MOUNT SINAI SCHOOL OF MEDICINE
of The City University of New York
Fifth Avenue and 100th Street, New York, NY 10029
Department of Psychiatry
May 19, 1971
Alfred Steinschneider, Ph.D., M.D.
Associate Professor
Department of Pediatrics
Upstate Medical Center
Syracuse, New York
Dear Dr. Steinschneider:
I have read with interest your involvement in the Second International Conference on S.I.D. Because of your active work in this area, I have hopes of enlisting your help in a study with which we have been involved at the Mount Sinai Hospital of New York for several years.
Several members of our Department of Psychiatry here have been interested in the phenomenology of Post-Partum Depression. We have been impressed with its variable duration, even up to one year, and of the various phenomenology it may exhibit. Such depressions may only reveal themselves through some unexpected and serious behavior. Attempts at suicide are, of course, our greatest concern, and sometimes may be the first evidence of a hidden post-partum reaction.
However, our group has come to recognize another phenomenon of the post-partum period that has been less well recognized or considered for a variety of reasons. We have found several instances of infanticide, not always associated with suicide, during the months following childbirth (or even adoption; interestingly enough. This curious occurrence can be explained psychiatrically).
As a result we have become very interested in infanticide as a specific manifestation of a depressive reaction to parturition. Our study excludes those cases in which infanticide is committed with full awareness and intent, in order to conceal or remove an unwanted pregnancy. This is a different category of infanticide, and unlike the post-partum reaction cases which apparently occur without the mother’s full awareness of her actions.
We are very eager to collect information about cases of infanticide in infants under one year, which you may know about. Since it is possible that some infanticides may be inadvertently hidden in S.I.D. statistics, I have been writing to various workers in the field asking for information. We are very anxious to avoid public dissemination of this study which would be needlessly disturbing to S.I.D. families. My article on this topic, “Crib Deaths: Their Possible Relationship to Post-Partum Depression and Infanticide” (Journal of Mount Sinai Hospital, May-June, 1968), did unfortunately get some unauthorized dissemination and we are anxious to avoid this in the future. Thank you for giving your time to this letter. We would be very grateful for any pertinent data you can send us.
Very truly yours,
Stuart S. Asch, M.D.
Associate Clinical Professor
Unit Chief
Mount Sinai Medical Center
Stuart Asch was a psychiatrist fresh out of residency when he accidentally walked into the morbid fears and fantasies of some young mothers-to-be. In the mid-1960s, he was a newly trained psychoanalyst, pondering the next step in his career at New York’s Mount Sinai Hospital, when he asked for a meeting with the hospital’s chairman of obstetrics and gynecology, Dr. Alan Guttmacher. He was interested in applying his specialty to obstetrical medicine.
Guttmacher, the first president of Planned Parenthood, thought it was an interesting idea. He gave Asch permission to hang around the obstetrics and gynecology floor. Talk to the women, he told him; see how they feel. When he did, Asch found that some women approached motherhood with deep insecurities about their ability to care for a baby. When he probed further, some of them confided that they were haunted by fears that their babies would die and that it would be their fault. As he accumulated records of these morbid musings, Asch wondered if any of them ever converged with reality. He knew that some women suffered severe postpartum reactions. He also knew that thousands of babies died each year without medical explanation.
When he broached this notion with obstetricians, he was met with great skepticism and a fair amount of anxiety. Not surprisingly, the doctors didn’t want to think that some of their patients might actually do harm to their babies. Furthermore, some pointed out, wasn’t psychiatry replete with latent wishes never fulfilled? It was a valid point. Asch decided to use his psychoanalytic tools to test his theory. In 1967, he called the legendary chief medical examiner of New York City, Dr. Milton Helpern. He was neither surprised nor displeased to learn that Helpern had himself wondered what might be behind the numbers of babies arriving in the city morgue after dying suddenly and inexplicably. Asch told the medical examiner he wanted to study the question from a psychiatric point of view. And he wanted to do it firsthand.
He proposed sending one or two psychiatric residents to interview mothers and their families after such deaths, right at the scene. They would do it delicately, of course, but perhaps some cases would provide enough psychiatric clues to piece together a homicide, along with a hypothesis. Helpern knew this was extremely tricky business—he was on the board of the local crib-death group—but he also believed that questions needed to be asked when babies died mysteriously.
To do the legwork, Asch recruited the hospital’s chief psychiatry resident, David Shapiro, whose wife happened to be pregnant, and another resident, Nathaniel Karush. Helpern arranged for the police to notify the Mount Sinai doctors whenever they responded to an infant death in the city, and deputized them as medical examiners—gave them badges and stickers that would give them access to virtually any death scene. The calls came steadily. Shapiro and Karush studied the scenes like detectives, talking to parents, watching for anything unusual—an affect, a circumstance—that might call into question a diagnosis of crib death. It was difficult work. Karush didn’t stay with it long. He decided he didn’t believe the premise that mothers could kill their own children. In fact, he found it appalling.
But Shapiro persisted and went out on about forty cases over the course of a year. He found five he thought were probable homicides. One was a young baby found dead by his parents, who were apparently winding down from a night of drinking. It looked like a classic crib death, but Shapiro was skeptical of the death scene: the house in shambles, the parents’ breaths a vapor of alcohol. Indeed, when the baby was brought to the medical examiner’s office and autopsied, a skull fracture on X ray made what really happened obvious. Asch wrote up his preliminary findings and sent the paper to the National Law Journal. Its publication had swift results. Helpern was inundated with calls and letters from parents who had lost children to crib death and thought Asch’s assertions cruel and horribly misguided. They called Asch a quack, a charlatan—a mother hater. A congressman from Seattle called Guttmacher’s office to complain. Abe Bergman wrote Asch a series of heated letters and so did Mary Dore. (“I was totally hysterical about Dr. Asch,” she remembered. “He was somebody you put up on a dartboard.”) Even the controversial Helpern found it too hot to handle. He asked for the badges and stickers. But Asch felt he had learned enough to justify pursuing his theory, even if it was the one scientific hypothesis whose validity depended on legal evidence.
Asch was skeptical of SIDS as a true medical entity. If you looked hard enough, he suspected, there would almost always be an explanation—whether it was an undiagnosed medical condition, an inadvertent overlaying or other form of accidental smothering, or, in some cases—he thought the figure could be as high as twenty percent—infanticide. The response to his first paper told him that his medical colleagues were unwilling to confront the darkest side of a dark question, that he was virtually alone in his thinking. But the reactions also chastened him. He realized he had underestimated the sensitivities of parents and their growing power as an interest group. He decided that his theory was perhaps still too speculative, and too incendiary, to disseminate widely. When he wrote his next paper, in 1968, he submitted it to a publication with a small audience—the journal of his own hospital.
