CHAPTER 17

Bergoni, the Italian police clerk, watched his wife brew espresso in a tiny pot she had found in a hardware shop near the hospital. She had pronounced Houston hospital coffee to be not only inferior in taste but potentially damaging to her husband’s liver. “It might give him a setback,” she announced to one of the staff who spoke Italian. All day long she prepared the thick, heavy coffee of Italy, poured it into thimble cups, dumped in three spoons of sugar, and gaily served it to the doctors and nurses who attended her Nino. She was annoyed they would not let Nino sip a bit of vino blanco.

Few operative results had so delighted the hospital. Maria was radiant, as strength was rushing into Nino’s wasted body. He seemed an old man when he had been carried vomiting into St. Luke’s ten days before. Now his eyes sparkled and there was color pushing away the grayness. The only thing that worried the staff was Maria’s unhidden rekindling of romantic desire. There was a day bed in the room and Maria was permitted to sleep nights on it, but one of the residents had to caution her, tactfully, about invading Nino’s bed for the immediate future. “It’s been two years since they had a married life,” said the doctor. “She’s probably forgotten what it’s like.”

Early in July, a reporter from Johannesburg, on an American tour to write about transplants and heart surgery, interviewed Cooley.

“June was the busiest month in our history,” Cooley said. “We did 115 open-heart operations, our all-time record.”

On another day, another reporter wanted to know why Norman Shumway at Stanford was continuing to do heart transplants, in light of the generally discouraging world results.

“Maybe he doesn’t believe in coronary surgery,” was Cooley’s reply.

The surgical fellows were all talking of how enthusiastic the chief had become over the grueling coronary-artery bypass operation. Only last April, they insisted, Cooley had thoroughly disliked it. Now Cooley was saying things like, “This operation is second only to sexual intercourse.” On some days there were as many as four scheduled on the green blackboard.

“He’s committed to it now,” said Dennis Cokkinos, the Greek cardiologist. “And once he’s committed to something, watch out. He’ll bomb all those other guys and their statistics.”

Cooley had done seven in three days and the seven men in their forties and fifties all seemed to be making excellent recoveries. “People are saying that you have become enamored of this operation,” I ventured, “that you’ll soon be doing more than anybody else in the world.”

He laughed. “Well, there’s a possibility, I guess, that I will. It’s true that others have identified with this procedure before we have. We did, however, an ancestor to this operation in 1964, some of the initial work on kids who had congenital anomalies. Lately we haven’t been considered very bold and aggressive with coronary surgery. It took a while before we were able to impress ourselves with the efficacy of the procedure. I think this is important. I won’t take someone else’s word for it, because the same individuals who are promoting this operation have promoted others in the past which proved to be relatively worthless.”

A few days later he expanded on the subject in a speech given to about forty doctors from Texas and Louisiana:

“I believe there is no other area of surgery that has enjoyed more fads than coronary surgery. In the past twenty years there have been operations which had largely psychological effects and which were very lucrative to the surgeons who did them. This led to the charge of charlatanism.

“This new operation, the coronary bypass, is the most tedious, most meticulous operation known to the surgeon. We must sew in a field no bigger than two millimeters across, sometimes only one. I believe we must have a quiet bloodless field. Therefore I clamp the aorta.

“This operation seems to bring relief. It is not a psychological effect, but a true physiological effect.”

But it would take the judgment of years before the surgeon could win all cardiologists over to his point of view. One, a prominent internist who practiced in downtown Houston and who had little to do with the heart hospitals of the Texas Medical Center, could barely conceal his fury. “I’ve had patients who simply do not need surgery, who defy my will, and who go directly to these ‘great’ heart surgeons. They suggest my diagnosis is based on jealousy. We’re not allowed our opinions anymore!” He was speaking to a visitor and his voice must have thundered through the closed door into the outer office and waiting room.

“With each new procedure, each new one supposedly better than the last, the surgeon rushes in and cries that it is the greatest, the newest, the most hopeful procedure, and he decries the one before it. We’ve seen this so often, we’ve been burned so often that we’ve become dubious of the surgeons waving the flag and beating the drum.

