The Texas Tornado

(See Cover)

Heart disease is the top killer in the U.S. today, and strokes rank third, just behind cancer. But heart disease and strokes both develop from diseases of the arteries, and together they account for 75% of all U.S. deaths. The deadly statistics, contends Houston Surgeon Michael E. DeBakey, make cardiovascular (heart-artery) disease the most pressing problem of modern medicine.

Dr. DeBakey speaks with singular authority. Since 1948, the dexterous scalpel and deft needle of Baylor University's professor of surgery have operated on more than 10,000 human hearts and arteries. From the far corners of the earth the great and the humble have traveled to Texas to have Surgeon DeBakey patch up their arteries with Dacron or implant artificial valves of plastic and sophisticated alloys in their hearts.

To Dr. DeBakey went H.R.H. the Duke of Windsor to have a potentially fatal, grapefruit-sized aneurysm removed from his abdominal aorta (TIME, Dec. 25). And it was to Dr. DeBakey and Houston's Methodist Hospital that the TV producers of the U.S. and Europe turned a month ago when they wanted to let 300 million televiewers, aided by Comsat's Early Bird, watch an exquisitely delicate heart operation, with the surgeon literally holding a life in his hand. To Dr. DeBakey both Presidents Kennedy and Johnson turned when they needed a man to head committees and commissions to recommend means by which Americans can get the best of medical and surgical care when they fall victim to heart disease, strokes or cancer.

While admiring colleagues boggle at the versatility and variety of his accomplishments--the arterial-replacement surgery, the delicate work inside the heart, the bold approach to strokes--DeBakey races on toward more imaginative goals. Now from his busy laboratories comes the confident prediction that surgical skills may soon be equal to the ultimate achievement--the implantation in a human of an artificial heart.

Diet & Stress. His vast experience has left Surgeon DeBakey firm in the conviction that the various artery diseases have as many distinct causes as there are different kinds of fevers. He is sure that it will take long and painstaking research to pinpoint all those causes and find cures or preventives. He is sure that causes and cures will eventually be found, but he is frankly disappointed with the results so far.

Diet and cholesterol are still largely unknown quantities. "We have examined thousands of arteries that had been blocked by arteriosclerosis, and we have compared the cholesterol levels of these patients with those of normal, healthy people," he says. "We can find no consistent, significant relation between the cholesterol levels and the extent and severity of the disease." The effects of stress the pragmatic surgeon dismisses with characteristic scorn: "Man was made to work, and work hard. I don't think it ever hurt anyone."

DeBakey is deeply involved in the forward-looking research that may some day do away with the need for his surgical skills. "We can't stand by and wait for final answers," he says. "There are lives to be saved today, and future illnesses to be prevented."

Widened Horizon. The artery disorders for which DeBakey and his colleagues have devised ever more daring surgical procedures fall into two main classes: blockages and aneurysms. Blockages may be almost anywhere--in the greatest vessel of all, the aorta, in the coronary arteries embedded in the heart wall itself, in arteries leading to the legs, and in the carotid and vertebral vessels carrying blood to the brain (see diagram, opposite page). The brain itself, however, is the province of the neurosurgeons.

Blockages in coronary arteries may go undetected for years, or cause moderately disabling disease, then suddenly become total or near-total shutdowns and cause the type of heart attacks called coronary occlusions. The reaming out of such an artery ("endarterectomy") is impossible in most cases and immensely hazardous at best.

Partial shutdowns of the aorta are sometimes caused by narrowing ("coarctation"), which may be present from birth, but more often by the later development of obstructive deposits containing calcium and cholesterol. What is responsible for these deposits is one of the basic questions not yet answered. In this area, DeBakey's work first dealt with shutdowns in the abdominal section of the aorta, because there the big blood vessel could be clamped shut well beyond the point where arteries branch off to supply the brain. The lower part of the body could be deprived of its blood supply long enough to let the surgeons cut out the diseased section and replace it with knit Dacron tubing. When the heart-lung machine became a practical adjunct in surgery, the horizon was suddenly widened. It became possible to operate anywhere along the aorta, while the machine supplied blood continuously to the brain.

Clots & Strokes. Obstructions involving the iliac, femoral and popliteal arteries supplying the legs and feet are common, and may actually begin in the aorta just before it splits to form the two main iliac arteries. A familiar feature of insufficient blood supply to the legs, which causes pain in the calf muscles so acute that the victim can hardly walk, is its on-again, off-again nature. Ten days after DeBakey has bypassed the blocked artery with a length of tubing, the patient who previously could walk no farther than a city block without disabling pain can usually go a leisurely mile.

