube at this point, beat its first of more than two billion utterances – da dum. Unknown to Ethel, she was twenty-one days pregnant. Her thread dangled briefly in mid-air.
Soon, the tube that was Denis Noble’s heart, a delicate scrap of mesoderm, would push towards life. In the dark of Ethel, it would twist and grope, looping blindly back towards itself in the primitive knowledge that circulation, the vital whoosh of life, deplores a straight line. With a tube, true, we can see from end to end, we can blow clear through or whistle a tune – a tube is nothing if not straightforward – but a loop, a loop, is a circuit of energy understood only by itself.
In this unfolding, intra-uterine drama, Denis Noble – a dangling button on the thread of life – would begin to take shape, to hold fast. He would inherit George’s high forehead and Ethel’s bright almond-shaped, almost Oriental, eyes. His hands would be small but unusually dexterous. A birthmark would stamp itself on his left hip. But inasmuch as he was flesh, blood and bone, he was also, deep within Ethel, a living stream of sound and sensation, a delicate flux of stimuli, the influence of which eluded all known measure, then as now.
He was the cloth smoothed beneath Ethel’s cool palm, and the pumping of her foot on the pedal of the Singer machine. He was the hiss of her iron over the sleeve press and the clink of brass pattern-weights in her apron pocket. He was the soft spring light through the open window, the warmth of it bathing her face, and the serotonin surging in her synapses at the sight of a magnolia tree in flower. He was the manifold sound waves of passers-by: of motor cars hooting, of old men hawking and spitting, and delivery boys teetering down Savile Row under bolts of cloth bigger than they were. Indeed it is impossible to say where Denis stopped and the world began.
Only on a clear, cloudless night in November 1940 did the world seem to unstitch itself from the small boy he was and separate into something strange, something other. Denis opened his eyes to the darkness. His mother was scooping him from his bed and running down the stairs so fast, his head bumped up and down against her shoulder.
Downstairs, his father wasn’t in his armchair with the newspaper on his lap, but on the sitting room floor cutting cloth by the light of a torch. Why was Father camping indoors? ‘Let’s sing a song,’ his mother whispered, but she forgot to tell him which song to sing.
The kitchen was a dark place and no, it wasn’t time for eggs and soldiers, not yet, she shooshed, and even as she spoke, she was depositing him beneath the table next to the fat yellow bundle that was his sister, and stretching out beside him, even though her feet in their court shoes stuck out the end. ‘There, there,’ she said as she pulled them both to her. Then they turned their ears towards a sky they couldn’t see and listened to the planes that droned like wasps in the jar of the South London night.
When the bang came, the floor shuddered beneath them and plaster fell in lumps from the ceiling. His father rushed in from the sitting room, pins still gripped between his lips. Before his mother had finished thanking God, Denis felt his legs propel him, without permission, not even his own, to the window to look. Beneath a corner of the black-out curtain, at the bottom of the garden, flames were leaping. ‘Fire!’ he shouted, but his father shouted louder, nearly swallowing his pins – ‘GET AWAY from the window!’ – and plucked him into the air.
They owed their lives, his mother would later tell Mrs West next door, to a cabinet minister’s suit. Their Anderson shelter, where they would have been huddled were it not for the demands of bespoke design, had taken a direct hit.
That night, George and a dicky stirrup pump waged a losing battle against the flames until neighbours joined in with rugs, hoses and buckets of sand. Denis stood behind his mother’s hip at the open door. His baby sister howled from her Moses basket. Smoke gusted as he watched his new red wagon melt in the heat. Ethel smiled down at him, squeezing his hand, and it seemed very odd because his mother shook as much as she smiled and she smiled as much as she shook. It should have been very difficult, like rubbing your tummy and patting your head at the same time, and as Denis beheld his mother – her eyes wet with tears, her hair unpinned, her arms goose-pimpled – he felt something radiate through his chest.The feeling was delicious. It warmed him through. He felt light on his toes. If his mother hadn’t been wearing her heavy navy blue court shoes, the two of them, he thought, might have floated off the doorstep and into the night.
At the same time, the feeling was an ache, a hole, a sore inside h
im. It made him feel heavy. His heart was like something he’d swallowed that had gone down the wrong way. It made it hard to breathe. Denis Noble, age four, didn’t understand. As the tremor in his mother’s arm travelled into his hand, up his arm, through his armpit and into his chest, he felt for the first time the mysterious life of the heart.
He had of course been briefed in the weeks prior to surgery. His consultant, Mr Bonham, had sat at his desk – chins doubling with the gravity of the situation – reviewing Denis’s notes. The tests had been inconclusive but the ‘rather urgent’ need for transplantation remained clear.
