Super Medicine

One day in February of last year Harold Dunkleberg, a house builder in the little town of Osborne, Kansas, noticed a lump under his right arm. He showed it to his wife, Rosalie, and she told him he ought to see a doctor. But Mr. Dunkleberg was reluctant to do that. He said it was just from wearing T-shirts that were too tight and, besides, he was too busy to go to the doctor. Still, Rosalie Dunkleberg couldn’t get that lump off her mind. She kept pestering her husband about it, and finally, in March, he went to the family doctor.

The doctor said the lump really ought to be taken out. Mr. Dunkleberg grudgingly accepted this diagnosis, but he put off the operation until the summer. On July 5, 1978, the doctor removed from Mr. Dunkleberg’s armpit a growth roughly the size of two fists pressed together and sent it off to Topeka for tests. Ten days later, the results came back and the doctor told Mr. Dunkleberg he had cancer—specifically, lymphoma, a cancer of the lymph system that can appear in many parts of the body.

Mrs. Dunkleberg is from Downs, Kansas, a town just east of Osborne, and she knew a man there, Jim Hart, who had had lymphoma. When Jim Hart heard the bad news he came straight to see the Dunklebergs. “Harold,” he said, “you feel good now but you have a son of a bitch inside you, and in six months it’ll get you.” He turned to Mrs. Dunkleberg. “Rosalie, if you love your husband, the only place you can go right now is M. D. Anderson Hospital in Houston.”

So on July 25, 1978, Harold and Rosalie Dunkleberg arrived at the Texas Medical Center, a collection of 24 institutions packed onto a 200-acre plot of land on Fannin Street just south of Hermann Park. Harold Dunkleberg was one of 1.5 million patients who came to the Medical Center last year. Like a great many of them, he was in serious trouble—so serious that his own doctor and his local hospital couldn’t do much for him. He came to Houston to receive from some of the nation’s leading specialists a major, protracted course of treatment that was his last chance to survive.

The Texas Medical Center is possibly the largest and most advanced complex of medical facilities in the United States. It has 23,000 employees, 10,000 visitors a day, 4127 patient beds, a physical plant worth $632 million, and an annual operating budget of $552 million. It is home to the M. D. Anderson Hospital—where Mr. Dunkleberg went for his treatment—which is the oldest institution there and one of the country’s best cancer centers. Texas’ only private medical school, Baylor College of Medicine, run by the brilliant and domineering Dr. Michael E. DeBakey, is there. DeBakey also does his famous heart surgery in the Medical Center at Methodist Hospital, Houston’s largest private hospital. DeBakey’s former protégé and bitter rival, Dr. Denton Cooley, is at the Medical Center, too, conducting the world’s busiest heart surgery at St. Luke’s Hospital and the Texas Children’s Hospital. Another large private hospital, Hermann, older and less prominent than Methodist and St. Luke’s but now building aggressively, is there. There is a second, almost brand-new medical school, the University of Texas at Houston. And Houston’s general charity hospital, Ben Taub, is also at the Medical Center.

Besides all that, the Medical Center contains two nursing schools, a dental school, a public health school, a high school for aspiring health professionals, and a dozen smaller patient-care facilities. Construction crews are perpetually at work there, building new hospitals, offices, and research labs, even a food factory that will upon completion prepare 12,000 meals a day. Patients come to the Medical Center from all over the United States, Europe, the Middle East, and Latin America. When the vice premier and supervisor of science and technology for the People’s Republic of China, Fang Yi, came to America this winter with his boss Teng Hsiaoping, one of the places he made sure to visit was the Texas Medical Center. “When you get outside Houston,” says one professor there, “the city is known for two things. It’s known for the oil industry and the Medical Center.”

Only one other medical center in the United States, the Chicago West Side Medical Center, has a comparable number of acres and patient beds. And the Chicago center—like the great medical centers of New York, Boston, San Francisco, Baltimore, and St. Louis—dates back to the nineteenth century. In 1940, what is now the Texas Medical Center was a prairie.

The Medical Center has grown, and continues to grow so dramatically, because it has been in the right place at the right time. It is in a rich, booming city whose leaders like to build monuments. It has grown up during a period when the federal government has invested heavily in medical research and the states in medical education. And medicine, during the years of the Texas Medical Center, has become more technological, more specialized, more expensive, and more admired by the nation at large. All these trends have directly benefited the Texas Medical Center. Despite a lot of talk about the importance of primary care, particularly in rural areas, the Medical Center is the direction American medicine has been going for the last forty years.

The end result is impressive. The doctors there are intelligent and hard-working, the facilities top-quality, much of the work indisputably lifesaving. Visitors invariably come away wowed.

But the impressiveness of the place is in a way unfortunate, because it distracts attention from the important question of why the Medical Center exists. Yes, miracles are performed there, but so are unnecessary procedures. Yes, the doctors are dedicated, but they’re also prima donnas. Yes, the care is good, but it’s a lot better for those who can pay for it than for those who can’t. Yes, the hospitals have won the world’s admiration, but they have done so partly through ardent self-promotion and concentration on the most spectacular and expensive kinds of patient care. The Medical Center’s main goal is producing advanced medicine, and it does that very well. But advanced medicine and health are not always the same thing.

THE CANCER WARD

When the Dunklebergs came to Houston, they joined a strange little community of people who have come to town for a course of treatment at the Medical Center. Some of these people go so far as to buy houses nearby; quite a few rent apartments; and the Dunklebergs, like most, settled into a motel that offered free shuttle bus service to the Medical Center. For two weeks, they would go to Anderson Hospital every day and Mr. Dunkleberg would undergo diagnostic tests.

Did he have any chance to be cured? Cure isn’t a word cancer doctors (oncologists) like to use; they prefer the word remission, meaning a cessation in the growth of the cancer cells. Nor do oncologists like to tell people whether they’ll live or die; they’d rather give percentages. Mr. Dunkleberg’s disease, lymphoma, once 100 per cent untreatable, now has rates of remission that go as high as 90 per cent for certain types. Of all the patients of Anderson Hospital, 40 per cent go home in remission. The cancer kills the rest.

There are three ways to treat cancer. The oldest, simplest, and most common treatment is surgery—just removing the cancer. The second is radiation therapy, which can kill localized malignancies. The third, and the most useful in treating a systemic cancer like Mr. Dunkleberg’s, is chemotherapy—the injection into the bloodstream of various chemicals so toxic that they can kill cancer (and other) cells. All three cause tremendous visible harm to the body. In most hospitals the average patient lying in his bed doesn’t look very bad; not so at Anderson. The surgery patients are often missing a leg or an arm. The radiation patients have badly burned skin and black lines on their bodies that mark the treated areas. The chemotherapy patients look worst of all. Chemotherapy almost always makes the hair fall out, so a chemotherapy patient is easily recognizable by baldness and lack of eyebrows. It often causes sterility, hormone imbalances that make the body look strange and puffy, and severe attacks of vomiting (for which the best-known antidote is marijuana, which younger patients smoke before coming in for their therapy and older patients often ask their doctors to prescribe for them—without success, since it is against the law in Texas).

One day in December I went on rounds at Anderson Hospital with a team of hematologists, specialists in cancers of the blood and lymph systems. The first patient they saw was a high school football coach from West Texas, a big, handsome man with silver hair who had myeloma, cancer of the bone marrow. Myeloma causes the bones to become thin, so that any movement is extremely painful. The coach was obviously a proud, brave man, and this was the first physical problem in his life that was beyond his ability to handle. That, as much as the pain, was tearing him apart. “I raised up a little today, but I started to break out in a sweat,” he told the doctors. “I want to get up and walk. I still think I could get up and hold onto something if I knew what angle to use. But then, if it bites you . . . boy, when it grabs you like that, I do not know how a human being stands it.”

Leaving the coach’s room, the doctors saw a woman leaning against the counter of the nurses’ station, crying in the loud, barking sobs of someone who has lost control. Her husband, a lymphoma patient, had just arrested — his heart had stopped beating. Inside his room, doctors and nurses were pounding on his chest, trying to revive him. In a minute or two his heart started beating again. That night he arrested twice more and was twice revived; and the next week, his cancer at bay, he went home. But there was no way for his wife to know that just then. Even if she didn’t think he was dead, it must at that moment have seemed just too much — the lengthy illness, living in the hospital, doctors pounding on her poor husband’s chest. A cancer hospital is an emotionally overwhelming place.

The doctors went from the wards downstairs to an outpatient clinic, to which Mr. Dunkleberg had come that day for a bone marrow biopsy. This is a diagnostic procedure in which a doctor sticks an evil-looking metal tube into a patient’s hip bone, vigorously works it around in a circular motion, and extracts a small core of bone and marrow to send to the lab for tests. If done exactly right, it’s a painful procedure; if not, excruciating. Mr. Dunkleberg and his wife went into a small treatment room, where he lowered his trousers and a young doctor inserted the tube into his hip. “Now this doesn’t hurt,” the doctor said. “It’s pressure, it’s pressure, I’m pressing real hard, but it’s not pain.” Mr. Dunkleberg was clenching his jaw and grunting; his wife was wringing her hands. Watching, I suddenly began to sweat profusely and felt my stomach begin to turn. With the last of my composure, I edged out of the room and ran through the halls, past amputees and people with black radiation marks on their faces and no hair, out to the parking lot, thinking: How can these people possibly live with this?

I discovered the answer in talking to the Dunklebergs a few hours later: through great, inspiring courage and dignity. Since that day in Osborne when they had learned of the cancer, their lives, like those of all patients with serious cancer, had been completely shattered. Luckily, Rosalie Dunkleberg had insurance through her employer, a grocery store, that covered all her husband’s medical care, but there were still the travel and hotel bills to pay, and neither of the Dunklebergs was working. Their two teenage children were living by themselves back in Osborne. “Sometimes I kind of ask myself,” said Mr. Dunkleberg, “ ‘What have I done to deserve this?’ But I figure the good Lord must have some reason.” Whether or not He does, the Dunklebergs were managing to live through the disease with their pride and love intact.

After his first two weeks in Houston last summer, the doctors had prescribed a course of chemotherapy called CHOP-B (a mixture of five chemicals) and sent him home to take his treatment. This lasted six weeks. Mr. Dunkleberg would go to the hospital in Kansas for checkups and twice had to lie on a table for two and a half hours while the five chemicals dripped into his body through an intravenous line. It would be two days before he could hold down any food.

A week before they were to return to Houston for more tests, Mrs. Dunkleberg noticed a small knot on the right side of her husband’s neck. “When we got there,” she says, “they said, ‘Well, obviously the CHOP hasn’t done you any good, so we’ll give you MOPP.’ ” This was a combination of four chemicals given in two doses. One of the chemicals was nitrogen mustard, which is so powerful that when it was injected by syringe Mr. Dunkleberg felt like he was being hit with a sledgehammer. This time he got his chemotherapy at Anderson, and after two weeks the Dunklebergs drove home again.

There, once again, he got worse. His right shoulder — and then his whole right arm down to his fingers — started to swell. The Dunklebergs got back in their car and drove to Houston. This time Mr. Dunkleberg was in so much pain that he couldn’t drive, and when he arrived at M. D. Anderson he moved into a room at the hospital as an inpatient. Mrs. Dunkleberg moved in too, and slept on a cot in her husband’s room, where she bathed him and fed him and helped him into the bathroom. He underwent a course of thirteen daily treatments of radiation on the shoulder, and the swelling went down. But at the same time a new lump was growing on the right side of his chest; by the time the radiation treatment ended in late December the new lump was the size of half a walnut, black and foreign-looking.

If there was any bright side to the Dunklebergs’ lives, it was the way their family and town and the hospital staff had rallied around them. “This was the first Christmas we were ever away from the kids,” says Mrs. Dunkleberg. “So some friends put out a box for donations in the store where I worked to fly the kids down here. It filled right up. A woman in Osborne named Mabel Cornwall, who we call the Flying Farmer, flew them down the day after Christmas. This whole thing has brought the family closer together. The children — well, our daughter realized right away how serious it was. The boy at first wouldn’t give Dad a kiss good-bye. But the last couple of times he did. And the people here don’t treat you like a number. The doctors remember your name.”

On the day I met the Dunklebergs they were trying to decide whether to try a third course of chemotherapy that the doctors had suggested: a group of chemicals known as L6, followed by a course of high-dose methotrexate. Both of these treatments, given separately, were common, but only one other person had taken them in combination. As I came in, Mr. Dunkleberg was pushing away his dinner because, he said, “This hospital food I ain’t crazy about.” Chemotherapy does strange things to the appetite — once, for instance, the hospital kitchen was cooking roast beef while he was receiving chemicals, and from then on even the thought of roast beef made him nauseous. He is a doughty, stubborn man, and was as determined not to eat as he was determined to live.