“But imagine the potential here! Every man in America over the age of 45 has some coronary artery narrowing, but many of them are asymptomatic, that is, they have no pain and can function normally and productively. I’ll tell you one thing, we’d better watch the surgeons because sooner or later they’re going to suggest that everybody, and I mean everybody, must have this spectacular operation to prevent having a heart attack. They’re going to recommend that everybody have an arteriogram as part of the annual checkup, and an occlusion will show up on an arteriogram, and WHAM! Onto the table.”

The cardiologist was out of breath and lit a cigarette. He insisted that he did not inhale. “We think surgeons lie like hell about their statistics,” he said. “The best results usually come from those who want to get their names in the papers. They’re even touting something new called an infarctectomy in which they take a near dead man immediately after his heart attack—the fellow is in shock—and rush him into the OR and cut out the dead part of his heart and bring the other parts together and stitch it up. The patient survives the operation, sure, but he dies twelve hours later in Recovery of ‘cardiac arrest.’ That’s crap! The patient dies, that’s all! Use of the term ‘cardiac arrest’ is actually a camouflage to cover the fact that the patient died from what the surgeon did to him.”

Two interesting and poignant pediatric cases arrived at Texas Children’s within days of one another. First came a three-month-old baby in a coma brought in by his mother. While the pediatric cardiologists began drawing blood and ordering all manner of tests, someone suspected an overdose of something and asked the lady if she had given the child any medicine. She had indeed—twelve aspirins that very morning. The baby had a bad cold and she decided to storm it. She had great faith in the value of aspirins and regularly lined her brood up each morning and gave them one aspirin each. “Well, your baby’s dead,” said one of the pediatricians, who was so upset by the woman’s stupidity that he could barely speak to her. It was the third death from acute aspirin poisoning that the hospital had seen in three months.

Next arrived Eric, a frisky black baby of eighteen months who got into his own trouble. Born with a ventricular septal defect in his heart, he was being watched until he grew large enough for open-heart surgery. He was also taking one digitalis tablet a day to slow down his fast heart and strengthen it. One morning he climbed up on his mother’s dressing table, discovered the bottle of digitalis tablets among her cosmetics, and chewed up sixteen—more than half a month’s dosage. The overdose slowed down his heart to the point where it was barely beating when the mother finally brought him in, empty bottle in hand. While one doctor put the comatose little boy on dilantin to stabilize his membranes (the same drug used in epilepsy,) potassium, and intravenous fluids to step up his urination, another went outside to the waiting room and scolded the mother. Later he was talking of the case and said that massive dosages of digitalis used to be a classic—and perfect—way of committing murder. “The victim’s heart would stop, it would appear to be a heart attack, and there was no way to measure digitalis in the blood stream. But the lab boys have discovered new methods to foil Agatha Christie.”

The danger was that Eric would go into heart block or arrhythmias. After a few days of intense observation, his heart picked up from a dangerous low rate of 60 to 100 and he was pronounced out of danger. Upstairs he delighted all the floor nurses by popping balloons in his bed and by making furious faces at everyone who passed by his door. There was one good side effect. His liver, which had been oversized from the bad heart, shrank from all the digitalis, and his lungs cleared up.

I followed but two more patients through Cooley’s surgery and each became pieces fitted to the puzzle he remained to me. But once they fell into place, the picture was incomplete.

One was a 47-year-old college dean, the other a six-year-old girl. They came from separate cities to enter the hospital within hours of one another and they had their operations a day or two apart. I grew to respect the courage and wisdom of the man, I fell irrevocably in love with the beauty and good nature of the child. I followed one down the mountain and watched death, I ran with the second up the other side to the summit and claimed life. I think I even saw Cooley break toward the end when he paused, then hurried past the room of the one who was dying. But it was but a dropped, perhaps forgotten, moment.

Nobody on Cooley’s staff was glad to see Clement Fisher return, not because he was an unpleasant man—he was, in fact, a cheerful and tolerant patient—but because he appeared at St. Luke’s in late summer needing a fourth replacement of the same mitral valve. The other three that Cooley had sewn into his heart over the space of nine months had, for one reason or another, grown defective. That he required his fourth open-heart operation in such a short period of time was discouraging to all concerned.

