“Mike and Denton accepted every speaking invitation from every county medical society. Mike became known as fearless for tackling desperate situations, ruptured abdominal aneurysms. They rapidly had their referrals and they rapidly had the largest series of operations ever reported. Pretty soon the guy with the aneurysm in New York would ask his doctor, ‘Who’s the best surgeon in this field?’ and the doctor would answer, ‘I don’t know who’s the best but the guy who’s done the most is Mike DeBakey.’ And the parent with a child with a hole in his heart would ask his doctor in Seattle, ‘Who’s the best for this?’ and his doctor would say, ‘I don’t know who’s the best but the guy who’s done the most is Cooley in Houston.’ And they very rapidly outstripped the more experienced and better known. Neither man oddly has ever relied on local referrals. Cooley gets a few; DeBakey gets hardly any at all.” Neither world-famous surgeon is greatly popular in Houston’s medical community.
When Albert Einstein suffered a ruptured aneurysm in 1955, his doctor telephoned DeBakey, described the case, and asked if surgery was possible. “By all means,” said DeBakey over long distance. “In fact, I will dictate what needs to be done.” But Einstein, perhaps feeling his work was done, refused surgery and died.
A young surgeon named Don Bricker came to Houston in 1961 from Cornell and was astonished to discover how rapidly and efficiently aneurysms were done, and the scope of the cases. “I had been in New York City and there was only one surgeon there even attempting them, and he took five or six hours on a case, and the patient often died. I walked into DeBakey’s OR and he’s doing five or six cases a day, and he took an hour on each one at best, and most of them lived!”
As he neared 62, everyone said DeBakey was making a few concessions to age. Rarely did he operate alone, calling upon Ted Diethrich or George Noon more and more to first-assist, and because they were full-fledged surgeons, often they did more. He no longer scheduled surgery on Christmas Day. (On a Christmas not too many years back, DeBakey was making rounds when he suddenly stopped to complain, “Where are all the residents? Where are all the interns and students? Nobody wants to help me; nobody cares anything about medicine any more.” The resident accompanying him said, “Sir, they’re all at home celebrating the birth of another great man.” And DeBakey laughed.) Sundays were usually free now, but not always. Last year a DeBakey patient had been scheduled for an aneurysm operation on a Tuesday when suddenly one Sunday morning while sitting up in his bed he ruptured. DeBakey rushed him to the operating room, lost him, and then told his resident John Russell that he was going to operate on every aneurysm in the house. By late Sunday night he had done three or four, and none was in further danger of rupturing.
There was open gossip that the eyes looming so large behind the trifocals were not as strong as once they were; for that reason, people said, he did not attempt the spectacular but optically grueling coronary artery bypass. But on this April day, as he sliced and sewed in an aortic valve into the heart, as he beckoned for a visiting surgeon to come closer and look, it would have been difficult to fault any part of the man or his work. He operated as surely as any master craftsman. He grumped twice about his assistants, saying “Can’t we do this right? For God’s sake, haven’t we done it enough?” And later, “If I only had a third sterile hand.… With a third hand I could do it all myself!” But these were outbursts, only minor rumblings, and they had been heard a thousand times before.
DeBakey had come to lean heavily on those who had been with him for many years, in particular two women. One was Mary Martin, the chief pump technician who had turned down an offer to go across the way and work with Cooley. In the beginning Mary had been the only pump technician; there were several now, but DeBakey called them all “Mary.” During the operation he said, without looking behind him, “How are we doing, Mary?” and Euford, bearded, replied, “Just fine, Dr. DeBakey.” The other woman was Ellen Morris, his personal scrub technician, the only one who ever scrubs for DeBakey. Each morning she rose early to pile her dyed blond hair up into an elaborate, towering coiffure, which she displayed beneath a see-through surgical turban of her own design. Other nurses had followed suit, and while most operating room women in hospitals elsewhere squashed their hair under flat, floppy caps, the women who worked on DeBakey’s service looked as if they had just left the beauty parlor as they passed the needle holders and sutures.
