Building Baylor College of Medicine and Expanding Surgical Frontiers, 1948-1963
At the end of the war, DeBakey returned to Tulane, despite offers from prestigious schools such as Harvard and from the Army itself. Happy in New Orleans, he probably would have made his career there, had he not received a job offer from what he considered a third-rate medical college in Houston, Texas, in 1948.
The Baylor University College of Medicine (BUCM) had moved to Houston from Dallas in 1944, to serve as the hub for the nascent Texas Medical Center (TMC). The TMC, later to become the largest medical complex in the world, was an initiative of the M.D. Anderson Foundation. Established in 1939, the Anderson Foundation had recently joined with the University of Texas to establish the M.D. Anderson Cancer Hospital in Houston, and planned to affiliate several other area hospitals with TMC. When BUCM dean Walter Moursand asked DeBakey to become the Department of Surgery chair, however, the TMC site was still mostly open land, with only one paved street. The medical college had no university hospital, no formal residency programs, and no formal affiliation with any Houston hospitals. It had just moved into a new main building from temporary quarters in an old warehouse. Most of its clinical faculty had chosen to stay in Dallas, so senior medical students got their clinical experience by working with local physicians, almost none of whom were board certified in their specialties. Much of the surgery was done--often poorly in DeBakey's opinion--by general practitioners.
DeBakey was skeptical regarding Baylor's potential, but his department chair, Alton Ochsner, urged him to consider the opportunity, noting that he could always return to Tulane if things didn't work out. After his initial interview, DeBakey told Moursand that he would accept the post only if he could have more space for the department and control of at least twenty beds at a local private hospital, so that he could set up an accredited surgical residency program. The dean agreed, and DeBakey and his family moved to Houston in December 1948. Despite Moursand's promise, several months passed with no hospital arrangement. Finally, the Hermann Hospital offered to make the beds available and appoint DeBakey chief of the Teaching Service, but not the surgery service. (In most medical schools the department chair controls both the teaching of residents and the surgical service at the affiliated hospital; this is a prerequisite for residency accreditation.) DeBakey found the situation unacceptable and prepared to return to Tulane. Before he left, however, he and Moursand met with the chair of Baylor's board of trustees to explain his departure. They told the chairman that the school was third-rate and doomed to remain so unless it got an approved training program at its hospital, because the quality of work there was mediocre. Any BUCM graduate desiring specialty training would have to seek it outside Houston, DeBakey noted; any patient looking for advanced care would have to do likewise. The chairman, a non-physician, was stunned by this news, and asked DeBakey to stay. He arranged to meet DeBakey's conditions, over the objections of the local medical community.
Fortuitously, within several weeks, another facility became available as a teaching hospital. Houston's Navy Hospital, built in 1946, was turned over to the Veteran's Administration; DeBakey's friend Paul Magnusen--by then the VA's Chief Medical Director--asked him to organize a faculty group to help staff it. With a new facility to work from, DeBakey was able to get resident training approval. Soon afterwards, DeBakey approached Ben Taub, chairman of the board of the Jefferson Davis Charity Hospital, about a teaching affiliation. Taub was enthusiastic (he had read Alan Gregg's discussion of how teaching affiliations improve the quality of care at hospitals), although the medical staff initially was not. An outside consultant was brought in, and recommended that the charity hospital become a teaching hospital. Several years later, Houston's Methodist Hospital joined the Texas Medical Center group, and also became a BUCM affiliate, and eventually, its primary teaching hospital.
During the next decade, with these resources, DeBakey rapidly built up the Baylor's department of surgery and its surgical residency program. He was able to draw on contacts from his Army days and his work on the Hoover Commission to find the right people to staff the medical college and the hospital research programs he initiated. And he developed contacts in the Houston philanthropic community, raising millions for the hospitals and for Baylor. To help fund the department of surgery, he arranged to assign his surgical fees and those of his surgical faculty to a department account, from which the surgeons received modest salaries and the remainder supported the department's operations.
As he got established in Houston, DeBakey offended many of the local physicians with his demands for hospital accreditation, board-certified physicians, and control of hospital beds and medical residents. They viewed him and his high standards--sometimes correctly--as a threat to their status quo. But DeBakey's surgical excellence and innovation soon made the medical world take notice of Baylor and Houston and helped transform both.
