Chapter 03: Portraits of MD Anderson Surgeons in the Seventies-Eighties: Part I

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Chapter 03: Portraits of MD Anderson Surgeons in the Seventies-Eighties: Part I

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In this chapter, Dr. Balch asks Dr. Copeland to talk about surgeons who were clinically excellent, but generally unrecognized because they did not publish. Dr. Copeland notes that Dr. Edgar White was Chair of the Department of Surgery and not operating when he arrived in 1971 as a fellow. He lists the faculty members at that time, noting that all the surgeons operated three days a week, rotating among the oncologic services. Next, Dr. Copeland notes that the idea of doing limb salvage surgery originated at MD Anderson. He describes an early procedure developed by Martin and Herman Suit to use post surgery radiation to save limbs. By 1986, limb salvage was a regular procedure, based on an NIH study that documented positive outcomes. Next, Dr. Copeland explains that he worked with Renilda Hilkemeyer, RN [oral history interview], head of the Division of Nursing, on his work on hyperalimentation. He then gives his impressions of Dr. Richard Martin.

Identifier

CopelandE_01_20190409_C03

Publication Date

4-9-2019

Publisher

The Historical Resources Center, The Research Medical Library, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

Overview; Portraits; MD Anderson History; MD Anderson Snapshot; Research; Collaborations; Building/Transforming the Institution; Multi-Disciplinary Approaches; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Professional Practice; The Professional at Work

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History | Surgery

Transcript

Charles Balch, MD

So Ted, let me go back a second and just review some historical signposts of people that you knew that we’re trying to capture. I’m talking about Ed White and Dick Martin, and maybe Charlie McBride. These are people that did not make many presentations, did not publish and therefore, currently, people don’t really know their contributions to the legacy of the MD Anderson Surgery Department, because they spent their time in the operating room giving excellent patient care. I’m wondering if you could just give us some vignettes, first about Ed White, who Lee Clark appointed as the first chief of surgery and who ran the operating room for all of the specialties as a group. In fact, I think it would be fair to say was the main chief of surgery operationally, under Lee Clark, who used the title of surgeon in chief for many decades, although he knew about and approved everything, including the purchase of equipment in the operating room. But Ed White was really the chief of surgery who made things operational. So what can you tell us about Ed White from your memories of being here in the seventies and eighties?

Edward Copeland, MD

Ed White was not operating by the time I arrived and we, the fellows, we the faculty, didn’t know how good a surgeon Ed White was. I relayed to you earlier, that one of the things that MD Anderson has to offer, that many people never mention, is the clinic and the patients from MD Anderson usually stay with MD Anderson for their follow-up visits, at least they did in those days. [So I developed a great appreciation for Ed’s ability as a surgeon reviewing his previous successes reviewing his patients’ records. From my perspective, Ed White and Bob Hickey were polar opposites, one supportive, the other occasionally obstructive. I have recounted the Hickey TPN story. I will use Ed White as a polar opposite. I reviewed every patient who had TPN requested to ensure that there was a reasonable chance of response to appropriate oncologic therapy. The prolongation of life for a suffering patient with no hope of an increase in survival or reduction of pain with the use TPN were not candidates for it.]

[Ed White recognized the significance of our discovery of the value of TPN for cancer patients. [Redacted] Ed White was a great guy!!]

Charles Balch, MD

That’s a nice quote.

Tacey A. Rosolowski, PhD

What was your impression of people he trained?

Edward Copeland, MD

Well, the MD Anderson is an interesting place. The four people who existed there when I arrived, [had been “trained on the job”. A good surgeon should be able to replicate himself. I use my training of John Daly as an example. Dick Martin, a surgeon’s surgeon had gone to Galveston to take a physiology fellowship with Dr. Poth. The depression hit and Dick needed a job. He joined Drs. White and Clark at the new cancer center (later named the MDAH).]

[The next to arrive was Charlie McBride, a Canadian who had trained at the Royal Victoria Hospital in Montreal (and he never let you forget it). He had also served in the Foreign Service, also a fact that you never forgot. Charlie was interested in liver transplants, will before the operation became feasible. Nevertheless, the Large Animal Laboratory that I previously described attracted Charlie to MDAH, in fact in remained in charge of it throughout my tenure at MDAH. As the institution became busier with patients, Charlie was pressed into service. He did not return to the Lab. He taught me the technique of modified radical mastectomy and the value of not disturbing an axilla filled with positive nodes. Leave those for radiation therapy to control. His operation was called extended simple mastectomy, a term that has disappeared from the lexicon. Charlie also did all the limb profusions for extremity melanoma until I arrived and shared them with him.]

