by Mimi Swartz
Intentionally or not, the young Dr. Cooley had perfected a veneer of cool. But, in fact, he was already determined to turn himself into a great surgeon. He took string to his room at night and practiced tying knots faster and faster, first with two hands, then with one. He worked with a scalpel and pieces of meat to find just the right way to hold his fingers in surgery to make the best cut. The more Cooley studied, the more he was drawn to the heart. A handful of doctors were just beginning to unravel its mysteries, and he felt a call to work in a field where the ground had barely been turned.
In the 1940s, Cooley soon came up against the same problem that flummoxed DeBakey and his colleagues: you could work around the heart, but you couldn’t get inside it. No one had any idea how to stop the heart and repair it without killing the patient. A defective valve or a weakness in the muscle was usually a death sentence.
At the time, Blalock had a very unusual partnership with a gifted black man named Vivien Thomas. Blalock had met Thomas in 1929 as a medical student at the Vanderbilt University hospital, when Thomas was working as a carpenter. Thomas had hoped to go to college and medical school himself, but the failure of a Nashville bank during the Great Depression wiped out his savings—and because he was black, his options were further limited. White schools had yet to become interested in turning out black doctors, and there were only two black colleges in the United States that offered medical training.
Blalock invited Thomas to become his “surgical technician,” a misnomer for the word “partner.” Thomas’ extraordinary gifts at surgery became quickly apparent, and it wasn’t long before he was running Blalock’s research lab, trying out new techniques on dogs. The times being what they were, Thomas continued to be classified as a janitor on the payroll.
Over the next few years, the two men did groundbreaking work on the causes of shock, saving countless lives on the battlefields of World War II by proving Blalock’s theory that loss of fluid in the blood vessels, not toxins in the blood, caused the body to go into shock. (Hence the IVs Bud would start on the battlefields of Vietnam decades later.)
But Blalock and Thomas were mostly concerned with breaking the last medical taboo: cutting into the heart itself. Soon they began causing heart defects in dogs so they could learn how to repair them.
In 1941, they had help from a brilliant Hopkins pediatric cardiologist by the name of Helen Taussig, who was then developing a theory of her own about a condition known as “blue baby syndrome,” a birth defect in which newborns turned blue because of a lack of oxygen and died within minutes. Taussig theorized that the problem was caused either by a partial blockage in the pulmonary artery and valve (a superhighway that carries freshly oxygenated blood from the right ventricle to the lungs) or by a hole that caused leakage between the ventricles of an infant’s heart—or maybe by some combination of both. Taussig thought the condition, commonly known as Tetralogy of Fallot, could be corrected surgically. She took her ideas to the august surgeon Robert Gross, who, not surprisingly—Taussig was a girl, after all—ignored her. So Taussig turned to Blalock and Thomas, who were not so dismissive. Blalock, in fact, said he had been thinking exactly along those lines.
In 1944, Blalock and Thomas tried the surgery on a dying baby, with Blalock holding the knife and Thomas telling him where to cut. They worked in a chilly operating room lit by two large windows and heated by cast-iron radiators. They had asked for volunteers, and one intern eagerly stepped up: twenty-four-year-old Denton Cooley. The surgery, in which they created an artificial passageway that joined the two major arteries that allow blood to flow from the heart into the lungs, took ninety minutes. Blalock removed a final clamp, and it was as if he had repaired a leak in a garden hose: as the heart began pumping normally, the blood began flowing normally, and the grayish-blue infant on the operating table turned a rosy pink.
The operation wasn’t a complete success—the baby died soon after of further complications. But for Denton Cooley, it was a turning point: he had seen for himself the drama, the risk, and the profound potential of a brand-new field, and he wanted in.