Rosalie Dunkleberg was much more enthusiastic than her husband about trying the new chemotherapy. “If we were someplace else, like Wichita or Kansas City,” she said, “it might be different, I might have my doubts. But we know Houston is the best place in the world. If it was any other place I’d be skeptical.”

“The thing about it is,” said Mr. Dunkleberg, “here, when you’ve got four or five doctors on the same case, you know they’ve got something going. But I’ve still got a little question in my mind. It’s still experimental. I keep trying to think positive, but I don’t know what to do. At first I was just supposed to be here five days. Now it’s up to three weeks if we do this. I don’t know how this deal’s gonna go. I kind of want to go home.”

“Dad,” said Mrs. Dunkleberg, “I saw what happened when we went home.”

BUILDING THE DREAM

The M. D. Anderson Hospital is named for Monroe Anderson, the man who deserves the first measure of credit for the existence of the Texas Medical Center. Along with his brother, Frank and the Clayton brothers, Will and Ben, Monroe D. Anderson was a founder of the world’s largest cotton company, Anderson, Clayton & Company. For more than half a century Anderson, Clayton’s lawyers have been the firm of Fulbright & Jaworski, now the fifth-largest law firm in the country. Two of the men who built the firm, John H. Freeman and William B. Bates (the firm’s name was once Fulbright, Crooker, Freeman & Bates) were close friends of Anderson’s as well as his lawyers.

All these men were born in the late nineteenth century in fairly humble circumstances, all but Freeman moved to Houston as young men, and all of them saw their fortunes grow beyond their wildest dreams as the city grew. They were, in a way, simple men. They led quiet lives. When younger people asked them for advice, they were likely to say that the secret to a happy life was hard work, honesty, thrift, and religion. Reading through their old speeches and interviews, it’s hard to escape the conclusion that they saw the world as an uncomplicated place, a place where progress was good and virtue was rewarded. They were happy. They loved Houston. They wanted it to grow and prosper and win the admiration of the world. So they started the Texas Medical Center.

In the mid-thirties Monroe Anderson’s health began to fail. Anderson had no heirs to provide for, so he decided, partly for business reasons and partly for altruistic ones, to use his Anderson, Clayton stock to set up a foundation for good works. In 1936 he established the M. D. Anderson Foundation, with an endowment of $300,000 and himself, Bates, and Freeman as trustees. Three years later Anderson died and left the bulk of his fortune – $19 million, the largest estate ever in Texas at tht time — to the foundation. Bates and Freeman chose a new third trustee and began discussing how to give away the money.

Of the original trustees, only Freeman is still alive. He is 92 years old now, nearly blind and legally deaf but mentally lucid. He still keeps an office at Fulbright & Jaworski, where he works with a green eyeshade perched on his forehead. “Back in the thirties,” he says, “we got the idea of establishing a white-collar hospital with Mr. Anderson’s money. In those days the very rich could take care of any expense from health problems. And the very poor could get it free. But the fellow in the middle — no provision was made for him.

“While we were considering that, the Legislature appropriated $500,000 for a state-owned cancer hospital and research facility, to be run by the University of Texas. We decided to abandon the idea of the white-collar hospital if we could get the cancer hospital. We told the university, if you put it in Houston and call it M.D. Anderson Hospital, we’ll provide a site and give another $500,000 to assist in the building and also help in the upkeep and maintenance.”

The white-collar hospital had been a good idea, but now destiny was calling the Anderson Foundation trustees. Destiny’s personal representative in Houston was Dr. Ernst William Bertner, a strong-willed, big-thinking man who was one of the city’s leading physicians. The son of a German immigrant, Bertner grew up in Colorado City. In 1913, while in training in New York, he happened to administer an anesthetic to the most powerful citizen of Houston, Jesse Jones. Jones was so impressed by Bertner that he asked him to come down to Houston as house doctor at a new hotel he was building, the Rice. Bertner accepted, and in the early forties he and his wife lived in an apartment on the same floor of the Rice as the John Freemans. Bertner became friendly with all the Anderson Foundation trustees, and he began to tell them that they could build a great medical center in Houston, one that would one day have a $100 million worth of buildings and, yes, overshadow the Mayo Clinic. The trustees thought Bertner was a little overoptimistic about what could be done, but his basic idea of a medical center caught their imaginations.

In 1943 the Anderson Foundation trustees persuaded the City of Houston to sell them a 134-acre plot of land south of Hermann Park, which was to form the bulk of the Medical Center’s grounds. Meanwhile the trustees, taking Bertner’s advice, began to look for a medical school and some general hospitals to join M. D. Anderson there. They approached UT’s Medical Branch at Galveston, but it wasn’t interested in moving to Houston. Then two of Freeman and Bates’ clients who were trustees of Baylor University mentioned the possibility of moving Baylor’s medical school to Houston from Dallas, where it was hopelessly embroiled in a battle with the private medical community. The Anderson trustees offered Baylor a site, a million dollars for a new building, and another million for research, and Baylor agreed to move. In exchange for free land and gifts of $500,000 from the foundation, other institutions signed up in rapid succession: UT’s new dental school; Methodist Hospital, which was abandoning an old downtown location; and a new Episcopal hospital, St. Luke’s. On the northern edge of the foundation’s property was Hermann Hospital, the leading private hospital in town, and the foundation offered it the same deal if it would build a new wing facing south on Medical Center land. By 1945, the Medical Center had two schools, a cancer hospital, and three general hospitals, and the trustees decided to create an organization to coordinate all the institutions’ activities. Texas Medical Center, Inc., was dedicated at a dinner for 650 at the Rice Hotel on February 28, 1946.

All these institutions are still at the core of the Medical Center, and the M. D. Anderson Foundation is still its most important financial angel. Over the years the foundation has given away $70 million, $35 million of it to institutions in the Medical Center, and has also increased its principal to $70 million. It has remained a very private organization, closely tied to Fulbright & Jaworski. Its current president, and probably the most powerful non-doctor at the Medical Center, is Leon Jaworski, who calls the Texas Medical Center “my chief outside interest.” The other trustees are Freeman, Hugh Q. Buck (another Fulbright & Jaworski partner), and A. G. McNeese (a former Fulbright & Jaworski lawyer who is now chairman of the Bank of the Southwest, a Fulbright & Jaworski client in which the Anderson Foundation is a major stockholder). They meet about once a month, usually over lunch at the Coronado Club, which, like Fulbright & Jaworski itself, is in the Bank of the Southwest building in downtown Houston. In addition to giving money away, the foundation lends it too — mostly to churches but also to friends. Both Jaworski and Buck have received personal loans from the foundation, which they promptly repaid when they became trustees, and the foundation’s list of outstanding loans now includes items like $1.5 million to the Houston law firm Bracewell & Patterson and $420,000 to Weingarten Markets Realty Company.

The Medical Center did not come into being only because of the Anderson Foundation, of course; as they say in medicine, it had a receptive culture to grow in. Houston in 1945 was a new, rich, unsophisticated town eager to get the grease out from under its fingernails. It had several dozen extremely wealthy citizens — the first generation of the oil rich, the Fondrens and Cullens and Sterlings — who were ready to turn their attention to good works and didn’t have the established network of charities that exists in, say, Philadelphia to exert a claim on their money. It was in a state whose government was rich and education-conscious, and a country whose government was rich and science-conscious. A medical center was the ideal focus for all these forces. It would be big and visible; it would benefit humanity; it would be a center of learning and technology; it would attract attention. All that was exactly what Houston wanted, and the Medical Center became the city’s central civic enterprise in a way that medicine is not in other major cities. It would come to dominate the city’s noncommercial life. It would become Houston’s glory and its redemption; it would be loud, rich, demanding of attention; it would, like Houston itself, get things done. The Chronicle summed up the city’s hopes for the medical center in a banner headline it ran in 1950: CITY GOES BIG LEAGUE WITH FAST-GROWING MED CENTER.

THE EMPIRE OF DR. DEBAKEY

Medical institutions can be created by lawyers and bankers and oilmen but they can be made famous only by doctors, and Texas Medical Center’s next stroke of good fortune was that it attracted some extraordinary ones. The first was Randolph Lee Clark, a big, barrel-chested surgeon, born in the Panhandle and trained in Virginia, Paris, and at the Mayo Clinic. In 1946 he signed on as the director and surgeon-in-chief of the M. D. Anderson Hospital. Clark was the first of what would become a migration of doctors from other cities to Houston and the Medical Center. What attracted him was what has always attracted people to Texas: big opportunities. In a way this is a euphemism for money, and in a way it isn’t. In Clark’s last year of private practice, 1941, he made $158,000; his starting salary at Anderson was $12,000. But the institution had a great deal of money and was brand-new, unformed. There would be plenty of facilities in Houston and no long years of waiting around for a brief turn at the helm. Those were Clark’s reasons for coming, and variations on them have been why hundreds of others have come since then. “People in the East,” he says, “were given a small, circumscribed territory. That’s why they left. Here in Texas your territory isn’t that limited.”

Clark built M. D. Anderson into one of the Big Three American cancer centers (the others are Sloan-Kettering and Roswell Park in New York) chiefly through two means: his enormous powers of persuasion and his penchant for thinking big. The most important recipient of his persuasive powers has been the Legislature, his most significant source of funds, where, in the words of one senator, “he brings a sack through every year and walks away with everything but the Capitol dome.” He is what is known in the trade as a medical statesman, which means that he can explain simply and forcefully what he needs money for, an ability most doctors lack. As for thinking big, his motto, framed on his office wall, is “Make no little plans,” and he likes to compare Houston today, in all seriousness, to Renaissance Florence. Now 72, Clark is an extremely active president emeritus of M. D. Anderson, having turned over the reins last year after getting seven consecutive extensions of the UT system’s mandatory retirement age. Part of his job now is developing a long-range plan for the hospital; he is presently trying to decide where it should turn its attention after (not if) it cures cancer.

In 1948, two years after Clark, Dr. Michael Ellis DeBakey arrived at the Texas Medical Center to take on the chairmanship of Baylor College of Medicine’s department of surgery. A druggist’s son from Lake Charles, Louisiana, he had practiced and taught in New Orleans under the tutelage of the most prominent doctor there, Alton Ochsner. A surgeon like Clark, and like Clark forty years old when he came to the Medical Center, DeBakey was looking for virgin territory, a place where he could do big things. His ambition, however, dwarfed Clark’s; while Clark wanted merely to build the world’s greatest cancer center, DeBakey wanted practically everything. He wanted to be the world’s greatest practicing surgeon. He wanted to build a great medical school and great hospitals around it. He wanted to be a national leader, perhaps the national leader, in the formulation of health policy, and the most prominent authority on all matters medical.

Perhaps as a result of his grander dreams, DeBakey became, much more than Clark, a figure of great complexity — certainly the most powerful man at the Texas Medical Center, arguably the most famous doctor in the world, but also a man capable of tremendous arrogance and unpleasantness, a man who won as many enemies as admirers, and who, in the end, seems for all his power and fame and great achievements curiously vulnerable in a way that Clark isn’t.

DeBakey began his surgical career at the Medical Center at Hermann, the grande dame of Houston hospitals and chief stronghold of the city’s community of private practitioners. He was immediately unpopular in the medical community. DeBakey is not like most private doctors. He achieved his eminence as a surgeon not just by having good hands — his hands are good, though nobody claims they’re in a different class from those of a dozen of his talented colleagues at the Medical Center — but also by doing more daring operations, and more operations, than anyone else, and by successfully promoting himself. He established what has become the tone of the Medical Center — big plans, fast growth, advanced surgery, lots of publicity. The Medical Center is full of monuments to DeBakey — a bust, a building, plaques. He has been written about, filmed, and photographed more than anyone else there. In 1966, when he performed the first implant of an artificial left ventricle, he invited a Life magazine photographer into the operating room and gave an interview to an ABC film crew upon emerging from the operation. It was natural that he and the private doctors wouldn’t get along. Medical societies still have official rules against publicity. They don’t like someone coming to town and overshadowing all their work. They don’t like professors at medical schools carrying on huge practices and using up a lot of hospital beds. In the fifties, Hermann broke its affiliation with Baylor and became once again a nonteaching hospital. DeBakey moved his base of operations to the less-established Methodist Hospital, two hundred yards away.

His specialty in those days, the early fifties, was vascular surgery — surgery on the blood vessels. He repaired vessels that were clogged with fatty material built up as a result of advancing years, high blood pressure, smoking, cholesterol intake, and genetic factors. A surgeon can cut open an occluded artery, take out the obstruction, and sew it back together; or he can bypass the obstruction by attaching to the vessel another channel through which the blood can flow around the blockage. DeBakey was a pioneer in these techniques. He was also a leader in developing operations to remedy a second form of vascular disease, aneurysms — sections of vascular wall that balloon out like weak spots on an overinflated inner tube. An aneurysm in a blood vessel is weaker than the healthy part of the vessel, and therefore in danger of bursting; the surgical remedy is to cut it out and sew the vessel back together, or to replace part of the vessel with new tubing. In surgery on both occlusions and aneurysms, DeBakey introduced the use of Dacron as an effective replacement for the human tissue of vascular walls. In all these cases the world of medicine generously credits DeBakey with great strides, and DeBakey credits himself even more generously. His book The Living Heart mentions his own contributions dozens of times, and mentions Denton Cooley not at all.