Both Mary and Ellen were not only capable and dependable, but intensely loyal—defensive of DeBakey against a hint of criticism. When a reporter asked Ellen if it were true that he sometimes yelled at inefficient nurses, she replied: “Dr. DeBakey would never do that. He is, after all, a Southern gentleman.”
On rounds that afternoon, Diethrich saw Mrs. Matthews, a tiny, wispy Florida woman on whom he had done two bypass arterial grafts, stretching practically from her armpits to her knees. She was a nice, uncomplaining lady, but one of those patients to whom complications swarm; every doctor has one disaster area like her on his service. She was in a special isolation room in the Intensive Care Unit for patients with infections. She reached up and took the surgeon’s arm and pulled him down and whispered, crying, into his ear. He put on a false bright face and whispered back, patting her gently.
He went out and motioned for Dr. Reed, the resident in charge of Intensive Care, to follow him down the hall out of earshot. At about fifteen feet Diethrich whirled and anger erupted. “Have you ever been sick, Doctor?” he almost shouted, and, not waiting for an answer, “Would you like to be told you’re bleeding internally?”
“But she was, she is,” said Reed quietly, not used to seeing Diethrich this way.
“Good God, Doctor, you’ve got to reassure the patient. This is a nut house anyway! Don’t make things worse. All you have to tell the patient is that she’s getting the best care she can get. That’s all! Understand? You’re playing God! You can scare a patient to death, because they will die of fright. It can happen, I assure you, it can happen.”
Bingham and The Roadrunner were both well enough to leave the hospital; Diethrich gave them a pass to spend a night on the town. They dined together at a seafood restaurant near the Medical Center and vowed—as people do on long ship crossings—to stay in touch.
Howard Stapler flew back alone to Indiana. But he had been there only a few days when a call came from Diethrich to prepare for a quick return to Houston. A hospital in Detroit had telephoned with a promising donor heart. A Lear jet was to fly there with the preservation chamber and pick it up. But within a few minutes, Detroit called back and the plan collapsed. The heart was a homicide case, and the legal complications were too tangled to unravel in the required speed.
Diethrich called the elated Stapler and told him to forget it for the time being. There was silence for a moment, and then both men hung up the phone.
CHAPTER 4
In the history of medicine, the surgeon waited a long time for celebrity and the time when hospitals would be built around him. The surgeon was considered an eccentric and second-class member of the profession well into the twentieth century. He was put in a special category and not permitted to associate with accepted members of the profession. The surgeon’s trade historically consisted of those patients who had been victims of violence; cutting, probing, and sewing them up was hardly as sophisticated as the mysterious work done by physicians who diagnosed ailments and whose shelves were crowded with pills and potions.
The art began in Egypt, as did most things, with certain people whom the royal physician permitted to sew up stab wounds and bind them with strips of cloth. A few centuries later in India, surgeons ventured upon the idea of taking a person whose stomach had been gutted with a knife or a sharp pole and washing out the wound with milk and rubbing it with butter. The real novelty of their treatment, however, was then letting black ants walk around for a few days within the wound before closing it.
Pope Calistas, whose twelfth-century spiritual stewardship was not theologically noteworthy, nonetheless earned
his place in medical textbooks by forbidding priests to attend the sick, a task they had previously monopolized. Who should take their place as bleeders and stitchers of minor wounds but, of all people, the barbers! These fellows not only had sharp blades to begin with, they also found biblical justification for their work in Ezekiel 5:1, “And thou, son of man, take thee a barber’s razor.…”
The invention of gunpowder in the fourteenth century gave surgery its greatest impetus. As soon as men learned how to shoot holes into their fellow men, a whole new line of work sprang up for the barber-surgeons. They made sure that they would attract potential customers to their shops by rigging up poles outside splashed with blood and wrapped around with bandages (the ancestor of today’s barber pole). Those legitimate surgeons who had been to medical school were so limited in their knowledge and skills that they offered little competition. A respected Italian surgeon, Giovanni da Vigo, for example, treated his gunshot victims by pouring boiling oil on the wound, followed by a plaster concocted from worms, minced-up toads, and snakes. A century later, a French surgeon, Dr. Paré was about to pour boiling oil on a wound—this being the accepted treatment of choice—when he discovered to his chagrin that his supply was depleted. He hurriedly brewed up a potion of oil of rose, turpentine, and egg yolk, and to his surprise, the patient healed faster than those who had received the burning oil.
