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© 2003 European Association of Cardio-Thoracic Surgery
The mid-century revolution in thoracic and cardiovascular surgery: Part 2Prelude to 20th century cardio-thoracic surgery12 avenue Villardin, CH-1009 Pully-Lausanne, Switzerland Received August 22, 2003; accepted August 25, 2003 In the year 2000 – when every medical student, if not patient – is well informed about open-heart surgery, organ transplantation, in vitro fertilization and video-assisted endoscopic operations, absolutely nobody can even imagine the working conditions in our Lausanne University Hospital when I started my internship in 1943. Anesthesia had barely advanced since the 1930s. Ether and nitrous oxide were given by mask under the astonishingly competent responsibility of one or two special nurses (still called sisters). Nobody had ever heard about the concept of ‘intensive care’. Fractures of the femur or tibia were kept on bed-rest for 3–6 months with plaster of Paris cast or ‘Kirschner traction’, and gastrectomy or cholecystectomy were our major operations. The early pulmonary resections performed elsewhere at the time (Zurich, Paris) were often still done under local anesthesia allowing the patient to expectorate, and according to the crude hilar massligation technique using the Shenstone Tourniquet. As a first year intern I had an unfortunate patient with ‘post-skull fracture staphylococcus meningitis’ on my ward. A fatal outcome was still the rule in such a case. Europe was at war and penicillin (Alexander Fleming, 1940) was not available. Fortunately, in neutral Switzerland our University Hospital obtained some of this ‘wonder drug’ through the American Embassy. Thus by an extraordinary chance, every morning around 7 am, before my daily schedule, I had to give this patient a dose of penicillin by spinal injection. So, not only I became an expert for the sometimes difficult spinal tap, but also I witnessed the first rapid cure in our Lausanne hospital, and probably in Switzerland, of an until then fatal complication. I mention this first experience with penicillin – in an otherwise fatal situation – as an illustration of the ‘state of the art’ half-a-century or almost 60 years ago. Thoracic surgery was an early choice in my case. In reaction to all the new information about this field coming in after the end of the war I decided early in my third year of internship to become a thoracic surgeon. It should be mentioned that Switzerland, before and during World War II, was the Mecca for the ‘cure’ of pulmonary TB, especially in the Alpine resorts of Davos and Leysin. Some Swiss surgeons therefore were experts in the surgical treatment of TB, thoracoplasty and extrapleural PNO, but had absolutely no experience of operations inside the chest. Already since boyhood I was attracted by everything American – I was able for instance to recite the names of all the American presidents from Washington to Roosevelt – and as a medical student I had many American friends who, unable to be admitted to US medical schools, had come to Zurich to study to become physicians. Right after the war the USA offered by far the best training opportunities in thoracic surgery and I was well equipped to contact some friends and study the literature to make my choice. Thus, to prepare for my training somewhere in the USA, I started early in 1946 to read every volume from 1931 to 1945 of the Journal of Thoracic Surgery which was then only available at the ‘Zentralbibliothek’ in Zurich. This preparation enabled me to itemize for future reference the most important topics and the corresponding leading specialists in the field. The Journal of Thoracic Surgery, today of Thoracic and Cardiovascular Surgery, is the official organ of the American Association for Thoracic Surgery, and since 1931 every paper presented at the Annual Meeting is published in this journal, giving an ideal overview of the state of the art. According to my reading it seemed at the time that for my training I had the choice between Baltimore, Boston, Ann Arbor or Los Angeles. Having good friends in Baltimore, who could introduce me to the well-known pulmonary surgeon W.F. Rienhoff, I opted for Baltimore, a decision that turned out to be an erroneous one. First, Johns Hopkins had become Blalock's center of cardiac surgery, at the time not my first choice, and Rienhoff, near retirement, was not active enough as a teacher in pulmonary surgery, the field I was interested in. I will come back to my Johns Hopkins experience in the important chapter on Blalock. Be that as it may, with my reading of the Journal of Thoracic Surgery in the spring of 1946 began my thrilling adventure of thoracic and cardiovascular surgery and from 1950 on I attended almost every meeting of the Association for Thoracic Surgery, as well as many others in the USA and elsewhere. As I did not want to arrive in the States completely innocent of thoracic surgery – I had never even watched a thoracotomy – I visited briefly Olivier Monod in Paris who, following a 3-month visit to the United States in 1938, had started to carry out very primitive thoracic surgery. Marcel Bérard (1908–1956, Lyon), a much more convincing surgeon whom I visited briefly in Lyon had taken up thoracic surgery following his visit to the USA in 1935. Both these surgeons very graciously let me assist them and so, when I finally started my voyage to Baltimore, I had at least a vague idea of what it was all about.
