THE BOYS ARRIVE
BY Helen Clapesattle
THE NEW ATLANTIC SERIAL
THE DOCTORS MAYO
THE BOYS ARRIVE
BY Helen Clapesattle
FOR years the Atlantic has been searching for a writer qualified to tell this great American story. In strict conformity to medical ethics neither the Doctors Mayo nor any of their staff were willing to undertake such a biography during the lifetime of Dr. Will and Dr. Charlie. Source material was assembled and eventually was turned over to Helen Clapesattle, a trained historian and editor of the University of Minnesota Press, whose definitive biography is entitled to take its place on the shelf of American achievement.
In the opening chapters the reader is introduced to the Old Doctor, William Worrall Mayo, who passed his impressionable years in the little town of Salford, England, then in the tumult of the Industrial Revolution. What he learned there made him a defender of the underdog. He studied chemistry under John Dalton, worked for a time in the hospitals of Glasgow, and then emigrated to America, keen to acquire his medical degree and try his luck on the frontier. With his wife, Louisa, he settled in Rochester in the 1860’s, and there their two famous sons were brought up.
The boys were reared in medicine as a farmer boy is reared in farming. They drove out in their father’s buggy or cutter, watched his diagnosis, applied the anæsthetic in the farmhouse operations, and from their father’s books and table talk learned the firm truths of a pioneer in surgery. ‘It never occurred to us that we could be anything else but doctors,’ Will Mayo insisted again and again. Will completed his medical studies at the University of Michigan, Charlie at Northwestern, and almost before the town knew it the boys were back home and practising with their father. Talk about the skill and integrity of the three Mayos began to circulate in Minnesota, but not until a tornado swept through Rochester, leaving some forty people wounded or dying in the Convent of the Sisters of St. Francis, did it occur to the Doctors Mayo or the Sisters that a hospital was needed in their town.
The town was skeptical, but the Sisters went ahead, accumulated the money, and six years later St. Mary’s Hospital opened its doors. By the close of 1889, sixty-two persons had been treated at St. Mary’s, and by the end of 1893 the grand total had passed a thousand. Despite the noisy hostility of the A. P. A., the Mayos went quietly on their way. They equipped the first operating room. Whenever time permitted they went East to see for themselves the new operative procedures, the improvements in surgery and equipment that became a working part of St. Mary’s as fast as money was available. The hospital paid its own way from the start, and, as the number of patients mounted, so did the prestige of the Doctors Mayo, whose operations were already being discussed at many a medical meeting. Dr. W ill became district surgeon for the Chicago and Northwestern Railroad, and the trainmen began to take pride in the cures at Rochester. In 1905 the two brothers performed nearly four thousand operations, assisted in office examination by Doctors Stinchfield and Graham, who were taken into partnership with them in the ‘90s. And the work went on. . . .
THE DOCTORS MAYO
BY HELEN CLAPESATTLE
THE Mayo offices stayed open all day. The doctors’ day began at seventhirty in the morning, and even then they found patients waiting, for the farmers rose early and the first train arrived in Rochester at six-thirty. Work went on without pause until seven or eight o’clock at night. The offices were open on Sunday forenoons too, for the convenience of the country folk who drove into town for church and liked to look after their souls and their bodies on the same trip so as to have the rest of the week free for farming.
Having to say ‘no more room’ too often at the hospital, the Sisters of St. Francis ordered the building of a second addition, a four-story wing to the west of the original unit. This brought the capacity of the hospital to one hundred and thirty-four beds, which the good Sisters thought would surely take care of all demands for some time to come; but before the carpenters had gone the new rooms were filling so rapidly that their delusion vanished. Orderlies and flitting summertime interns were no longer help enough in the hospital; more assistants were needed in permanent residence.
One day early in 1901, Dr. Albert Plummer of Racine, Minnesota, called Dr. W. W. Mayo to see a patient of his in consultation, as he had been doing on occasion for years. The Old Doctor was away at the time, so Dr. Will decided to make the trip in his stead. When he arrived he found Dr. Plummer in bed with a cold and unable to keep the appointment; but Henry would go with Dr. Mayo to see the patient, said Dr. Plummer, referring to his son, who was in practice with him.
Soon Henry appeared, with a microscope in his hand, and he and Dr. Will got into a little buckboard behind an old gray team and started on the hour’s drive to the patient’s house. ‘A slender, eager boy, dreamy appearing, full of ideas and ideals, his thought rushing ahead of his language’ — so Henry Plummer seemed to Dr. Will that day. He must have known the boy before, for Plummer had spent several summer vacations at St. Mary’s Hospital during has school days, first at the University of Minnesota and then at the Northwestern University Medical School, from which he had graduated in 1898. But not until that day did Dr. Mayo learn what young Plummer was really like.
The patient they were going to see was suffering from leukemia, and during the ride they discussed the chemistry and physiology of the blood. Dr. Will was amazed at Plummer’s knowledge of the subject. When they reached the bedside the young man took a drop of blood from the ear of the patient and another from the ear of the hired man and demonstrated to Dr. Will the microscopic differences between them. On the way back to Racine he continued to talk about the blood.
‘I was overcome that this gangling boy should know so much about the blood, and I so little,’ confessed Dr. Will later. He knew enough about it to realize that much of what Henry Plummer was telling him was not yet to be found in print, and he had long been convinced that the condition of the blood was a vital factor in the success of an operation and that analysis of the blood would soon be as routine as urinalysis in diagnosis.
When he got home that night he said to Dr. Charlie, ‘That son of Dr. Plummer’s is an extraordinary young man. He knows more about the blood than any other man I have ever met. I believe we ought to get him up here to take charge of our laboratories; he would do us a lot of good.’ Dr. Charlie agreed, the invitation was extended, and a few weeks later Henry Plummer joined the staff in the Masonic Temple offices.
That event must be red-starred in any history of the Mayo Clinic. Dr. Will Mayo himself said the hiring of Henry Plummer was the best day’s work he ever did for the Clinic. There was genius in the man, with the eccentricity that so often accompanies it, and both contributed mightily to the development at Rochester.
Dr. Plummer addressed himself first to the task for which he had been employed. He took over the supervision of the clinical laboratories, which had been sadly neglected, and quickly brought their methods and apparatus up to date. He also took charge of the X-ray and gradually built X-ray diagnosis solidly into the structure of the practice. He was a congenital perfectionist, to the despair and sometimes the exasperation of those who worked with him.
