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 characterize 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.”

Q. “What was their relationship in the beginning?”

A. “Professional. No warmth. Mike, after all, had come from a Lebanese immigrant family in Lake Charles, Louisiana, and his mother taught him how to sew his own underwear and he worked in his father’s drugstore and when he finally got to Tulane, he was not popular. In fact, he was very much an outsider, the owl, the foreigner, the guy who didn’t get invited to join a top fraternity. It wasn’t that he was not well liked, I just don’t think people paid much attention to him at all. Cooley, on the other hand, was the son of a rich society dentist in Houston and they owned a lot of the north side of town. Denton was always the most popular kid in the crowd, the leader, the one with charisma, the star athlete, the one all the fraternities at the University of Texas fought to rush. And the handsomest son of a bitch to ever pick up a scalpel. How’d you like to shave Mike DeBakey’s face every morning and then have to look across the table at Denton Cooley?”

Q. “Was there trouble between them from the beginning?”

A. “No. For a few years, Mike was the maestro, Denton played the protégé, although he was equally as skilled and knew far more about heart surgery—such as it was—than Mike. DeBakey, in fact, didn’t start poking around hearts until about 1961. He had concentrated on his aneurysms and vessel work, Denton did the hearts, and the arrangement seemed ideal. I was around during the first big aneurysm DeBakey did, but not having the overview that he has, I didn’t even know history was taking place. Judging from the coolness with which they went at it, you’d have thought it was a routine operation. Denton ‘first-assisted,’ but I heard, had you stood at the table, you might have wondered who was leading whom.”

Q. “Why is there antagonism toward the two men within the Houston medical community?”

A. “Some are jealous. Hell, Mike and Denton shouldn’t be doing hernias and gall bladders, but they do, and it is irritating to the rest of us. The patient is usually some prominent fellow who has asked for them and who might make a big donation to their causes. Others of us feel that medicine should be conducted quietly, privately, not in headlines or on the Johnny Carson Show. And with Mike, it’s just because he is so impossible to deal with.”

Q. “Meaning?”

A. “Meaning he is consumed with his work and himself. The human factor is missing. If you looked back over the careers of the great surgeons—and Mike is certainly in that category, it’s tragic that his personality clouds his magnificent contributions to the art—you will find that all of them, Cushing, Halstead, whoever, had a peak period of perhaps ten productive years. These were years of impact. Of history. And then they de-accelerated, usually by more and more teaching, by developing rapport with their younger men, by helping them get good jobs and by taking pride in their achievements. There is none of this warmth, this fatherly feeling with Mike, Out of 25 years of heading Baylor’s surgical department, Mike does not have one—not even one—chairman of a surgery department somewhere. Dr. Alfred Blalock, who was Denton’s mentor at Johns Hopkins, has them scattered all over academic medicine. This is Mike’s shortcoming—he becomes a rival to his own doctors. If he doesn’t fire them or run them off, he becomes jealous and envious of them.”

Q. “But what does the medical world as a whole think of DeBakey and Cooley?”

A. “No matter what excesses they have committed, they have made Houston the finest cardiovascular institution in the world. We have doctors coming here from the seven continents to see in one week what they wouldn’t see in years of observation somewhere else.”

Q. “Is heart work done in Houston that is not done anywhere else?”

A. “No. Mike and Denton just do ten times more of it.”

Q. “May I ask a rude question.”

A. “Sure.”

Q. “Are you ever jealous of those two across the street?”

A. “Truthfully? Of course. I sit here in a little office and Mike and Denton are over there in surgical palaces. But I content myself with knowing that I am a good surgeon, that I stay with my patient before, during, and after the operation, that I have a good relationship with my family, that I have a good relationship with my peers.”

Q. “What is that peer relationship?”

A. “In Houston it is clean-cut. We are not a city brushed with sophistication. In New York, I know of internists who make sweetheart deals with surgeons. No one has ever spoken to me this way in Houston. If one did, the conversation wouldn’t last fifteen seconds.”