[The next to arrive was Marion McMurtry. He came with one of the thoracic surgeons from Utah with the expectation of running an electronic microscope laboratory. The institution got busier and he, too, got pressed into service. To my knowledge, he never developed an electron Microscope. The best that I can describe Mac’s operative talents is by stating that of the few times a needed another surgeon to help get me and the patient out of trouble, I called Mac.

The fourth surgeon who was there when I arrived was Marvin Rhomsdahl. He had come for the University of Illinois to get a PhD in Immunology. The institution got busier and he, also, was pressed into service. I don’t think he ever got the PhD but he was the most sound scientist of the group.]

[There had been others like John Stehlin who had been at MDAH but had departed before I got there. So, the first surgeon to be formally trained in surgical oncology on the MDAH faculty was me. For that reason, I did not consider it a big deal for John Daly to join me without having to take a formal fellowship.]

Charles Balch, MD

I have, Ted, I have in front of me, the list of surgical procedures from 1972 to 1973, and it’s interesting that the busiest surgeon was Charlie McBride, by far, second is Dick Martin, and then you, among this group.

Edward Copeland, MD

That’s right, but I didn’t know that, but we all operated three days a week, and so we were busy. [I suppose I was a bit cocky in those days. I once told Bob Hickey that if I could pick my fellows, I could do all the surgery and I think for a moment I believed it. Of course, I had another job at the medial school, but primarily administrative. Stan Dudrick and Jim (Red) Duke were busy clinically but protected my time to work at MDAH. And for this dedication to my career, I will be forever grateful. In fact, their sacrifice is the topic of my Presidential Address to the Southern Surgical Association and entitled “Heroes and Friends.”]

Charles Balch, MD

Marvin Romsdahl also, in fairness, was also very busy.

Edward Copeland, MD

[ ]

Charles Balch, MD

[ ]

Edward Copeland, MD

[ ]

Charles Balch, MD

[ ]

Edward Copeland, MD

[Herman Suit, a radiation therapist at MDAH, and Dick Martin along with William Enneking at the University of Florida got the idea of using wide local excision of extremity sarcomas followed by comprehensive radiation, but not circumferentially around the extremity because of the fear of creating lymphedema. The success of this technique in sparing the limb, rather amputating it, was followed by the development of preoperative radiation therapy designed to reduce the sarcoma mass to allow for limb sparing. The muscle(s) in which the sarcoma developed were originally excised from origin to insertion.]

[This limb sparing technique was being use at MDAH when I arrived and enough data had been accumulated to show the results were equal to amputation BUT the patient got to retain the functional limb. Bob Benjamin [oral history interview], a medical oncologist at MDAH, showed the addition of chemotherapy to this technique would also reduce occurrence of distant metastasis.]

[Fred Eilber, a fellow who followed me took this technique to UCLA and added Adriamycin infusion to the radiation protocol and further reduced recurrence. Murray Brennan at Memorial Sloan Kettering later improved the technique by simply debulking the sarcoma visually and then using radiation therapy. He later recognized the value of frozen section to ensure complete excision of the lesion and reduce local recurrence. Our philosophy at MDAH of removing the involved muscle from origin to insertion eliminated the need for this intraoperative maneuvering. If more than one muscle was involved, preoperative radiation therapy would “back” the disease into one muscle bundle.]

[I am a great proponent of randomized prospective trials but, in my opinion, they can be carried to the extreme. The NIH Surgery Branch set out to see if limb sparing therapy as described was equivalent to amputation of the affected limp. Remember MDAH was using limb-sparing techniques when I arrived there in 1972. The results of the NIH randomized trial was presented at the American Surgical Association in 1986 and showed the two treatments equal in all respects. It has always been hard for me to fathom a patient entering a trial where one arm is the amputation of a limb when non-randomized studies done at MDAH and other institutions had shown the two treatment results comparable.]