Dr. Will was of the opinion that the Mayos could not have won the recognition they had if they had been lost in a crowd of surgeons in a large city. Yet he knew that Rochester had disadvantages to be overcome, among which was the distance from adequate laboratory facilities. Dr. Plummer was soon urging that it was time for the partners to make laboratories something more than a stepchild in their practice. Eventually the Mayos decided to employ a competent, well-trained pathologist to give his full time to the task of organizing and developing adequate laboratories. They chose Dr. Louis B. Wilson, assistant professor of bacteriology and pathology in the University of Minnesota.
Shortly after Dr. Wilson began his work at St. Mary’s, Dr. Will remarked to him, ‘I wish you pathologists would find a way to tell us whether a growth is cancer or not while the patient is still on the table.’ The problem immediately engaged Dr. Wilson’s active mind. The essence of it was to find a satisfactory method for handling fresh tissues. By the end of April 1905, he was able to give the Drs. Mayo his report within five minutes at most and often within two minutes of the time they handed him a bit of tissue just removed from the patient! Fresh-tissue diagnosis quickly became the scientific mainstay of Mayo surgery and one of its distinctions.
Visiting doctors had become a regular feature of the Rochester scene, partly because of a growing tendency among surgeons to travel for observation. For some time they had been dissatisfied with the work of their medical societies; the programs seemed theoretic and academic, of little help in the solution of practical problems. Most men wanted to see a fellow operator demonstrate his work, instead of listening to him talk about it.
By now Rochester was unquestionably one place to be included in every surgeon’s itinerary. Early in 1906 there was published in Boston a description by Dr. George N. P. Mead of a trip he had just made to the little Minnesota town. On the train he found himself one of eight doctors bound for Rochester, from California, Texas, Iowa, Kentucky, New York, and Massachusetts. Going directly to the hospital upon their arrival, they were conducted into a moderately large, well-lighted operating room, where Dr. W. J. Mayo was performing a resection of the stomach. When he had finished the major part of the procedure, he suggested that the visitors go into the next room, where his brother was doing some work he was sure they would wish to see. They went reluctantly, feeling sure they could not possibly see anything as fine as what they had just witnessed.
But they were quickly disabused of that notion. The younger brother was doing a thyroidectomy for exophthalmic goitre ‘with remarkable skill.’ The men watched in fascination, for the patient was stirring so restlessly that most surgeons would have stopped operating,
‘and would have sworn, too. Not so Dr. Charles Mayo. He went right on, where a single false cut might have meant a bad case of bleeding, or the severing of a nerve and possible paralysis; he cut true, with a marvelous sureness and dexterity of touch, and the job was soon done.’
The visitors spent the morning that way, passing back and forth between the two operating theatres. Dr. Will alone did ten operations, and Dr. Mead reported that together the two brothers were doing four thousand operations a year, ‘a total that is simply staggering.’ He concluded, ‘It is no wonder that foreign surgeons count Rochester one of the places in America that simply must be seen.’
On June 7, 1906, seven of the visiting doctors present in Rochester met in a room of the Cook House and organized the International Surgeons Club. The purpose of the organization as stated in the minutes was to provide a means ‘whereby the many physicians who come here to see the work done at St. Mary’s Hospital by the Mayo Brothers may be enabled to meet together and discuss the work of the day and other matters of mutual interest.’ According to the plan of organization, any visiting physician could become a member of the club by paying a nominal registration fee (at first fifty cents, later a dollar, and finally two dollars). Officers were to be elected each Monday afternoon, and two reporters were to be appointed daily to take notes on the next morning’s clinics and present them as an aid to discussion at the afternoon meeting. All this was carried on by the visitors themselves. The Mayo brothers took no part in it. Although they were named honorary members of the club, they attended its meetings only when they were asked to speak, because they wanted the discussions to be frank and free from any possible embarrassment of their presence.
Only once did Dr. W. J. Mayo interfere. When it became quite apparent that the club was to be a lasting thing, he informed the members through their secretary that he did not like their name and wished they would adopt something less pretentious. To oblige him they voted to drop the ‘International’ and become simply the Surgeons Club.
Actually the charter members had not been unreasonably optimistic. When it was only three weeks old the Surgeons Club admitted to membership on one day Alexis Thompson of Edinburgh, Henry Stokes of Dublin, W. H. Parkes of New Zealand, and Baron Kamhiro Takaki, surgeon general of the Japanese Navy. By the end of its first summer the group numbered more than three hundred members, the roster of whom reads like a medical roll call of the American states, the Canadian provinces, and many foreign lands.
When the number of spectators at the clinics rose to forty and more a day, keeping order became a problem, so the Surgeons Club prepared rides of conduct, copies of which were given to visitors when they arrived, and assigned to the daily reporters the added task of enforcing them. Larger club quarters having become a necessity, the entire second floor of the building next door to the Mayo offices was rented, redecorated, and furnished with tables, chairs, and a blackboard.
The Doctors Mayo recognized their obligation to arrange things so that the visitors could see all they had to show. For the time being they solved the problem by having built to their order — and probably Dr. Charlie’s design — a number of metal platforms mounted on wheels and topped with handrails on which people could lean. These stands, each carrying a number of men, could be rolled into positions from which the occupants could see what the surgeon was doing, and they were high enough to permit the spectators to look over the operator’s shoulder without getting in his way. The brothers also had slanting mirrors installed above the operating tables in such a way as to make the work visible at a considerable distance from the table.
There was as much to be heard as seen in a Mayo clinic, for the brothers accompanied their operations with a running clinical commentary, reviewing the case history and the diagnosis, describing the conditions they found, and explaining what they did and why. No man could attend Dr. Will’s clinics very often without witnessing such a demonstration as this: —
The history, read by the assistant while the anæsthetic was given, was a classic one of ‘stomach trouble,’ — years of treatment for indigestion without relief, — yet when incision brought the stomach into view it looked perfectly normal.
‘You have heard the history, gentlemen, but you see this stomach. In my opinion there is nothing wrong with it; the trouble is somewhere else. If I am right, in a few minutes you will notice a spasm of the pylorus.’ And shortly there did appear a spasm of the pyloric muscles evident to all.