Though his first paper had appeared in a legal publication, Asch didn’t approach his subject from a criminal justice point of view. He didn’t want to prosecute mothers who killed their children during a postpartum psychosis, or, for that matter, during any other kind of infanticidal episode with psychiatric roots. Prison wasn’t the place for them, he believed. When the Queens district attorney’s office asked him for the names of the women he suspected after his first paper was published, he refused. He was a psychiatrist, and he wanted them to be given treatment. Mostly, he wanted to shed light on the issue—maybe it could save some children. He managed to get his theory listed at the bottom of a table of “Recently Proposed Hypotheses” presented by Marie Valdes-Dapena at the 1969 SIDS conference, but, not surprisingly, he wasn’t invited to Orcas Island to speak about it. His theory was reduced on Dapena’s table to three words: “Asch—1968—Infanticide.” That was the price, Asch supposed, of devoting one’s research to such an abhorrent thesis as this: “Some hostile impulses and thoughts toward both the fetus and the newborn infant are quite within the normal range of maternal ambivalence.” He believed that the vast majority of women with such feelings managed to repress them, but as he would note ruefully in a later paper, most of his fellow citizens found it impossible even to consider the suggestion that in some cases “mother love might be replaced by murderous impulses.”
But the subject continued to preoccupy him, and in 1971, Asch set out to gather another round of data—case studies from around the United States that might demonstrate that infanticide was more common than people dared think—and this time, if the results were solid enough, to publish it in a major psychiatric journal. He began writing to pediatricians and others who dealt with sudden infant death, asking if they were aware of any possible infanticide cases, particularly those initially attributed to the newly popularized medical acronym SIDS. One response came from a doctor who described a mother who was a “cold, unempathic woman” whose “relationships with people were determined by their ability to fulfill her needs.” After the birth of her son, she became depressed, withdrawn, and preoccupied with the fear that the baby would die of pneumonia. She took to immersing him in cold water to build up his resistance and pinning a blanket tightly over him in his crib. He was found dead one morning, his face pressed down into the mattress.
Alfred Steinschneider did not respond to Asch’s query. His private reactions to the psychiatrist’s letter are unknowable. But it is a pertinent question, considering the timing of the correspondence. On the morning that Asch wrote to Steinschneider, ten-day-old Noah Timothy Hoyt was attached to a polygraph machine in the pediatric autonomic lab at Upstate Medical Center. Six days before, Steinschneider had admitted the fifth child of Waneta and Timothy Hoyt to the hospital for observation and study.
The baby was born twenty-one minutes before midnight on Sunday, May 9, 1971—Mother’s Day. He was named for Noah Kassman, the obstetrician who had delivered him and all his brothers and sisters. In the maternity ward of Tompkins County Hospital, the routine was the same. For the fifth time in less than seven years, the Hoyts became parents of a “normal newborn,” as Dr. Roger Perry put it once again on the birth record. A note jotted in the lower left corner of the nursery record by the delivery room nurse added Molly to the list of dead siblings, trailing off perfunctorily: “1st—died heart, 2nd—thymus, 3rd—choked, 4th—died.”
The nurses at Tompkins County noted that Noah had some trouble with feeding his first couple of days, but other than that he seemed fine. “Good baby,” a nurse wrote. Shortly after noon on his fourth day of life, she snipped off his hospital ID bracelet, put him in his mother’s arms, and sent him into the world. The latest version of the Hoyt family headed straight for Syracuse.
If Waneta and Tim had had their way, they would have had another child as well. Despite Waneta’s new pregnancy, they had decided to keep open the adoption application they’d reactivated the week after Molly died. The file contained an updated report from Dr. Kassman. “Patient has had four live births,” the obstetrician wrote. “All children have died in infancy, possibly from poorly understood genetic disease. Parents and children have been under study at Upstate Medical Center.”
Waneta requested an older child, telling her new caseworker at Social Services that she “needed” a child in her home to help her through the pregnancy. And if her fifth baby followed the fate of the first four, she added, she would still have the adopted child. The application received a cool response from the caseworker, a mother of five herself named Alberta Weisz. She felt uncomfortable with the Hoyts’ history of loss and the impulsive way they pursued adoption, and she was especially concerned about Waneta’s expressed “need” for a child. She made a point of dragging her feet on the application.
Impatient, the Hoyts applied to a private agency in Tompkins County, Family and Children’s Service of Ithaca. In January, Weisz got a call from the Ithaca caseworker, asking what she knew about the Hoyts. Weisz wrote back:
… It would appear that this couple has suffered a great deal of grief. Neither has resolved their emotional need for a natural child. It almost seems like the couple considers the adoption process as a second resource, but not a complete fulfillment. The Hoyts requested an older child. It does not seem a particularly good time to introduce an older child into a home during final months of pregnancy.… It seems like an adopted child could be an “insurance policy” for the family. The Hoyts need a child in their home to help them through their fifth pregnancy. They need the child to buffer their grief should the fifth child not survive. The question in mind is whether a child needs them as parents.
Four months later, Noah Hoyt, an only child, was settled into his first home—the pediatric ward of Upstate Medical Center.
His sister’s death eleven months before had aroused Steinschneider as a scientist. He saw it not in the context of Stuart Asch’s hypothesis, but in terms of his own. Molly’s death fit just about everything he had come to believe about SIDS: the near-misses, the recurring apnea, the association with respiratory infection, the final event coming in her third month. There was only one loose end. Most SIDS deaths seemed to occur during sleep. It wasn’t clear that Molly was asleep when she died.
A year later, Steinschneider was even more absorbed by the pursuit of his theory. Though Molly was the most dramatic of his subjects—the only one he studied who had gone on to die—she was but one of a number of babies he had recruited for his apnea research in the two years following the 1969 conference. There was, for example, a month-old boy whose mother had rushed him to the emergency room one day when she noticed he was pale and not breathing. Steinschneider admitted the baby to the CCRC, studied him in the lab, and, as with Molly, sent him home with a monitor after three weeks in the hospital. The baby spent the better part of four months shuttling between his home and the hospital. Later, in pursuit of a possible familial link, he studied the baby’s sister, with similar results. In all instances but one, the emergency was apparently triggered not by any signs of distress in the baby but by the hyperactive apnea monitor, set to alarm at fifteen seconds.
Steinschneider’s consuming fascination with apnea and its possible connection to SIDS had become well known among the pediatrics staff at Upstate. They tended to see him as an intrepid investigator of SIDS whose work was shrouded in a little mystery: the driven scientist, always up in his lab, hooking up babies to monitors, poring over polygraph paper, scribbling calculations. Since Molly’s death, he had been trying to refine his sleep studies in an effort to isolate the difference between normal apnea and perilous apnea in advance of the final event. He hadn’t been able to do it for Molly, but her death could be viewed as a step in the scientific process. Predicting and preventing death was becoming his obsession.