For more than 700 years, barbers clung stubbornly to their knives, resisting the efforts of legitimate practitioners through the law and royal decree to wrest the privilege from them. Bloody battles were fought in the cobblestone streets of seventeenth-century Paris between barbers—who used the same rasoir for cutting off toes and trimming mustaches—and those doctors trying to establish a legitimate surgery within the Royal Medical Academy. But Louis XIV was so enthralled with his barber-surgeons that he ordered public demonstrations of surgery to be given on fair afternoons in the royal gardens. Fashionable citizens flocked to attend. Meanwhile, across the Channel, Henry VIII had granted a royal charter in 1540 to “The Masters, Guvernors of the Mystery and Commanlty of Barbours and Surgeons of London.”
One of the few legitimate surgeons of Medieval times, a Frenchman named Henri de Mondeville who practiced at the beginning of the fourteenth century in Paris and traveled with the king and his armies, set forth four qualifications for a surgeon: he must not be afraid of evil smells; he must cut or destroy boldly—as an executioner; he must know how to lie in a courteous way; and he must know how to extract a gift or a fee from his patients.
Not unpredictably, other laymen tried to enter what had become a highly lucrative line of work. (One Paris barber-surgeon had an estate outside the city with 175 servants and stables for 300 horses.) In Copenhagen, the Danish king authorized the public executioner to do surgery when he was not otherwise engaged. Frederick I of Prussia in 1796 appointed his favorite hangman to be not only a public surgeon for the nobility, but his personal court physician. In Italy the steam-bath keepers so pestered the barbers for work that they finally were taken in as co-cutters. This news quickly reached Germany and Sweden, where the rich tradesman could, in one convenient visit, take steam and have a worrisome skin tumor sliced away. In nineteenth-century Austria, there still existed three classes of surgeons: doctors of surgery, medico-surgeons, and bath keepers. In Britain even today, the surgeon traditionally does not bear the title “Doctor.” He is called “Mister,” which must frustrate some parents who have paid for ten years of medical education.
What pulled the surgeon out of the barber shop and into the hospital were the advent of (1) anesthesia, in America, in the mid-nineteenth century, and (2) the use of sterile methods to fight infection, preached first by Lister in England, then by W. S. Halstead in America. Halstead, the great Harvard teacher and surgeon, introduced surgical gloves in 1890, not so much to protect the patient from possible infection, but to protect the hands of his scrub nurse, which had become chapped and rough. By 1911, masks were widely used, though some surgeons felt them unnecessary. Some general practitioners, however, agreed that the surgeon had at last chosen something that fitted his avocation, which bore a striking resemblance to the work of an executioner.
The conflict between physician and surgeon is as old as medicine and will endure as long as there are those who cut and those who diagnose. I once attended a patient conference at a medical school and the internist in charge, presenting the facts of a case, said matter-of-factly, “This patient was subjected to surgery.” The phrase is heard in classes every day. One Houston heart surgeon, discouraged over a patient’s death, remarked—not entirely facetiously—“The cardiologist kept this guy on the string for twenty years treating his angina; it was almost an annuity. When he finally went into massive heart failure, the cardiologist sent him to me at a minute to midnight.” The internist would probably have snapped back, as I have heard other internists do, “It is my duty to protect my patient from the surgeon as long as possible.” Eight hundred years ago, the French surgeon Mondeville wrote a treatise on his craft that drew the lines remarkably well:
“Surgery undoubtedly is superior to medicine for the following reasons:
“1. Surgery cures more complicated maladies, such as toward which medicine is helpless.