In the summer of 1946 the USA was an extraordinarily stimulating country. Although today, 54 years later, nobody would compare the environment at the end of our century after the cold war, Vietnam, Watergate and all the rest to our world of 1946, and although I may not have retained the enthusiasm of my early professional life, my first trip to the USA in that summer of 1946 remains one of the absolute highlights in my life. We few young surgeons, among others Henry Lebrigand, future French pioneer in thoracic surgery, not only discovered a new road to surgery but, more generally, became part of a new ‘life-style’, privately and professionally. When I left Lausanne on June 19, 1946 I had never been on an airplane and today's airport crowds would never dare to step in one of those ancient DC3 or Lockheed Constellations for a transatlantic flight. After take-off from Geneva at 5 pm, we landed at La Guardia airport, New York the next day, June 20 at 8 pm, actually 2 am the next day in Geneva. We had three stopovers: Paris, Shannon (Ireland) and Gander (Newfoundland). The seven-member crew of the TWA Constellation took good care of us, 57 passengers, during the actual 24 hours flying time, of which 12 hours was over the North Atlantic. It was a great adventure and compared with a boring Jumbo flight of today with 300 or more other passengers, I would not have missed that first transatlantic flight in 1946 for anything traveling can offer me today. After 3 to 4 sight seeing days in New York I left from Pennsylvania station by train and via Washington and Philadelphia to finally go to Baltimore, the Johns Hopkins and Thoracic Surgery.
This first US thoracic episode turned out to be somewhat of a disappointment, but in fact opened the door to many insights into the country and the profession. Hopkins (Fig. 1) is a prestigious historical institution, which owed its surgical reputation to the famous W.S. Halsted (1852–1922). The surgical reputation in the late 1940s was due to the great Alfred Blalock (1899–1966) and to a lesser degree to the thoracic pioneer W.F. Rienhoff (1894–1980) (Fig. 2). Arriving at Johns Hopkins I first had to get used to the surroundings and then to realize that far from being a center of pulmonary surgery the subject that I was interested in, Hopkins had become the Mecca of cardiac surgery. Hopkins was an old, even old-fashioned hospital (like our Lausanne hospital) situated in what today is called the ‘inner city’. In July, without air conditioning in those days, it was terribly humid and hot. I had a room across the street in one of those typical brick buildings with ‘walk-up stairs’ on 533 North Wolfe Street. Half-a-century later it is amazing to remember how we lived, before air conditioning, all windows and doors open, getting relief two or three times a day with a cold shower. Surprisingly the question of violent crime never came up. In spite of my disappointment concerning general thoracic surgery, my absolute priority, I immediately realized the importance of what was happening in Blalock's operating room, in fact the birth of cardiac surgery. Consequently I mailed a detailed report concerning diagnostic and surgical techniques back to Lausanne, encouraging my chief, Professor Decker, to consider cardiac surgery as well. However, his priority, right or wrong, remained pulmonary surgery, important for our TB patients. Even after my return I could not convince him of a future for cardiac surgery, just as at the time he did not yet accept the importance of specialized anesthesia in his surgical department. Thus, cardiac surgery, as well as anesthesiology, had to wait several years to be established in Lausanne.