Pioneering Work in Cardiovascular Surgery
Like all first-generation cardiovascular surgeons, DeBakey had trained in general surgery, doing both thoracic and abdominal procedures, but not working on the heart or its major vessels. Cardiology had developed into a distinct specialty before World War II, greatly aided by tools such as the electrocardiograph (EKG) and cardiac catheters, which allowed physicians to measure pressures within the heart chambers. Radiographic techniques for studying arteries had also been developed. By contrast, cardiac surgery advanced slowly, owing largely to the difficulty of interrupting the heart's function long enough to repair it, without risking brain damage. But the boundaries of thoracic surgery were expanding rapidly during this period, often with dramatic results. In 1944 Alfred Blalock and Helen Taussig at Johns Hopkins had devised an arterial shunt operation that prolonged the lives of many "blue babies" born with heart defects. That same year, Robert Gross at Harvard and Clarence Crafoord and K.G.V. Nylin at Sweden's Karolinska Institut had each repaired a coarctation of the aorta (a congenital constriction of that large artery in the descending portion near the heart) by removing the defective section and suturing the aorta ends together. By 1949, Gross had begun using homografts--sections of preserved aorta from cadavers--to bridge the gap after excising the coarctation. Dwight Harken's wartime success at getting pieces of shrapnel out of still-beating hearts inspired him to use the technique (after many animal trials) to correct mitral valve stenosis, a common outcome of rheumatic fever. (Prior to the advent of antibiotics, starting in the late 1930s, rheumatic fever often followed streptococcal infections such as strep throat and scarlet fever. This caused stenosis, i.e., scarring and narrowing of the heart valve openings, particularly the mitral valve through which blood flows from the left atrium to the left ventricle. With the flow of oxygenated blood from the lungs thus seriously reduced, patients were often chronically short of breath to the point of being disabled. Over a million Americans suffered from rheumatic heart disease at mid-century.) In 1948, Harken, working in Boston, Charles Bailey in Philadelphia, and Russell Brock in London independently carried out successful mitral commissurotomies to re-open the constricted valve. With the heart still beating, they made a small incision in the left atrium and, working by touch alone, opened the stenosed valves with a finger, sometimes fitted with a small blade. This was a "closed heart" procedure, carried out by opening the left chest cavity to gain access. Though risky, especially in the early years, there was soon great demand for the operation; hospitals everywhere were pressured to offer it. Meanwhile, some surgeons, e.g., John Gibbon in Philadelphia and Clarence Dennis in Minneapolis, were investigating ways to maintain circulation artificially with pump oxygenators. Others, like Wilfred Bigelow in Toronto, believed that controlled hypothermia might be used to decrease metabolic rate so that the heart could be slowed or stopped for a few minutes without danger to the patient.
DeBakey was especially interested in several serious diseases of the blood vessels. At Tulane, he and Ochsner had studied constrictions and blockages of the peripheral circulation, and possible surgical remedies for these problems. The most common were blockages of femoral (leg) arteries and their branches, usually caused by deposits of plaque (cholesterol, calcium, blood platelets, etc.) on the inside of the arteries. Over time, even partial blockages cut down circulation, causing cramping and pain at first, then restricting blood flow enough to cause tissue death, which would require amputation. Earlier surgeons had tried endarterectomy (opening the vessels and clearing out the plaque) or sympathectomy (severing one of the sympathetic nerves to relax constriction of the blood vessels) but these produced only temporary improvements. At Baylor, DeBakey continued these investigations, but also turned his attention to aortic aneurysms. An aneurysm is a ballooning of the arterial wall caused by the pressure of circulating blood against weak spots in the inner wall. Weak spots may be congenital (as in the case of Marfan syndrome) or caused by diseases such as late-stage syphilis or, most commonly, by atherosclerotic plaque. Depending on the location and size of the weak spot, the aortic wall might bulge out into a pouch on one side (a sacciform aneurysm), or it might be uniformly distended around its circumference (a fusiform aneurysm). Under the continuous force of the heart's pumping, the aneurysm grows larger and the arterial walls thinner and weaker. If not treated, it will likely burst, causing a fatal hemorrhage. Even if it doesn't rupture, it can press on neighboring organs and tissues, causing pain and damage. A third type of aneurysm, a dissecting aneurysm, occurs when a tear forms on the inside of the aorta and blood is forced in between the inner and outer walls, splitting them apart. Dissecting aneurysms are very dangerous, usually fatal within days.