The work of researchers at UCLA had made him fascinated by the notion of rapid eye movement sleep and its relationship to breathing. In the lab he began labeling each fifteen-second period of his subject’s sleep either a “REM epoch” or a “Non REM epoch,” and then correlating these with incidence of apnea. He also came up with an elaborate formula he called the Apnea/Duration percentage—A/D% for short—to quantify a baby’s apnea, whether brief or prolonged. He calculated a baby’s A/D% by adding up the duration of all periods of nonrespiration of two seconds or more (measured in tenths of a second), dividing that number by the duration of the total sleep, and then multiplying that number by 100. It was a kind of apnea scoring system.
Jack Schneider, the head of the research unit, had long found Steinschneider’s research a waste of time—“all this nutty monkeying around,” as he put it. Now he felt his fixation on measurements and statistics bordered on the ridiculous. “I thought it was a crock of shit myself,” Schneider said. “But I’m not into that sort of thing. It’s fairy-type stuff. You know, they run off reams and reams of polygraph paper, and what do they have?” Schneider’s views had nothing to do with the Hoyt family or with his wife’s suspicions about Molly’s death. Nor was it the theory he found misguided, so much as the method of research. “It was the whole approach. It’s like you take a shovel full of pebbles and you throw them into a large swimming pool and then you measure the wave heights and you try to locate where some particular pebbles fell. You’re relying on ten billion pieces of information to try to extract which pebble made that wave. And that never did strike me as a very intelligent way to find things out. He’s measuring respiratory rates. What can you measure? Well, you can measure how often it occurs, right? You get a tracing of it. Somebody’s breathing. And you’ve got a thing that moves when he breathes. But is there anything about the previous ten thousand breaths that tells you that the next one is going to be the last?”
Noah Hoyt’s early life was a replay of his sister’s. The day of his arrival at Upstate, Steinschneider met the Hoyts in the examining room and arranged for a resident to take a history and examine the baby. She found him healthy, though “suspect for respiratory distress syndrome.” He was admitted as a research patient, but because the CCRC was now only an outpatient center, he was placed in the pediatric nursery, a glassed-in room on the main pediatric ward on the fourth floor, a level beneath the research center. It had five cribs holding babies with assorted congenital and neonatal difficulties. Like Noah, some of the babies came from long distances to be treated by the pediatric specialists at Upstate. Unlike Noah, these babies had obvious, sometimes serious problems, everything from hydrocephalus to the more general “failure to thrive.”
The closing of the CCRC as an inpatient unit, and the changes in the nursing staff that resulted, meant that only a few of the nurses who had gone through the trauma of Molly the year before would now be taking care of her brother. Joyce Thomas and Corrine Dower were gone, but Thelma Schneider was still there and so was Julie Evans. That was more than enough memory to cause a stir when Noah appeared on the ward just eleven months after his sister’s mysterious death. The two senior nurses would have opposite roles in Noah’s care. Assigned to the pediatric nursery on the fourth floor, Julie had been with Molly only sporadically. Now Noah would be hers. Thelma was still up in the research clinic, working with outpatients, so she would not have much to do with Noah.
Julie was in her mid-fifties, a grandmother of three. She had worked for Jack Schneider at Crouse-Irving Memorial a decade before, then followed him to the new university hospital when he became the head of the research unit. She was full of energy and efficiency, always scurrying around in care of the babies in her charge. She reminded one of the young nurse’s aides who came under her wing of Dorothy’s Aunt Em—all business, a mother hen who was much too busy taking care of babies to pay attention to the social scene that was an inevitable backdrop of the nurse’s life. Some of the younger, unmarried nurses did their jobs, chatted over coffee, made plans for after work, and kept their eyes open for an eligible doctor. Julie had eyes only for the babies. If something bothered her about a baby’s care, she did something about it. She had not been centrally involved in the talk about Molly, but she knew about it. Now, as Thelma had been to Molly, she would be one of Noah’s surrogate mothers; his protector.
From the night of the Hoyts’ first visit, Julie felt that Waneta was unlike any mother she had encountered as a nurse. “You don’t see your baby for a few days,” she remarked. “You come in and you want to pick up your baby and hold him and feed him and talk to him. She didn’t do any of that.”
When they came to visit, Waneta and Tim would ride the elevator to the fourth floor and make their way to the ward. It would be early evening, dusk beginning to settle on a spring night in Syracuse, when this subdued, insular young couple from a distant farming town appeared at the nursery. Two decades later, Julie could still see the scene unfolding in her mind, in sharp detail because the visits were so ritualized, Waneta’s behavior so consistently disturbing: She comes in, looks at the baby, and then she sits down. She doesn’t kiss the baby. She doesn’t pick him up. She doesn’t ask, but I tell her how he’s been doing. Then I pick him up and hand him to her, put him in her lap. I bring in a chair for her husband. And she’s holding the baby, but I know that she doesn’t want to hold the baby. You can tell just by the way she’s holding him. I’m afraid she’s going to drop him or something. She doesn’t have her arms around him. She has one arm around him, and the other is … I don’t know where the other one is. So I take the baby from her and put him in her husband’s lap. And she doesn’t like that one bit. She pulls her chair next to him, and she strokes her husband’s leg, runs her hand up and down his leg. She’s jealous, is my impression. Her husband is more affectionate with the baby. She resents it. You can see it in her face. And then the minute I pick up the baby and put him back in the crib, she’s all right.
Picking up where Thelma had left off with Molly, Julie began bringing her observations to Steinschneider. Like Thelma, she had known him a long time—ever since he was a medical student—and liked him. His wisecracks made her laugh, and his lack of ceremony made him easier to be around than some other doctors. Julie had a bit of the firebrand in her, and with Steinschneider she felt comfortable stepping on, if not actually crossing, the line of authority long established by the hospital caste system.
“I don’t like the way the mother is acting,” she told him after her first few encounters with the Hoyts. “There’s no maternal instinct there. She pulls away from the baby, like she really doesn’t want to be bothered. I’ve never seen a mother act that way.”
Steinschneider had heard all this before, but apparently Molly’s death had not caused him to reevaluate his stance. When Julie said she’d be afraid to send the baby home, he told her he couldn’t keep the baby in the hospital indefinitely, and went back to looking for apnea.
His studies were now a good deal more inventive than those he had conducted with Molly. Several times a week, he brought Noah into the lab and, besides the strain gauge on the baby’s chest, he put four electrodes around his left eye—one above and one below and one on each side—to measure his eye movements. He found that Noah had many more brief periods of apnea during REM sleep. Sleep position, though—stomach versus back—made no difference. He had the baby, now three weeks old, injected with drugs such as Ritalin, a brain stimulant whose use on hyperactive children would later become hotly debated. He determined that both Ritalin and another drug, Diamox, seemed to decrease the frequency of Noah’s apneic pauses. In fact, they made him breathe too much. The nurses documented the pitiful incongruity of a seemingly healthy baby being alternately fed and drugged, the results barely distinguishable in the charts. “Given Ritalin in left buttocks,” Thelma Schneider wrote on May 27. “Took 5 oz. Enfamil. Burped well. Developed generalized flush and rapid breathing.” It was all part of a day in the life of Noah Hoyt.