‘That does not tell us where the trouble is, but it is not in the stomach. I will see if it is in the appendix.’ And he pulled into view a badly diseased appendix.
The next day the visiting doctors might see him operate on a ‘dyspeptic’ who had a normal stomach but a gall bladder full of stones. Such object lessons went home as they would have in no amount of verbal teaching alone, and soon a paper on stomach or gall-bladder disease at any American medical meeting was likely to call forth a flock of comments beginning, ‘The first time I understood this matter was when I saw Dr. Will Mayo in his clinic . . .’ Dr. Ernest Hall, of British Columbia, did not greatly exaggerate when he declared that Dr. Will Mayo was teaching the surgical world the pathology of the upper abdomen as Lawson Tait had taught it the pathology of the pelvis.
Dr. Charlie was working in too many fields to have yet attained such an outstanding position in any one, but he was fast rising to the fore in thyroid surgery, and visitors noted it. Dr. Andrew Smith of Portland, Oregon, vice president of the American Medical Association, reported to the Surgeons Club one day that Dr. C. H. Mayo had that morning ‘dissected and shelled out two cysts of the thyroid with such ease that it seemed very simple. The cysts seemed to roll out,’ in great contrast, said Dr. Smith, to a similar case he had seen elsewhere not long before, in which the patient had almost bled to death. Dr. Will saw what was coming and once remarked to Dr. Haggard, ‘Charlie is going to be the Kocher of America.’
As a clinical speaker Dr. Charlie was unique. He ‘kept his audience in a bubble of anticipation. During the morning’s work of anything from ten to fifteen major cases he might discuss the number of nails and match-heads, the weight of charcoal and gunpowder, which could be made from the constituents of the human body; he might philosophize about the gall bladder of the pocket gopher, the pineal eye of the tuatara lizard, the galls on his oak trees, the tuberculous lesions of turkey’s livers, or a hundred other odd subjects, and between these divagations introduce sound clinical teaching drawn from the accumulated wisdom of his vast experience. Those who listened . . . fascinated by his extraordinary discourse never knew what curious information his wide reading and shrewd observation would bring to light.’
The Mayos’ surgery was, in the words of one who studied it, ‘the essence of the techniques of all masters of surgery, enriched with the original ideas of the Mayo brothers.’ They did not claim to be original very often; they were more concerned that they should know and practise the very best methods available, no matter who had discovered them. To repeat Dr. Will’s fine figure of speech, they were gathering good ideas from every source, tying them into practical bundles for which they provided the string, and demonstrating the use of the bundle to all who wished to learn it. Those functions they rightly considered about as important for the advance of surgery and the better care of the sick as the function of discovery itself.
Both men were perfectly frank about their ræle, constantly telling visitors where they had picked up this good thing or that. Sometimes it was from their father, often from Joseph Price, Ochsner, Murphy, or Halsted. ‘I used to do this differently, but Moynihan showed me his method when he was here and it was better, so I use it now,’ Dr. Will would say. And Dr. Charlie, ‘The first time I tried this operation I got stuck at this point, but Dr. George Monk of Boston was here and he told me what to do.’
Asked to compare the two Mayos as surgeons, Dr. Haggard replied, ‘Dr. Will is a wonderful surgeon; Dr. Charlie is a surgical wonder.’ The amazing characteristics in Dr. Charlie were his versatility and ingenuity. Other surgeons could not get over the ease with which he turned from removing a thyroid in one case to taking out a prostate or a varicose vein in the next, always with admirable skill. To him was due the range of surgery at Rochester, which made it possible for one man to say, ‘If you stay here long enough you can see every operation known to surgery.’
His ingenuity in devising operative procedures for the unusual case became a byword in the profession. The Fellows of the American Surgical Association met in Rochester one year and, wanting to see Dr. Charlie’s peculiar talent in action, asked Dr. Will to select some difficult case that Charlie had not examined and let them see what he did with it. As Dr. Will told the story: ‘I chose the case of a woman who had been operated on several times before coming here, and whose condition was apparently hopeless of surgical repair, and had the Fellows examine her. They all agreed that it was a case hopeless of relief, and so the whole crowd was prepared to see Charlie floored. The patient was placed before him, and when he looked at the ghastly postoperative results he whistled. Then, without apparent effort, he outlined an entirely new plan of operative treatment, which was successful, and the crowd of doctors was simply dazed.’
The Mayos’ ‘system’ of diagnosis was one of the most discussed features of their work, and the visitors usually went to the offices in the afternoon with considerable anticipation. There was certainly nothing impressive at first glance about the Masonic Temple and its rather dark hallway, furnished only with wooden benches and a framed copy of ‘The House by the Side of the Road ‘by Sam Walter Foss.
Or hurl the cynic’s ban —
Let me live in a house by the side of the road
And be a friend to man.
But through that hallway, and the examining rooms that flanked it, passed a hundred and fifty or two hundred patients daily. While the Mayo brothers were busy at the hospital throughout the morning their associates carried on the work of diagnosis downtown, and patients who seemed likely candidates for surgery were asked to return in the afternoon for examination and a final verdict by the Mayos themselves.
When a diagnostician had a patient for one of the Mayos to see he stepped into the hall and stuck a piece of colored cardboard above the door frame, a red card for Dr. Charlie, a green card for Dr. Will. All afternoon the Mayos went back and forth from one room to the next, pausing often to exchange a pleasantry or word of greeting with some new arrival waiting his turn in the hallway.
Many American surgeons, and some of the greatest of them, became patients of the Mayos. In less than two years Dr. Will operated on three nationally known professors of surgery in three Philadelphia medical colleges — J. William White, Charles H. Frazier, and William W. Keen.
When Dr. White arrived he was so sure he had cancer of the bowel that he told Dr. Will he almost hoped he wouldn’t recover from the operation. He didn’t want to live ‘with that thing inside of’ him. As incision brought the sigmoid flexure of the colon into view the surgeon pathologist who had accompanied Dr. White took one look at the hard nodular mass and turned away. Yes, it was cancer.
But Dr. Mayo and Dr. Wilson were not so sure. A few months before they had had a patient — also named White, strangely enough — whose colon presented a very similar appearance, but Dr. Wilson had been unable to find any evidences of cancer. The mass had proved to be an intestinal diverticulum, a protrusion of the inner lining through the outer wall of the bowel.