Charles Balch, MD

[ ]

Edward Copeland, MD

[ ]

Charles Balch, MD

One thing just for the record here. In the seventies and eighties, you and I, when I was at University of Alabama at Birmingham, were general surgeons. We opened in every body cavity. I was trained in head and neck, thoracic, extremities, GI, liver, and it’s very different than it is today. But what I’m hearing from you, that you and your colleagues really operated in many different areas; maybe not in head and neck, because by that time, Dick Jesse, Bill McComb and a young person named Helmut Goepfert [oral history interview], were doing head and neck full-time.

Edward Copeland, MD

[One of my reasons to take a fellowship at the MDAH, as I think I said earlier, was to become qualified in Head and Neck Surgery. My rotation for 4 months was with Oscar Guillomonddegui, one of the most technically competent surgeon with whom I have had the pleasure to work. I did all the cases with his help except for the removal of a temporal bone. I was good and qualified after that experience, again as I said, one of the attractions of Jackson, Mississippi was the opportunity to work with an accomplished head and neck surgeon there. However, when I had the opportunity to stay at the MDAH I had to choose between Head and Neck and general surgical oncology. Actually the decision had already been made for me since I replaced Marion MacMurtury, I still did, however, neck dissections for melanoma and thyroid disease when indicated.]

Charles Balch, MD

[ ]

Edward Copeland, MD

[ ]

Tacey A. Rosolowski, PhD

What was seen as the advantage of having people circulate among those different oncologic approaches?

Edward Copeland, MD

You became competent in all of them. That’s a good question, but the better question is, why did we stop doing it? [ ]

Charles Balch, MD

Exactly.

Edward Copeland, MD

[ ] [The early days of liver resections is a good example of doing multiple operations. Dick Martin had the most experience with liver resections, but Fred Ames and I were eager to participate. Dick watched us do a couple and then was available if we needed him. The liver is easy to mobilize. Removal of the left or right lobe is a challenge but not that difficult. For segmental resections, we just made sure that the hepatic artery remained intact and we did obstruct the right, left or middle hepatic veins depending on the segment we wished to remove. Segmental anatomical resection came into being later, but Fred and I had no problem with our simple approach to removing a lesion without having to remove the entire lobe.]

Charles Balch, MD

Ted, could you give us any historical vignette that might be quotable, about Dick Martin, and about Bill McComb.

Edward Copeland, MD

Bill McComb --I can’t, because Bill McComb had actually stopped operating, essentially stopped operating when I got here. Dick [Richard] Jesse was the head [of Head and Neck when I arrived and had surrounded himself with faculty members who shared the same philosophy of integrating surgery with radiation therapy.] Bill McComb was an excellent head and neck surgeon as I say, and cut his teeth, as I recall, at Memorial Sloan Kettering.

Charles Balch, MD

He actually published a large series on bilateral neck dissections, among other things, and you published with Bill McComb on hyperalimentation of the head and neck patients.

Edward Copeland, MD

[ ] [Correct, the Head and Neck population of patients were interesting. They often had a history of alcohol intake and smoking. Many were severely malnourished. To correct the malnutrition feeding tubes were inserted through the nose and various nutritional solutions, to include puréed food were instilled. The problem, however is that chronic malnutrition leads to malabsorption. Chip Souba showed that the absorptive enzymes such as sucrase, maltase, lactase, etc are not present in the brush border of the columnar cells of the small bowel. In fact, these cells have often become cuboidal and functionless. Replenishing the patients by gut was almost useless. Correcting malnutrition with TPN resulted in increased muscle mass, protein anabolism to allow wounds to heal and a return of immune competence. The return of muscle mass was often dramatic and postoperative complications plummeted.]

[Dr. McComb was especially interested in the return of immune competence after nutritional repletion. It had been the belief at Memorial Sloan Kettering that the head and neck cancer was, itself, responsible for depressed immune competence since the immune response returned after the cancer was removed. What was forgotten was that these patients had been at least partially replenished by feeding tube preoperatively and the immune test had not been repeated immediately preoperatively. Our group tested immune competence before TPN and before surgery, when immune competence had already returned and the cancer remained intact. Thus a long held fact from Memorial had been dispelled simply by conducting the right experiment. Dr. McComb was quite impressed by this observation.]

[A nurse, Mary Ann Rapp, was responsible for maintaining sterility of the catheter insertion sites in these patients, a somewhat difficult job considering where their lesions were located and the operative sites needed to extirpate their cancers. Actually, I owe a good deal of my career to Mary Ann. She kept extensive records on each of our TPN patients that allowed me to accurately publish the results of our work.]