Noah’s breathing was even less eventful than Molly’s. He had far fewer periods of what Steinschneider defined as prolonged apnea, and the ones he put into the record were suspect. When a nurse reported a monitor had buzzed but that she couldn’t tell whether Noah had stopped breathing, he counted it. When another nurse wrote during her shift, “2 short 5 sec apnea periods, stimulated self,” Steinschneider described both periods in his record as “prolonged.” He listed one prolonged episode for May 29. “Having short periods of apnea” was all that was reported by the nurses that day. In none of these instances did a nurse have to take any action to stimulate Noah’s breathing. By the time Steinschneider sent him home with an apnea monitor on the afternoon of June 15, after thirty-three days of observation, Noah had gone 813 consecutive hours in the hospital without a moment of respiratory distress. He arrived home for the first time in his life at 4:00 that afternoon.
The next morning, he was rushed back by a Newark Valley ambulance. Waneta told the emergency room doctors she’d called for help after reviving Noah with mouth-to-mouth resuscitation.
It had been an awful morning, she told Steinschneider when he met her in the examining room. “I was in the kitchen when I heard the alarm,” she said. “I went in and he wasn’t breathing.”
Steinschneider asked if the baby had become cyanotic. “He was kind of dusky pale,” Waneta said. “I shook him and he perked up. Then fifteen or twenty minutes later, he was asleep in my arms and he turned dark and pasty and he stopped breathing again. I gave him mouth-to-mouth, and he started breathing again. He slept most of the time in the ambulance.”
Steinschneider put down his pen and examined Noah. The only thing obvious was that he had a very slight runny nose. He ordered a round of tests—electrocardiogram, urinalysis, blood work, chest X ray. Everything was negative, but Steinschneider readmitted Noah to the ward, instructed the nurses to monitor him around the clock, and made plans to get more of his respiration on paper in the lab. It seemed to him that Noah, the brother of four dead children, had survived a near-miss—maybe two.
The treatment was going to cost the Hoyts a lot of money. A week before Noah’s discharge, Steinschneider had been forced to transfer him off “research status.” With federal money now in short supply and the reins being tightened, Noah was now just like any other patient. Tim talked about his financial problems with Steinschneider, who told him he would try to keep the baby as a research patient. If the Hoyts allowed him to use Noah in his research, there might be a way to avoid the hospital charges. They signed a consent form permitting Steinschneider to use the voluminous and still growing records of their babies to help Noah qualify as a subject.
Gail Dristle had never had what she considered a serious job before she was accepted into the nurse’s aide training program set up by Upstate Medical Center in 1970, soon after her twentieth birthday. She didn’t count the job she quit to enroll, working the counter at the Plaid Stamps redemption center on West Onondaga Street. The nurse’s aide program she saw advertised on a bulletin board could lead to a career: interesting work, good pay, dependable benefits. She was a single mother with a two-and-a-half-year-old daughter. Maybe she would even go on to become a full-fledged nurse. She was eager to get her life in order.
The training period was a nine-week, 360-hour course beginning with classroom study in a building across the street from the hospital, followed by hands-on clinical training. At graduation, Dristle was asked what area she’d like to work in, and she picked pediatrics. The hospital was careful about assigning new nurse’s aides to pediatrics because of the high-level care required and the emotional toll of working with sick children. But she had done well in class, and when nobody else asked for it, she got the assignment. Her first patient was a one-year-old girl with a brain tumor.
Gail found the hospital culture slightly mysterious, and the pecking order of the nursing staff—a hierarchy within a hierarchy—formidable. She watched and listened, tried to learn the nuances of caring for ill children, observed the boundaries between nurses and nurse’s aides. Doctors were a whole other level. “M.D. equals Major Deity,” one of the nurses told her one day. She watched the interactions, and saw how completely the dynamic was defined by gender. If women knew their place, nurses really knew their place. Nurse’s aides? Watch yourself. “If a doctor indulged a nurse, treated her nicely, she just lapped it up,” she remembered. By the same token, a doctor’s authority was supreme. She felt the aura the first hour she was on the ward.
Gail was flattered when one of the senior nurses, an energetic woman who seemed to be one of the unofficial authority figures on the ward, began taking a special interest in her. “Half these nurses weren’t trained right,” Julie Evans told her. “I’m going to train you right.”
Julie brought Gail into the nursery. “These babies have special needs,” she said. “The parents can’t always be here, so we have to take special care of them.” She explained the requirements of each baby and showed her how to document the care in the Nurses’ Notes. Gail remembered what she’d been instructed in the classroom. “Just write down the facts. No opinions, no judgments. You never know—these notes could wind up in court. If you have an opinion about something, there are other systems to deal with it.”
Julie was a natural mentor, and Gail felt a warmth and a basic goodness that struck an emotional chord. Julie, she thought, was everything her own mother was not. She also appreciated the rebel in her. Julie was not one of those nurses who observed a quiet subservience in the presence of doctors.
When she came in for work each day, Gail got herself a cup of coffee, then walked down the hall to a small room for morning report. The charge nurse from the previous tour would pass along pertinent information about patients to the next shift, then the supervisor for the oncoming staff would assign nurses to patients—eight or ten nurses for twenty or thirty children. It was a gathering of white uniforms that occurred three times a day, not unlike what goes on in a typical police station house between shifts. It was here, a few months into her career as a nurse’s aide, that Gail first began hearing about Noah Hoyt.
This was the baby everyone was watching. He was in for observation because of a family history of infant death, Gail understood, and was to be kept on an apnea monitor virtually around the clock. She found it unsettling that a baby so young, so seemingly normal, could be in so much trouble that every one of his breaths had to be accounted for because it might be his last. Here’s one you have to worry about every time he goes to sleep. It didn’t take long for her to figure out that there seemed to be more to it than that.
Gail wasn’t assigned to Noah during his first few weeks on the ward, but she couldn’t help but pick up on some of the coded gossip about the baby’s mother that hung in the air at report, and in the ward generally. She felt uncomfortable with the talk, unqualified to pass judgment. But she was curious. A nurse who’d introduced herself as Dotty seemed especially hung up on the baby’s mother. One day, Gail asked her which one Mrs. Hoyt was. Gail hadn’t noticed anyone visiting Noah. “She doesn’t come much,” the nurse said sharply.
A couple of days later, Dotty walked up to her outside the nursery. “Gail,” she whispered conspiratorially. “The Hoyts are here. Go in and tell me what you think.”
“What?” Gail replied, taken aback. She thought Dotty was a bit too judgmental, and she was reluctant to feed the gossip.
“Just go in and tell me what you think,” Dotty pressed.