The most daring, and still somewhat controversial, of Dr. DeBakey's innovations is an operation on arteries leading to the brain; it is done to ease the effects of a stroke and to reduce the likelihood that the patient will have more strokes. Though some strokes are the result of hemorrhaging from burst arteries, the great majority are caused by clot shutdowns where the arteries are inside the skull and inaccessible. But Dr. DeBakey thinks that as many as 20% of the clots occur in the carotid and vertebral arteries, below the floor of the skull, where the surgeon can get at them through an incision in the neck.

Clotting in the carotids, as in the coronaries, results from narrowing of the vessels by atherosclerosis, the deposition of porridge-like material containing cholesterol and other complex chemicals. Again, though theories abound, no one knows the underlying cause of the process or how the sites of deposits are determined.

DeBakey did his first carotid endarterectomy in 1953. Ever since, he has been disappointed that the idea has been slow to catch on. One difficulty is that precise X-ray diagnosis, demanding great skill of the radiologist, is essential to show just which arteries are narrowed and where. Arteriography of this type is also highly uncomfortable, if not acutely painful, since the patients usually are fully conscious and only mildly sedated; partly because they must remain as cooperative as possible during the tests, partly to avoid the risks of anesthesia.

If only one of the four brainward arteries is involved, the operation is not too dangerous when done by skilled hands. But the risks increase if, as is often the case, two or even all four of the arteries are diseased. In any case, when an artery is exposed and clamped on each side of the diseased section, Dr. DeBakey has to slit it before deciding just what repair procedure will be best. It may be enough to ream out the atheromatous stuff from inside the artery. Afterward, however, simply to sew up the wound would make the artery narrower and increase the risk of a later shutdown. The reamed section must be made wider by stitching a patch of Dacron over the slit.

In many cases, the blood supply to the brain through other arteries is too tenuous for even one of them to be clamped shut for long. Then Dr. DeBakey has to install a temporary shunt of synthetic tubing while he works on the diseased section. If the blockage is too severe to be reamed out, DeBakey either leaves a permanent bypass in place or replaces the diseased section completely with a graft.

Up to the Arch. "Aneurysm," first used around A.D. 200, describes part of a vessel that has been "widened across." It remained buried in medical texts until DeBakey made it a household word. Aneurysms arise from two main causes: either an arteriosclerotic process, which weakens the artery wall, or a process by which two layers of the three-ply wall separate and blood forces them farther apart. Doctors call this second class "dissecting" aneurysms. Aneurysms are also classified by shape: saccular (like a bag) or fusiform (spindle-shaped). The saccular is likely to be on only one side of an artery, while the dissecting is usually fusiform and surrounds it.

Beginning in 1949, Dr. DeBakey diagnosed many aneurysms among aged veterans and charity patients--but usually at autopsy, for the disease was almost always fatal. Working with Dr. Denton A. Cooley, DeBakey decided that something could be done about the problem if the artery could be strengthened with a synthetic wrapping--or, better still, cut out and replaced. Freeze-dried calves' arteries and segments of human arteries taken from accident victims were tried, but grafts of Dacron tubing proved to be the answer.

Steadily, the Baylor surgeons worked their way up from simpler and more accessible aneurysms in the abdominal cavity. The advent of the heart-lung machine had the same stimulating effect on aneurysm surgery as it had on arterial obstructions: it made possible the removal of diseased sections of the aorta in the chest cavity, in and around the aortic arch, near where the arteries branch off to the arms and head. The Duke of Windsor's case was typical of the more manageable abdominal type, although his aneurysm proved to be larger than expected.

Perhaps the most forbiddingly difficult of DeBakey's aneurysm cases involved a man of 38 with a dissecting aneurysm that began in the chest cavity above the diaphragm and had not only grown in width but had also extended downward through the diaphragm, making a wide split where there is normally a tight fit. Worse still, the splitting of the arterial walls extended into parts of four branch arteries--the two renals, supplying both kidneys; the mesenteric, supplying much of the intestines; and the celiac, supplying the stomach, liver and spleen. Using a graft with six connections, Dr. DeBakey replaced the entire assemblage of arterial piping.