Cooley was the most prominent member of a team of talented young surgeons that DeBakey brought to Baylor in the fifties. Cooley was a native Houstonian, a product of the University of Texas and the Galveston Medical Branch. He had gone on to train in Baltimore and London and to become the country’s most promising young heart surgeon. As such, he was the perfect complement to DeBakey, the great vessel man. What attracted Cooley to Baylor was DeBakey’s reputation and his volume of work, the chance to return to Houston, and the new Medical Center. E. W. Bertner was Cooley’s mother’s obstetrician and therefore (as Cooley is fond of pointing out) the first man he ever saw. Growing up, Cooley often heard Bertner talk about his grand plans for the center. “‘Not everyone appreciates what the future holds,’ Dr. Bertner used to say,” says Cooley now. “He used to say it would be the most renowned medical center in the world.” In the middle and late fifties, DeBakey and Cooley’s surgery attracted worldwide attention, and incidentally brought prosperity to Methodist, which became the Medical Center’s largest hospital and filled 20 to 25 per cent of its beds with cardiovascular patients.

Those were the years when the federal government began heavily subsidizing medical research — which before World War II had been largely the province of doctors who happened to inherit fortunes — and DeBakey was in the thick of that, too. In 1948 Congress established the National Heart Institute (now called the National Heart, Lung, and Blood Institute), and throughout the fifties and sixties DeBakey testified frequently on Capitol Hill. In 1964 DeBakey’s old friend Lyndon Johnson appointed him chairman of the President’s Commission on Heart Disease, Cancer, and Stroke. After years of making its most spectacular advances in immunizing people against acute diseases like polio, medicine was turning its attention to chronic, noninfectious diseases like cancer and heart disease. Dr. Jonas Salk was the last hero of the acute era; DeBakey was the first of the chronic era.

To the press, his patients, politicians, the wealthy, celebrities — everyone except his own employees — DeBakey is charming and impressive. As a public speaker, he is probably without equal in medicine. He speaks in a courtly Louisiana accent, explaining the most advanced concepts in language that a layman can understand, exuding dedication, sincerity, and a sense of the importance of his work. In private he must be equally winning, for he has assembled a large collection of devoted friends among the powerful and famous. He has operated on King Leopold of Belgium (Princess Lilian in gratitude erected a bronze bust of DeBakey outside Methodist), Guy Lombardo, Joe Louis, the Duke of Windsor. Howard Hughes was on his way to Methodist when he died in a plane in 1976. Jerry Lewis credited DeBakey with saving his life by breaking him of an addiction to pills last year, and has given Baylor and Methodist the Jerry Lewis Neuromuscular Disease Research Center. A large contributor to the DeBakey Medical Foundation is his friend Frank Sinatra, who gives $20,000 a year.

Nor has DeBakey ignored the prominent citizens of Houston. He has built strong ties to the business community and to several people with large personal fortunes, who have been very good to Baylor and Methodist over the years. It is easy to understand the claim DeBakey exerts on these people: he has been the great man in their midst, the good cause, the bringer of the world’s acclaim to Houston. DeBakey is particularly close to Ben Taub, a retired tobacco wholesaler and investor with whom he used to breakfast every Sunday, and to Mrs. W. W. Fondren, the widow of one of the founders of Humble Oil. Both have been extremely generous to the Texas Medical Center; both are in their nineties now and are quietly in residence at Methodist Hospital.

DeBakey is a driven man. He works seven days a week, many hours a day — it’s hard to tell how many because he prefers to conduct much of his business in secrecy. Legends about him abound: DeBakey sleeps two hours a night. DeBakey sleeps for fifteen minutes every three hours and not at all at night. DeBakey never walks, only runs. DeBakey won’t let the resident in charge of the cardiovascular intensive care unit ever leave the hospital during the two months he is on duty there. One story popular among medical students is that once the wife of one of DeBakey’s residents was having a baby and he asked permission to be at her side. Fine, DeBakey is supposed to have said, two hours off will be enough, won’t it? He is a very serious man who believes in being tough on people. He dominates those around him. The students and residents at Baylor are proud of his renown, but not many really like him.

As he was becoming more and more famous as a surgeon and medical statesman, DeBakey was also coming to dominate Baylor College of Medicine. In the sixties, in addition to mastering cardiac surgery, appearing on the cover of Time, transplanting hearts, and receiving honors around the world, he became Baylor’s president and chief executive officer. In 1969 the school severed its ties with Baylor University, mainly because, as a Baptist institution, Baylor had objections to receiving the tax funds a medical school so desperately needs. At the same time the medial school’s board of trustees was dissolved and DeBakey assembled a new one, headed by L. F. McCollum, a Methodist Hospital board member and retired chairman of Conoco.

In short order, Baylor raised $32 million in private funds for buildings and salaries; obtained from the Legislature the most generous funding that any private medical school gets from any state government, $12 million a year; built the $34 million Neurosensory Center in partnership with Methodist; increased its annual budget from $18 million to $70 million; won $26 million in grants from the National Heart and Lung Institute for its first national demonstration center, beating out thirty other medical schools; and recruited a spate of bright young department chairmen from all over the country. Now workmen are finishing the new twelve-story Michael E. DeBakey Center for Biomedical Research and Education at Baylor, and the school is kicking off another major fund drive, called the Campaign for the Eighties.

The board has played as important a part as DeBakey in all this, by raising money and helping to woo new stars to Baylor. When Stanley Appel, a hot ticket in academic medicine, came down to look at Baylor last year before accepting the chairmanship of the neurology department, the board gave a dinner for him at the Petroleum Club at which every member stood up and gave a little speech, saying how much he wanted Stanley Appel to come to Baylor College of Medicine and what he personally would do to make sure Appel’s career there would be a happy and fruitful one.

“In the next decade,” says Appel, who turned down a similar job at Harvard to come to Baylor, “it will be far easier to bring intellect to money than money to intellect. In the sixties the National Institues of Health were so bountiful that anybody could get support for his research. Now the ‘haves’ are the places where the community has the resources to support the program. When I looked at Baylor, I said, show me a commitment. They said, here’s a building, the Neurosensory Center. That’s a rather tangible commitment — thirty four million dollars. That’s damn unusual. The ambience of Houston, in addition to boomtown, is a sense in the community . . . well, it’s almost like tithing. That’s the way Houston feels about the Medical Center.”

Along with Baylor, Methodist Hospital has done very well. It now has 1200 beds and a $95 million physical plant and is building the new Total Health Care Center across Fannin Street. Cooley’s present bailiwick — St. Luke’s, Texas Children’s Hospital, and the Texas Heart Institute — has assets of $117 million and 1008 beds. By comparison, Massachusetts General Hospital in Boston, probably the most distinguished teaching private hospital in the country, has 1082 beds. And the daily semiprivate room rate at St. Luke’s and Methodist is about $92, compared to $189 at Mass General.

Dr. DeBakey is a very busy man, and I was never able to arrange to get more than a few glimpses of him. On the day I was supposed to interview him, I presented myself in the cardiovascular surgical suite at Methodist at 8:30 in the morning. One of his nurses led me up to the observation room above one of the operating rooms, where I could watch through a glass dome as DeBakey performed one of the four operations on his schedule that day. On the operating table was a draped body, lying with only its neck visible. DeBakey’s assistants were cutting the neck open and exposing the carotid artery, which carries blood to the brain.

Presently DeBakey strode quickly into the operating room, a deep frown on his face. At seventy, he is still wiry and erect. His hair, once graying, is not jet-black. He was wearing white leather boots with three-inch platform heels. Every other surgeon at Texas Medical Center, Cooley included, operates in a green hospital-issue scrub suit; DeBakey wears royal-blue scrubs with his initials embroidered on the breast pocket. He clapped his hands and a nurse held up a surgical gown for him to step into; then he went to work. With an air of fierce concentration, he blocked off a short stretch of the artery, which is about the width of a pencil, with clamps and routed the blood through a plastic tube past the blocked section. Then he cut open the artery, scraped out some pale yellow material, and sewed a small patch of Dacron over the incision. He removed the plastic tube, sewed up a few leaks, and sutured back together the patient’s muscles, then the fat, then the skin, his hands moving quickly and surely. This was a routine operation for him, and it took him less than half an hour.

From the observation room I went upstairs to DeBakey’s suite, which had a metal plaque outside proclaiming it to be the Michael E. DeBakey Heart and Blood Vessel Center. After a short wait, DeBakey walked in and sat down, looking preoccupied. He is not a handsome man but certainly an impressive one, with a wise, deeply creased face, a great leonine head, and big, long-fingered surgeon’s hands. He shook my hand and said he was very busy, that he had only a few minutes to spare and didn’t want to waste any time. After a few minutes of perfunctory conversation he went back into his office.

DeBakey still does delicate surgery, still flies all over the world, still testifies in Washington and lobbies in Austin, has a young wife, and a one-year-old baby, wields enormous power, has both achieved more and been recognized more than most people ever dream of. He even gets along with the private medical community now. But he is also inescapably 70 years old and that can’t make him happy — what other explanation can there be for the dyed hair and the platform heels? His mentor, Alton Ochsner, retired from surgery at 70. His rival, Cooley, is only 58. DeBakey can’t operate for too many more years; even ten years ago, when Thomas Thompson wrote Hearts, the talk was that he was not as good as he used to be. Nowadays, one hears passionate defenses and denunciations of his ability. After watching him work, I would feel confident about having him operate on me. But no surgeon can go on forever. DeBakey has built his whole life on never slowing down, never letting anyone surpass him, and soon he will have to.

Very quietly, the Baylor trustees DeBakey selected ten years ago have set up a search committee to look for his successor as the medical school’s president. Late last year they gave him a new title in addition to president and chief executive officer: chancellor. This was publicly presented as just another honor. In fact, it was designed to be a title DeBakey could retain after his retirement, which, it is said, will be announced later this year. To be sure, he will continue to be extremely active in the affairs of the school, and for that reason it is unlikely that the board will confer presidency on a strong-minded outsider. Whoever becomes president, DeBakey is certain to go out in a new shower of accolades. But it is impossible to believe that that will finally make him content.

BREAD AND BUTTER

On a Monday afternoon not long ago, Ernest Salazar checked into the Neurosensory Center for an ear operation. He was a prototypical Texas Medical Center patient. He had come there for an advanced surgical procedure, to be performed by an academic doctor in an expensive specialty wing. What gets the glory at the Texas Medical Center is the spectacular rate of growth, the research, the towering figures, the heart transplants; but the bread and butter of the place is provided by people like Salazar. Operations like his are what the Texas Medical Center does all day.

A friendly, calm man of 39 who works as a business analyst for Gulf Oil in Houston, Salazar has always been in excellent health except for his ears. From early childhood he had painful infections that eventually ate away his eardrums, impaired his hearing, and made it impossible for him to go swimming. As he grew up the infection subsided and he came to accept his bad ears as his fate. But four years ago, when he moved to Houston from Ohio, the pain flared up again and he decided to have something done. His wife’s doctor recommended that he see an old acquaintance of hers from medical school, Dr. Bobby Alford, chairman of the department of otorhinolaryngology (ear, nose, and throat) at Baylor College of Medicine. Salazar had contacted a doctor downtown on his own, but he decided to go to Alford instead. “Baylor, head of department — it sounded pretty good to me,” he says.

He came to be very happy with his decision. In 1975 and 1976 Alford operated on Salazar, once on each ear, building him a new set of eardrums and rearranging his middle ears to improve his hearing. As a result of these operations he was no longer in pain, he was able to swim, and he could hear better, though still not perfectly. Now he was ready to start the second phase of his treatment. Alford wanted to operate once more on each ear, in order to check its progress and to try to further improve Salazar’s hearing. Alford had told Salazar that while the first series of operations had been absolutely necessary, the second series was elective, but Salazar had been enthusiastic about going ahead with them. The next morning, then, he would have his third ear operation, the second on his left ear.

Thirty years ago, an Ernest Salazar could almost certainly not have had that operation. Thirty years ago there was no Texas Medical Center and few places in the country specialized in advanced ear surgery. Thirty years ago the microsurgical techniques used on Salazar’s ears didn’t exist. Perhaps more important, thirty years ago a middle-class person like Salazar couldn’t have afforded this sort of elective operation.