Fisher, a college dean, was a tall, spare man with china blue eyes and a wide East Texas drawl. He told the investigating doctors that his heart trouble had begun when he was thirteen and running track. “The coach felt the longer and harder we ran,” he said, “the more wind we’d have for the dashes. One day I felt something pull inside my chest.” The Houston cardiologists were more inclined to suspect childhood rheumatic fever than a rare traumatic injury to the heart, but Fisher insisted that as far as he knew he had never had the disease. “My mother took me to a doctor a few months after that day on the track, and he said I had strained my heart and that I should spend the rest of my life in bed. I did no such thing. Believe me, I’ve had a great life! But I always paid extra insurance premiums for a heart murmur.”

In 1940 when he obtained a marriage license and had a physical examination, the doctor diagnosed a “leaky valve.” “He said it was flapping in there like an old barn door,” Fisher said. “At that time the only thing a fellow could do was accept it and live with it. Nobody was cutting into hearts then. To tell the truth I never paid much attention to the damn thing until a couple of years ago when I was helping the workmen move some billiard tables in the student union building and I strained so much I went into my office and lay down. I went to see my doctor who chewed me up and down. ‘You durn fool, you’ve done it again,’ he says to me. ‘I oughta kill you, but I’ll write Denton Cooley.’”

Fisher flew to Houston in the autumn of 1969, where the cardiologists discovered that the valve was leaking so much blood that the heart was functioning at about 30 percent of capacity. Cooley replaced the defective natural valve with a plastic and metal one and sent Fisher home as he had done with hundreds of successful patients before. “I hardly got off the plane before the new one started leaking,” Fisher said. “My arteries and veins stuck out like cords of steel on my arms and legs because the heart was throwing so much pressure on them. My heart had been functioning at that 30 percent capacity so long that when Cooley fixed the valve and sent the heart back up to normal, the valve just couldn’t stand the pressure and tore loose.”

In December, Cooley tried a fascia lata valve, one made from the tough tissue of the patient’s own inner thigh.

It seemed to be holding well until Fisher was released from the hospital and drove to the Houston airport. There he was told that his scheduled flight had been cancelled but if he hurried to a gate at a far-off end of the terminal he could catch another airplane. Fisher picked up his own suitcase and that of a friend and ran down a long, polished corridor. “By the time I stepped off the plane at home,” he said ruefully, “the second valve had torn loose.”

Three months later, when his body was strong enough to accept a third major operation, Cooley sewed in another valve, but the tissue around the valve was becoming so necrotic that it did not hold. Now Cooley was faced with the unpleasant job of trying to make a fourth one stick. “I don’t think anybody’s ever tried four before,” said John Zaorski. “I’ve never seen it in the literature.”

Fisher remained good-natured, unlike some who return to hospitals for a re-do, convinced they were victims of inept medicine. (A few years before, my appendix burst during lunch one afternoon in New York and I was operated on that evening by a well-known and expensive surgeon. In the three months that followed the wound would not heal and I had to return for a second operation to scoop out the silk stitches—which I was “spitting,” they told me—and infection. I was, with no challengers, the supreme grouch of my floor.)

Before his second valve replacement, while being examined by Cooley, Fisher presented the surgeon with a small bottle of glue to make it stick. Cooley had laughed and said he would use it intravenously. Before the third, Fisher asked Cooley what kind of warranty the apparatus carried. And now, as he waited the fourth, Fisher sent his wife out for a zipper.

Tammi, who was only six, had enormous deep-set blue-gray eyes. Her body was tiny from a deformed heart, but she carried it with grace. One moment she would be sitting on her bed playing a card game called “Hate,” the next strolling down the hall watching the other heart kids play. But Tammi would only watch. She held herself aloof and if she was frightened, some check within her held it from sight.

Cooley leaned over her and listened to her heart. He nodded noncommitally and smiled at the beautiful precocious little girl and her parents, a barber and his wife.

Outside he told the entourage of young doctors that Tammi had a bad AV commune, the highest-risk heart surgery. Earlier that summer, Cooley had won one of them—the boy who cried like a cat—and lost one. Few surgeons in the world would bother, or dare, to try. “Most places would send her home to die,” said Dr. Ugo Tessler, an Italian resident who was new to Cooley’s service. (On July 1, most of the foreign doctors had left and a new dozen had come to take their place.)

Tessler walked on, frowning. “She won’t last through surgery.”

“How long can she live without it?” I asked.

“She won’t. She’s going to die.” Tessler’s voice was flat and final.

Cooley was on his way down a flight of stairs, on his way to see Fisher, but Tammi was on his mind.