Triple-Play Team. Surgeon DeBakey performs such intricate operations so; often that he seems to be supplied with inexhaustible energy. His 20-hour day begins before dawn, when he tackles the paper work in his den at home. His first chore at the hospital starts at 7 a.m., when he checks three adjoining operating rooms to make sure they have all been set up in accordance with orders worked out with his two chief assistants, surgeons Dr. H. Edward Garrett, 38, and Dr. Jimmy Frank Howell, 32. A typical day's schedule reads:

ROOM 3

Mrs. A.B.--mitral commissurotomy, with pump stand-by

Mr. C.D.--right carotid endarterectomy

Mr. E.F.--left carotid endarterectomy

ROOM 4

Mrs. G.H.--aortic valve replacement, with pump

Miss I.J.--mitral valve replacement, with pump

Mr. K.L.--right carotid endarterectomy

ROOM 5

Mr. M.N.--aneurysm of abdominal aorta

Mr. O.P.--right femoral-popliteal bypass; right lumbar sympathectomy

Mr. Q.R.--renal artery bypass

Surgery begins at 7:30, and in what the Houston virtuosos have come to regard as routine cases, operations may get under way in the three rooms at once, with Drs. DeBakey, Garrett and Howell each taking charge in one. If a case is expected to be of more than average difficulty, DeBakey will have Garrett or Howell as his chief assistant, facing him across the operating table.

Though DeBakey cannot do the entire operations in all the cases he schedules daily, he usually does the major part of three or four and somehow arranges the timing so that he is on hand at the most crucial stage of all the others. In his office he keeps an administrative assistant and three secretaries frantically busy. Except for business occasions, he allows no time for lunch; he keeps going by nibbling snacks in the office and punctuating the day with coffee.

The incredible drive for perfection, the unending concern for his patients, the utter domination of his life by his profession, have won Michael Ellis DeBakey the nickname of "the Texas Tornado." The TV scriptwriter who created such a character would sooner or later conjure up flashbacks to a boyhood in the family drugstore and an early love for medicine. In DeBakey's case, his life outdoes such fiction.

His father, Shaker Morris DeBakey, 80 this week, came to the U.S. from Lebanon when he was 15. By the time his son Michael was in high school, Shaker DeBakey owned a drugstore where the boy helped out and nourished the desire--acquired years earlier--to become a doctor. From his father, says Mike DeBakey, he learned his early-rising habits, the absolute abhorrence of wasted time that has marked his en tire career. His mother, whom DeBakey remembers as "the most compassionate and sweetest person I've ever known," also contributed to his career. She taught her two sons and four daughters how to sew with precision--a facility for which Mike and his brother Ernest, who is a surgeon in Mobile, Ala., are forever grateful.

Banana Breakfast. A straight-A student, DeBakey raced through Tulane for both his B.S. and M.D. degrees, stayed to get an M.S. for research on peptic ulcer. He got appointments to the universities of Strasbourg and Heidelberg, where he also continued courting Diana Cooper, a pretty nurse whom he had met in New Orleans before she went to the American Hospital in Paris. After Europe and marriage, it was back to Tulane to the department of surgery under Dr. Alton Ochsner.* During the '30s, young Dr. DeBakey became an expert in blood transfusions and invented a roller pump to assist them. That pump, he thought wistfully, might some day be useful in some sort of heart-lung machine to sustain a patient during surgery. Twenty years later it was.

Wartime service in the Army surgeon general's office gave Colonel DeBakey a chance to become an exacting critic of the quality of surgery, and in 1948 he moved to Houston with misgivings. Baylor's College of Medicine was just sorting itself out from the shambles of a wartime move from Dallas, and it was difficult to find a hospital surgical service with enough patients for DeBakey's practice and teaching. But he found a powerful ally in a retiring millionaire, Ben Taub, and soon got a major hospital program rolling. DeBakey and Taub are still fast friends, and breakfast together every Sunday.

Every other day in the week, breakfast is no more than coffee and a banana. By 5, DeBakey is at work in his den, the one room in his comfortable Regency house to which not even his wife or the maid has a key. The huge horseshoe-shaped desk (like almost everything else that DeBakey owns, it is the gift of a grateful patient) is crammed with stacked lantern slides of diseased arteries, patients' histories, statistical analyses of the results of thousands of operations, reprints of reports by other surgeons, masses of correspondence, and a tiny portable TV. If DeBakey switches it on, it is only to have it remind him when it is 6:30 and time to head for the hospital.

If, as is usually the case, DeBakey is in a jam between journeys to far cities or foreign lands, he spends the dawn hours writing scientific papers in longhand. He finds that the time it takes to write makes him use words with the precision that is so precious to him. If he has a day or two to spare before a speech or manuscript is due, DeBakey dictates to a tape recorder and later revises the typed draft. His professional bibliography now numbers no fewer than 619 scientific reports.