In Dr. White’s case, too, Dr. Wilson reported the condition to be diverticulitis and not cancer. White’s pathologist friend and the watching surgeons were strongly inclined to doubt Wilson’s diagnosis, but when they examined fixed-tissue preparations later they were forced to admit that he had been right. Within two weeks Dr. White was serving as president of the Surgeons Club, and he lived for some thirty years longer.
The visiting surgeons found the Old Doctor very entertaining, and they often asked him to talk to the club about the early days, the education of his sons, and the building of St. Mary’s Hospital. Some of them would stop to chat with him a while in his little room at the hospital, and to one of them at least it seemed that ‘a visit to Rochester is not complete without making the acquaintance of this most interesting man.’
When he walked around the corner to the offices he did not always bother to don formal attire, but went without a collar, just putting a button through the fastening of his shirt. He was dressed that way one day when the brothers received word that a group of European doctors were to arrive on the next train, then almost due, and Dr. Charlie rushed to the drygoods store a few doors down the street to buy a collar and tie for his father. While he fussed around to get the old man spruced up for presentation to the visitors, the office staff stood by and laughed, because Dr. Charlie was so entirely unconscious of the fact that he needed sprucing up as much as his father did.
There were many indications still of the remarkable man the Old Doctor was. When the Methodist Episcopal Church of Rochester celebrated its semicentennial he was invited to give one of the addresses. The audience expected him to dwell upon the history of the church and the town, for the subject assigned him was one on which he at eighty-seven was well qualified to speak, ‘The Changes of Half a Century.’ But Dr. Mayo brushed the topic impatiently aside and chose instead to describe the marvels of three industrial plants he had recently visited, concluding with the hope that Rochester would soon make use of its water power instead of coal for operating its electric light plant.
The next year he set off for the Orient. James J. Hill had learned that his old friend, ‘the little doctor,’ wanted to visit China and Japan, and invited him to make the journey as a guest on one of Hill’s boats. He sailed from Seattle in March, and for more than five months his family and friends heard nothing from him. Then he returned in good health and full of tales, proud because he had gone on around the world and had celebrated his eighty-eighth birthday on board the ship with a party and cake provided by the officers.
But when anyone asked him a question he could not answer about the Orient he referred them to his wife. Mrs. Mayo had refused Mr. Hill’s invitation to accompany the doctor on his journey, but she had sent for all the books on China and Japan she could get and knew more about those countries than her husband by the time he returned.
‘Madam Mayo,’ as she was called to distinguish her from her daughters-inlaw, had lost none of her forthright vigor in spite of her snowy hair and comfortable grandmotherly appearance. When an errand took Mrs. Mayo to the offices she often spent an hour or two talking to the patients, many of whom she knew from the days when she helped take care of them as babies. One day she walked into the waiting room to find Dr. Will trying to comfort a woman who was sobbing violently. She walked right up to them and asked what was the matter. Blessing the fate that sent her over at that moment, Dr. Will explained that he had just had to tell the woman she had a hopeless case of cancer. Mrs. Mayo sat down beside her, hauled her fear into the open, and talked about it in a matterof-fact way. Death, like birth, was just a natural process, she said. She had seen many people die, and most of them were contented when the time came; they accepted death as a release and just dropped off to sleep. As she talked the woman stopped crying and was soon able to go her way with something like calm.
When he was past ninety Dr. Mayo began experimenting with a process for extracting alcohol from animal and vegetable wastes. While he was supervising an experiment one day the mechanism got stuck, and he impatiently thrust his hand in to see what was wrong. It had only seemed to stick. The doctor’s hand and lower forearm were badly crushed.
Not liking the way his sons fixed him up, he got the hired man to help him rearrange the bandages and splints to his own satisfaction. The injury was so severe, however, that within the next year three operations were necessary, the last to amputate the hand and forearm. The nerves had been so bruised that Dr. Mayo suffered intense pain much of the time, and his general health failed rapidly under the strain. His life closed on March 6, 1911, just a few months before his ninety-second birthday. Mrs. Mayo’s death came four years later, on July 15, 1915.
Late in 1911, on the way home from a meeting of the Southern Surgical Association in Washington, Dr. Charlie was taken suddenly and acutely ill in New York. He diagnosed his own trouble as gallstones, but the physicians called in to attend him said it was appendicitis, and Dr. Joseph Blake operated to remove the appendix.
The idea of the great surgeon himself in need of an operation caught the public fancy, and throughout the nation newspapers carried the story in detail. For a few days after the operation they printed the brief daily bulletins from the hospital announcing that Dr. Mayo’s convalescence was progressing nicely.
Then came a sudden flurry of headlines: ‘Famous Surgeon Takes Turn for the Worse’; ‘Condition of Dr. Mayo Alarming’; ‘Dr. Charles Mayo Dying in the East.’ When the relapse occurred it was decided that Dr. Charlie did have gallstones after all and that he must undergo a second operation.
The news reached Dr. Will about four o’clock one morning, and he decided to go at once to New York, taking Florence Henderson, Dr. Charlie’s anæsthetist, with him. They left Rochester at fourthirty, riding a locomotive engine to Winona to catch the morning train for Chicago. Word of their journey preceded them, and when they reached Winona a special train was waiting. The railroad men set themselves the task of breaking all existing records to get Dr. Will to his brother’s bedside, and freight cars were shunted onto sidings and other passengers were made to wait while ‘Dr. Mayo’s train’ sped through on a cleared track.
The story had everything, or could be made to have it, — irony, drama, sentiment, suspense, — and the newspapers made the most of it. Dramatic headlines pictured the great surgeon lying at death’s door, his anxious wife waiting in the next room, his loving brother racing with a nurse to his bedside. They traced the record-breaking journey mile by mile, even the last wild ride from the station to the hospital in the car of Dr. Raymond P. Sullivan, a former surgical assistant to the Mayos.
The only thing they missed was Dr. Will’s wry comment that during the train trip he was afraid Dr. Charlie would not live until he arrived, but after Ray Sullivan began that mad dash to the hospital he feared he would not live to get there.