Like most salaried Americans today, Salazar had a group medical insurance policy at work that would cover the lion’s share of the cost. In 1940, 10 per cent of Americans had some form of medical insurance; today, over 80 per cent. The growth of health insurance is one of the developments that made the Texas Medical Center possible. “If I had to pay for it out of my own pocket,” said Salazar the evening before the operation, “I’d have to think twice about having this operation.” As it was, the operation, which wasn’t strictly necessary and might not accomplish anything, had a direct cost to the patient so low as to make it worthwhile. In a country with a socialized medicine system like England, Salazar wouldn’t have had to pay a penny for such an operation, but on the other hand he would have had to wait months for it if he could get it at all. Health insurance means that in this country we have a sort of socialized medicine for the middle class, which means more medical procedures are performed than if there were no insurance. That’s one reason our health bills — and inflation — are so high.

On the morning of the operation, Tuesday, a nurse awakened Ernest Salazar at six and gave him a Valium tablet, followed by a shot of morphine. Feeling drowsy, he put on a light gown and was wheeled into the surgical suite. In the operating room the anesthesiologist inserted a needle attached to a small plastic tube into his arm and said he was going to drip sodium pentothal through it. That was the last thing Salazar remembered.

A little before nine, Alford came into the operating room. Salazar was completely covered with sterile surgical drapes, except for his left ear. Alford sat down on a stool next to the operating table, pulled over a high-powered microscope, and peered down Salazar’s ear canal. He could see the eardrum he had built, a pearly-gray sheet of muscle that had grown in perfectly. Then he pulled back Salazar’s ear, took a scalpel, and began to cut.

He made a semicircular incision about four inches long just behind the ear, carefully deepening the cut and stopping the flow of blood with an electric instrument called a Bovie, which looks like a soldering iron and cauterizes the blood vessels. Presently Alford reached the ear canal with his scalpel. He took a plastic cord and ran it through his incision, into the ear canal, and out the ear. Then he tied back the ear like a flap, leaving it looking only precariously attached to the head, and peered into Salazar’s middle ear through the microscope.

Under high magnification, Salazar’s middle ear was a beautiful sight. Against a background of luminescent china-white bone, delicately filigreed with tiny red blood vessels, there stood little white projections that looked like a strange kind of plant life. Alford poked around with long-handled, needlelike probes and pondered his next move.

In the middle ear there are three minuscule bones — the malleus, the incus, and the stapes — which through vibration transmit sound waves from the eardrum to the inner ear. Alford could see that there was no infection there, which was good, and he could also see why Salazar’s hearing was imperfect. In the earlier operation Alford had removed Salazar’s diseased malleus and rearranged his middle ear so that vibrations would be transmitted directly from the incus to the stapes. But in the intervening time an infinitesimal space had opened up between the two bones. What Alford had to do was improvise a way of closing that gap.

He asked the nurse to bring him an incus from a freezer in the operating suite where such spare parts are kept, and turned his attention to Salazar’s mastoid bone. With a drill, he slowly cut a small chip of bone out of the mastoid, taking care to avoid hitting the facial nerve. When he was finished he drew out the chip with a tweezers. It was about twice the size of one of those “tiny time pills” that come in cold capsules, and the spare incus was just a little bigger. Then Alford swung the microscope back to the middle ear and dropped the bone chip into the gap he was trying to close. There was still a little space left, so he dropped the spare incus in too. To hold everything in place, he stuffed the cavity with small puffs of a special plastic that dissolves in a few days, untied the flapped-back ear, sewed it up, and packed the ear canal with cotton wadding. The operation was over at 11:15 a.m.

At 3:30 p.m. Salazar woke up in his room, feeling woozy, a big bandage on his ear. He dozed off and on for the rest of the day, and the next day he went home. Five weeks later Salazar went back to the Neurosensory Center, his bandage off and the packing removed, for a hearing test. As it turned out, his hearing had improved so slightly that he couldn’t notice any difference. His out-of-pocket expense for the operation had been $102, with the insurance company picking up the rest. The hospital’s bill had been $1098.89; the anesthesiologist’s, $304; and Alford’s, $710, for a total cost of $2112.89.

“I guess what I got out of it was that he was able to examine the ear and see if there was infection,” Salazar said. “And I’m very happy about that. I’ve got no complaints. I’ve got to look at the whole program. When I came to Dr. Alford, I was in pain. I couldn’t swim. How could I complain?”

THE MAKING OF A DOCTOR

At about nine o’clock on a Friday night in December, a man named Ernie Smith wandered into the emergency room of Ben Taub General Hospital. He walked up to the triage desk, where nurses decide which patients will be treated immediately and which will have to sit in the waiting room until there is a free moment for them. Because Ernie’s head and face were almost completely covered with blood, the triage nurse sent him in for treatment. Over the loudspeaker, someone said, “B Team, patient check,” and Dr. Roxann Rokey resignedly walked over to take a look.

Ernie was not only bloody but also filthy, dressed in tattered clothes, and very drunk. He was a big white man in early middle age, and for all his problems he had a rakehell, devil-may-care insouciance about him. Rokey considered him for a moment, then pushed his nose with her finger. It was soft and squishy. “Does your nose usually look like that?” she asked him.

“I don’t know, doc,” said Ernie. “Does yours?” He grinned broadly and looked around at the other doctors, nurses, and policeman, hoping for a laugh. “Payday,” somebody mumbled.

“That’s a good girl there,” said Ernie, obviously overcome with remorse at having made a joke at Rokey’s expense. “You going to take care of me?” She said she and the other doctors would, and dispatched him to the suture room, where a third-year medial student cleaned his face and sewed him up. “A guy took me out,” Ernie explained to the student, who seemed less than fascinated with his story. “On the street. And I didn’t even have fifteen dollars. I’m no stool pigeon, doc, but I tell you what. I’m gonna get him. I’ll pay his hospital bills, too, and I ain’t no Howard Hughes.”

Roxann Rokey is a first-year medical resident at Baylor College of Medicine — in other words, she’s what used to be called officially, and still is called informally, an intern. A medical internship is one of the great rites of passage in American life, a grueling year spent learning to be a doctor, with time off only to sleep and sometimes not even for that. “It’s sort of like an extended fraternity hazing,” says one intern at Baylor. “The older doctors say, ‘If we went through it, you can too.’” A generation ago interns had to work as much as 36 hours straight, for as little as $50 a month; now it’s more like 12 or 18 hours at a stretch and $10,000 a year. For the month of December Rokey had been working from 7 p.m. to 7 a.m., seven days a week. Her husband, also a Baylor intern, was working from 7 a.m. to 7 p.m., and on that Friday night she hadn’t seen him in five days.

Baylor interns work at several hospitals — Methodist, St. Luke’s, Veterans’ Administration — but Ben Taub is the most important part of the internship. “Big city hospitals are places to see a lot and do a lot,” says one doctor who trained at Ben Taub. “You work hard, the pay is terrible, and you need a strong stomach. People who like to do go there. At Ben Taub, it’s up to you — you get out there and do it. At Methodist you do histories and physicals. You’re somebody’s boy.” The reason urban charity hospitals are the best places for a doctor to train is not a pleasant one. The reason is that it’s difficult to learn to be a doctor in a private hospital. The only way to learn to be a doctor is by doing, and paying patients don’t like to be the ones doctors learn on. So most American doctors learn on poor people and then move on to treating people who can pay for medical services.

“If you’re an indigent patient,” says Richard T. Eastwood, executive director of the Texas Medical Center, “there’s more willingness to have eight medical students, residents, and interns hovering around you as a doctor explains what you have. If you were paying the whole bill you wouldn’t want a bunch of students punching you around and taking a long time to diagnose you. If you were well-to-do you might not want a resident to deliver your child. But if you weren’t paying you’d be glad. Public patients are available as teaching material. They’re especially important in training surgeons. When you do your first operation, it’s not going to be on Mrs. Fondren.”

In July 1949, the Houston oilman Hugh Roy Cullen announced that he was willing to donate $1.5 million for a new general charity hospital in the Texas Medical Center to supplement the existing charity hospital, Jefferson Davis. Early in May 1963, almost fifteen years later, Ben Taub General Hospital finally opened its doors, the only purely charity facility in the Medical Center and the only one that the can-do city of Houston didn’t build efficiently and impressively. The building of Ben Taub (named for a close friend of DeBakey’s who was Houston’s staunchest supporter of charity hospitals) was held up all those years by an endless chain of controversies. No aspect of the hospital’s planning went smoothly, and by the time it was finally built Cullen had pulled out his funding and the project had been repeatedly scaled down. Today the elevators at Ben Taub have buttons for ten floors, but the hospital has only six.

Among the many roadblocks to the hospital’s construction, two stand out: the unwillingness of the citizens of Houston to pay to operate it, and the fervent opposition of the Harris County Medical Society to its being located in the Medical Center and controlled by Baylor, which desperately needed a nearby affiliated charity hospital in which to train its students and residents. The medical society complained that Baylor professors would use the hospital to conduct private practice, and as a result a part-pay clinic was dropped from the plans. The Medical Center site, the private doctors said, would be too far away from the parts of town where most of the poor lived and would create traffic and parking problems. As for the citizens of Houston, they four times voted down the establishment of a Harris County Hospital District that could levy taxes in order to finance the hospital’s operation.

With the help of its traditional allies, the Houston business and political establishments, Baylor won the battle over the site, but Ben Taub had to open with no hospital district, woefully underfinanced. Then came the publication, in 1964, of what is still known in Houston medical circles as The Book: The Hospital by Jan de Hartog, a Dutch writer who during a year in Houston as a visiting professor had worked as an orderly at Jefferson Davis. The Book led to a spate of publicity about the conditions at Jefferson Davis and Ben Taub, and in 1965 the hospital district finally passed. Today Baylor has its teaching hospital and Houston has a good but, for a city its size, unusually small charity hospital (470 beds; Dallas’ Parkland Hospital, for example, has 800).

Ben Taub is obviously different from the rest of the Medical Center. It stands forlornly off in a corner of the plot of land, the only institution in the Medical Center that faces out toward Hermann Park rather than in toward the other hospitals. It has a special entrance and is inaccessible from any of the streets inside the Medical Center — Freeman Street and M. D. Anderson Street and the rest. And it is sealed off from its neighbors by a somber, gray brick wall.

Ben Taub is not a pleasant place to learn to be a doctor. Besides the exhaustion, residents must face a hospital overcrowded with people who obviously lead terrible lives and are also terribly ill (60 per cent of the admissions are through the emergency room, and the patients upstairs on the wards, as one intern says, “would be in the intensive care unit in other hospitals”; by comparison, the quiet emergency rooms at Methodist and St. Luke’s are almost vestigial). Patients scream, moan, and gasp with pain; they are disfigured and ill-cared-for; by the time they arrive, their diseases have progressed far past the point when they should have sought medical help. They are victims of society in a general sense; in terms of specific cause and effect, which is what doctors are trained to look for, they are victims of themselves — alcoholics, people who have gotten in knife and gun fights, diabetics who won’t take their insulin, reckless drivers, and drug addicts. The only common ailment at Ben Taub that is not the patient’s fault is hypertension, perhaps the greatest chronic health problem among blacks.

As a result, compassion for the patients does not run high. “It’s really hard to get up for treating these people who keep coming back here again and again,” says Jerry Goldberg, another Baylor intern, more political than most. “It’s hard to get altruistic like I was in SDS. Some of the patients we call slugs. They’re disgusting people. They won’t take showers or anything.” The first response to that is to concentrate on the individual patient and to regard the broader question of the health of indigents as permanent and insoluble. Even the patient is easier to deal with as a medical problem than as a person. “The first time you walk down the ward and hear people screaming, it gets you right here,” says Goldberg, clutching his midsection. “But after a while you stop paying attention to it. You just use the pain as information.”

One night at Ben Taub a white hippie came in unconscious, having overdosed on drugs. Two residents took him into a treatment room and stripped off his shirt, commenting contemptuously as they did so on how dirty he was. They figured he had overdosed on heroin, so they injected him with naloxone, a heroin antidote that is supposed to bring on instant cold turkey. Nothing happened. They tried another dose. The hippie still lay there unconscious. A third resident ducked his head in, saw what was happening, and walked out to the waiting room to talk to the hippie’s girlfriend. A minute later he came back. “For chrissakes,” he said, “didn’t anybody think of asking what the guy took? I just asked his girl friend. It wasn’t heroin. It was barbiturates.”

On that Friday night in December, the only patient at Ben Taub by whom the doctors were visibly moved was a little boy named Anthony, who was bruised and crying when his mother brought him in. She said someone had broken into their house, hit Anthony with a broom, thrown him against a wall, and left. The residents obviously didn’t believe her, and treated her with frosty, tightly controlled politeness, while clucking and cooing over Anthony. He was the only obvious victim that night.