Gail looked in through the nursery window, then back at Dotty. The nurse nodded her encouragement. “Okay,” Gail said tentatively. Go in easy, she told herself. These people have lost children.
She went into the nursery, turned toward a corner of the room, and stopped abruptly. There was Noah’s mother, standing about eight feet from the crib, near her husband, her arms folded tight. She was glaring. A split second later Gail realized that she was glaring at the baby. Gail thought, What’s wrong? What’s she going to do? She was about to ask what the matter was when Waneta broke her concentration, and her eyes met Gail’s.
“Uh … hi …” Gail stammered. “I’m Gail.” Neither Waneta nor Tim said anything in response, and Gail tried to exit as quickly and unobtrusively as possible.
She was shaken by the encounter. She was sure the look she had seen was anger—“a very quiet, very powerful anger”—and she felt sure that it was directed at the baby. How could a mother be angry at such a tiny, helpless thing? she thought. Maybe she was going through some crazy kind of grief Gail told herself. Maybe she’s angry at God for killing her children.
“Something’s wrong here,” she said to Dotty. “I don’t know what it is, but there’s something real wrong here.”
“Oh yeah,” Dotty said. “Something’s wrong all right.”
Noah’s return in the ambulance on June 16 focused the concern of the nurses in the same way that Molly’s cycle of discharge and readmission had intensified the worry of the nurses who were taking care of her. Juxtaposed against Waneta’s obvious disregard for her baby in the hospital, the consensus among Noah’s nurses was that, at the very least, his mother was emotionally incapable of caring for a baby. Like the nurses a year before, they flipped through the possibilities. Perhaps the earlier deaths had scarred her so deeply that she could no longer connect with her child. Whatever the reason, the nurses agreed Waneta’s behavior was nothing short of bizarre. They decided they should try to draw her into a relationship with her baby. At afternoon report one day when the Hoyts were expected in that evening, Julie Evans said, “Let’s try to get Mrs. Hoyt to bond with the baby today.” It became a familiar refrain.
Comments like these struck a raw nerve in Gail Dristle. As a child, she had been the victim of relentless abuse at the hands of her mother, a woman so brutal that Gail often wondered how she and her brother had survived. Her mother had been confined to a psychiatric hospital for a time after her brother’s birth, and Gail spent years looking into her icy gaze, searching for peace that never came. Her mother’s abuse had left an indelible mark and made her attuned to the signs. Now she was beginning to realize that there were children passing through the pediatrics ward who were very likely being physically abused at home and that there didn’t seem to be a reliable system to protect them. She began to see that the medical mores of the time made it difficult for staff members to take responsibility for what might be going on outside the walls of the hospital. “People saw what they saw,” she remembered. “The worst was when you knew they were going back to a bad situation. I remember a five-month-old baby with a skull fracture. There was a social work department. But what they emphasized in training was what not to do.”
She decided to tell Julie about the incident in the nursery. She wanted to see if it fit with the vibrations she was picking up, and if it did, what they added up to. Julie listened, and nodded empathetically. She acknowledged that there was a problem with Noah’s mother, but left it at that.
Gail, though, could not leave it at that. On days when she was assigned to Noah, she would mother him, not merely nurse him. On days that Noah was not among her patients, she made it a point to visit him. He was such an agreeable, sweet-natured, beautiful baby, she thought, the kind about whom mothers tended to say later, “He was my best baby.” If only his mother could see that. She found it impossible to maintain the delicate emotional balance Julie had instructed her was essential for survival in pediatrics. She saw that Noah began to notice when she came in the room, that he stirred, smiled at her with his sky-blue eyes, as if reaching out for her attention—“like he was just laying there waiting and loving it when somebody walked in the room.” She would feed him, then lull him to sleep with a song, the rhythm of the rocking chair keeping time with the lullaby. “Hush, little baby, don’t say a word,” she would sing, just as she had sung at home to her own daughter, Maria, “Poppa’s gonna buy you a mockingbird. And if that mockingbird don’t sing, Poppa’s gonna buy you a diamond ring.…”
Gail began listening closely to the whispers that she had made a conscious decision to tune out before. She paid careful attention to what was said about Noah at report. And she began asking questions. How many children had died before Noah was born? How old were they? How did they die? Some of the answers were right in the history at the nurses’ station, but she didn’t want to seem like a snoop. Julie began opening up, but cautiously. She told her Molly had died after leaving the hospital, but didn’t say how soon after. She said there had been other children, but wasn’t sure how many, or how they had died. There was confusion among the nurses about the entity Steinschneider was studying. When Gail heard from one of the nurses that one of the Hoyt children was two years old when he died suddenly, she said, “Two?” “Well, apparently this can happen at any time,” the nurse said. And Gail said again, “Two?” She resolved to never allow Waneta to be alone with Noah in the nursery and noticed she wasn’t the only one with this self-imposed rule.
By mid-July, Noah had spent virtually his entire two months of life in the hospital. In all this time, Julie could not remember Waneta ever kissing him. What she remembered, couldn’t forget, was how she stroked her husband’s leg whenever he had Noah in his arms. The father was warmer, she thought, though some of the nurses could be heard ridiculing his seeming obliviousness.
When the Hoyts visited, Julie would accompany them into the nursery and try to lead by example. She would pick up Noah, kiss him, and cuddle him, sometimes with exaggerated enthusiasm. “I would try to get the baby’s mother to react,” Julie later remembered. “But it was a lost cause. And then when I saw how she’d react, I would tell Dr. Steinschneider right away.”
It was an echo of Thelma Schneider’s pleadings a year before. Like Molly, Noah had not had a moment of illness more serious than a runny nose. Even by Steinschneider’s standards Noah could not be considered a baby with problems. Though he remained committed to his original diagnosis of apnea, Steinschneider had to concede that the machines made it difficult to confirm. “Alarm has sounded,” he wrote one day, soon after Noah’s readmission. “However I believe this was not because Noah became apneic but rather that the machine was not picking up shallow respiration. Will have machine checked out.” A week later, he wrote, “No bona fide prolonged apnea. Awaiting new machine.” Another day, Len Weiner, a fellow pediatrician filling in on rounds, looked in on Noah and tried to think of something to write in the Physician’s Record. He came up with this: “53-day-old baby followed by Dr. Steinschneider for apnea. Four sibs died of ‘crib death.’ Essentially the child is here for testing on the polygraph.” Noah might have been the healthiest patient in University Hospital, yet those taking care of him sensed disaster if he was allowed to leave.
As Steinschneider got closer to discharging Noah for a second time, Julie Evans began begging him to find an alternative. Cornering him in the hallway one day after a visit by the Hoyts, she decided to tell him her worst fears. “I think she’s doing something to those kids,” she said. It was the first time anyone had put it so bluntly.