The journalists took this occasion to tell once more, on a wider scale than ever, the whole story of the Mayos and their hospital. They reminded their readers of Robert Herrick’s novel The Healer, the story of a backwoods physician whose great skill and kindness drew so many patients to his humble abode that he had to build a hospital for them. Here was that very story come to life. Those efforts of ‘trainmen and railroad workmen along the line of steel stretching halfway across the continent to facilitate the lightning-like trip from Rochester’ were not inspired by the surgeons’ fame but by their heart-warming humanity. The railway men knew, sang the newspaper men, that the Mayos were doctors to whom the life of the laborer meant as much as that of the banker. Said the Mining Gazette of Houghton, Michigan: —
This all sounds like patent medicine advertising, does it? Well, it isn’t. The Mayos are as adverse to advertising as the rest of their brethren profess to be, but we have heard too many stories of the kindness of the Mayos, have heard of too many cases where sufferers have been cured of their bodily ills, and where the Mayos failed to make the raid on their pocketbooks that is the usual accompaniment of surgery. We have heard too much of that to pass up this opportunity to say something about the Mayos.
When daily bulletins had traced Dr. Charlie’s second convalescence, his removal from the hospital to a hotel, and finally his journey back to Rochester, the newspapers concluded the incident by voicing the thanks to Providence of ‘thousands and thousands who owe their lives and health to Charles Mayo.’
Their growing reputation brought honorary degrees — to both Mayo brothers from the University of Maryland and to the elder from the University of Michigan and Columbia University. But more important than any degree was an enduring friendship that began when Dr. Will was in New York. The other party to it tells the story: —
We were standing in line at Columbia University at commencement in June 1910, wearing borrowed academic gowns and about to receive degrees. Around us were a lot of notables whose faces we recognized. But we were put side by side and we looked at each other like a couple of dogs for a minute. Finally Dr. Mayo said to me, ‘I don’t know what I’m doing here,’ and I said, ‘You’ve got nothing on me, neither do I.’ Then we both grinned and he said, ‘Who are you?’ And I said, ‘To tell you the truth, I am just a country editor from a little town in Kansas called Emporia and my name’s White.’ He grinned again and said, ‘Well, all right, I am just a country doctor from a little town in Minnesota called Rochester and my name’s Mayo.'
The publicity that made the Mayo brothers a target for the darts of resentful doctors made them also a magnet drawing patients to Rochester from all over the country. To this the brothers’ many speeches contributed, for now that they were becoming known to laymen the newspapers found it worth while to publish what they said to medical societies, especially on subjects of general interest like Dr. Will’s favorite topic, the curability of cancer of the stomach in its early stages. To his familiar topics in the field of the upper abdomen and the intestines Dr. Will was beginning to add discussions of surgery of the kidney and the spleen, the latter a new field in which he was again pioneering for American surgeons.
Dr. Charlie continued to talk about everything from bunions to bladder tumors, but the subject rising rapidly to monopolize his bibliography and the one of most interest to laymen was surgery of the thyroid. By the end of 1908 he was able to report the results of one thousand operations for goitre. The period of trial and error in the field was over, and the major problems of surgical technique had been solved. Surgeons had learned how to control hæmorrhage, how to avoid myxedema, how to escape tetany by leaving the parathyroid bodies intact — in short, what to do and what not to do. Operation for simple goitre was now relatively safe in competent hands.
But nearly half of Dr. Mayo’s thousand cases were operations for exophthal-mic goitre, with a mortality of about 5 per cent. Only Kocher of Switzerland had a better record in that disease, and the usual record in the United States was a score or two of cases with a death rate often as high as 25 per cent. Exophthalmic goitre was one of the most treacherous and perplexing maladies the surgeon had to deal with.
Reports of these results brought other surgeons to Rochester to see how Charles Mayo did it, but they were bewildered by the array of procedures he used. Why did he do this in one case and that in the next? Dr. Charlie and Dr. Plummer could not tell them. There was just something about the look of the patient that they had learned to recognize, but what it was not even Dr. Plummer could put into words. Consequently the method seemed very mysterious, and instead of trying it for themselves most of the men simply sent their patients to Rochester. Operations on the thyroid mounted from a total of one thousand to five thousand in four years, and took the place of appendectomies as the most frequent operation in Rochester. Beginning in 1911 and for ten years thereafter thyroidectomies made up more than one tenth of the total number of operations performed by the Mayos and their associates.
The ripeness of time that is a leitmotiv in the story of the Mayos appeared in this spread of their reputation, for it coincided with a period of national prosperity. The rising values of farm lands, still a broad jump ahead of rising taxes, and the expansion of industry and commerce in the cities provided money for improving the conveniences of homes, for multiplying churches, colleges, and public libraries, for beautifying cities with parks and playgrounds and imposing buildings — and money for journeying halfway across the continent if necessary to see the doctor of one’s choice.
Equally important was the increasing mobility of the population. The automobile was beginning to carry men’s minds and bodies beyond their own back yards. So the people and the money came. The number of persons registering annually at the Mayo offices rose steadily to fifteen thousand in 1912 and then more than doubled in the next two years — the beginning of what those who experienced it can describe only as ‘an avalanche of patients.’ The office force found it exciting, never knowing what wealth or fame or far-distant place might be represented in the rush that followed each train’s arrival.
More registrations meant more work at St. Mary’s, too much for the Sisters to cope with alone. Sister Joseph decided it was time to institute a school for nurses. The school opened with a class of two, chosen from five applicants, on November 19, 1906. Three others were admitted four months later and eleven the following year, with applications coming in from states as distant as New York and Oregon.
Equally urgent was the need for additional hotel accommodations. A member of the Surgeons Club observed that every second house in Rochester had two or three of its rooms occupied by convalescent patients, their friends, or visiting surgeons. Even so there were not rooms enough, and the newspapers were reporting that they got anxious inquiries every day from persons unable to find suitable lodgings.
Knowing such a situation could not long endure, Dr. Will suggested to John Kahler that he build a high-class convalescent hotel that could be turned into a hospital if the need arose. Kahler hesitated, so to encourage him the Mayos decided to break their rule and invest $10,000 in the venture.
The Kahler House was opened in May 1907. Sixty of its beds were set aside for hospital purposes and Dr. J. E. Crewe, the secretary of the Surgeons Club, and Dr. E. H. Beckman of the Mayo staff became the resident house physicians.