A few attempts had been made to surgically treat aneurysms and blockages of the lower-body circulation before 1950, but it was DeBakey who developed and perfected the techniques that truly remedied these conditions. Inspired by Gross's and Swan's use of homografts in repairing aortic coarctation, in 1952 he and Denton Cooley did the first American repair of a fusiform aneurysm of the abdominal aorta, removing the compromised section of aorta and replacing it with a preserved aortic section obtained from a cadaver. (They later learned that Charles Dubost at the Broussais Hospital in Paris had performed a similar operation in 1951.) The following year, they performed a similar resection and graft repair of an aneurysm in the descending thoracic aorta. By 1956, they had done about 800 such operations, working their way up to more difficult repairs of aneurysms of the ascending aorta and aortic arch. For these, they had to slow or bypass normal circulation, using hypothermia or heart-lung machines, which had just recently become available.[see below] The first aneurysm repairs were all done with preserved homografts, taken from cadavers at Houston's morgue, where DeBakey and his medical residents did most of the autopsies. The grafts caused no rejection, and lasted for years. But because human blood vessels are not always easy to obtain or to preserve, and could have hidden defects, DeBakey's group began experimenting with grafts made of new synthetic materials such as nylon and Orlon. (In 1952, Arthur Voorhees and his colleagues at Presbyterian Hospital in New York had made the first synthetic grafts from Vinyon-N, a material used in parachutes.) DeBakey made his first prototypes from woven fabric on his wife's sewing machine. Within a few years, he found Dacron to be the best material, and had Thomas Edman at the Philadelphia Textile Institute design a special knitting machine to make seamless, flexible Dacron tubes in various shapes and sizes. These grafts could be sterilized, cut in any direction without fraying, caused little tissue reaction, and retained their strength longer than homografts. Soon DeBakey's team was using them routinely for aneurysm and for bypassing blockages in the lower abdomen and legs. DeBakey's surgical techniques and his prosthetic arteries rapidly became the standards for repairing or bypassing diseased blood vessels.
Open Heart Surgery
DeBakey and his group at Baylor were also among the first to become proficient in open-heart surgery during the 1950s. Open-heart procedures were first performed by F. John Lewis at the University of Minnesota in 1952 and Henry Swan at the University of Colorado in early 1953, using hypothermia. Swan went on to do hundreds of cardiac procedures with hypothermia, with an impressive survival rate, but the available operating time with this method was less than 10 minutes, which limited the type of repairs that could be done. In May 1953, John Gibbon at Jefferson Medical College in Philadelphia broke through the major barrier to longer cardiac operations, successfully using his heart-lung bypass machine to carry an eighteen-year-old patient's circulation for 26 minutes while he repaired a large atrial-septal defect. But the early machines used by Gibbon and his fellow surgeon-inventor Clarence Dennis (who first attempted an open-heart operation in 1951, and did the second successful procedure in 1955) were often unreliable, and in the first few years, mortality rates for such procedures was quite high. Improved heart-lung bypass machines were soon developed, however, and DeBakey, Cooley, and their colleagues quickly adopted the new technology. During 1956, using a modified DeWall-Lillehei bypass machine, they did nearly 100 open-heart surgeries, repairing atrial septal and ventricular septal defects and other congenital heart problems. As he had with vascular surgery, DeBakey rapidly developed better techniques, and advanced the state of cardiac surgery with his careful ongoing analysis of large series of clinical cases.
Endarterectomy and Patch-graft Angioplasty
DeBakey pioneered several other important surgical techniques during his first decade at Baylor. Endarterectomy, in which an artery is opened and cleared of atherosclerotic deposits that are narrowing or blocking the channel, was a technique devised by J. Cid dos Santos (one of DeBakey's colleagues during his year at Strasbourg) in 1947. DeBakey was among the first to use this for blocked arteries in the legs, and in 1953, he did the first endarterectomy on the carotid arteries that supply the brain. Carotid endarterectomy has since become a routine operation for helping to prevent ischemic stroke. His work led him to develop the fundamental concept that many types of vascular disease are segmental; the atherosclerotic plaque that occludes blood vessels (or weakens their walls to cause aneurysm) is localized, rather than distributed all along the artery, and can be effectively treated surgically.
DeBakey devised a procedure to repair dissecting aneurysms in 1954, and classified them into three types, based on where they originated in the aorta. Another of his innovations, patch-graft angioplasty, solved a common problem with small-vessel endarterectomy: suturing the artery often constricted its opening. In 1958 he found that grafting a small Dacron patch into the incision prevented such narrowing. These patch grafts could also be used on larger vessels where removal of a sacciform aneurysm left an opening in the vessel wall. In 1963, DeBakey received a Lasker Award "for his brilliant leadership and professional accomplishments, which were in large measure responsible for inaugurating a new era in cardiovascular surgery."