According to Longmire, Blalock's most important contribution was not the blue-baby operation, but his much earlier research on traumatic hypovolemic shock (1930). Undoubtedly, considering his research, teaching as well as surgical technique, Blalock (1899–1964) should be considered one of the great surgeons of our time. Beside his original research and his meticulous surgical technique, Blalock was a wonderfully inspiring teacher. In 1947 he visited London and Paris, together with his resident Henry Bahnson (Fig. 3), a future pioneer in his own right. Together with Russell Brock at Guy's Hospital and d'Allaines and Dubost at Broussais Hospital (Fig. 4), he demonstrated the first operations for Tetralogy in Europe (Fig. 5). The lecture ‘On the surgical treatment of congenital heart disease’ he gave on both occasions was an absolute masterpiece. I had heard it before in the USA and it had been so inspiring that I traveled to London and Paris in order to listen to that great teacher two more times. It certainly was there that he inspired several young European surgeons to take up cardiovascular as well as thoracic surgery. Charles Dubost, the first French heart surgeon, was there in 1947—still a young resident at Broussais Hospital. We later became good friends and in 1987, 40 years later, he wrote to me ‘Blalock inspired me so much that there and then I decided to forget about stomachs, the rectum and the rest to devote my career to what was to become an entirely new specialty’. For me Blalock, first in Baltimore and then in Paris and London, produced the same enthusiastic vocation. The impact Blalock had on the evolution of mid-century surgery is also due to the many outstanding leaders he trained, Longmire (1914–) UCLA, Cooley in Houston, Bahnson (1920–) in Pittsburgh and Sabiston at Duke University, to name only a few. In summary, without minimizing the many other important factors, one can definitely consider Blalock's work and teaching at Johns Hopkins during the mid-1940s, the turning point for modern cardio-thoracic surgery. As for Rienhoff he, unfortunately, was then past his prime but his name will remain a milestone in the history of lung resection, since, as we will see later, he was the first to describe the individual hilar dissection technique in 1933 and establish the rules for a secure bronchial suture. One of the many visitors to watch Blalock operate was Bert W. Cotton, who had been in Boston, Overholt's right-hand man during the war years and came through Baltimore on his way to California to establish his own practice as a thoracic surgeon. On his recommendation I obtained a fellowship with Dr Overholt beginning in September. I had no intention of remaining in Baltimore until then and, again on the advice of my new friend Bert Cotton, who was himself on something like a ‘surgical postgraduate tour’, I decided to visit the famous Mayo Clinic, normally active during the summer when most of the leading surgeons in Boston and other major cities were on vacation. Thus, I left Baltimore and traveled via Chicago to Rochester, Minnesota, the home of the Mayos. Chicago, where I visited one or two hospitals rapidly, was like New York, an absolutely remarkable experience and I will come back to this early 1946 visit when remembering the leading surgeons of these two important medical centers—New York and Chicago. But, for now, the neophyte I was, was on his way to the Mayo Clinic which, then as today, was somewhat of a Mecca for medical pilgrims.
The story of the Mayo Clinic (Fig. 6) is too well known to be told here once more (cf. bibliography). Suffice it to remember that at the end of the 19th century, ‘in the middle of nowhere’, the elder, William W. Mayo (1819–1911), a British immigrant country doctor, founded a group practice with his two sons, in the small town of Rochester, Minnesota. Under the leadership of his two sons, William J. Mayo (1861–1959) and Charles H. Mayo (1865–1939) (Fig. 7) two brilliant surgeons, the Mayo Clinic developed into the world famous institution it still is. The concept has served as a model for ‘many never quite equal’ organizations, the Lahey Clinic in Boston, the Ochsner Clinic in New Orleans, the Cleveland Clinic, and many other less important ones. The essence of that early visit in 1946 was that a young European surgeon trained in an at the time optimal surgery initiated by our great Swiss masters, Theodor Kocher (1841–1917) and Cesar Roux, discovered a surgical organization technique and efficiency never dreamed of before. Never before had I seen such a meticulous organization in diagnosis, surgical technique and postoperative care. J.S. Lundy, one of the early pioneers in anesthesiology – he introduced the intravenous pentothal-induction – was the chief of a large staff of anesthesiologists, a profession at the time unknown in continental Europe. Early postoperative ambulation was also still a surprise for surgeons who, at home, used to keep their patients in bed for several days after minor operations! During the month or 6 weeks I spent in Rochester I was an enthusiastic observer of the outstanding surgeons, the names of some I still remember – Oliver Beahrs, E.S. Judd, Gray and ReMine – who alternatively, 3 days a week, performed several gastric, biliary and colon operations per day with a precision and speed I had never seen before. However, the lasting influence on my career as a thoracic surgeon was zero. Theron Clagett, called Jim Clagett, deserves a separate chapter in any history of 20th century thoracic surgery. Clagett, with Overholt, Sweet and Chamberlain, was one of the most important and influential mid-century thoracic surgeons.