* * *
Cooley reported for his first day of work as Baylor College of Medicine’s first chief of cardiovascular surgery on June 1, 1951. Even for a native Houstonian like him, the atmosphere could not have been pleasant. Jefferson Davis Hospital was an Art Deco monolith adjacent to Houston’s Buffalo Bayou—it looked a lot like a twelve-story Depression-era state capitol—and inside, the temperatures and the humidity would have been even higher, given the lack of air-conditioning. The halls were crowded with patients on stretchers and slumped in wheelchairs; they were mostly black, virtually all of them poor. At the time, Jeff Davis was Houston’s only charity hospital, and like charity hospitals everywhere at the time, it exemplified certain antebellum and pre-Medicaid attitudes about the less fortunate. Sometimes there were as many rats and roaches scurrying in the hallways as nurses.
DeBakey, however, believed medical care was a right, not a privilege. Three years into his efforts to rebuild Baylor, he had already commandeered Jeff Davis as one of the medical school’s first teaching hospitals. Its cadavers went to the anatomy studies, while the surviving members of Houston’s indigent population were suddenly graced with a profound uptick in their medical care—in exchange for serving as guinea pigs for Baylor interns. Accustomed to the hell of New Orleans’ Charity Hospital and battlefield hospital tents, DeBakey was oblivious to the misery around him, except as it applied to his ability to relieve it. He flew through the hospital halls, his white-coated entourage flapping like hapless gulls behind him.
On Cooley’s first day, DeBakey had gathered this small group around the bedside of a patient named Mitchell, whose first name has been lost. He was forty-six, but not a young forty-six, crippled as he was by an aneurysm of the aortic arch—in layman’s terms, a dangerous weakening of the arterial wall where it curves just above the heart. If the artery burst, the patient would die within minutes. DeBakey’s medical team had already tried the treatment of choice, wrapping the artery in cellophane to support the weakened wall, but the technique wasn’t helping. Weak, winded, and unable to move, Mr. Mitchell seemed to have run out of options.
DeBakey greeted the man with a warmth he seldom showed his underlings. Then he turned to the patient’s chart, flipped through it, checked Mr. Mitchell’s vitals, and stopped to ponder, seemingly in the grip of a novel idea. Abruptly DeBakey fixed his owl eyes on the newest member of his team and asked what he would do for the poor man.
Cooley answered without hesitation: the patient needed surgery to cut out the aneurysm. Everyone had a good chuckle over that, because no one had ever removed an aneurysm. It wasn’t done. You used the cellophane wrap and hoped for the best. Everyone knew that.
Except, apparently, Denton Cooley, who at thirty-one was fresh from training in what were quite possibly the best hospitals in the world. After graduating in 1945 from Hopkins, he fulfilled his military service by running a small hospital in Linz, Austria, for three years, and then eagerly returned to Baltimore, where he was enshrined as chief resident on the Hopkins cardiac service until he finished his training in 1950.
By that time, the most advanced surgeons knew from experience on the battlefield that the heart might be more receptive to repair than was previously known. One surgeon removed bits of shrapnel embedded in a wounded soldier’s heart, and the patient made a complete recovery. Other doctors had been able to reach and repair minor damage to the mitral valve, one of the most important regulators of blood flow into the left ventricle. Cooley, like the handful of others in his field, could sense that heart surgery was coming into its own.
DeBakey had heard of Cooley’s skills and had recruited him for Baylor; Cooley went because oilman Hugh Roy Cullen had just donated $22 million to the school, a good indication that big things were going to happen. DeBakey agreed to hold Cooley’s job for a year while he studied at London�
�s illustrious Brompton Hospital with Russell Brock, one of the most accomplished heart surgeons of the time. Everything seemed to be falling into place: Cooley had married Louise Thomas, a pert, pretty surgical nurse and the daughter of a prominent Maryland physician, and they already had a little girl named Mary.
Now, however, Michael DeBakey was treating him like a rube. Worse, DeBakey had done it before. Back in 1945, Cooley had hoped to fulfill his military requirement by working at Walter Reed Army Hospital, in Washington, DC. He hand-carried Blalock’s recommendation letter to the surgeon general’s office, where he encountered a pretentious officer who took the letter and, Cooley always believed, torpedoed his chances. But he wasn’t going to let DeBakey thwart him again. Maybe putting up with his father’s abuse gave Cooley an edge over more easily intimidated doctors.