“We have no proof of that,” Steinschneider said dismissively. As far as he was concerned, the nurses were making extreme assumptions, thinking the worst without any evidence. As a scientist, Steinschneider believed, he had a more rigorous standard. What counted was what you knew, not what you thought. “I knew that babies were killed—c’mon,” he would say one day. “We talked about it at the meeting in 1969. We talked about it in the hallways. I thought about it. And I thought about other things. I thought maybe there was a genetic cardiac anomaly. Maybe there was a genetic endocrine problem. The first baby died of heart disease. The second baby died of choking. The third baby died of congenital adrenal hypoplasia. This is what the experts are telling me. Are they competent? You call them incompetent—I ain’t. Then when the fourth baby died, I had just met Molly [Dapena], and I asked her to review the case because I thought maybe these cats are missing something. Because I want to know. I may be dogmatic, but I’m not pretentious. And she came back and said, ‘I don’t know.’ ”
Doing something to those kids? Steinschneider considered it a baseless thing to say. Certainly, he had no intention of having a talk with the Hoyts. Nor was he inclined to discuss it with anyone else. Among those he didn’t consult was Stuart Asch, the psychiatrist who had written him two months before. He had asked Molly Dapena to look at the tissue slides of Molly Hoyt, but had not broadened his query. Had he asked her, for instance, to look at the autopsy report of the third child, Jimmy, she might well have called the pathologist incompetent, might have told Steinschneider something like: “Where did this man go to medical school? The whole autopsy doesn’t make sense. It’s totally off the wall.” That’s the way she would put it years later. In 1971, given what she had come to know about the “Moores,” the Philadelphia family mythologized by Life magazine, had Steinschneider given her all the circumstances of all the Hoyt children’s deaths, Dapena might well have advised him against dismissing too easily what the nurses were telling him.
Julie Evans looked up at Steinschneider with beseeching eyes. “You’re going to send Noah home,” she said, “and that’ll be the end of him.”
That afternoon, July 20, Steinschneider did send the baby home. He told the Hoyts to bring him back in a week.
When Steinschneider was working on his Ph.D. at Cornell in the mid-1950s, he became fascinated by a psychological precept called the Yerkes-Dodson law, and made it the centerpiece of his doctoral dissertation. Its essential principle was this: Determination was a good thing but only up to a point; if a task was especially difficult, a puzzle overly complex, too much motivation could be detrimental. Many years later, oblivious to any irony, Steinschneider explained it this way: “If something’s very difficult, too much drive can get in the way. Which is not surprising. When people panic because the drive is so strong, they persevere and make errors. People trying to open the door when there’s a fire in a closed place, even though there may be two doors, they get stuck on one door and won’t go to the other one.”
Cognizant of Molly’s death a year before, Steinschneider thought about how it might be linked to her brother now in his care; how all of it—the autonomic studies in the clock tower, the puzzling deaths of the first three Hoyt children, the studies of Molly and Noah—might be connected. There were two doors available, but he could see only one. The apnea door.
After sending Noah Hoyt home for the second time, Steinschneider wrote a discharge summary of the baby’s month-long stay in the hospital. In this entry, he wrote that Noah had had three spells of prolonged apnea on July 1, three more on July 2, two on July 9, and one each on June 23, June 30, July 3, July 4, July 10, July 15, and July 19. It was a curious way to interpret the observations of the nurses whose carefully documented reports were his source. In fact, ten of those fifteen incidents were either unquestionable false alarms or undocumented instances in which the apnea monitor sounded but Noah was found to be breathing. And on three of those days—June 23, July 10, and July 19—the nurses documented no apnea at all, not even short periods. “No apnea noted,” read the nursing notes of each shift. Nor had Steinschneider himself documented any prolonged apnea in the lab on those days. Contrary to the Physician’s Record handwritten and signed by Steinschneider, when Noah went home that Wednesday afternoon, he had gone thirty-four days in the hospital with barely a hint of apnea.
The next morning, Steinschneider got a call from the baby’s mother. Noah was not doing well. He had slept through the night, Waneta said, but after his morning feeding he started to cough and “turn colors.” What colors? Steinschneider asked. “Red, blue, pale,” she said. “And then he held his breath. I gagged him, and he spit up.”
“He probably aspirated some formula,” Steinschneider said. He decided that the baby should come back to the hospital.
Waneta called her brother-in-law. “Can you take me and the baby to Syracuse?” she said to Chuck. “I’ve gotta get him to Upstate Medical.”
Chuck picked up Waneta and the baby, and raced north. Noah seemed basically okay, if a bit listless. “But with the luck she had with the rest of them,” Chuck would say later, “I wasn’t taking any chances.” Howard Horton’s question three years before—Was Waneta doing something to the babies?—was now just a distant painful memory. Obviously, these were babies with problems. Chuck made the trip in forty-five minutes.
When word spread among the nurses on the fifth floor that Noah was back yet again, they were at once dumbfounded, relieved, and overwhelmed by the sense that Noah was running out of time. How many times could they go home for the night with Noah discharged, only to find him in the nursery when they came in for work the next day as if he’d never left? Were these emergencies his mother’s way of saying she didn’t want the baby? Were they aborted attempts on his life? Julie Evans sensed that even Steinschneider seemed to be aware of the absurdity of the pattern. “Noah Hoyt’s back,” he told her that morning. “I can’t find anything wrong with him.”
Gail Dristle had said her good-byes to Noah that Wednesday, hoping, as she later put it, that Waneta “didn’t have the guts to do what I felt deeply she was capable of doing.” When Gail came in to work the next afternoon and found Noah in the nursery, she breathed a sigh of relief. And then, she realized the implications. She overheard two nurses talking. He has no apnea, one was saying. She’s making it up. Maybe we should be making it up, said the other. Maybe it would be better if we say there is apnea, so he doesn’t send him home again. They decided to try to enlist the help of one of the pediatric residents.
Gail went into the nursery. She picked Noah up, kissed him, and carried him over to the rocking chair. She fed him, rocked him, and began to fantasize. I’ll take him home with me, she thought. I’ll just walk out the door. I’m not going to keep him and raise him. I’ll just take him home, and wait for them to come after me. And then I’ll say, “Do something about this woman.”
Gail wondered where the doctors fit into this. She saw Steinschneider’s name on the charts, but never saw him in the nursery. “Is there a doctor aware that Mom’s not okay here?” she had asked Julie one day.
“He’s aware,” Julie had said.
“Well, why isn’t anything happening?”
“It’s not what he’s concerned about.”
“What’s he concerned about?”
“SIDS. Research.”
Rocking Noah now, Gail gazed out the window of the nursery and played out her interior fantasy. She looked down at Noah and began to cry.