A little after midnight that night, the first Code Three (the most extreme of emergency cases) of the evening came in. The emergency room had been forewarned via radio of his arrival by the two men in the ambulance that picked him up, who were taking orders from the fire department paramedics who work in Ben Taub’s telemetry room. The men in the ambulance had hooked up electrodes to the patient’s chest, so that his heart’s rhythm was visible on the paramedics’ oscilloscope screen.

Curtis Watson was the paramedic monitoring the case. He stared at the oscilloscope, which showed a wildly intermittent heartbeat. “It’s a gunshot,” he said. “the EKG is going crazy. They can’t get an IV line in him. They put the wrong goddamn tube in him.”

He picked up a microphone. “Are you squeezing that bag good? Are you doing CPR?” He turned and resumed a conversation he was having with a friend about the sorry lot of a fire department employee whose fate it is to be an emergency medical technician. “And all the guys back at the fire station call you a gut-scooper. That’s the worst part. They say you wouldn’t make a pimple on a fireman’s ass.” He picked up the microphone again. “Keep somebody on that boy all the time, goddammit. Get that second line started.” He turned around again. “He’s dead. He’s a goner. I guarantee it.”

Indeed he was. Ten minutes later the ambulance pulled up and the driver and technician rolled the man in, pumping furiously on his chest. He went straight into one of the emergency ward’s two trauma rooms, where the residents and nurses lifted him up onto the table. Because the man had been shot in the back, there was no sign of his injury except that his abdomen was bloated from internal bleeding. A big, gray-haired black man in his fifties, he looked perfectly at peace lying there in his roomy striped boxer shorts. The third-year surgical resident, Dr. Joseph Perlman, felt his pulse and shook his head. “Nothing,” he said. “He’s DOA.”

“No, he’s not,” said one of the emergency room nurses. “He’s an ER death. If you bring ‘em in here and then pronounce ‘em, that’s supposed to be an ER death.”

“He’s DOA,” said Perlman, but when he looked at the nurse he saw a look of total bureaucratic rigidity on her face. “Okay, he’s an ER death. If that makes you happy, fine.”

“It doesn’t make me happy, but that’s what it is,” said the nurse. Somebody wheeled the dead man out and attached a tag to his big toe. The next day’s paper said he was Alfred Prescott, shot by robbers who had broken into his house, Houston’s 434^th homicide victim of 1978.

By now the emergency room was jammed with patients — victims of stabbings, gunshot wounds, auto accidents. At about two in the morning, a young Mexican American named Valiente walked into the emergency room, his shirt soaked with blood. The residents led him into one of the trauma rooms and cut away his clothes to reveal a body completely covered with elaborate, beautiful tattoos. Somebody had stabbed him in a pool hall on Lyons Avenue.

Perlman gave him a local anesthetic, cut open his wound a little, and poked a gloved finger inside it. Valiente, naked, in pain, in a room full of strange people, with tubes in his arm and his penis, looked on in horror. “Hey, doc,” he said to Perlman, “do I get a chance? I need odds, man, odds.”

“The odds of your dying are real slim,” Perlman said, “but the odds you’ll need an operation are real good.”

A few minutes later another Mexican American walked in, also suffering from a stab wound, also tattooed front and back: Valiente’s brother-in-law, Evaristo. “Where’d you get those tattoos, Evaristo?” one of the nurses asked him. He rose up a little with great effort and muttered, “In college,” smirked, and sank back, exhausted, onto the table.

As the two brothers lay waiting for x-rays, another stabbing victim came in, all the way from Jacinto City, in one of the city’s ambulances. The ambulance driver followed him into the trauma room, a worried look on his face. “Um, listen, man,” the driver said to the young man, who was writhing in pain on the table, “since you’re not a resident of Jacinto City the ride’s gonna cost you thirty bucks. You want to pay now or you want me to bill you?”

With what seemed to be the last of his strength, the young man grunted, “Bill me.”

The ambulance driver shrugged apologetically and said to the assembled doctors and nurses, “I’m required to ask that.”

“One thing you have to remember,” said one of the residents, under his breath. “The zoo does not end at Hermann Park.”

That night, from 11 p.m. to 7 a.m., the emergency room saw 89 patients. Forty-two had some kind of trauma or extreme injury — 12 aggravated assaults, 12 auto accidents, 5 gunshot wounds, 9 stabbings, 3 drug overdoes, and 1 cardiac arrest. In the morning, 20 of the 89 went upstairs to the wards, admitted as patients. Two went downstairs to the county morgue, which is in Ben Taub’s basement.

If you’re not a doctor, it’s likely that you’ve never spent any time in a place like Ben Taub; that you’ve never saved someone’s life or watched someone die; that you haven’t spent years working on your feet all night as a matter of routine. Doctors are different. They are true professionals. They have genuine expertise. They train longer than anyone else. They can produce results more dramatically beneficial than anyone else, and they confront more of the side of life that most people prefer not to think about. No wonder they’re immodest and impatient with the minor concerns of most of us. They live more apart from the rest of society than other professionals, in a world with its own rules and a strong impulse toward continuity and self-preservation.

The differentness starts early. Most doctors will say they decided on medicine before adolescence, perhaps because of a trip to the hospital or the influence of an admired relative or neighbor who was a doctor. Medicine often runs in families. In any case, it’s very difficult to become a doctor if you don’t know that’s what you want to do by the end of your freshman or sophomore year in college, because the pre-med requirements are so heavy and medical school is so difficult to get into. And to decide to go pre-med is to begin the lifelong segregation from the nonmedical world. “We were all a little different in college,” says a surgeon at the medical center. “We were the kids with thick glasses. We didn’t go to football games. We didn’t go skiing.” Senior residents — having had four years of medical school and at least three of additional training — often go through a phase where they think, “My God, my old friends who aren’t doctors are out in the world, doing things, making money, and I’ve hardly been outside a hospital in years.”

During all that time, doctors are learning how hospitals and the human body work. They often come to think of social problems as insoluble, but they know they can help one person who comes to them sick. Their minds don’t run so much toward thinking about controlling costs, about health in general, or about how society works as toward making people well, one by one.

Besides patients and medicine, what the interns and residents at Ben Taub think about is how tired they are, how much more time they have to spend there, and how to avoid living this way forever. They swap horror stories and try to decide what to do with their lives as doctors — what specialty to enter and what kind of medicine to practice.

None of their options involve real financial risk or hardship. It’s virtually impossible to be a doctor and not make at least four to five times the median family income, and the chances of losing one’s livelihood are infinitesimal once the proper credentials are attained. But there are still important differences among the careers doctors can have.

There is government practice, which means working for a salary on a hospital staff. The hours are regular and there are no office or malpractice insurance worries. The pay is low for a doctor but high for a government employee — a fifty-year-old Army doctor makes about $45,000 a year. Because there is little chance to make great medical breakthroughs or to have continuing relationships with patients, the prestige is not very high.

There is academic medicine, which seems much more appealing to most residents than private practice. The private doctors that a bright young resident sees seem to him to lead dull professional lives. They seem to deal with the same simple diseases over and over while sending their really interesting cases on to specialists, to be behind on the latest medical developments, to be making no contribution to the advancement of human knowledge, and to be faced with terrible financial temptations to perform unnecessary procedures and to book patients for needless stays at the hospital. “There’s a subtle pressure over at the Medical Center,” grumbles one private Houston doctor. “Only if you stay in academic work will you be doing something important. If you open an office, you’re wasting your time.” Like a government doctor, an academic doctor makes less than most doctors and more than most professors. An assistant professor at M.D. Anderson starts at $24,000; a full professor there makes perhaps $60,000; and a senior professor at Baylor as much as $70,000. And medical school professors who are in clinical fields—surgery, for instance—split their fees with their schools according to complex, closely guarded formulas, thus making much more than professors in nonclinical fields like anatomy or cell biology.

In private practice, the money is much better. A well-established private practitioner in Houston has no trouble at all making a six-figure income. One young doctor in his last year of training as an oncologist told me that if he went with a private clinic he would make $50,000 the first year and $80,000 to $100,000 the second. A private radiologist in Houston can make from $200,000 to $300,000 a year. Denton Cooley is said to make well into seven figures. According to its 1977 federal income tax return, St. Luke’s Hospital that year paid their pathologists, Lind, Milam & Associates, $1,849,979. Out of this, of course, must come insurance premiums and overhead. Besides money, the advantages of private practice are personal contact with a loyal flock of patients over the years and less competitiveness than in academia.

The one option residents at the Medical Center almost never consider is practicing in rural areas, although the main reason the state pours money into the Baylor and University of Texas medical schools is that rural Texas is underdoctored. UT is a state institution, but even at Baylor, the only private medical school in Texas, just 1.5 per cent of the operating budget comes from student fees. The theory of the Legislature has been that if the state needs doctors, the solution is to appropriate money to train more of them. But if they’re educated in a place like the Medical Center, the whole thrust of these new doctors’ training is that the successful doctor is one who does advanced, specialized work; a life prescribing minor antibiotics to the people of Texas seems to be a failure to fulfill one’s early promise. Because the demand for medicine in Houston is apparently limitless, there is every incentive to stay there.

As for Roxann Rokey, she is weary of being an intern. She thinks more and more about going into anesthesiology, a field that has regular hours. Young doctors increasingly want to be able to spend their evenings at home, pay enough attention to their children, and take weekends off. The life they’re exposed to in their years at the Medical Center is exciting, but they wonder whether the personal price is ultimately too high.

There’s one other thing the Baylor interns talk about a lot: what happened to three of their classmates. One intern died of heart failure. One shot himself in the head. A third, an aspiring surgeon, graduated from Baylor College of Medicine and went off to a prestigious surgery residency at Johns Hopkins. But at the end of his first year there he was asked not to come back and he returned to Baylor, severely depressed, to start over again as a surgical intern. One night he told his senior resident he was “going out for a Coke,” went to a lab, mixed a deadly solution of cocaine and lidocaine, and injected it straight into his heart.

WINNERS AND LOSERS

If there was a particular day when the Texas Medical Center came of age, it was April 4, 1969. On that day a man named Haskell Karp died on Denton Cooley’s operating table and Cooley brought him back to life by removing his heart and replacing it with a metal and plastic machine. For 63 hours the artificial heart kept Karp alive; in the meantime, Cooley and Mrs. Karp went on national television to make a plea for a new human heart for him. The TV appearance worked—a just-deceased young woman with an intact heart was flown down to Houston from Boston. Cooley transplanted her heart into Karp, who died twenty hours later.

The Karp episode brought the Medical Center’s fame to fever pitch—the place swarmed with reporters and cameramen—but it brought out other things as well. It shortly became apparent that the artificial heart Cooley had implanted was developed under a federal grant in DeBakey’s lab—Cooley may or may not have stolen the plans for the actual heart, but he certainly did lure away DeBakey’s artificial-heart researcher without telling DeBakey and flagrantly violated academic and governmental procedures. The episode led to a final, bitter split between Cooley and DeBakey that was symbolized by Cooley’s leaving the Baylor faculty and DeBakey’s later appearing in a malpractice suit brought by Mrs. Karp that concluded in 1972. It was now apparent that the Medical Center was not growing fast enough to keep everyone happy—that it was a place of intense rivalries and squabbling over space, equipment, and glory.

The artificial-heart incident was also the start of a period of concern about whether medicine ought to impose limits on itself. Six months earlier, the Medical Center had been the world’s most enthusiastic heart transplanter, a place with limitless faith in the practicability of advanced medicine. After the death of Karp the transplants quickly dwindled and people began to wonder whether it had all been worth it. For years there had been no distinction between what doctors could do to keep a patient alive and what they should do, but now a gap was opening up. Could the money spent on transplants be better spent on some other aspect of health? Was it better sometimes just to let people die?

It was during that time that the University of Texas set up its medical school in Houston, the Medical Center’s second. The new school was the biggest institutional addition to the Medical Center since the forties, and its early history has not been smooth. The Texas Medical Center isn’t a simple, ebullient place anymore. It can’t accommodate everyone’s ambitions. In the seventies, some of the people and institutions there have won, but some have had to lose.

By the mid-sixties, Hermann Hospital, the stately old dowager of the Medical Center that had decided to go private while all the other hospitals there were affiliating with Baylor, had fallen on hard times. The other major hospitals in the center—Methodist, St. Luke’s, and Anderson—each had a university affiliation; Hermann did not. Each of the others was strongly identified with one of the major chronic diseases that had, in the years since the conquering of polio, become the focal point of the nation’s medical attention—heart disease in the case of Methodist and St. Luke’s, cancer in the case of Anderson. Hermann was identified with no particular medical cause. The three other hospitals each had a charismatic surgeon-leader with whom they were identified in the public mind—DeBakey, Cooley, and Clark; Hermann had no such figure. The other hospitals had invested heavily in technology, had greatly expanded their facilities, had performed spectacular procedures, had mastered that most important of Medical Center arts, the art of getting publicity; Hermann had not. “Hermann fell further and further behind,” says one doctor who practices there. “It was literally and figuratively perched on the edge of the Texas Medical Center, ready to fall off.”