The patient needed an aneurysmectomy, Cooley now argued, persisting. You cut out the weakened portion of the arterial wall and then sew the aorta back together. Cooley had done two such procedures at Hopkins. “He sure doesn’t have a chance lying here in bed,” Cooley added, grimly eyeing the patient.
DeBakey turned on his heel and swept out of the room as if he had never asked a question at all, much less heard the answer. But later that day he sent Cooley a message: he should schedule the aneurysmectomy for nine-thirty the next morning. That night, Cooley raced across town to the VA hospital to grab some surgical tools unavailable at Jeff Davis—a chisel and special mallet. The next morning, he was just finishing when DeBakey burst into the OR, gowned and gloved, as if he had been called to assist in an emergency.
There wasn’t one. Mr. Mitchell recovered and went home. DeBakey published a paper on the procedure, and got himself lauded, not for the first time, as an intrepid and inventive surgeon. He rewarded his new surgical head by omitting Cooley’s name from the paper—stingy, but DeBakey’s right as chief—and then sent Cooley seven hundred cases to review. Cooley stashed the files in a drawer and, like DeBakey, forgot about them.
* * *
For a while, Cooley appeared to adopt a “forgive and remember” attitude toward DeBakey. Houston was already building a reputation as the most innovative center of heart surgery in the world, thanks to the two men. Papers by Cooley and DeBakey—written separately and together—were coveted by medical journals. They toured—separately and together—Europe, Asia, and South America, lecturing at medical schools and showing off their latest techniques. Those exhibitions also served as excellent marketing tools for drawing still more patients to Houston, accompanied as the visits were by breathless press accounts.
Fortunately, the two surgeons didn’t do exactly the same thing. DeBakey was a vascular surgeon—he worked on the arteries and veins around the heart—while also serving as a masterful lobbyist for public health. Cooley was completely focused and utterly fearless in his approach to the terra incognita of the heart. When one reporter suggested he might be taking too many risks, Cooley was ready with a response: “I’m often obliged to experiment inside the heart of a patient whose problem hasn’t yet been worked out in a dog.”
Central to the progress of heart surgery, Cooley believed, was a machine that could keep the blood oxygenated and circulating through the body long enough for a surgeon to operate on the heart—something that worked on the heart’s circulatory system like a bypass on a highway. Cooley was already known for his velocity in the operating room—his autobiography is replete with record-breaking speeds for operations—but some complex repairs were still beyond his nearly superhuman skills.
Heart surgery in its beginnings and for subsequent decades would continue to be brutal, coarse, and rudimentary. There was nothing like an MRI or even effective cardiac catheterization to help a surgeon identify the problem. Once he began to cut, he was essentially flying blind. Just getting to the heart was something of an ordeal, for doctor and patient—a procedure known as a full median sternotomy. The surgeon made an incision into the sternum, and then put his index finger in the sternal notch, the space between the neck and collarbones. Then he took what’s called a sternal saw and cut through the sternum, separating the breastbone in two and steadying it with a retractor. Sometimes, in the process, a surgeon would break a rib with the retractor, and sometimes he would accidentally cut into the pericardium, the membrane covering the heart, or even, unfortunately, the heart itself. Even today, with so much technology, surgeons can never be sure what they will find. “The heart will always surprise you,” is something of a cliché for a reason.
Nowadays, the heart-lung machine is an elaborate and exacting device that keeps both organs functioning while the heart goes offline for surgery. But in the earliest days cardiac surgeons had nothing like that. They had to imagine what a device like that would look like, and how it would function. Cooley wanted something better than the machine John Gibbon had begun to develop with the help of IBM in the 1930s. Other doctors were making improvements to the original device, and Cooley thought it would be a great idea to bring such a machine to Baylor. He went to DeBakey with the prospect. The response: no thanks. DeBakey and his team were already working on their version of the heart-lung machine. He did not ask Cooley to help out.