Meanwhile Mr. and Mrs. Charles Chute, finding their boardinghouse filled to overflowing all the time, tore it down and built a sanatorium twice the size, but within six months that too was so overcrowded that the rooms were engaged as much as a week in advance. So the proprietors again doubled the size of the Chute Sanatorium, and in the new wing set apart a small ‘operating room’ for the postoperative care of their patrons. Dr. Judd entered into residence as the house physician.
As the number of operations mounted the surgeons too needed more help, especially Dr. Charlie, who sometimes feared he would have time for nothing but removing goitres. The Mayos naturally chose their new men from among the graduates of medical schools whose faculties and standards they knew — principally the University of Minnesota, the Johns Hopkins Medical School, and the University of Toronto, with whose staff Dr. Will became acquainted when he went there to receive the honorary degree they bestowed on him.
The surgical assistantships at Rochester were worth much more in experience than the hundred dollars a month they paid, and the Mayo brothers never lacked applications from able, welltrained young men. The assistants profited almost as much from the hospital rounds they made with Dr. Will and Dr. Charlie as from the operating-room experience, for the two brothers, each in his own way, had become consummate masters of the art of handling patients. One or the other of them visited every patient at least once a day during his stay in the hospital, and oftener if necessary. The great and the wealthy took this attention for granted, but it was not reserved for them, and to lowlier ones the daily visit from ‘my doctor’ with his word of cheer, little joke, or just his attentive, sympathetic ear, became a vivid memory to be talked of or written about many years later.
The Mayos came to realize that the effective training of these assistants was part of the professional and social responsibility that Henry Plummer insisted the development at Rochester entailed. Dr. Will evidently had the problem on his mind during one of his trips East, because on the morning after his return he said he had been impressed anew with the undesirable status of interns, residents, and house physicians in most Eastern hospitals. They seemed to spend their days in subservient yes-siring, in being flunkies for the permanent staff. He did not want any such attitude to prevail at Rochester, and he thought it might help if they called the men something other than interns or assistants. Well, why not ‘fellows of the Mayo Clinic’? So that is what they became.
A committee was formed to supervise their training, with Dr. Beckman as chairman and Drs. Plummer, Wilson, and Sanford as members. They were to select the new men, assign them to services, and schedule lectures and conferences to supplement the practical experience of the fellowship. They worked out a three-year rotation by which each fellow would spend one year in pathology, one in diagnosis, and one in surgery, but the plan was left flexible enough to be adapted to each man’s special interests.
In 1907 Mrs. Maud H. Mellish joined the staff as editor and librarian. She undertook to issue a volume of collected papers, comprising the publications of the group from 1905 to 1909 and including some reprints she rescued from oblivion in the coalbin. The book was entitled Collected Papers by the Staff of St. Mary’s Hospital Mayo Clinic. It was the first of a series of annual volumes that still continues.
Almost simultaneously with Mrs. Mellish’s coming a new system of keeping records was installed. The old ledger system had served well enough when the staff numbered three or four and the patients a thousand or two a year, but as the numbers grew it proved intolerably cumbersome. Dr. Plummer set out to devise a new system. For more than a year he studied the problem, wont traveling to see what others were doing and, getting little help from medical practice, turned to business and industry for ideas.
The dossier system he subsequently evolved has become a model for medical records. Each patient is registered upon arrival and assigned a serial number. An envelope bearing that number is set up in a central file, and in that envelope is placed all information about that patient: the diagnostician’s clinical history, the surgical and hospital records, and the findings of all laboratory examinations, each set down on standardized record forms that Dr. Plummer drew up in conference with his colleagues. All subsequent correspondence with the patient is filed in the same envelope, and if he returns for a second, third, or fourth visit, he is always given the same number and the records are put into the same envelope. Thus is accumulated in one place a full and accurate history of each patient’s physical condition as far as it is known to the Rochester doctors.
The Mayo brothers had by this time arranged their schedule so they operated on alternate days, Dr. Will on Tuesday, Thursday, and Saturday and Dr. Charlie on the other three. To fill up his Friday schedule Dr. Charlie had to use a little blarney, telling his patients that, far from being an unlucky day, Friday was his very luckiest. The brothers still depended on each other’s opinion. If Dr. Will could not be sure about a patient he would tell the clinician to have Charlie examine him, and then the two brothers would reach a conclusion together.
The afternoons in the office were often hectic, especially for Dr. Charlie. An extra measure of the consultation fell to his lot, partly because Dr. Will needed time for the duties of management and partly because Dr. Charlie had trained most of the younger surgeons. When Dr. Judd or Beckman or Henderson wanted advice it was likely to be in a field he had learned from Dr. Charlie. The eye, ear, nose, and throat men often wanted his opinion on some obscure case, too, and the younger clinicians usually turned to him when they were in difficulty. As a consequence of the many demands upon his time, Dr. Charlie was often so worn out by late afternoon that he slipped quietly away and went home. But this usually complicated matters in the office, so the staff took to hiding his hat and coat. The strategy worked sometimes, but if Dr. Charlie was very tired he just went home without them.
The rapidly accelerating growth was making the problem of more space acute. The surgeons took over the operating rooms at both the Kahler House and the Chute Sanatorium, and new additions were built to both. Then in 1912 Mr. Kahler and his associates ventured to construct a larger and more pretentious hotel, the Zumbro, thus relieving pressure on the Cook House so that one of its floors could be turned into quarters for the orthopædic surgeons. In the same year still another addition was built to St. Mary’s Hospital, raising its capacity to three hundred beds and six operating rooms.
But expansion at the offices was not so easily managed. Because it occurred only as forced by need and without previous plan, what had resulted was a collection of offices and laboratories sprawled helter-skelter along the block and mixed honeycomb-fashion with shoestores and drugstores and restaurants. When the partners needed another room or two they rented them wherever they could find them, boarding up their street fronts and building a passageway at the rear to connect them with the other offices. When they had to find more space for the library, which under Mrs. Mellish’s energetic management had grown to several thousand volumes, they built a two-story structure on the lot behind their offices and moved into it the library and the editorial office, the general correspondence office, and the art studio, which now had a staff of four photographers and two medical artists. Needing still more space the next year, they built an annex connecting the library with the offices to house the X-ray department. The crowding finally became intolerable.