Charles Balch, MD

How do you spell Mary Ann’s name?

Edward Copeland, MD

Mary Ann Rapp, R-A-P-P.

Charles Balch, MD

So, can you give us your perspective on Dick Martin, who to me is an unsung hero that I’m hoping that we can resurrect the incredible value he gave through the years, as the chief of general surgery.

Edward Copeland, MD

Dick Martin was the best surgeon at MD Anderson and that included me, so if I had a problem, I’d call Dick. [If he wasn’t available, I would call McMurtry.] The first liver resection I ever did, I had Dick stand there and not scrub but tell me what I was doing right or wrong. He was the premiere technical and judgmental surgeon at the MD Anderson, that’s as good a praise as I can give to anybody. [His humility belied his ability. One never appreciates a surgical service with no problems until you run a department yourself. In years I was at MDAH,, I do not recall a disagreement in our operating room and that includes everyone in all specialties. Dick set the standard without ever knowing that he set it. As I think about this today, I am even more amazed. MDAH was a fun place to work. I remember riding home down Westheimer one day and the radio announcer said that 90% of people work 8 hours a day to support the remaining 16 hours. I worked 10 or more hours a day, then went home and rested so I could enjoy the next day’s 10 hours of work. My work was my hobby and Dick Martin is the man most responsible for this experience.]

Charles Balch, MD

Can you tell us about his personality, his dedication to teaching?

Edward Copeland, MD

You could learn from Dick by watching him but also, he would talk to you while he was doing a case. He was not vitriolic by any stretch of the imagination. He was a calm, cool, collected person.

Charles Balch, MD

My impression is that he was mild mannered.

Edward Copeland, MD

Yes. [ ] I remember one day, we got into the vena cava [behind the left lobe of the liver while taking out an adrenal gland. Dick packed the post hepatic space with laparotomy pads and continued to remove the adrenal. I said Dick don’t you think we should mobilize the right lobe of the liver and stop the bleeding. He said that it would probably stop with the packing, and if not, we would deal with it later. This was said in a very matter of fact way with no visible fright (except from me!) When the packs were removed, all bleeding had stopped and could not be demonstrated by elevating the liver.] [ ] [Several years later, Harlan Stone at Emory described packing the liver and returning another day. I already knew that Harlan’s technique would work because Dick Martin had demonstrated it to me several years earlier.] That is the best I can tell you about Dick Martin; bright, innovative, a good observer and wonderful man to work with, a very dear friend throughout his career. [We belonged a small travel club together which was primarily social; the last day, however, members would present difficult cases to the group. I knew that Dick Knew exactly how to handle the cases but he usually remained silent. When I would ask why he would say, “they will figure it out”.]

Charles Balch, MD

And I think the context here is when you and I were in the seventies and eighties, the approach was the more radical the surgery, the better the results and curing the patient was because we didn’t have systemic therapy of any kind. Radiation therapy was still early, so we would tend to do more radical surgery, which of course carried more morbidity and mortality.

Tacey A. Rosolowski, PhD

I think we’ve lost the connection.

Charles Balch, MD

Are you there Ted?

Tacey A. Rosolowski, PhD

Yeah, we’ve lost the connection.

[Pause in Recording – technical difficulties]

Charles Balch, MD

Dr. Copeland, the other thing is, that we had in common, is that Ted Copeland, me and John Mendelsohn [oral history interview], were the finalists to become president of MD Anderson. He was the third person.

Tacey A. Rosolowski, PhD

I’d forgotten that he was the third person, right, because I thought the timing was kind of odd, you know when he left.

Charles Balch, MD

That was in 1996. By that time, you could see from the history, he’d gone back to Florida as the chair of surgery, then he became the dean and he’d done quite well, but what a legacy he has had as an academic surgeon.

Tacey A. Rosolowski, PhD

For sure, it’s very interesting.

Charles Balch, MD

Probably the most distinguished of anybody in surgery in those 50 years, including me.

Tacey A. Rosolowski, PhD

Wow. It’s very interesting to hear him talking about whose personalities come together and kind of create these—

Charles Balch, MD

He’s a southern good old boy isn’t he?

Tacey A. Rosolowski, PhD

He certainly is, he is.