For all those reasons, the trustees of Hermann, the last bastion of private medicine, decided in the mid-sixties it was time to affiliate with a medical school. Ideally, such an affiliation would not be with Baylor, because Hermann needed a major infusion of money, people, and excitement, and becoming Baylor’s third-string teaching hospital wouldn’t accomplish that. So what Hermann began to push for was the establishment of a brand-new medical school by the University of Texas, with Hermann as its centerpiece.

In the meantime, the University of Texas system had undertaken a study of the state’s medical resources, showing Texas to be severely underdoctored. There were 267,000 doctors in the U.S., but only 11,000 in Texas. One result of the study was that its primary author, Dr. Charles LeMaistre, was catapulted from a professorship in Dallas to the chancellorship of the UT system (he later fell from that eminence and became Lee Clark’s successor as president of M.D. Anderson Hospital). Another result was that, in the 1969 session, the Legislature appropriated $10 million for the establishment of a University of Texas Medical School at Houston, to be affiliated with and physically joined to Hermann Hospital—part of a $49 million package intended to double the number of medical students in the state. Baylor College of Medicine originally had qualms about the establishment of a new medical school in its own back yard, but the university placated it by agreeing that the new school would not tamper with Baylor’s hospital affiliations or steal its faculty. In that same session of the Legislature—whether coincidentally or not is the subject of some disagreement today—Baylor agreed to increase its class size from 84 to 168 in return for a grant from the state for every student who was from Texas. Today that brings Baylor $20,000 per Texas student per year in state funds.

In 1970 the new medical school in Houston hired its first dean, Dr. Cheves Smythe, who had been the number-two man at the Association of American Medical Colleges. Smythe is a witty and charming man through whose veins courses the bluest of South Carolina blood, a career academic doctor raised in Charleston and educated at a New England prep school, Yale, and Harvard Medical School—which is to say that he could not count among his virtues having a great deal in common with the private doctors of Hermann Hospital, Houston, Texas.

The university put up an impressive new building and Smythe built up a faculty from scratch, but from the beginning there were troubles with the private doctors. Suddenly the chiefs of service at Hermann were the newly arrived UT department chairmen, out-of-towners who believed in using patients for teaching. The Hermann doctors didn’t like a bunch of interns and residents crowding into their patients’ rooms to hear little lectures on pathology. Private patients at Hermann were accustomed to being treated with an accommodating, understanding touch, not to being put on display for doctors in training. Most of all, Hermann doctors, like most other physicians, had been trained to believe that their relationships with their patients were almost holy and certainly inviolable. The doctor assumed the burden of total responsibility for the patient’s survival. In return he got total control over the patient’s medical treatment. Nothing—and certainly not medical students—was supposed to get in the way of that.

These were the general complaints; there were specific ones too. Old familiar schedules were changed at Hermann. New nurses were brought on. Comfortable routines were upset. There were renovations of the hospital that meant a temporary reduction in the number of beds and difficulties getting patients admitted. Worst of all, the new department of medicine decreed that all orders on patients should normally be written by residents and not by the patients’ own doctors, a policy that was disastrously unpopular and was dropped after a year and a half.

All the doctors’ bitterness culminated in a meeting in 1971 over the composition of the hospital’s executive committee. UT professors had a solid majority on the committee, and the private doctors wanted to increase their representation. They lost—the composition of the committee remained unchanged—and the doctors realized that their hospital had irrevocably slipped from their grasp.

A few months later two longtime private practitioners at Hermann, Dr. Henry Glass and Dr. Thane Sponsel, got together with about twenty of their friends and decided things had gone too far at Hermann Hospital. It was time to leave and start a hospital of their own. “We just felt there was a need for an acute/general-care hospital where patient care was the primary thing,” says Sponsel today. “There wasn’t a hospital left over there where you could practice medicine.” With money raised by selling limited and general partnerships and taking out bank loans, the doctors bought three blocks of land just across Hermann Park from the Medical Center and built Park Plaza Hospital, which opened for business in April 1975 and is now, with four hundred beds, the largest privately owned, for-profit hospital in the United States.

Park Plaza was a disaster for Hermann and UT. Spin-offs are not uncommon in a major medical center—in the years of Park Plaza’s founding, much of the obstetrics-gynecology department at Methodist was walking out and starting Texas Woman’s Hospital on Fannin Street. In the case of Woman’s, Methodist was strong enough and the spin-off minor enough that the storm was weathered without major trouble. But Park Plaza was an unusually vulnerable hospital. Hermann’s main source of business was not path-breaking heart surgery but long years of goodwill built up between private doctors and their patients, and now that was gone.

When Park Plaza opened, the average daily patient census at Hermann immediately fell by one hundred. By the end of 1975, Hermann was only using 400 of its 620 beds. In the fiscal year of Park Plaza’s opening, Hermann lost $7.5 million. Suddenly UT didn’t have enough patients to teach on.

In late 1975 the hospital brought in a new director to get its house in order, a slick, enthusiastic, management-minded 37-year-old named W.F. “Bill” Smith, who was vice president of a national chain of proprietary hospitals. “When I first came here,” says Smith, “I literally signed all checks and looked over all purchase orders. I went through the mail every day. Plus, in the first three weeks I met around the clock with groups of employees in the auditorium. I told them I knew things were bad and they had to help and if they didn’t they could leave. I said it very bluntly. And it worked.” The next year, the hospital’s deficit was $2.2 million; the year after, $1.9 million; the year after that, $920,000. Hermann is also building ambitiously, and Smith is full of plans for new specialty centers, like a Texas Kidney Institute.

Smith’s major task has been not so much managing the hospital as marketing it. A private hospital like Hermann may be technically nonprofit, and it may not be able to advertise, but like any business it must take in more money than it spends and create a public demand for its services. For that reason publicity is essential, and Smith understood that well. His masterstroke was not the financial controls or the new buildings but an unlikely-sounding program that began in the summer of 1976: the leasing of a helicopter to bring emergency patients to the hospital. Life Flight, as the helicopter program is called (the hospital added a second helicopter in 1977 and a third last year), was the first thing Hermann ever did that showed a real understanding of the dynamics of the Texas Medical Center. The three helicopters are dispatched from a room full of oscilloscope screens and blinking lights in Hermann’s emergency center. When an emergency call comes in from anywhere within 135 miles of the hospital, one of the helicopters starts to rev up. A surgical resident, a nurse, and a pilot all dash upstairs to the heliport and climb in amid an impressive array of medical equipment. The helicopter takes off in a blaze of glory to return shortly with a premature baby, a burned oil worker, or a teenage auto accident victim, each of whom without Life Flight would have been a goner.

Another of Smith’s accomplishments has been to increase Hermann’s public relations staff from four to eight, and Life Flight has been filmed, photographed, and written about more than any other feature of the Medical Center in the last two years. Life Flight has been of great help in filling those empty beds—10 per cent of Hermann’s patient load comes from Life Flight, and these patients stay longer (and pay more) than most. More generally it has, in Smith’s words, “helped in building our image as a tertiary-care hospital” and thus pulled in patients indirectly, too. The only non-fans of Life Flight are the doctors at Ben Taub, where Life Flight patients who have arrived at Hermann, been stabilized, and been found to have no insurance (via a procedure known at Ben Taub as “the wallet biopsy”) are sent for treatment.

UT, however, is still not out of the woods. Life Flight has helped it become a leader in the booming medical specialty of trauma but it still needs more patients for teaching. In the emergency room, Dr. James H. “Red” Duke, a popular, aw-shucksing country boy who listens to (and sometimes sings along with) country music tapes in his office, presides over a trauma specialty operation rivaled only by Ben Taub’s, which has been brought to first rank by Dr. Kenneth Mattox, a young surgeon like Duke, but less country and more intense (his nickname is the Roadrunner). In addition, UT has cancer patients at M.D. Anderson, heart surgery patients at St. Luke’s, and private patients at Hermann, St. Joseph’s downtown, and suburban Memorial; but Baylor has all the public patients and hence all the best teaching material. UT was supposed to have 200 students in a class by now, but because of the lack of teaching patients it is still at 150.

UT appears to have no designs on Ben Taub, but it would like a piece of the huge obstetrical service at Jefferson Davis, the nation’s second-largest deliverer of babies, and coequal status with Baylor at Houston’s Veterans Administration Hospital. It looks, however, as if UT will have no such luck. Both the Veterans Administration, which runs VA, and the Harris County Hospital District, which runs JD, are happy with the job Baylor is doing, and it’s conventional wisdom that splitting academic control of a hospital doesn’t work. And DeBakey is unalterably opposed to sharing the two hospitals with UT.

As for Cheves Smythe, he was fired as UT’s dean in 1975, but remains there as a professor of medicine. “When I came here,” he said not long ago, in the course of recounting his experience in the Medical Center, “I didn’t really understand what I have now come to appreciate. And that is that Texas is different.

Birth and Death

Karen Adams is the head nurse of the Neonatal Intensive Care Unit at Texas Children’s Hospital, which opened in 1974 and contains twenty plastic cribs, in which lie tiny, often misshapen babies who could not survive without the tubes and wires running from their bodies to the machinery that fills the ICU. There are machines that monitor the babies’ heartbeats and blood pressures, oxygen pumps, and oscilloscopes, all emitting various blips and beeps. There is a nurse for every one or two babies, and three to five doctors on duty around the clock. Each day in the Neonatal ICU costs at least $350, and total bills can run as high as $30,000. With few exceptions, the Neonatal ICU is for those with insurance.

Adams gave me a tour of the ICU. We saw a tiny baby, two weeks old, that had weighed a little over two pounds at birth. It was as long as a normal baby, but without an ounce of fat. Its skin clung to its ribs, and its legs and arms were like sticks. The baby was suffering from internal bleeding in the ventricles of the brain, an inoperable condition that is one of the main killers of premature babies. “This one’s probably going to make it,” said Adams, “but as far as brain damage, I don’t know.” We saw a baby with hyaline membrane disease—a disorder of the lungs that makes breathing difficult. A tube pumped oxygen into its mouth; its tiny chest expanded and contracted with what looked like incredible effort. We saw a baby born with its intestines outside its body, waiting in the ICU to gain enough strength for an operation.

“Most of our babies are premature, from high-risk mothers,” Adams said. “When we first started, most of them died. Now most of them live, but at least a couple a month die. Working in the ICU can be both depressing and very rewarding. The strain here can be unbearable. You’ve worked with these babies a long time, and sometimes they just die. You can’t do anything.”

Then we came to a baby I’ll call Gwen, the star of the ICU and another hyaline membrane case, who after six months was finally off the respirator and breathing on her own. Adams picked her up, cradled her in her arms, and kissed her. “This is our pride and joy,” she said. “She’s going home after Christmas, but we get to keep her until then. That’s our present.”

Having a baby in the ICU has been very hard on Gwen’s parents, as it is on most. These parents, often young people who have never had a major disappointment, sometimes want desperately to save their babies, even when it can’t be done. Or they just lose interest in the baby, which they have, after all, barely seen, and that is what has happened with Gwen’s parents. Or they ask the hospital to turn off all those machines and let the baby die. The hospital will do this, but never simply at the parents’ request—instead, the parents and doctors hold long conferences, largely to give the parents the feeling that it was the doctors’ decision. They’ve found that otherwise, sooner or later, the parents will be torn apart by feelings of guilt, even if their baby would have spent an entire lifetime in a coma in a hospital.

One thing that quickly becomes apparent at the Medical Center is how little the most famous medical ethics case of the decade, that of Karen Anne Quinlan, reflects the real world of medicine. The Karen Quinlans—people in comas, being kept alive at great expense—are quietly taken off their machines, and they die. At the Medical Center, this happens almost every day. The only real debate on the point among doctors is between the passive euthanasiasts and the active euthanasiasts. The passive euthanasiasts believe it’s permissible to turn off the machines when there’s no hope the patient will return to consciousness. The active euthanasiasts believe that a doctor ought to be able to terminate the life of a patient who is conscious, is in great pain, and wants to die.

THE COOLEY TOUCH

The Texas Heart Institute is nestled somewhere in the bowels of St. Luke’s and Texas Children’s hospitals, a secret place one comes upon after going up an elevator and through a series of labyrinthine corridors. It has no windows or anything else to communicate a sense of what time of day it is. Everything is very modern and spotlessly clean. Machinery is everywhere. There are patients, of course, but when they’re in the Heart Institute they’re generally unconscious, full of tubes, and connected to complicated monitoring machines, so they are like part of the futuristic landscape.