At last it seemed clear that the only way out of the difficulty was the one Henry Plummer was urging: the construction of a separate building large enough to meet the needs of the group and adapted to its peculiar purposes. Dr. Will hesitated to take the step; he was afraid it was too ambitious. But finally one Saturday night when the group after a particularly hectic day voted in favor of the move, the Mayos gave their consent. Dr. Plummer was named chairman of the building committee. By ten o’clock the next morning Plummer had called an architect down from St. Paul and was outlining the problem to him.
The site selected was that of the old Mayo home across from the Central School. Working without a precedent to guide them, the architects had to rely upon Henry Plummer for their knowledge of the exact purposes to be served and the problems to be met, and Dr. Plummer proved as much of a perfectionist in this as in everything else he undertook. No detail of mechanics or materials was too small to receive his personal scrutiny and decision.
The building was formally opened on March 6, 1914. During that afternoon and evening the rooms were shown and their intended uses described to some sixteen hundred persons. They saw the spacious first-floor lobby, cheerful and restful with soft-colored marbles, semidirect lighting, wicker furniture, and a fountain banked with palms — so different from the old hallway waiting room! Around it were ranged the business offices, registration desks, and principal examining rooms. From it they climbed an impressive double stairway to the second floor, where they saw more examining rooms, the X-ray cubicles and dark rooms, and some of the clinical laboratories. On the third floor were the handsome library, the assembly hall, and more laboratories, on the fourth the pathologic museum, art studio, and the workshops of the instrument makers, and on the fifth the experimental laboratories with adjacent roof-top runways for the animals.
All the research and diagnosis had been gathered into the one building and organized into divisions and sections. The scattered clinical laboratories were at last brought together in a section of clinical pathology under the direction of Dr. Sanford. Dr. MacCarty was named head of the section of surgical pathology, though he of course remained at St. Mary’s Hospital, Dr. Mann of the section of experimental medicine, and Dr. Kendall of the section of experimental biochemistry. Together they made up the division of laboratories, of which Dr. Wilson was the director.
The library, editorial office, and art studio were joined in a division of publications, with Mrs. Mellish its general director as well as the head of the editorial section. A trained librarian had been engaged to relieve her of direct responsibility for the library. Into the division of records and statistics, in charge of Mabel Root under the supervision of Dr. Plummer, were gathered the registration clerks, desk girls, and filing clerks. And finally to the business office, from which Mr. Graham had retired, leaving it in the highly capable hands of Harry Harwick, was allocated full responsibility for investigating the financial status of the patients, assessing their fees accordingly, and collecting them.
Those were the various members of the body, and its central nervous system was the means of ready communication by telephone, signal lights, and telegraph ticker. Each floor was connected with the main file desk in the basement by a constantly moving conveyor belt. When a history was wanted on floor three, say, the desk girl there had only to pencil the number on a request card and put it on the carrier. In the file room below, the desk girl pulled the history and put it into the proper compartment of the carrier, from which it was automatically tripped off at desk three above-in two or three minutes, with no more trouble for the doctor than a spoken number.
A flat panel with room for many signal lights had taken the place of the ungainly semaphores above each examining-room doorway, and to each doctor had been assigned a specific call on the new ticker. When his tick sounded, no matter where he was in the building he had only to lift the receiver of the nearest telephone to learn from the operator what was wanted of him and where.
When Henry Plummer appeared at the offices of the telephone company asking them to install a system that would enable the doctors to talk to each other directly, to the operator, or to an outside person at will, the officials stared at him. That was impossible, they said. ‘No, it isn’t,’ replied Plummer calmly. ‘Call in your engineer and I’ll show him how to do it.’ The engineer came, and Dr. Plummer explained with diagrams. So the first intercommunicating telephone in the country was installed in the new building. As far as mechanical aids could contribute to effective coöperation, Henry Plummer had provided them.
At his suggestion, too, the custom of making definite appointments for each patient was now adopted, to eliminate many hours of tedium for the patients and to encourage the reference of patients from one doctor to another. But here again Dr. Will stepped in with a warning. The sick person was not to become the patient of the group in the sense that he was to be referred from one man to another with no one in charge of his case. He must remain the private patient of the examining clinician, who should have full responsibility for his case, making use of the special knowledge of his colleagues as he thought best.
It is not possible to assign a date for the founding of the Mayo Clinic. It came into being too gradually for that. The germ of one phase of it existed in the Old Doctor’s clinics at Mrs. Carpenter’s; the outpatient aspect appeared when St. Mary’s was built and the brothers began trying to persuade their patients to come in to them instead of calling them out to the homes; adding the first partners and adopting a program of laboratory development initiated other phases. But with the reorganization and the new building of 1914 the Mayo Clinic emerged as a distinct institution, ‘a complete clinic, including laboratories, housed under one roof, and independent of any hospital.' It has grown to three times its size since then, its building has climbed fourteen stories farther into the sky, its sections have multiplied and its activities expanded to take in medical treatment and put surgery in something like its proper place in the whole of medicine, but the central idea and the fundamental organization had been achieved by 1914.
To be precise, the Mayos were not the fathers of group practice, but of private group practice. Coöperation of a sort among clinicians, surgeons, and laboratory men was taken for granted in municipal, state, and university hospitals; it was something quite new in private practice. And the more centralized control made it possible to develop greater homogeneity and integration than was possible with the loose-knit, constantly shifting, and part-time staffs of public institutions.
Given the state of medicine that demanded specialization and the volume of patients that permitted it, what made the Mayo Clinic possible was the brothers’ attitude toward their associates. They did not merely mouth the Old Doctor’s dictum, ‘No man is big enough to be independent of others’; they really believed it. And so they did not consider their employees hirelings but fellow workers, who must also travel to other centres to learn, have time for research and writing, and be granted independence in opinion and action. Their ability and reputation would not dim the glory of the Mayos; it would enhance it. Feeling so, Dr. Will and Dr. Charlie actually managed to retain, in coöperative form, the individualism Dr. Will said could no longer exist in medicine.
Shortly after George E. Vincent became president of the University of Minnesota in 1911, he was surprised to learn that one of the most promising members of the medical school faculty had left a few years before to take charge of the laboratories of two country doctors in Rochester, and apparently had never been sorry. The more he heard about the Mayos the more curious he became, so he went down to see them. Not the least impressive aspect of their work, he found, was the well-rounded, systematic training they were giving to their thirty-six fellows. Facetiously he remarked to Dr. Will that he and his brother were poaching on the preserves of the university, for they were actually conducting a graduate school of medicine.