O. Theron Clagett (1918–1990) (Fig. 8) was born in Jamesport, MO, but raised in Colorado where he started out in private practice for a few months before coming to Rochester as a postgraduate fellow in 1935. When I had the chance to watch him operate 10 years later he was what I can only describe as a ‘surgeon's-surgeon’. By the sheer variety of operations and technical ease I think he stands above any other surgeon I have seen since. It has been said that he personally performed 20,000 to 30,000 major procedures during his career, and that the surgeons he trained had together done at least another 1,500,000. I know from two of his trainees, my friend Hawley Seiler, as well as Bob Glover (Bailey's associate), that Clagett could be a stern taskmaster but he was deeply attached to the men he had trained. I remember that he told me in his office that I would see that very soon his then young associate John Kirklin was going to be one of the best surgeons in the USA. Clagett's list of honors, distinctions and medals would fill two pages and can be consulted elsewhere. What I would like to tell future surgeons as well as historians is the essence of this extraordinary man, the essence being expressed in his presidential address at the 1962 AATS meeting. Forty years ago I may have been too young to comprehend the fundamental originality of the surgical philosophy he expressed that day. However, reading the text today it expressed the very quintessence of clinical surgery at any time. With the enigmatic title ‘Research and Prosearch’ Clagett would start out by explaining that linguistically the two letters RE mean return—looking backwards or re-discovering. On the contrary, if we want to look forward into the unknown, we should use the prefix ‘PRO’ combined with the Latin ‘spectare’ (to look) we arrive at the word ‘prospect’. Reminding his audience that as a youth he had worked ‘forward ‘ as a mine worker ‘drilling, blasting, mucking’, looking forward into the unknown he arrives at terms like prospector during the gold rush – rushing forward into the unknown. As an example of research he then gave an exhaustive lecture on the ‘thoracic outlet syndrome’, ‘cervical rib’, etc., searching far back into the past up to Halsted and beyond, finding that everything had already been said 50 or more years back. So much for research before analyzing and criticizing the ‘current frenzy for research’ (1962). Returning to his analogy of the gold rush and the disillusioned prospector, reminding that research fever, like gold fever, often leads to bitter disappointment, Clagett regrets the ‘tyranny of research’, as a result of which and unfortunately ‘a superb clinical surgeon and teacher may get little consideration for lack of an adequate bibliography’. In conclusion, he insists that in all evidence he is not against prosearch and the great surgical advances it has produced. However, ‘my plea is that we restore the proper values to the relative importance of patient care, teaching and prosearch – I would not reduce the place that prosearch has earned, but I would restore the status of patient care and teaching for an equal position’. Thus spoke Clagett, an outstanding representative of the most advanced surgery in the most respected institution 40 years ago. An eminently contemporary complaint of academic surgeons today.
Before leaving the fascinating Mayo Clinic interlude for my final destination, Boston, and up-to-date thoracic surgery, it is part of our heritage to briefly review the early history of pulmonary surgery. The resident of the year 2000 who performs a routine lobectomy under ideal conditions of anesthesia and instrumentation may not be able to imagine the stony road from a tourniquet suture–ligature lobectomy for unchecked bronchopulmonary suppuration in the 1920s to the anatomical individual dissection pneumonectomy described by W. Rienhoff in the 1933 Johns Hopkins bulletin – sensational progress indeed in less than two decades. The principles for a secure bronchial closure Rienhoff described almost 70 years ago are still the basis of a good technique today:
Here one should also remember the Swedish surgeon Clarence Crafoord (1899–1984) who, more or less simultaneously, published a detailed operative technique in his thesis ‘On the Technique of Pneumonectomy in Man’ (1938). It is also interesting to note that in an earlier study Quinby suggested painting the bronchial stump with tincture of iodine. Aside from the disinfection, the irritation by iodine induces granulation of the peribronchial tissue – a technique I insisted on until the end of my career. Actually Rienhoff performed his first successful dissection pneumonectomy on July 24, 1933, only a few months after the historical one by Evarts Graham. Together, Edward Archibald (1872–1945) and Rienhoff were called ‘The Fathers of Modern Pneumonectomy’. Having thoroughly studied the literature before coming to the US it was a logical decision to train with Rienhoff. However, in 1946 – 13 years after his breakthrough – at the still early age of 52 years, he was more or less in the twilight of his career, a nice southern gentleman living at Hopkins in the shadow of the great Alfred Blalock. The first pneumonectomies by Nissen (1931), Cameron Haight (1932) (Fig. 9), Evarts Graham, Rienhoff and Overholt (1933) were of course already the end result of several decades of trying to resolve the problems of partial lung resection or lobectomy. In fact, until 1933, surgeons, first of all Evarts Graham, were concerned that sudden ligation of the main pulmonary artery would result in the clinical situation of massive pulmonary embolization.... Partial lung resection has of course a long history going back to the late 19th century. Without going into any details I could in passing mention again the exploit of Tuffier (1891) and the tragic story of M.H. Block (1881), episodes that had actually very little to do with the beginning of pulmonary resection. As I mentioned earlier, Tuffier, a really original pioneer, performed what might have been the first partial lung resection by dissecting extrapleurally, clamping and suturing ‘en bloc’ a tuberculous apex, without risking an open pneumothorax. The tragic story of M.H. Block is often quoted. Apparently he performed a partial lung resection on a cousin at her own request. Not only was the specimen free of tuberculosis (!), but also the patient unfortunately died during or shortly after the operation. According to a letter by Walton to the Boston Medical and Surgical Journal, Block faced with legal problems ‘took his own life shooting himself through the head’. Nissen, however, trying to verify the anecdote in Danzig, could not find any documentation confirming the event.