Pre-Op, Post-Op. Houston's normally seething traffic is mercifully light when DeBakey takes off for Methodist Hospital in his Alfa Romeo Sprint (a gift from a grateful Italian patient) at an unpredictable speed and in no particular gear. A man who never walks if he can drive, he gets his exercise by refusing to wait for elevators. He lopes up and down stairs and covers the hospital's labyrinthine corridors at a brisk pace. Professor DeBakey has a handsome, spacious, blue-carpeted office in Baylor's College of Medicine, and rarely uses it. In Methodist Hospital, Surgeon DeBakey has a tiny office, as cluttered as his den, and runs it like an Army command post.

After the staggering schedule of operations, the afternoons are for staff conferences, with internists, cardiologists, radiologists and his chief assistants. Many an oldtime surgeon thought his job was done when he had laid down the scalpel and the last suture was in place. Not DeBakey. He belongs to the latter-day school typified by Harvard's Dr. Francis D. Moore (TIME cover, May 3, 1963), which insists that no less important than the operation itself are the study and preparation of the patient beforehand, and his care and study while he is recovering. DeBakey interrupts pre-operation conferences for quick trips to the intensive-care area to check on patients who may be just coming out of anesthesia or getting ready to take their first hesitant steps.

Nearly every day there are other hospital or medical meetings to take DeBakey's time. And always there are long-distance telephone calls about patients, or plans to further medical progress. Even when DeBakey promises his long-suffering wife that he will be home for dinner, he is usually so late that she eats alone, then gives him a tray at his desk in the den while he is making phone calls. He takes work into the den and stays until midnight.

His backbreaking schedule of operating and writing has no effect on DeBakey's income. All fees from his operations, running far into six figures annually, go to the College of Medicine, and he takes only his professor's salary.

Trips, says DeBakey, are his major relaxation, and next month he takes off for Italy to receive the $16,000 St. Vincent Award of the Turin Academy of Medicine. By way of thanks, he will demonstrate some of his operations. There will also be trips to Brussels to see Marie Liliane, Princess de Rethy, for whose charitable organization DeBakey operates on many Belgian children, and to Paris to see the Duke and Duchess of Windsor. Later come a week in Israel and a busman's holiday in Athens, with DeBakey demonstrating surgery while a guest of Queen Mother Frederika.

Gap & Lag? Once back in Houston, back to his wearing schedule, back to the demands of days filled with life-and-death decisions, DeBakey will return to the medico-political battles that he never shuns. A progressive Democrat and an acquaintance of President Johnson, DeBakey favors the use of federal funds for medicine. "The Federal Govern ment," he says, "has already put a lot of money into medicine, and every physician in the United States is better off for it--better off than he ever was before."

The American Medical Association, which gave DeBakey its Distinguished Service Award in 1959, now finds itself in violent disagreement with almost everything he says. The report of the commission he headed (TIME, Dec. 18), recommending the establishment of intensive-care centers for heart disease, strokes and cancer, and community centers for diagnosis and emergency care, has jolted organized medicine to the soles of its surgical boots.

The report asserts that there is a wide gap between the quality of care available at major medical centers and that available in the smaller cities and rural areas; that there is a lethal lag between the development of new lifesaving techniques and their adoption by physicians in general. The A.M.A. denies the existence of such a gap or such a lag and plans to fight the proposals, which it sees as a plot to reorganize U.S. medicine under federal control. The DeBakey commission has on its side the President and such powerful congressional allies as Senator Lister Hill.

Even DeBakey's enthusiasm for an "artificial heart" and his confidence that it can be built stir debate among conservative colleagues. Critics scoff about science-fictioneering. But DeBakey is in good company: the Cleveland Clinic's Dr. Willem J. Kolff, who invented the artificial kidney, is one of the handful of other eminent researchers working on an artificial heart. DeBakey says emphatically that he believes it will ultimately be possible to replace an entire human heart with a self-powered and virtually indestructible plastic pump. But he adds with equal emphasis that the best surgeons are still far from ready to start replacing hearts.

Assistant Ventricles. What the medi cal and physical sciences can do today, says DeBakey, is to produce a replacement for part of the heart--its main pumping chamber, the left ventricle--and use it temporarily to support the failing natural heart, which thus can rest and regain its power. Five years after DeBakey put together a research team that now includes Dr. C. William Hall and Dr. Domingo Liotta, they not only produced a replacement for the left ventricle--or, more precisely, an assistant ventricle--but proved its practicality with actual tests in more than 100 laboratory dogs.