Dr. Roger Stanke, the resident, listened to what the nurses had to say about Waneta’s failure to bond. He thought it might be a good idea to bring her in for some remedial mothering lessons before sending the baby home again. All she needed, he felt, was some “reassurance and guidance.” Steinschneider had no objections. On Sunday, Stanke saw Waneta sitting in the nursery, feeding Noah, with Tim beside her. She was surrounded by a group of nurses who were animatedly trying to teach her how to connect with her baby. The attention had at least one effect. For the first time that any of the nurses could remember, Waneta was smiling. Stanke was pleased with what he saw. He scribbled his note for the day in the Physician’s Record. “Parents here taking active part in patient’s care,” he wrote. “No apnea noted.”
Gail, watching the same scene, saw it from a different angle. “She was the center of attention, and she basked in it,” she remembered. “It was like you were teaching a five-year-old how to change her doll—and the woman’s already had five children. And I’m standing there looking in and saying to myself, ‘I don’t think it’s gonna take.’ ”
On Tuesday, six days after Noah’s last readmission, the mood on 4A was as anxious as on any day since the Hoyt family had first appeared at Upstate fifteen months before. Noah was to be discharged once again that evening, and everyone knew it.
Late in the afternoon, Julie Evans pulled Steinschneider aside. “Why are you sending him home?” she challenged him, her voice rising.
“There’s no reason to keep him here,” Steinschneider said.
“Here’s a nice, normal baby that anybody would give anything for, and it’s so obvious his mother doesn’t care about him. She doesn’t want him. She doesn’t give a damn about him.”
“Look,” Steinschneider said, opening his hands. “What can I do about it?”
“She’s going to do away with him,” Julie said flatly. “I’ll bet you she killed the other one.”
“But can you prove it?” he challenged her.
“I’ll even tell you how she does it. I’ll bet she puts a pillow over their heads and suffocates them.”
“You can’t prove that,” he repeated.
Julie had to concede this point. She couldn’t prove it. “I’ll bet you a quarter that baby is dead by tomorrow,” she said finally, exasperated.
Steinschneider chuckled at the notion of such a macabre wager. When she heard this, Julie knew that she had done all she could. She knew who was in charge. She had worked within these protocols of medicine for thirty years, and even a situation as extraordinary as this could not change them. There was no other place to go with this. Julie felt betrayed, as much by medical culture as by Steinschneider, and embittered at her powerlessness.
Gail shuddered when she saw the Hoyts step off the elevator shortly after 6:00 in the evening and make their way onto the ward. In the nursery, Steinschneider examined Noah and pronounced him fit. He wrote that Noah had been fine this last stay, except for one period of prolonged apnea on Friday. (“Alarm went off, pt. breathing,” a nurse had written.) Waneta, picking up where she left off on Sunday, fed her baby and played with him as two nurses looked on. Steinschneider gave the Hoyts the usual instructions. “Let’s bring him back next Monday,” he said. Then Julie, following hospital rules, picked up Noah and carried him toward the elevator, his parents close behind.
They descended to the lobby and walked past the front desk and through the front door. Julie waited with Waneta, while Tim brought the car around and pulled up. Waneta slid in beside him. Julie cradled Noah, kissed him gently, and placed him on his mother’s lap. “Good luck with him,” she said stoically. She turned back toward the hospital. That’s the end of that poor baby, she said to herself as she headed back upstairs.
“Dr. Scott?”
“Yes.”
“Sheriff’s Department calling. We’ve got a baby in distress up in Newark Valley. The parents haven’t been able to get any medical assistance. Can you go up there?”
Dr. John Scott, an osteopath, was one of the Tioga County coroners, but when he got this call just after breakfast on a hot Wednesday morning in July, it was his service as a physician that was being requested. He drove quickly from his home in Apalachin to the sheriff’s department in Owego. Then he hopped in a patrol car and took off for Route 38, a deputy at the wheel. This must be some emergency, Scott thought, watching the radar in the police car climb all the way up to 108 miles an hour as the signal bounced off trees and parked cars. He held on to the door handle, looked over at the deputy, and prayed nobody got in the way.
They made it to Newark Valley in seven minutes, the sheriff’s siren wailing past the dairy farms on a summer morning, and reached Davis Hollow Road just ahead of the local ambulance. “It’s the trailer,” the deputy said. He pulled to a halt, and he and Scott headed for the front door.
Inside, Scott saw his tiny patient lying on the couch, motionless. The baby’s mother stood apart, swaying from side to side, her husband trying to comfort her. Scott saw that there were two electrode receptors with wire leads attached to the baby’s chest, the kind he associated with electronic monitoring devices in hospital intensive care units. He’d never seen one in someone’s home, or on an infant. He sat on the couch, and leaned into the baby. He detected no breath. He checked for a pulse, then examined the baby’s eyes. He looked up at Waneta. “The child is deceased,” he said. She was crying quietly. “I’m sorry,” Scott said.
“Can you tell me what happened?” he asked. Waneta didn’t answer.
“He’s had problems,” Tim said agitatedly, jumping past the immediate question. He had been summoned home as soon as he arrived for work on a road job. “He’s been at Upstate Medical. We just brought him home last night.”
“Who’s been treating him at Upstate?” Scott asked.
“Dr. Steinschneider.”
Scott reached Steinschneider in his office in Syracuse. “This is Dr. Scott in Tioga County,” he said. “I’m at the home of Mr. and Mrs. Hoyt here in Newark Valley. I understand you’ve been treating their infant son.”
“Yes, I have,” Steinschneider said.
“The baby has passed away this morning.”
There was a pause. “I’m sorry,” Steinschneider said softly. He asked Scott what had happened. He wasn’t entirely sure, Scott said; the baby had apparently died suddenly while asleep. He presumed the death was related to whatever condition required the use of the monitor.
“This is the fifth child in the family that’s died,” Steinschneider informed him.
“The fifth one?” Scott said.
“He spent most of his life on our pediatric service. I discharged him last night. We treated another child in the family last year, who also died suddenly. There seems to be a problem sustaining life in this family.”
“I see.”
“We’ve had this baby on an apnea monitor continuously in the hospital. He’s been maintained on one at home.”
“Yes, I see that here.”
“Are you going to do an autopsy?” Steinschneider asked.
“Certainly,” Scott replied. He had arrived as a physician; it had turned into a coroner’s call.
“Would you let us do it here in Syracuse?” Steinschneider asked. “I’m very interested in the case.”
Fine, said Scott. Just as long as I get the results. Of course, said Steinschneider.
Waneta took the phone, and Steinschneider conveyed his sympathies. He asked her the same question he’d asked her a dozen times before: “What happened?” Waneta said the apnea alarm had gone off while the baby was sleeping and she was in the shower. Tim had just left for work. The baby was blue and not breathing when she got to him. She tried to revive him, but this time, she said, it was too late.
Steinschneider asked Waneta to come up to Syracuse. She and Tim would have to sign a form consenting to an autopsy. “All right,” she said.
Steinschneider hung up the phone and went downstairs to the ward. He saw Julie Evans and pulled her aside. “Noah died,” he said softly.