“I’d like to think that no patient is too sick for surgery,” he said almost to himself. “I’d also like to think that the only ones we turn away here are the ones who don’t need surgery.”

“Will you attempt the operation on Tammi?”

“We’ll see.”

Trying to make Fisher’s fourth valve stay in place, Cooley used a technique of overlapping heart tissue around the mouth of the valve and sewing it doubly tight. He went out after the operation and told Mrs. Fisher, a stylish, attractive woman in a Chanel-type suit, that he felt sure it would hold.

“I’ve heard that before,” she said as he walked away. “I’ve heard everything before.” She was weary and her eyes were red from lack of sleep. She had not, in fact, slept well for nine months of failing valves.

During Fisher’s operation, Tammi was taken for the third heart catheterization of her young life. Five months after she was born, a hometown pediatrician detected a murmur. “I’ve heard these before,” he said. “I can only give you an educated guess, but I don’t think there’s anything to worry about.” But when she was one year old, Tammi fell short of breath, refused to lie down, to stop crying. Her mouth and lips turned blue; cold sweat popped out on her forehead. She was in classic heart failure. Her mother drove the baby in panic to the hospital, where she was slapped into an oxygen tent and put on digitalis to strengthen the tiny heart. When she was three, Tammi was brought to Texas Children’s Hospital in Houston for her first catheterization, which revealed the suspected AV commune. And in the June of her sixth year, the Houston cardiologists catheterized her again. Jim Nora had told Tammi’s mother, “We’ve gone as far as we can without doing something.… She doesn’t have much time left.”

During the next two months the barber and his wife addressed themselves to a cruel dilemma: whether to keep the merry, prankish child at home and seize the time left and crowd it with love—or return her to a hospital where there was the darkest pessimism. “We lived with it for a long time,” the mother said while she waited in the snack bar with a cold cup of coffee, waiting for Tammi to be brought back from the catheterization lab. “Dr. Nora had told us the last time that we needn’t fear anything sudden happening. She wouldn’t go … overnight. But now I know the gradual decline is setting in. I can see her slipping every day. If Dr. Cooley feels there is a chance, only a tiny chance, then we’ll put ourselves in his hands and the Lord’s.”

The night before, after Cooley had dropped by to listen to her heart, I had returned and visited with Tammi. There seemed no sickness about her other than her thinness; she fairly burst with life and humor. “Dr. Cooley’s going to fix your heart up,” her father said, as we played Battle with her well-worn deck of cards.

“Mmmmmmmm,” said Tammi, showing me how she could shuffle, “I think I may wait. When I’m about nine, I may let him.” She was a princess dispensing favor. She dealt out a hand quickly and began sorting her fate. She looked up and affected a pensive look. “But I would like to beat John in a race,” she said, explaining that John was a very fast child who lived in her neighborhood.

We walked down the hall and stopped to look at a bulletin board outside the nursing station, which was filled with photographs and letters from children who had happily returned home after heart surgery. Tammi’s eyes found and lingered on a picture of a solemn boy with a large incision of his chest. The stitches had not yet been removed.

“Would you look at that,” she said. “They cut that little boy all up.”

On the third postoperative day, Fisher threw a small clot to his brain which, hopefully, only temporarily paralyzed his side. He also developed jaundice and turned a dull yellow. His eyes seemed on fire. Zaorski listened to his heart and shook his head with weariness. I asked what was happening but he said he had to hurry to another case.

Dr. Chuck Mullins, one of the many able pediatric cardiologists, did Tammi’s catheterization with Nora coming into the room now and then. “This kid’s heart seems so malformed that the catheter just flops from side to side,” he said. He was gently moving the catheter at an incision in her arm and watching its passage into the heart over a television screen. The wire moved murkily into the shadow that was the heart. “Her heart is a mess,” he said. “It’s outgrown her body.” The shadow was enormous. It was evil.

Nora had stopped for a cup of coffee just outside the catheterization lab. I asked him what causes congenital defects in children. “There are many reasons,” he answered, “largely unknown ones. The major one is probably the hereditary predisposition. Then there are environmental triggers—bacteria, radiation, insecticides in food, maybe the mother took too many drugs like dexedrine during her pregnancy to keep from getting fat. Women take such incredible things during pregnancies. We’re highly interested in viruses now; we’re studying blood from newborns to see if the baby had an infection in the womb.”