Early in 1914 the administrative board of the University of Minnesota medical school appointed a committee to make plans for instituting graduate work in clinical medicine. Almost from the first discussion of the plan the idea of a possible affiliation with the Mayo Clinic had been considered. Guy S. Ford, university dean, went down to Rochester to investigate the situation from the standpoint of the graduate school — that is, to see what the Rochester setup had to offer in the way of qualified students, qualified instructors, and adequate material and support. He reported when he returned: —
I found a condition that satisfied me upon all three points.... I am not speaking of the first floor of the Mayo Building primarily, nor of the operating rooms of St. Mary’s Hospital. I found what I was looking for in the laboratories, museums, and library of the upper floors, and in the countless case records in the basement of the Mayo Building. The richness of this material, not seen by the casual visitor, furnishes opportunities for graduate medical work in certain lines such as can be found nowhere else on this continent, nor probably in the world. I found a research and teaching staff available and at work, sufficient to do its full part . . . in a coöperative plan such as that under consideration. Some of these were doing nothing but research. The only difference observed between those who were engaged part time in clinical practice and our own part-time staff was that the private practice in Rochester was conducted under the acid test of observers from all over the world.
An obstacle to the affiliation appeared early in the negotiations: the Mayo Clinic was not a corporate body with which the university could readily make a contract. President Vincent suggested that to overcome this the Mayos form a corporate foundation to handle the educational and research phases of their work, and Dr. Will immediately recognized the excellence of the idea; it would provide an agency for managing activities essentially outside the scope of the Clinic proper and would also make unnecessary the affiliation of the university with the Clinic. So on February 8, 1915, Drs. Mayo, Graham, Plummer, Judd, and Balfour (Dr. Balfour had been made a participating partner in 1912) executed articles incorporating the Mayo Foundation for Medical Education and Research, and the next day Dr. Will and Dr. Charlie endowed it by transferring to three trustees, Burt W. Eaton, George W. Granger, and Harry J. Harwich, securities amounting to a million and a half dollars.
Meanwhile the conferences and discussion had produced tentative terms of affiliation between the university and the Foundation. The university would conduct a part of its graduate education in medicine at Rochester for an indefinite period of trial, during which the Foundation would make available free of charge all the facilities of the Mayo Clinic and the Rochester hospitals and the Mayos would personally pay all expenses, so the interest on the endowment could be added to the principal until the fund reached a total of two million dollars. The work at Rochester was to be carried on by a board of ‘scientific directors’ and a selected faculty, both appointed by the university regents on nomination by the Foundation and approval by the administrative board of the medical school. All details as to courses of instruction and the requirements for degrees were to be worked out by a joint committee, under the supervision of the dean of the graduate school, in which school all the students would be registered and from which they would receive their degrees. The trial affiliation could be terminated by either party on one year’s notice, but if and when the affiliation became permanent the Mayos would transfer the endowment fund from their trustees to the university regents, subject to the condition that the income be used to maintain the graduate work at Rochester. This trial affiliation was arranged in 1915.
But unexpected and bitter opposition had appeared among members of the medical faculty, the alumni, and the state’s doctors. When a public hearing on a pending legislative bill instructing the regents to dissolve the affiliation was announced, some of the university officials considered the situation so serious that they asked Dr. W. J. Mayo to appear for the Foundation. It was an amazing request to make-to ask a man to defend himself for being magnificently generous! But after a minute’s thought Dr. Will replied, ‘I’m a good soldier. If you gentlemen think it’s necessary, I’ll do it.
The chamber was crowded the night of the hearing. The backers of the bill presented their arguments at length and with vehemence, President Vincent and Regent Fred B. Snyder replied, and then Dr. Mayo took the floor. The chairman had asked the audience not to applaud the speakers, but now, forgetting his own injunction, he led the crowd in a resounding tribute to the state’s most famous son.
Then the people hushed as Dr. Mayo began to speak. He talked without notes or manuscript, simply, earnestly, colloquially. ’Every man has some inspiration for good in his life,’ he began. ‘With my brother and me it came from our father. He taught us that any man who has physical strength, intellectual capacity, or unusual opportunity holds such endowments in trust to do with them for others in proportion to his gifts.’
He went on to describe the unusual opportunity that had been his and his brother’s and what they had sought to do with it. He told how, as their income grew with their practice, they had come to feel a sense of trusteeship for the money. He explained the ideals they had sought to apply in their practice and the purpose they wished to achieve with this gift of money and service.
As he continued, his voice rose. ’I can’t understand why all this opposition should have been aroused over the affiliation with the university. It seems to be the idea of some persons that no one can want to do anything for anybody without having some sinister or selfish motive back of it. If we wanted money, we have it. That can’t be the reason for our offer. We want the money to go back to the people, from whom it came, and we think we can best give it back to them through medical education. Now let’s call a spade a spade. This money belongs to the people, and I don’t care two raps whether the medical profession of the state like the way this money has been offered for use or not. It wasn’t their money.’ He paused a minute and his voice was quiet again as he resumed. ‘“That these dead shall not have died in vain.” That line explains why we want to do this thing. What better could we do than help young men to become proficient in the profession so as to prevent needless deaths?’
Except for those few lines reported by the newspaper men present, no record of Dr. Mayo’s talk survives. It is a ‘lost oration.’ But twenty-five years later men from varied walks of life who had heard it were still referring to it as the greatest, most eloquent speech they had ever listened to. It put an end to the bill.
Minnesota men might carp and heckle; others took the gift at its face value, and when the affiliation was made permanent another wave of articles about the Mayos rolled over the land. The New York Post thought their story ‘one of the most stirring in the annals of medicine’; the New York Sun said, ‘The world can scarcely ask more from the fund than that it will develop more Mayos’; and the Kansas City (Missouri) Journal added, ‘The finest feature of the whole enterprise is the exemplification of the theory of stewardship, which holds that human talents and the financial results they produce are in fact held in trust for the benefit of the community or for the race as a whole. That sets the final seal of enlightened philanthropy upon the gift.’ But the editor of a small Colorado paper capped them all. He concluded his account with a burst of uncontrollable feeling, ‘God, but it’s good to live in a generation of such men!’
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