It was tried in a human for the first time on July 19, 1963. The man, a Negro, 42 years old, was almost dead from failing kidneys and a heart hopelessly damaged by a narrowed aortic valve. The assistant left ventricle implanted in him by DeBakey was about the size and shape of a banana. It looked like two Silastic sausage casings, one inside the other; it had a valve at each end of the inner sac and a 1-in. tubing leading from the outer balloon to an air pump. When it was installed, most of the patient's blood bypassed the natural left ventricle, leaving it free to take a rest. Pulsations of air in the outer sac supplied alternate suction and pressure to send blood coursing through the patient's body.

The doomed man improved markedly and lived almost four days on his artificial half-heart (TIME, Nov. 8, 1963). After that, it was no failure of the device that ended his life; it was old and irreversible damage to his liver, lungs and kidneys.

New models of assistant ventricles have been produced steadily, in improved shapes and for both ventricles (see diagram, left). It is only seven weeks ago that the DeBakey team ran what it thought was a highly successful experiment with a unit that replaced both of a dog's ventricles. Yet progress in the field is so fast that within four days the researchers were dismissing their test as old hat. They were getting as good or better results with a single ballooning sac inserted in the left ventricle alone. It seems, says Dr. Hall, that this may be enough in many cases to stimulate, if not precisely duplicate, the work of nature's complex four-chambered heart.

What really counts is a strong and steady beat in the left ventricle to send blood coursing through the trunk to the head and limbs. Once that is achieved, nature is likely to take over and get the rest of the circulatory system, including the three other chambers, to work effectively in unison. However, if both left and right ventricles have been severely damaged, they might be replaced by a two-in-one prosthesis with a single pump (see diagram, right).

Muscles or Batteries. All artificial hearts or half-hearts so far have relied on an external power source almost as bulky as a washing machine and infinitely more complex and delicate. The patient has to stay in bed, hooked up to this pulsating pump by an air hose passing through a hole in his chest. For a man with an artificial heart to get up from his bed and walk, let alone work, the power supply must be inside him. It may be electrical, depending on the long-lived, high-performance mercury batteries now being perfected for cardiac pacemakers (TIME, Jan. 11, 1960). Another possibility would be to install an electric coil inside the body and have it operated through induction by a power pack worn outside the heart. Either system would supply adequate electrical stimuli but only a smidgen of mechanical power.

Better yet, DeBakey and his co-workers believe, it may eventually be possible to harness one of the body's powerful muscles, perhaps in the shoulder girdle, to such a pacemaker. Then, when the little device gives its electrical command, the muscle will contract, and in the process it will squeeze an implanted bellows, which in its turn will squeeze the left ventricle or both (see diagram, center). Like all gadgeteers, the heart researchers also dream of using atomic power.

Just two weeks ago, the DeBakey team was well pleased with the results of a 40-hour test in a 150-lb. calf with a complete artificial heart. But the problems to be solved before routine use in man are still forbidding. The external heart-lung machine, which Dr. DeBakey has done so much to advance, can tide a patient over for only a few hours, during and after surgery. Dr. DeBakey wants an artificial heart element that can be installed while a patient is still on the operating table and left in place to tide him over the first few dangerous days of recovery. Then it might be removed.

"Is It Presumptuous?" When he looks farthest ahead through the tops of his trifocals and peers toward the artificial heart that may be implanted permanently, DeBakey says: "It is deficiencies in materials and our lack of knowledge about how they will work over a long period that are holding us up. The materials we have, good as they are, still damage the blood to some extent, and they may become rigid after long use. I am confident that if $50 million were made available today for just this kind of research, an artificial heart, or the vital parts of one, could be ready for permanent implantation within three to five years."

Medicine and surgery, Dr. DeBakey insists, have solved most of the problems of heart replacement that lie within their specific fields. What is now needed is a total effort in cooperation with physicists and industry to solve the problems of materials and power supply. "If artificial hearts can work, as they have, for 40 hours or more," says Michael DeBakey, "is it presumptuous to say that it could be done for 40 days or 40 years? Today it may be only a dream; tomorrow it will be a reality."

* One of the nation's greatest teachers and practitioners of surgery, who first indicted smoking as a major factor in the cause of lung cancer. Many of DeBakey's early writings were on this subject. The admiring DeBakeys have middle-named two of their four sons Alton and Ochsner.

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