“What about when the mother gets German measles?” I asked.

“That’s the most widely known cause, when a mother has German measles in the first trimester of pregnancy. But it accounts for the smallest percentage of defective hearts, less than 5 percent. If a woman does have German measles during the first ninety days of pregnancy, there is a 60 percent chance the baby will be born with congenital heart disease.”

When the catheterization was over and before Tammi was sent back to her room, Dr. Mullins talked with her mother. He tried to conceal his despair. “There’s really no choice,” he said. “Either you take her home and wait—or you consider surgery, even though the risk is high. Very high. She simply has no heart reserve left. The heart can’t rally on demand and produce more output. You and I can run, climb stairs, rally to fight an infection. But her heart can’t. A cold might be a catastrophe. And I don’t know a way in the world to keep a child of six away from infection.”

The mother seemed confused. “But are you recommending surgery?”

“Dr. Cooley will have to decide and then it will be up to you and your husband. I just wanted you to know what I think.”

Later that afternoon, the fellows in the coffee room were talking of Tammi and Don Bricker heard the conversation.

“She’s going to die,” he said. “I wouldn’t touch her.”

“Then what would you do?” someone asked.

He threw up his hands in surrender. “Give her to Denton.”

The buck stopped at the surgeon’s desk in his tiny cubbyhole overlooking the operating room. The collected wisdom of fifty centuries of medicine was at his finger tips—Tammi’s x-rays, the films of her catheterization, the sheets with the chemical equations, the recommendations, the calculated guesses. But only the man who held the knife could decide whether to bring the child to the operating table that he could see from his desk.

He went to her room as she was eating and asked her parents to follow him into the corridor.

“I think I can help her,” he said. No one had really expected him to turn the child down.

“Would you do it if she was your little girl?” The mother asked.

“If she were mine, I wouldn’t want to. But I’d do it.” I had heard him give the same answer many times, almost automatically. But on this hot summer night the voice lacked its positiveness.

Both parents nodded as one.

When the surgeon went away, Tammi piped up, “Dr. Cooley didn’t say anything to me. I must be too beautiful.”

That night during dinner at his home, John Zaorski talked of Fisher. “I think I heard a leak today,” he said. “I’d guess the valve’s torn loose.” He added that he was not 100 percent certain. But happily, Fisher’s jaundice had cleared up and he was later transferred to a private room. With the yellow cast gone from his body, he was psychologically better and the paralysis from the stroke seemed to be easing. His wife and married daughter were guardedly optimistic.

On the morning of Tammi’s operation, Dr. Mullins passed by surgery. He had wanted to watch the procedure, but he had to catheterize the second of identical six-year-old twin blond girls whose Tetralogy of Fallot had been repaired a year ago. Both twins were spectacular successes and were back only for checkups. “I’m crossing my fingers with Tammi,” he said, “… and saying a few prayers as well. Her heart’s as big as yours or mine.”

What worried Mullins most was the deteriorating mitral valve, one of the many defects that he suspected in her heart. “Denton can probably sew up the holes, but the valve is the problem,” he said. “The surgeon has a completely different thinking on valves than we do. Denton talks about them lasting ten years, but they can also last only five years or five months. The average seems to be about four or five years. I wouldn’t want to face a life of having my chest opened and the surgeon into my heart every four years.… Because once that valve goes out—it’s out. And life depends forever thereafter upon the strength of a piece of metal and plastic.”

Tammi watched Diane, the nurse with the Raggedy Ann doll, explain how she would look after surgery and her face grew unusually solemn. At six could a child really understand that which was going to happen to her?

Sedated with Nembutal and Demerol, Tammi was rolled to surgery at 9:30 A.M. She waited briefly for her turn in Room 2. I leaned over the stretcher. I was masked but she recognized my voice. “I’ll see you in a little while,” I said. “I’ll keep the cards warm.” She bounced her head up and down. “You may have to deal,” she said. “I’m so sleepy.” On the table, she struggled against the black mask that came toward her, sending the vapors of cyclopropane and halothane into her lungs. Quickly she was out. Quickly she was still and silent.

She lay nude on the table while the team performed its preparatory ballet about her. The heart within the tiny body was leaping. “Her head almost vibrates every time the heart beats,” said one of the doctors. “Poor kid.”