“2. Surgery cures diseases that cannot be cured by any other means, not by themselves, not by nature, not by medicine. Medicine indeed never cures a disease so evidently that one could say that the cure is due to medicine.
“3. The doings of surgery are visible and manifest, while those of medicine are hidden, which is very fortunate for many physicians. If they have made a mistake, it is not apparent, and if they kill the patient, it will not be done openly. But if the surgeon commits an error while performing an incision on the hand or arm, this is seen by everybody present and could not be attributed to nature nor to the constitution of the patient.”
Mondeville then talked about the difficulty of getting work: “Even in the case of a strictly surgical disease, if a sly physician has been called first, never will a surgeon see the case. More than that, the physician will tell the patient, ‘Sir, it is evident that the surgeons are vain and pompous people. They don’t know anything about reasoning and are completely ignorant. If there is anything they know, they got it from us, the physicians. They are bad and cruel people, and ask for and receive huge fees. On the’ other side, you, sir, are feeble, inclined to be sick and delicate, and the expense involved in calling a surgeon could affect you too much. Therefore I advise you, in your interest, and out of sheer love, not to call for a surgeon, and although not a surgeon myself, I will endeavor to help you without them.’”
The Houston surgeon Don Bricker will have much to discuss with Mondeville if they ever meet sometime in a celestial medical society. “The surgeon,” says Bricker, “is a therapist who wants to make the patient well. As contrasted with the internist, he wants to do it with his own hands. The surgeon doesn’t seek the intellectual challenge which delights the internist. If a patient comes in with a hernia, he points to it, the surgeon recognizes it, the surgeon fixes it, the patient says, ‘thank you.’
“The internist, conversely, gets his greatest satisfaction out of diagnosing some disease like Hodgkin’s. The surgeon would be dismayed because he couldn’t treat it. The surgeon is straightforward and lacks the deviousness of the internist. The internist is often bitter because the surgeon does not need him. The surgeon is the only member of medicine who is the complete doctor. There is no disease that isn’t likely to develop someday into a surgical condition.”
But there are two widely recited slogans in the medical schools of America. One, according to the internist, is the surgeon’s motto: “When in doubt, cut it out.” The other, which I saw on a Baylor students’ bulletin board, is: “The surgeon’s hands are lean and nimble; his head would fit inside a thimble.”
A conversation with a Houston surgeon not affiliated with either Michael DeBakey or Denton Cooley:
Q. “Would you characteri
ze the nature of the modern surgeon for me?”
A. “You can usually spot them in the first year of medical school. As a rule, the surgeon is the most well-coordinated individual. He’s probably the best athlete, he is more gregarious, he’s more affable, he’s less introverted, he becomes more politically active, he is more ambitious.…”
Q. “You left out loyal, obedient, trustworthy, and brave.”
A. “Those, too. As well as slightly egomaniac. But I would say to that, spare me the surgeon who doesn’t have this ego. The man who cuts on you has to feel that he is the only man who can do the job. There is no room for weak sisters in the OR.”
Q. “Would you say that DeBakey and Cooley are typical surgeons?
A. “Carried to the nth degree. Mike came to Houston in 1948 with a pretty fair country reputation as a cutter. He had been over in New Orleans working for Dr. Alton Ochsner and he was very much the junior man there. He was anxious to start running his own show. What he found was medicine of an almost primitive sort being practiced here. He found none of the things they had promised him in order to get him over as head of Baylor’s surgery department. Baylor itself had only just been lured down a couple or three years earlier from Dallas by a group of fat cats who coughed up $10 million to get it here. Mike set things in motion from the first week he arrived. For the past 25 years he has bludgeoned his way to where he is, without doubt, the most powerful doctor in America. When I talked to him in those days at first I thought he was a megalomaniac—but now I realize he knew where he was going all the time. He seemed to have a master plan even then. He let me know in no uncertain terms that he—and what he was going to do in medicine—was something special. He had a manifest destiny. But then, in 1951, along came Denton Cooley, and so did he. Denton had the same overview of history.”
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