Charles Balch, MD

He would have been comfortable in Mississippi. I thought this was interesting, when he said he wanted to stay in the South.

Tacey A. Rosolowski, PhD

Yeah, yeah, well the culture piece is really huge.

[Redacted]

Charles Balch, MD

Ted let’s go back, because I’d like to have some quotable things about Dick Martin, both as a consummate surgeon, but also his role as a leader among the surgeons --what he did outside of organizations such as the SSO or the Southern Surgical-- so that we can capture a little bit more about who he was.

Edward Copeland, MD

Sure, yeah we can do that.

Charles Balch, MD

It was what was called by some, the surgeon’s surgeon.

Edward Copeland, MD

[Dick Martin was a surgeon’s as I have said before. All of these men who were originally at the MDAH were self-taught and then they taught me and multiple other successful oncologic surgeons. This fact is rather unusual once you think about it. I asked my Chairman at Penn, Dr. Johnathan Rhoads if he thought that a fellowship at the MDAH would be a valuable experience. He was in doubt because Penn was considered to be an excellent institution for cancer care. In fact, Dr. Rhoads was the President of the American Society. Dr. Rhoads was wrong but in fairness to him, I had a two-year experience in the Army (one in Viet Nam) before going to MDAH for the fellowship. The concept of a modified radical mastectomy was new to me as was staging for Hodgkin ’s disease at the time. I was already an accomplished technical surgeon: but I needed polishing. One of the best experiences, however, was my time spent on the clinic with the wealth of follow up patients dating sometimes from the early 50s.] [ ]

Charles Balch, MD

Okay.

Edward Copeland, MD

They were still—we may just want to keep on going Charlie, for now, what the hell is going to happen here.

Charles Balch, MD

That’s okay, we’re still recording.

Edward Copeland, MD

We can do that when we see each other obviously.

Tacey A. Rosolowski, PhD

Right, we can still do our work. Yeah.

Charles Balch, MD

Dick Martin was also—who was in charge of the fellowship training?

Edward Copeland, MD

[The fellowship program was set up by Ed White and I assume other faculty members had some input, I did not. We had three types of fellows: those who wanted surgical oncology as an academic career, exampled by me, Fred Eilber and Everette Sugarbaker, those who wanted the “ticket” to get a “leg up” in private practice (this even happened by surgeons who would come for an observation period of one month), and then residents who just needed more surgical experience to make a living. These latter individuals were often from programs of friends of Dr.White. This mix changed as the UT medical school matured and people like John Daly, David Ota and Kim Jessup began to come as fellows.]

Charles Balch, MD

And when you were there who was the designated person to organize and lead the fellowship training?

Edward Copeland, MD

I don’t know that.

Charles Balch, MD

Okay. So it probably wasn’t anybody, it was just—

Edward Copeland, MD

I think it was Ed White.

Charles Balch, MD

Ed White and then Dick Martin, who succeeded him.

Edward Copeland, MD

Yes. I can almost assure you, that’s the way it was because we had a kid from University of Minnesota who was not good technically. I know for a fact that Ed White brought him down to get more surgical training so he could earn a living, and he did that at the quest of the chairman of surgery at Minnesota at the time.

Charles Balch, MD

Actually I know that for a fact, there were a number of people who were recruited for an additional year of general surgery training here.

Edward Copeland, MD

That’s correct, that was done directly through Ed White and as far as I’m concerned, no one, nobody, but once again, keep in mind that I was on the medical school faculty, not the MD Anderson. I was on the MD Anderson faculty but not to the point of being on—well I actually was on committees.

Charles Balch, MD

So was your salary from UT Houston or from MD Anderson.

Edward Copeland, MD

My salary was paid by UT Houston but it was funneled over from MD Anderson [The fellowship program was set up by Ed White and I assume other faculty members had some input, I did not. We had three types of fellows: those who wanted surgical oncology as an academic career, exampled by me, Fred Eilber and Everette Sugarbaker:; those who wanted the “ticket” to get a “leg up” in private practice (this even happened by surgeons who would come for an observation period of one month);and then residents who just needed more surgical experience to make a living. These latter individuals were often from programs of friends of Dr.White. This mix changed as the UT medical school matured and people like John Daly, David Ota and Kim Jessup began to come as fellows.]

Chapter 03: Portraits of MD Anderson Surgeons in the Seventies-Eighties: Part I

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