Dr. Phil Allmendinger came into the room. A burly, surgical resident from Connecticut, he was spending six months of his third year of residency in Houston beside Cooley. He had arrived on July 1, the change-over date, and in but a few weeks had become overwhelmed by the variety and volume of heart work. “It’s everything I had hoped it would be,” he wrote to a friend in Connecticut. “Already I’ve seen lesions it would take a year to encounter back there.” Allmendinger quickly won the nurses with his decisions in the Recovery Room; the women made immediate and generally accurate evaluations of the new doctors. “Did you come early to get a good seat?” he whispered through his mask. Already the room was crowded. An AV commune would sell out any operating room.

One of the nurses said that Cooley was in a snappish mood. “I saw it the moment he scrubbed in,” she said. Allmendinger knew why. The day before Cooley had lost a difficult aortic aneurysm patient. Also, during the repair of a ventricular septal defect on a two-and-one-half-year-old girl from South America, one of the new foreign fellows had, for reasons unknown, taken the clamp off one of the tubes connecting the patient to the pump-oxygenator. Allmendinger, assisting, glanced down and saw a huge air bubble swimming toward the patient. He made a diving grab for the tube to shut off the bubble’s course and put the clamp back on. Cooley saw only the dive and was angry. “Christ, Doctor, everything we do in this operating room has a definite purpose,” he said. “Don’t you know an air bubble like that would go directly to this patient’s brain?”

When Cooley lowered his head and returned his gaze to the field, Allmendinger glanced discreetly toward the fellow who had made the blunder. But the guilty man did not speak up and accept the blame. Rather than squeal on a junior colleague, Allmendinger let it ride. Cooley worked for the rest of the operation in stormy silence.

One of the ward nurses had not helped his disposition on the morning of Tammi’s operation by charging in and complaining that six patients on her floor had been told they could go home but that no one had written the discharge medication and papers. “Nurses stab you in the back this way,” said Allmendinger. “They should complain to you, but they go direct to the chief.” Cooley got on the loudspeaker and acidly told Zaorski, “There are patients stacked up on Three South. Let’s get ’em out of here.” The general gloom that surrounded Tammi’s chances was heavy in the room, and there was a thoracic aneurysm that had to be done after the child. And Hallman was on vacation.

John Russell sliced into Tammi and began peeling back the layers of skin and tissue. The nurse Gwen was hovering behind him preparing the electric saw. “Ready for the saw, Dr. Russell?”

“Just about.”

Gwen waited a moment or two. “Ready now?”

Russell nodded. She handed him the saw and he applied its blade to the child’s chest. “Okay. Hit it.”

The nurse switched on the current and the blade chewed through the breast bone.

“Through?” asked Gwen.

“Yeah.” Russell gazed at the heart.

“I didn’t hear you go through.”

“It’s very soft bone. You don’t hear the pop in kids.”

A visiting doctor standing on a stool shook his head. “Jesus Christ, look at that greedy heart.”

Wordlessly, Cooley entered the room. Three doctors stepped back from the table to permit him entry. Hurriedly he put the child on the pump. When her blood was flowing through the tube into the oxygenating machine and back again into her body, when the gross heart was still enough for him to enter, he cut it open, peeled back a flap and stitched it tightly to the thoracic cavity to keep it out of the way. His fingers found the atrial septal defect—one of the suspected holes in the heart—and he began trimming a piece of Dacron to cover it. “The hairy part,” Allmendinger whispered to me, giving me a play by play, as he could see better than I, “is the valves … whether he’ll be able to resuspend them … or replace them.”

But when Cooley was finished sewing in the patch, his slender fingers moved again inside the heart. He stopped. He re-entered. He stopped again. It was not his custom to stop. His surgery was always a fluid motion. Fifty eyes raced from his face to his hidden hands and back again. What horror had he encountered? Suddenly he smiled. “We have an ostium primum, I believe, gentlemen,” he said. There was not the second suspected hole in the heart. Nor would the valves have to be replaced. There was only one complicated hole in the heart, an atrial septal defect known as ostium primum. As a sudden storm breaking the August heat, the tension in the room shattered. Some of the visiting doctors even left, as people walk out of a disappointing play. Cooley satisfied himself one more time that the valves were not damaged, then closed the pericardial sac. “This just goes to show that one peek is worth two finesses,” he said as he sewed. He was elated. He was, in fact, triumphant. “The cardiologists have been finessing this child all of her life, seeing shadows and pronouncing her doomed and predicting her death. All the surgeon had to do was go in and look. Now she should be fine!”