Naturally he would, Mr Bonham said, be familiar with the procedure. An incision in the ribcage. The removal of the pericardium – ‘a slippery business, but routine’. Denis’s heart would be emptied, and the aorta clamped prior to excision. ‘Textbook.’ The chest cavity would be cleared, though the biatrial cuff would be left in place. Then the new heart would be ‘unveiled – voilà!’, and the aorta engrafted, followed by the pulmonary artery.
Most grafts, Mr Bonham assured him, recovered normal ventricular function without intervention. There were risks, of course: bleeding, RV failure, bradyarrhythmias, conduction abnormalities, sudden death…
Mr Bonham surveyed his patient through his half-moon specs. ‘Atheist, I presume?’
‘I’m afraid not.’ Denis regarded his surgeon with polite patience. Mr Bonham was widely reputed to be one of the last eccentrics still standing in the NHS.
‘A believer then. Splendid. More expedient at times like this. And fear not. The Royal Society won’t hear it from me!’
‘Which is perhaps just as well,’ said Denis, ‘as I’m afraid I make as poor a “believer” as I do an atheist.’
Mr Bonham removed his glasses. ‘Might be time to sort the muddle out.’ He huffed on his specs, gave them a wipe with a crumpled handkerchief, and returned them to the end of his nose. ‘I have a private hunch, you see, that agnostics don’t fare quite as well in major surgery. No data for The Lancet as yet but’ – he ventured a wink – ‘even so. See if you can’t muster a little… certainty.’
A smile crept across Denis’s face. ‘The Buddhists advise against too much metaphysical certainty.’
‘You’re a Buddhist?’ A Buddhist at Oxford? At Balliol?
Denis’s smile strained. ‘I try to keep my options open.’
‘I see.’ Mr Bonham didn’t. There was an embarrassment of categories. A blush spread up his neck, and as Denis watched his surgeon shuffle his notes, he felt his chances waver.
The allegro now. The third movement of the Piano Trio – faster, faster – but the Schubert is receding, and as Denis surfaces from sleep, he realises he’s being whisked down the wide, blanched corridors of the Heart Unit. His trolley is a precision vehicle. It glides. It shunts around corners. There’s no time to waste – the heart must be fresh – and he wonders if he has missed his stop. Kentish Town. Archway. Highgate. East Finchley. The names of the stations flicker past like clues in a dream to a year he cannot quite summon. Tunnel after tunnel. He mustn’t nod off again, mustn’t miss the stop, but the carriage is swaying and rocking, it’s only quarter past five in the morning, and it’s hard to resist the ramshackle lullaby of the Northern Line.
West Finchley. Woodside Park.
1960.
That’s the one.
It’s 1960, but no one, it seems, has told the good people of Totteridge. Each time he steps onto the platform at the quaint, well-swept station, he feels as if he has been catapulted back in time.
The slaughterhouse is a fifteen-minute walk along a B-road, and Denis is typically the first customer of the day. He feels underdressed next to the workers in their whites, their hard hats, their metal aprons and steel-toed Wellies. They stare, collectively, at his loafers.
Slaughter-men aren’t talkers by nature, but nevertheless, over the months, Denis has come to know each by name. Front of house, there’s Alf the Shackler, Frank the Knocker, Jimmy the Sticker, Marty the Plucker, and Mike the Splitter. Frank tells him how, years ago, a sledgehammer saw him through the day’s routine, but now it’s a pneumatic gun and a bolt straight to the brain; a few hundred shots a day, which means he has to wear goggles, ‘cos of all the grey matter flying’. He’s worried he’s developing ‘trigger-finger’, and he removes his plastic glove so Denis can see for himself ‘the finger what won’t uncurl.’
Alf is brawny but soft-spoken with kind, almost womanly eyes. Every morning on the quiet, he tosses Denis a pair of Wellies to spare his shoes. No one mentions the stink of the place, a sharp kick to the lungs of old blood, manure and offal. The breeze block walls exhale it and the floor reeks of it, even though the place is mopped down like a temple every night.
Jimmy is too handsome for a slaughterhouse, all dirty blond curls and American teeth, but he doesn’t know it because he’s a farmboy who’s never been further than East Finchley. Marty, on the other hand, was at Dunkirk. He has a neck like a battering ram and a lump of shrapnel in his head. Every day, at the close of business, he brings his knife home with him on the passenger seat of his Morris Mini-Minor. He explains to Denis that he spends a solid hour each night sharpening and sanding the blade to make sure it’s smooth with no pits. ‘An’ ’e wonders,’ bellows Mike, ‘why ’e can’t get a bird!’