Julie stared up at him. “I told you so!” she snapped. “I told you so!” She turned on the heels of her white shoes and stomped off, leaving Steinschneider alone in the hallway.
Gail Dristle came to work full of trepidation. She had stirred half the night, then awakened with such overwhelming fear that she considered not going in to work. Now she stepped off the elevator on 4A, and walked to the small room off the nurses’ station. She put her lunch in the refrigerator. She poured herself a cup of coffee. She came out into the hall and started walking down for morning report. In the hallway she saw a nurse standing by herself, with a strange look about her. The nurse looked up as Gail approached, and their eyes met. Grim-faced, the nurse shook her head slowly, side to side. “Oh my God!” Gail cried out, collapsing against the wall in tears.
A few minutes later, the nurses gathered for report in stark silence, their heads bowed in shock and anger.
“Noah Hoyt died this morning,” the charge nurse announced.
“What was it this time?” somebody asked, her voice dripping with disdain.
“Oh, the monitor went off and she didn’t hear it,” came the answer, equally sardonic. “She was ‘in the shower.’ ”
“Maybe they’ll do something now,” Gail said tersely. Nobody responded.
The nurses went about their duties that day in a fog of unreality. They believed they had virtually watched a murder being committed. Gail went home in tears, and didn’t come back to work for four days. At night, she sat alone in the dark and got drunk.
Noah arrived at the hospital for the fourth and final time on the morning of his death. He was taken to pathology; his parents rode the elevator to the fifth floor to see Steinschneider.
During Noah’s life, as the cycle of hospital admissions became more foreboding, Tim had begun to wonder if Steinschneider was the authority he seemed to be. “I don’t think they know what the hell they’re doing up there,” he told Chuck after his brother had raced Noah back to the emergency room. Now, seeing Tim’s frustration after Noah’s death, Steinschneider told him that some things in medicine simply could not be explained. SIDS was a great mystery, and that was why he was studying it. “When we go to medical school,” he said, “they don’t give us a book that says, ‘This is all you’ll ever need to know; use this and you’ll always be right.’ There is no such book.”
Maybe the autopsy would offer some clues. Tim signed the consent form first, with Steinschneider signing as a witness; then Waneta signed, with Nurse Fran Tomeny as her witness. In his lab on the same floor as the pediatrics ward, Bedros Markarian stood beside pathology resident William Kleis, who began the autopsy at 2:30 that afternoon.
Markarian had consulted on Molly’s tissue slides a year before, but didn’t connect that passing matter with the body before him now. Steinschneider, though, prepared the pathologist for Noah’s autopsy with a brief history of the baby and his four siblings. Whatever the reason for the misunderstanding, Markarian noted in his report that Noah’s brothers and sisters “all died from crib death before one year of age”—notwithstanding the ostensible circumstances of the deaths of Julie and Jimmy, and Jimmy’s actual age. But if Markarian was a little fuzzy on the details, the unusual string of deaths did lead him to think it wise to rule out trauma. Before Kleis made the first cut, Noah was given a total body X ray.
Steinschneider made apnea, and his emerging belief about its relationship to sudden infant death, the central theme of his briefing with Markarian. “He was very intense,” Markarian remembered. “And he talked a lot about apnea.” Steinschneider told Markarian that Noah had been observed on an apnea monitor virtually his entire life, both in the hospital and at home, because family history made him a high risk for sudden death. And the monitors had picked up plenty of potential trouble. The baby’s life, he said, was marked by many apneic periods, including episodes at home that were serious enough to require resuscitation and readmittance to the hospital. Markarian did not question the accuracy of what Steinschneider was telling him. He had no reason to. He thought Steinschneider was a good man with a fine reputation. So he did not know, for instance, that the second Discharge Summary, dated eight days before Noah died and documenting fifteen episodes of prolonged apnea in the hospital, was largely a fiction. It camouflaged the fact that every one of Noah’s crises had come on the three days he had spent at home with his mother.
Thus briefed, Markarian brought Noah’s body into the lab, just down the hall and past a pair of doors from the pediatric nursing station. He supervised as Kleis began the postmortem, narrating as he went. “… The eyes are blue in color … there is frothy fluid exuding from both nostrils and from the mouth.… There is no evidence of trauma … a total body X ray performed before the autopsy revealed no evidence of fractures.”
Kleis removed Noah’s organs, examined them, and found them to be normal, though the lungs contained an unusual amount of fluid. Looking further, the pathologists saw that the right bronchial tree contained a large amount of “frothy, blood-tinged fluid,” and that there was some swelling indicating bronchiolitis, an inflammation similar to bronchitis, caused by a respiratory virus. “The left lung is saved for the pulmonary research lab,” Kleis dictated. Examining Noah’s brain, he found some additional mild swelling. Pending the results of the microscopic examinations, the pathologists reported their provisional diagnoses as bronchiolitis, pulmonary and cerebral edema, and pulmonary atelectasis, a failure of part of the lung to expand at birth, most commonly associated with premature babies. The latter finding could only be confirmed by examining the lung tissue slides.
None of the preliminary diagnoses really explained Noah’s death, leaving Coroner John Scott with a dilemma when he got the results the next day. He was known for his industriousness as a physician. His office hours sometimes ran past midnight. He tried to be equally diligent as an arbiter of death. He knew that all the autopsy findings were “secondary to some causative situation,” as he put it in his coroner’s report. But under the circumstances, Scott hadn’t expected the results to be otherwise. Though he, too, misunderstood the family history Steinschneider gave him on the phone—he thought two of the previous siblings were toddlers, not one—Scott’s conversation with the SIDS researcher from Syracuse left him with little doubt that all five children were victims of what he still called crib death. That, he believed, was the unknown “causative situation.”
Scott wanted to write the words “sudden unexplained death” on Noah’s death certificate. That, he felt, would be the most medically accurate thing he could say. But he believed such an empty finding was frowned upon by the profession, and that the custom of the day was to list instead the factors contributing to death, as best as they could be determined. Hence, he listed Noah’s immediate cause of death as “acute bronchiolitis.” Where the document asked for “approximate interval between onset and death,” Scott wrote, “2 HRS.” As a secondary condition, he listed pulmonary atelectasis.
Neither of these findings survived microscopic examination. The lung tissue revealed mild pulmonary congestion, but no virus—no bronchiolitis. The histology examination also failed to show any cells with abnormal growth that would sustain a finding of pulmonary atelectasis. This left only two final diagnoses: pulmonary edema and cerebral edema—death by swelling, as it were. Markarian knew the findings were meaningless.
John Scott never changed the official cause of death to reflect Markarian’s final diagnosis. But to him it was a moot point. He wrote his report attributing Noah’s death—and the deaths of all the baby’s brothers and sisters—to SIDS. Without another word to the sheriff’s department, he sent the one-page report to the county clerk’s office in Owego for filing.