By mid-afternoon, Tammi was groggily awake and asking for a hairbrush. She returned to her room the next day and 36 hours after the operation was walking about her room. Her recovery astonished her mother. “Mama came in and found me walking around the room and almost had a heart attack,” Tammi said, accepting my kiss. “Now let’s play cards.” Her doll was beside her on the bed; she had had an operation as well, her chest was covered with a large bandage, and tubes dangled from her arm.

The jaundice had come back and Fisher had turned the color of an old coin. It was difficult to talk with him, but he wanted to talk. His voice was raspy. He spoke of the things cluttering his mind—his love of flying, his work at the university, his family, his ordeal. I complimented him on his courage. He closed his eyes tightly and when he opened them there were tears in the yellowness of them. “I’ve given up many a time,” he said. “Nobody knows it. I’ve laid back and said, ‘I quit.’ I feared the Intensive Care Unit. I’ve always had a fear of choking to death—it happened that I almost drowned once—and when they put me in that room full of sick people and stuck the tubes down my throat, I knew they were going to let me lie there and strangle to death. The roof of my mouth is still sore from where I pushed on the breathing tube.”

He fell silent for a time. I took it as my signal to leave. “I’m ashamed of what I just told you,” he said. “A man shouldn’t give up that way.…”

The women of his family had gathered. Over the weekend, the men had come, too—brothers, brothers-in-law, sons-in-law. But they had gone away. “Men can’t sit in the hospital and wait the way we can,” said one of the women. Mrs. Fisher refused to let them move her husband back to the Intensive Care Unit. “He’s had enough,” she said. She sat outside his room in a chair, leaning against the corridor wall. Before she would go in to relieve her daughter, she would go to the ladies’ room and put on fresh makeup and achieve a difficult, but workable smile.

Fisher’s heart had slowed down and was betraying his body. Fluids were collecting everywhere. Diuretics were administered to speed up expulsion of the liquids, but they always came back. Tourniquets were tied on his arms and legs to stop the fluids from going to his heart and drowning him—that long hidden fear. But it was an exercise in palliation. Even he must have known.

The last time I made rounds with Denton Cooley he began at the summit. He inspected Tammi’s rapidly healing incision and swooped her up for her mother’s camera. She challenged him to play cards with her sometime and he laughingly accepted. He seemed almost reluctant to leave her. Phil Allmendinger had already noticed, in the brief time he had been with the surgeon, how much Cooley favored the pediatric cases. “I think he only comes alive when he’s with the congenital heart kiddies,” Allmendinger said. “They trust him, they don’t ask questions, they have rapid healing powers, and they get well quickly. It’s usually permanent with them. They don’t give the surgeon that tiny, nagging doubt in the back of his head that so often haunts him with the grownups.”

As Cooley strode toward the adult floor, he gestured with his head back toward Tammi’s room. “That case shows how necessary it is for the surgeon to go ahead sometimes when everybody else is predicting disaster. Tammi is fine, there’s no more murmur, she’s looking good, she’s alive!”

He walked on and spoke to John Russell. “It makes all the weeping and wailing of relatives worthwhile,” he said. “When we first started doing this work, kids died on the table every week. We practically had to wade through hysterical relatives.”

He was in fine fettle for half an hour, a pleasant half-hour with a series of bright, sunny rooms and, within, patients and families whose faces were cheered when the surgeon entered. But finally there was the woman sitting in the chair outside a room, and the entourage stopped. Russell looked at the name on the door and said, unnecessarily, “It’s Mr. Fisher.”

There was nothing to do. There was nothing left for the surgeon except to wrestle with his soul for that last moment. He had already seen his failure, and nothing—neither his hands nor his sorrow—could alter the destination. Mrs. Fisher did not look up. His face sagged and he shook his beautiful head. “Poor bastard,” he said softly as he moved on. There was nothing to do but move on to the next patient.

Fisher died the next day.

Tammi went home and five months later, at Christmas, wrote me a letter in New York. “Dear Tom,” it read, “I am a Brownie. I marched in the Christmas parade. I did not get tired. I love you. Happy Christmas! Love! Tammi.”