The Heart Institute was created by and around one man, Denton Cooley, whose bronze bust stands in the lobby. Cooley began planning the institute in 1962, when his departure from DeBakey’s cardiovascular service was complete, and it was formally dedicated ten years later. It is an institution carefully designed to be an efficient setting for the world’s largest cardiovascular surgery service, as well as a pleasant place for the surgeons there to spend the great majority of their time. What Cooley wants out of life is to live in a world where he can operate as much as possibly, under optimum conditions, and to be recognized as the greatest heart surgeon there is. He wants to operate faster and better and more than anyone else, and to take on the cases that make other surgeons throw up their hands. Like DeBakey, he is a prominent citizen of Houston and the world, with the emphasis more on Houston than in DeBakey’s case. He is constantly in the local society columns, and is a member of the local business establishment in a way DeBakey isn’t. If he seems today happier than DeBakey, part of the reason is that DeBakey wanted more, wanted to be a major figure in medical politics as well as a surgeon. Cooley, wanting only to operate, could build an institution around himself, exactly to his specifications, and be happy as a clam. DeBakey, wanting to change the world as well, had to move in an arena so big that he couldn’t possible control all its elements and so had to be always wary and sometimes disappointed. Even Cooley, because of his departure from Methodist and Baylor and his subsequent fame—is one of DeBakey’s disappointments, but DeBakey, precisely because he is so difficult and vain and competitive, may have helped, in a sense, to spur Cooley on to become what he is today. And Cooley, perhaps, has done the same for DeBakey.

The Heart Institute has eight operating rooms and does between 25 and 30 operations a day. In a single year 5000 adults and 1000 children will undergo open-heart surgery there, and another 1000 adults will undergo vascular surgery. About 200 of the 7000 will die during surgery or just afterward. All of these patients come to the Heart Institute because of Cooley’s reputation, but he doesn’t do all the operations himself. Residents and fellows open and close all of Cooley’s patients, and Cooley’s associates do some of the institute’s operations, sometimes to his specifications, sometimes on their own. But Cooley himself has certainly done, and continues to do, more heart surgery than anyone else in the world.

His bread-and-butter operation these days is the coronary artery bypass, an operation popularized in Cleveland in the sixties but now done in greater volume—3000 a year—at the Heart Institute than anything else. The aim of a bypass operation is to route blood around occluded arteries inside the heart, thus relieving angina pain and possibly preventing heart attacks. This is done by removing a length of vein from the leg and attaching one end of it to a coronary artery and the other to the aorta, so that blood will flow through the bypass rather than the artery for that distance. The vein used for the bypass is roughly the size and consistency of a large fishing worm, so sewing it into the heart taxes the eyesight and the hands to their limits. “Bypasses are Chinese water torture,” says one heart surgeon. “They’re lucrative and a good operation, but you start to see ‘em in your sleep.”
They’re also controversial, especially since the publication in 1977 of two studies claiming that the bypass does not prolong life or prevent heart attacks. The august New England Journal of Medicine, which is to medical journals what the New York Times is to newspapers, has warned that the operation is being performed on people who don’t really need it but who believe—without any evidence—that it will make them live longer. The journal said America’s bypass bill is nearly a billion dollars a year (each year about 3000 bypass operations are done at the Texas Heart Institute at a cost of $10,000 to $12,000—with the surgeon’s fee $4000 to $5000 of that—for an annual bypass income of $30 million), and that “the enormous funds already being devoted to this procedure divert support available for other, perhaps more necessary, aspects of medical care.” Virtually everyone at the Medical Center, of course, hotly denies these charges.

The reason people come to the Heart Institute in such numbers for bypasses—which are now available all over the country—is that when you know your chest is going to be opened up and your heart stopped, you want to get the very best care. Most people think the best care means the best surgeon—for pre- and postoperative care, you could stay in your hometown and be ministered to by a less busy organization. Dr. William A. Nolen, a Minnesota surgeon who had a bypass operation and wrote a book about it, decided not to go to the Texas Heart Institute when a friend told him, “Bill, if you think the Mayo Clinic is impersonal, wait till you see Cooley’s operation. It makes the Mayo Clinic look like the warmest, most sociable place on earth.” There are certain operations—on children’s heart defects, or on cases everyone else has given up on—where the reasons for choosing Cooley over anyone else are compelling. For bypasses, they are not; he has an efficient operation, great hands, and a very low death rate, but so do surgeons at a dozen other places. But in matters of this importance, it reassures people to know they’ll be opened up by the best pair of hands in the business, even if the difference between the best pair of hands and the seventeenth-best pair is insignificant.

For people in Houston the advantages are overwhelming because the Heart Institute is right there. The operation has become a sort of status symbol in Houston, and the city is full of men who are proud that they have had their chests sawed open and veins sewed onto their hearts by Denton Cooley, and then been put together again with wire and thread. Most of them say they never felt better, but some of them report one strange side effect of the operation. For about a year afterward, for no reason at all, there will be odd moments when these vigorous and successful men will suddenly burst into tears.

In midafternoon on a Wednesday in December, Cooley strolled into Operating Room 3 of the Heart Institute to do a bypass. By the time he got there, his associates had already opened up the patient’s right leg, pulled out part of the saphenous vein, and put it in a little cup of saline solution. They had sawed open the chest and pried the rib cage apart with a heavy metal retractor. They had cut open the pericardium (the sac around the heart) and routed the patient’s blood via large plastic tubes through a machine that temporarily takes over the work of the heart and lungs so that the heart can be stopped for the operation. Then they had draped the patient, so that all of him that was visible was the heart itself and the top of his head—his eyelids taped shut, electrodes attached to his forehead, his toupee in perfect array.

Cooley walked over to the right side of the operating table and the nurse handed him a scalpel. A big man, he was wearing glasses with what looked like tiny telescopes attached to each lens, and attached to his head was a flexible plastic tube through which shone a bright beam of light. He rested one hand on the heart and with the scalpel began to probe the yellowish surface of the heart for the artery. Completely steady and at ease, he drew the scalpel across the heart, making tiny pokes here and there, until there was a small ooze of blood. He had found the artery.

“Eureka,” he said. “I have found it.” He looked around the table at the assembled surgeons, nurses residents, and technicians. “Now who was it that first said that?” He spoke in a sort of Texas-accented W.C. Fields mumble that indicated he was preparing for a little operating room jiving.

“Archimedes,” someone said.

“That’s right,” said Cooley. “It was Archimedes, an ancient Greek.” He cut a small incision along the artery, making the hole where he would attach the bypass. “Now, Archimedes sat down in his bathtub one day and saw that he was displacing water with his body.”

He picked up the saphenous vein, cut it to shape, and began to sew it to the artery. He used a fine thread attached to a tiny crescent-shaped hook. With a needle holder in one hand he would push the hook through the vein and then through the coronary artery and then he would grab the hook with the forceps in the other hand and draw the thread through, completing the stitch.

“Archimedes felt that as much as he weighed was how much the water he displaced weighed. This was an important discovery. I have some friends who are architects, and they tell me when you build a building first you have to figure out how much that building is going to weigh. Then you dig up that much dirt.” He sewed through the last gap between the vein and the heart and drew them together. “You have to weigh the dirt to make sure it’s exactly the same as what the building’s going to weigh. It’s very scientific, you see. And that”—here he looked up from the heart and glanced around at his audience—“that, my friends, is the principle of real estate in Houston, Texas.”

The next case in that room, and the last case of the day, was a man with an aneurysm in the upper part of his aorta, perhaps the most difficult problem in heart surgery. He was 49 years old, obese, and hypertensive, and he had suffered from terrible chest pains for three years. The mood in the operating room changed completely. Cooley worked in total silence for two and a half hours; the room and the observation dome above were crowded with residents eager to see something this spectacularly difficult attempted.

Cooley cut open the blown-up part of the aorta and removed a mass of clotted matter the size of an orange, so big that it was difficult to imagine that there could have been extra room for it in a human chest. Then he began laboriously replacing most of the man’s aorta with an inch-thick, foot-long Dacron tube.

The great problem in the operation would be time. The heart-lung machine, which reroutes, pumps, and oxygenates the blood while the heart is still and thus makes open-heart surgery possible, can be dangerous if used too long. After too much time on the machine, the blood, already thinned with an anticoagulant called heparin, can refuse to clot. Any of several organs can fail. The safe time to be on the machine is generally thought to be one hour, though Cooley had had this patient’s body temperature lowered to 68 degrees in order to make it safe to be on the machine longer.

Still, the time on the machine was an hour and fifteen minutes, and after Cooley had finished his sewing it became clear that something was amiss. The final ritual of most open-heart operations is taking the patient off the machine, restoring the flow of blood, and touching the heart with two electric-shock disks. At that point the heart should start to beat regularly. The blood pressure should be normal and stable. The blood should be able to clot. But in this case the heart would beat regularly for a while, then irregularly; the blood pressure wouldn’t stay up; and the chest cavity kept springing little leaks. The anesthesiologist injected protamine, a coagulating agent, into the man’s bloodstream, and Cooley kept sewing up the leaks, but every time one was closed there seemed to be a little pool of blood forming somewhere else. Cooley ordered the heart-lung machine turned back on. All that could be seen of the patient besides his chest cavity was a pinkish, well-manicured hand that poked out from under the drape.

A little after seven, having stood at the table for three hours, Cooley ducked out of the operating room and into his office—a room just a few feet away that is cluttered with medical journals, pictures, plaques, 8-track country-music tapes, and television sets—and left his associates to watch over the patient. He drank a Coke, put on a white coat, and took off on his rounds, a resident in tow.

Generally Cooley would walk hesitantly into a patient’s room, smile, and mumble, “Hello, I’m Doctor Cooley. How’re you feeling? We’re going to get you fixed up tomorrow morning, all right? Fine.” In the room would be the patient, lying in bed, his wife at his side (heart disease in adults is primarily a male affliction, because estrogen somehow retards cholesterol buildup and because only in recent years have women smoked cigarettes as heavily as men), invariably watching television. Patients usually seemed surprised to see Cooley, as if they hadn’t known that personal contact with the man who was going to save their lives was part of the deal, and they seldom reacted to his little speech except by nodding and smiling. Thirty per cent of the Heart Institute’s patients are foreign—a planeload flies over from the Netherlands every two weeks—and in those cases Cooley would smile a lot and make some rueful stab at communication. One little girl with congenital heart disease said to him accusatorily when he came into her room, “I know who you are. You’re famous. My mommy showed me a book about you.”

In the hallway between rooms, the resident would fill Cooley in on the next patient. “This next patient is Mr. al-Diab, doctor,” he said in front of one room. “He’s from Iran.”
“Iran, Texas? I don’t believe I’ve ever been to that town.”

“I think it’s up in the Panhandle,” the resident said.

While Cooley was making rounds, Dr. John C. Norman was in the operating room down below, sewing up leaks in the aneurysm patient’s chest, watching the heartbeat and blood pressure and brain waves on electric screens, muttering to himself. He kept sewing and watching and muttering for another two hours. But the patient kept bleeding, and finally his brain waves went flat. Norman told the technician to shut off the heart-lung machine and pronounced him dead.

Weary and depressed, he went up to his office to write the necessary reports. To cheer himself up, he thought for a moment about Mr. Clancy, another of his patients. “Mr. Clancy is going to make it,” he said. “He should be dead. He was dead about fifty times, but we saved him. One we win, one we lose. Of course, you remember most the ones you lose. They leave a little scar. But Mr. Clancy should have been in the morgue by now, and he’s going to go home.”

John Norman is the director of research at the Texas Heart Institute and, aside from being a heart surgeon and a work addict, is different from Cooley in just about every respect. Cooley is a product of San Jacinto High School, the University of Texas, and the Medical Branch at Galveston; Norman went to Harvard, then to Harvard Medical School. Cooley is a passionate believer in free enterprise, a real-estate speculator, a man who can think of no prospect as horrible as working for the federal government; Norman is a liberal who edited a book called Medicine in the Ghetto, a lifelong academic, an enthusiastic procurer of government grants. Cooley is a tall man of relaxed bearing and a deeply chauvinistic Texan; Norman is slight, wiry, constantly in motion, and a loyal Bostonian. Cooley is white, Norman is black. It’s hard not to think that what attracts the two men to each other is the unlikeliness of the partnership, and indeed they milk their differences for all they’re worth, bantering endlessly across the operating table about Boston versus Houston, Harvard versus UT, liberalism versus conservatism.

The bond between them is, generally, a desire to be involved in the biggest and best cardiovascular surgery in the world; both are competitive overachievers. More specifically, the bond is a titanium cylinder about the size of a soup can, with a tube sticking out of each end—the ALVAD, or artificial left ventricular assist device, a replacement part for the most important chamber of the heart. Norman and Cooley are doing the pioneering experiments on the ALVAD in humans.