So Cooley struck out on his own. He traveled to Minnesota to meet with Walt Lillehei and Richard DeWall, who in 1955 were also working on a heart-lung machine. In this device, blood from the patient flowed through tubes into a container where it was exposed to bubbles of oxygen, then “defoamed”—air bubbles were fatal—and returned through a helix-shaped coil to the patient’s body. The results were promising. (By that point, Lillehei was also well into a hard-partying phase. He took Cooley to a roadhouse for a very long night, and then prepared for surgery the next morning by having a nurse pop an amyl nitrate capsule under his nose. Lillehei’s hell-bent-for-leather leanings made him an early role model for the first heart surgeons as much as Chuck Yeager was for The Right Stuff test pilots. Yeager, however, was never prosecuted for failing to pay his taxes.)
Cooley imported the machine to Houston, just in time to respond to a desperate plea from a colleague who had a patient with a hole in the wall, or septum, between the left and right ventricles. His only chance to live was open-heart surgery, but even Cooley wouldn’t be able to perform this kind of operation without some kind of mechanical help.
The year was 1957, and the number of open-heart surgeries that had been performed in the United States up to that time amounted to a meager fifty. Cooley doesn’t write about how long it took him to decide to operate, but anyone who knew him would guess somewhere in the neighborhood of two seconds. He connected the patient to the pump and then sewed up several tears he found in the septum (“I managed to do the entire procedure in only twenty-five minutes of cardiopulmonary bypass time, which was quite a feat in such a complicated case”). The patient lived for six more weeks; then, as happened often in the early days of heart surgery, he died of an infection.
Still, Cooley saw the operation as an enormous success. “We were in the open-heart business,” he would write. News spread quickly among other cardiologists and surgeons, and Cooley’s office was flooded with referrals. After all, a slight chance of survival was better than none.
But Cooley knew he could improve on the original, and decided to build his own machine. This being Houston, he got an oil broker pal on the phone and explained he wanted to build a heart-lung machine and sure could use some help. He might as well have been asking for a home improvement loan: Cooley’s friend promptly sent over a check for $5,000. Then Cooley, with the help of three associates, headed to a local hardware store, bought the parts he needed, and had them all fabricated into a heart-lung contraption at a place called Commercial Kitchens, where, of course, Cooley was a friend of the owner. What he designed was a smaller version of Lillehei’s machine, one that could be easily sterilized and that more effectively removed air bubbles from the blood. It was nicknamed the “Cooley Coffeepot” because it looked
like a percolator. Within four months, Cooley had used his device successfully thirty-nine times. By the end of that year, he had performed more open-heart surgeries than anyone else on the planet.
DeBakey had kept close tabs on Cooley’s progress—his own heart-lung machine hadn’t gotten very far. He scheduled an operation on a child with a heart defect, intending to use Cooley’s machine and Cooley’s team—but not Cooley. That plan did not go over well. Cooley complained that DeBakey had no right to schedule an operation using his device and his people without his permission. DeBakey was unmoved: Cooley, he claimed, had created the machine while on the Baylor faculty. Cooley countered that he had raised the money privately. Uncharacteristically, DeBakey backed down and allowed Cooley to do the surgery, which, given the differences in their age and technology know-how, was probably a smart idea.
The operation was successful, and once again patients clamored for Cooley’s touch. By the beginning of 1959, he had performed six hundred successful operations using the heart-lung bypass machine. With more refinements, Cooley began performing ever more complex surgeries that had never been done before—treating calcified aortic valves and correcting previously fatal congenital defects, along with rare aneurysms and pulmonary embolisms (blood clots in the lungs). Cooley and his heart-lung machine were in such demand that he could sometimes be seen carting it from one hospital in the Texas Medical Center to another in the family station wagon with the help of his wife, Louise.
To Cooley, the invention and popularization of the heart-lung bypass marked the true beginnings of heart surgery: “The first time in history that this mysterious muscular organ, the source of life’s pulse, could be arrested, cut open, repaired, closed and restarted,” as he put it.