Denis pays £4 for two hearts a day, a sum that left him stammering with polite confusion on his first visit. At Wilson and Jeffries, his father earns £20 per week.
Admittedly, they bend the rules for him. Frank ‘knocks’ the first sheep as usual. Alf shackles and hoists. But Jimmy, who grasps his sticking knife – Jimmy, the youngest, who’s always keen, literally, to ‘get stuck in’ – doesn’t get to slit the throat and drain the animal. When Denis visits, there’s a different protocol. Jimmy steps aside, and Marty cuts straight into the chest and scoops out ‘the pluck’. The blood gushes. The heart and lungs steam in Marty’s hands.The others tssktssk like old women at the sight of the spoiled hide, but Marty is butchery in motion. He casts the lungs down a chute, passes the warm heart to Denis, rolls the stabbed sheep down the line to Mike the Splitter, shouts ‘Chop, chop, ha ha’ at Mike, and waits like a veteran for Alf to roll the second sheep his way.
Often Denis doesn’t wait to get back to the lab. He pulls a large pair of scissors from his hold-all, grips the heart at arm’s length, cuts open the meaty ventricles, checks to ensure the Purkinje fibres are still intact, then pours a steady stream of Tyrode solution over and into the heart. When the blood is washed clear, he plops the heart into his Thermos and waits for the next heart as the gutter in the floor fills with blood. The Tyrode solution, which mimics the sugar and salts of blood, is a simple but strange elixir. Denis still can’t help but take a schoolboy sort of pleasure in its magic. There in his Thermos, at the core of today’s open heart, the Purkinje fibres have started to beat again in their Tyrode bath. Very occasionally, a whole ventricle comes to life as he washes it down. On those occasions, he lets Jimmy hold the disembodied heart as if it is a wounded bird fluttering between his palms.
Then the Northern Line flickers past in reverse until Euston Station re-appears, where Denis hops out and jogs – Thermos and scissors clanging in the hold-all – down Gower Street, past the main quad, through the Anatomy entrance, up the grand, century-old staircase to the second floor, and into the empty lab before the clock on the wall strikes seven.
In the hush of the Radcliffe’s principal operating theatre, beside the anaesthetised, intubated body of Denis Noble, Mr Bonham assesses the donor heart for a final time.
The epicardial surface is smooth and glistening. The quantity of fat is negligible. The aorta above the valve reveals a smooth intima with no atherosclerosis. The heart is still young, after all; sadly, just seventeen years old, though – in keeping with protocol – he has revealed nothing of the donor identity to the patient, and Professor Noble knows better than to ask. The lumen of the coronary artery is large, without any visible narrowing. The musc
ular arterial wall is of sound proportion.
Pre-operative monitoring has confirmed strong wall motion, excellent valve function, good conduction and regular heart rhythm.
It’s a ticklish business at the best of times, he reminds his team, but yes, he is ready to proceed.
In the lab of the Anatomy Building, Denis pins out the heart like a valentine in a Petri dish. The buried trove, the day’s booty, is nestled at the core; next to the red flesh of the ventricle, the Purkinje network is a skein of delicate yellow fibres. They gleam like the bundles of pearl cotton his mother used to keep in her embroidery basket.
Locating them is one thing. Getting them is another. It is tricky work to lift them free; trickier still to cut away sections without destroying them. He needs a good eye, a small pair of surgical scissors, and the steady cutting hand he inherited, he likes to think, from his father. If impatience gets the better of him, if he sneezes, if his scissors slip, it will be a waste of a fresh and costly heart. Beyond the lab door, an undergrad class thunders down the staircase. Outside, through the thin Victorian glass panes, Roy Orbison croons ‘Only the Lonely’ on a transistor radio.
Denis drops his scissors and reaches for a pair of forceps. He works like a watchmaker, lifting another snipped segment free. A second Petri dish awaits. A fresh bath of Tyrode solution, an oxygenated variety this time, will boost their recovery. If all goes well, he can usually harvest a dozen segments from each heart. But the ends will need to close before the real work can begin. Sometimes they need an hour, sometimes longer.
Coffee. He needs a coffee. He boils water on the Bunsen burner someone pinched from the chemistry lab. The instant coffee is on the shelf with the belljars. He pours, using his sleeve as a mitt, and, in the absence of a spoon, uses the pencil that’s always tucked behind his ear.
At the vast chapel-arch of a window, he can just see the treetops of Gordon Square, burnished with autumn, and far below, the gardeners raking leaves and lifting bulbs. Beyond it, from this height, he can see as far as Tavistock Square, though the old copper beech stands between him and a view of his own attic window at the top of Connaught Hall.
The Story: Love, Loss and the Lives of Women: 100 Great Short Stories Page 40