Norman decided he wanted to be a doctor during his freshman year at Harvard. He looked around for the toughest, most competitive, most challenging thing to do, and hit upon becoming a pre-med. Of his entering class of 1000, 500 were pre-meds, and he knew that only 25 of them would get into Harvard Medical School, so that became his goal.

As he came to the end of medical school he decided he wanted to do his internship at the Peter Bent Brigham Hospital in Boston, for much the same reason he had wanted to be a doctor—it was the toughest and the best. But the professor he was closest to kept telling him he should go back home to Charleston, West Virginia, and set up a quiet family practice. An internship at the Brigham, the professor said, wasn’t for him. To Norman it was obvious what his professor was really saying: it was all well and good for blacks to become doctors, but they were not meant to play the really big medical game. The Brigham turned him down.

Norman didn’t tell the professor, or anyone else, what he thought about that; he only became more determined to rise to the very top. He picked the toughest specialty, surgery, and the toughest subspecialty, cardiovascular. He became a chief resident. He returned to Harvard, still wounded about the Brigham but still quiet about it, and rose steadily up the academic ladder.

Ten years ago, when Cooley put the artificial heart into Haskell Karp, John Norman had at last achieved it all. He was a tenured associate professor of surgery at Harvard Medical School, married to a professor at Boston University, father of a teenage daughter, owner of a beautiful house in the suburbs. He was 39 years old and just coming into the best years of a career at the peak of academic medicine. He was engaged in an important series of experiments with artificial parts of the heart, implanting mechanical left ventricles into hundreds of calves. The fine old world of Boston medicine was horrified by what Cooley, the cowboy, the egomaniac, the outlaw, had done that spring with DeBakey’s heart. He had set back artificial heart research twenty years, given it a bad name. Norman himself disapproved.

But there was something else. Norman was tired of implanting left ventricles in calves. He wanted to try them in human patients. He thought it could work, and he knew that in Boston it could be years and years before he would get his chance. In 1971 he went to Russia to deliver a lecture. On the plane back, Denton Cooley happened to sit down next to him. “By the time we were over Warsaw,” says Norman, “we were talking business. By Paris, we were coming to terms.” In 1972 Norman moved to the Texas Heart Institute.

The first clue a visitor picks up that Norman does not live a normal life is the bathroom in his office. The office itself is large and comfortable; the desk is littered with paperwork, the walls with diplomas and citations. But in the bathroom there is a bowl full of tiny bars of hotel soap next to the shower; a full range of toiletries on the ledge of the sink; and a small but complete business wardrobe hanging on hooks on the door. The fact is, Norman has no residence in Houston. His house and his wife are still in Concord, Massachusetts, to which he returns for a brief visit every month or two. In Houston he sleeps on a bed tucked away in some little-known room of the hospital. But he saves someone’s life almost every day, and he is on the crest of the wave of medical research. He is playing the biggest game.

On December 23, 1975, Norman and Cooley implanted their first ALVAD in a human patient. In 1978, appropriately enough on Valentine’s Day, but with relatively little fanfare, they followed an ALVAD implant with the first heart transplant done in Houston in almost nine years. The ALVAD is still being perfected, but eventually it is supposed to be able to take over most of the functions of a worn-out heart, allowing it to recover, at which point the ALVAD will be removed and the heart will take over again. At this writing, Norman and Cooley have implanted 21 ALVADS in humans whose hearts have stopped working. All the recipients have died.

At 8 a.m. one day in early January Norman appeared in Operating Room 3 of the Texas Heart Institute for his first case of the day. He had been up since 5 a.m. writing up reports and putting to bed the new issue of Cardiovascular Diseases, the Heart Institute’s journal. In the preceding week he had implanted the latest ALVAD, worked through the holidays, entertained his daughter in Houston, mailed off 165 pounds of application material for renewal of one of his federal grants, talked to Joseph Califano, and been asked by the Encyclopaedia Britannica to write its article on surgery. There was no particular reason for him to be in the operating room that morning, or ever, for that matter—his job is to do research, not cut. But he loves it so much that he does both and scrimps on sleep.

The first case was a carotid artery, and Norman began to cut away the fat and muscle to expose the occluded blood vessel. “We’re going to take out the eggs, the restaurants, the late nights, the cigarettes, the bad women,” he said, trimming back the flesh around the vessel. “I can feel the cholesterol in there. It’s like a rock. If your artery clogs up like this you’ll get a stroke.” Now he had a four-inch stretch of artery exposed. “This is more a preventive operation than a curative one. They did the first one in France in ’forty-eight. I think DeBakey introduced it here in ’fifty-one or ’fifty-two. Anyway, he and Cooley popularized it.”

Cooley ambled in, cut open the artery, and took out a glob of yellowish material that felt like a piece of rubber. He cut a small piece of Dacron and began to patch up the incision.

“Dr. Cooley,” said Norman. “Who was it that first did this operation?”

“Denton A. Cooley,” Cooley said.

Up in his office after the operation, Norman said, “Was it Cooley or DeBakey? Who knows? It was probably one of their assistants. It doesn’t matter; they popularized it. This medical center was nothing in 1948. And you couldn’t have picked two better types to build it up. They’re cut from the same cloth. They’re robber barons, megalomaniacs, great talents. I’ve known Cooley since I was a boy. I first heard of him when I was an intern, in ’fifty-four. Since he started, he’s been the hottest thing coming down the pike. He is bloody good. He’s smooth, he’s slick, he’s a gifted person. He and DeBakey are not ordinary people. There’s something in these guys. They’d pay you to let them operate on you, if they had to. Look what they’ve accomplished—my God!”
Norman walked out to the coffee machine and poured himself a cup. He also cut a big chunk from a fruitcake that was sitting there and stashed it behind his desk for later consumption; he hardly eats, and when he does it is in the office, because he considers even the hospital cafeteria a waste of time. As he was settling back again, there was a call from the operating suite: Dr. Cooley felt things were going too slowly, so could Norman get back downstairs?
In Room 3, a large, white-haired man, a bypass case, was spread out on the table. A junior surgeon was down at the foot of the table tugging out the saphenous vein. Norman positioned himself near the head, sliced down the chest with a scalpel, and picked up the electric saw.

“This guy is D.A.C.’s neighbor,” Norman said. “River Oaks. Fat, too. We’ve got a millionaire on the table.”
Cooley walked in. “What’s this guy do, doctor?” Norman said.

“Plaintiff’s lawyer.”

“Oh, yeah? What kind of work?”
“Oh,” Cooley said innocently, “you know, medical.”
“He sues doctors?” said Norman. “Turn off the machine!”
When Cooley had done three of the five bypasses on the man’s coronary arteries, Norman had to dash out to give a speech to a group of cardiologists-in-training in the Texas Children’s auditorium. He ran to his office, where an assistant showed him, at an approximate rate of two per second, the slides he was to talk about. Then he gathered them up, dashed downstairs, pocketed a sandwich that was sitting on the table outside the lecture hall, and whizzed through an hour’s talk about the progress on the ALVAD.

Back in his office, Norman carefully avoided a group of visiting dignitaries in town for the convention of the American Association for the Advancement of Science. A Texas Heart Institute fellow from India, about to return home, came in to say good-bye. His mastery of English was not complete, so he just wrung Norman’s hand and murmured over and over, “Great man, great man.” Later there was an interviewer from the Canadian Radio Network and then a group of four scholars from Stanford who were doing research on ethical and political issues in medicine and were interested in the ALVAD.

Norman is Cooley’s emissary to the medical ethics world, which views Cooley himself with great suspicion because he doesn’t play by everyone else’s rules. One of Norman’s jobs is to make sure the ALVAD is developed in a way that doesn’t horrify the respectable medical establishment, and with the Stanford group he took great pains to explain the detail with which every step of the ALVAD’S trials was being recorded, the care taken to get informed consent from the patients, the closeness of the Heart Institute’s cooperation with the government, the discretion with which the project team was handling the press.

“Before December 23, 1975,” he told the group, “we had no idea what would happen in man. None. Zero. We had done five hundred calves. We still didn’t know. And each time we did a patient we learned. We reported everything.” He went on to describe their progress, ending with an account of the Valentine’s Day transplant.

“That sounds like the old Cooley,” one of the visitors said sarcastically.

“Oh, no,” said Norman, “that was done under the auspices of the National Heart, Lung, and Blood Institute. We did complete reports. I’m basically a company man.” A sign of the cooperation is that the government foots the bill for ALVAD implants, at $25,000 to $30,000 a case.

An intriguing question is what happens if Norman is right about ALVAD and it does work. Does the government make it available to everyone whose life it could save, adding perhaps billions of dollars to the national budget to keep a small, old, very sick minority of the population alive a few more years? Or should it be available only to those who can afford it, with the thousands of others who could have benefited by it dying for lack of funds? Norman is as aware of this dilemma as anyone, and he accepted an article for Cardiovascular Diseases that speculated about a national health agency in the year 2002 passing out perfected ALVADS to a computer-selected random minority of those people who needed them rather than funding every case.

I asked Norman what his own solution to this hypothetical ALVAD dilemma would be, and he said he didn’t know. “Should I be doing what I’m doing—developing something that may or may not work—or should I be working in Ben Taub?” he said. “That’s a tough one. I guess it comes down to where I am best used. Should health be a right or a privilege? I know what it is: it’s a privilege.” He pulled his surgeon’s cap down over his forehead and leaned forward confidentially. “It probably should be a right.”

“You know,” he said, changing the subject slightly, “it’s very rewarding taking care of patients. One time I was up in Washington at a conference and there was an engineer from Switzerland there who had banged his finger. There I was—the great researcher, hearts, philosophy, papers, right?—and I said, ‘Wait a minute.’ I took off my registration nameplate. I heated the pin on the back with a lighter. For ten minutes I spun the pin on his fingernail, and I opened up his subcuticular hematoma. His pain went away immediately. He felt good. I felt good.”
Like so many of the doctors who work at the Texas Medical Center, John Norman is a man of extraordinary intelligence and capacity for productive work, dazzlingly skilled, his heart firmly fixed in the right place. What has primarily motivated him in life is a strong desire for this country’s highest nonmonetary rewards—prestige, recognition, being the best. Working at Ben Taub or fixing someone’s painful finger does not seem to him to be the fulfillment of all his talent and promise and expertise—it may be health care but it isn’t medicine. So he works on an expensive, experimental replacement part for the human heart. It’s path-breaking work, and he says that in a few years the ALVAD will be perfected. And when it is, I asked him, what happens them? He shrugged. “Our society probably won’t be able to afford it. Think of what the money for one ALVAD could do if you spent it in Fifth Ward.”

Norman’s last case on that day was a replacement of an artificial valve in a woman’s heart. After her first valve replacement the woman had stopped taking her anticoagulant pills, and as a result the valve had clogged up and she had had two strokes. When Cooley came into the room he cut open her heart and took out the old valve, a hard plastic-and-wire affair that was filled with clotted blood.

The schedule was running smoothly again, and Cooley was in a good mood. “Did you know, Jack,” he said to Norman, “that I applied to Harvard Medical School?”

“No kidding. What happened?”

“They turned me down. You know why?”

“Why?”

“On my application, I said I liked girls. When they turned me down I said, ‘Hey, wait a minute, I could also learn to like boys.’ But they said, ‘Sorry, you have to have it from birth.’”

Cooley picked up the new valve, which was more technologically advanced than the old one, a soft, floppy disc the size of a half dollar, made from a cow’s pericardium.

“You know,” said Norman, across the heart, by way of conversation, “in two weeks I’m going on a site visit for NIH.”

“Jack,” Cooley said, “you got to stand up to the government. That’s what they want. Now myself, I’m going on a cruise.” This was in reference to the Heart Institute’s symposium, “Advances in Cardiovascular Medicine and Surgery,” to be held the next week aboard the Stella Solaris as it cruised from Galveston to Cozumel to Montego Bay, laden with doctors and Houston executives. “With my friends and neighbors…white flannel trousers…with cameras at the ready…” While he talked, Cooley was running stitches from the inside of the heart through the edge of the new valve, building an intricate cylinder of threads, in the middle of which the valve was suspended.

“Did you see the folks from the American Association for the Advancement of Science convention?” said Norman. “They were here today, looking around.”

“Ah, good. Did we discuss algorithms with them? You know, we’re at the forefront of the advancement of science. We’re the nose cone of the advancement of science….” Cooley got a dreamy look in his eyes at this talk of intellectual matters. He was finished sewing the valve by now, and looked at it suspended there in the threads for a moment. “Ah,” he said, assuming another of his voices, this one an excruciating pidgin French. “Ah, littérature.”

“Literature,” said Norman.

“Ah,” said Cooley, still in his French accent, “Massachusetts.”

“Massachusetts.” Here was Norman called on once again to defend the East, private schools, big government, and play-by-the-rules medicine. “Ah, Texas,” he said. “The lonely frontier.”

Cooley chuckled and pushed the new valve into the heart.