It may seem superfluous to have mentioned once more these ‘prehistoric’ anecdotes having very little to do with the first coordinated approach to lobectomy during the famous 1920s. The two prominent surgeons who initiated a systematic approach to partial pulmonary resection were Harold Brunn (1894–1950) at Stanford in San Francisco, and Howard Lilienthal (1861–1946) (Fig. 10) at Mount Sinai Hospital in New York City. In this context I should also mention the Shenstone-tourniquet invented by the Canadian surgeon Norman Shenstone. The tourniquet constriction of the hilum at the time allowed a fairly speedy resection, prevented spilling of copious sputum and simplified hemostasis by suture–ligature. Brunn, as well as Lilienthal performed all their first lobectomies under hilar constriction by the tourniquet. To cut a long story short, Harold Brunn published a detailed description of a one-stage – still mass-suture–ligature – lobectomy in 1929. He had only six cases with one operative fatality. Although there can be no question about the importance of Brunn's detailed description, he was preceded by several years and many more cases by Lilienthal. From 1910 on Lilienthal had operated on a growing number of cases – initially by the ghastly two-stage method leaving the ligated bronchiectatic lobes to slough out of an open wound. From 1914, long before Brunn, he started doing one-stage lobectomies and in 1922 he published his series of 30 cases. His horrendous rate of mortality of 43%, and for bilobectomies 70%, may be explained by the desperate cases of longstanding suppuration (before antibiotics) he had to take on. He felt that individual dissection – although the ideal technique – would take too long, and still used the tourniquet technique. In fact at the time every operation was a race with death and Lilienthal explained ‘that any lobectomy lasting longer than 45 minutes would almost certainly result in the loss of the patient. Patients desperately asked to be operated and even threatened suicide if refused the chance of operation’. ‘To refuse to operate on a wretched patient otherwise incurable, merely because the statistics may be unfavorable, seems hardly fair. To have been the instrument of restoring one of these doomed patients to blooming health after years of revolting illness and risk of fatal hemorrhage is the richest reward surgery can offer’.
It is somewhat difficult to write and read about that kind of surgery, when in the 1950s a mortality exceeding 5 or 6% was unacceptable and when today mortality, even for coronary surgery, has dropped to the 1% range. Still, at the time Lilienthal and others like him were highly respected surgeons, and one can only realize how overwhelming the revolution, technical and ethical, from 1930 to the 1950s has been. Coming briefly back to the tourniquet it seems, as often is the case, that several surgeons almost simultaneously had the same idea, hence the confusion on names. Shenstone, the associate of Robert Janes, both were academic surgeons in Toronto, that is the Shenstone–Janes tourniquet. Another Canadian, Bethune, who apparently worked later on in China, seems to have had the idea before the group at the Toronto General Hospital. Therefore the Pilling Company sold the tourniquet under the name of Bethune tourniquet (Fig. 11). Nevertheless, it was Shenstone and Janes who popularized the technique.
I arrived in Boston as a visiting fellow of the Overholt Clinic on September 1, 1946. I was 30 years old, and the time I spent in Boston in 1946, and again in 1950, was the most important experience in my life as a surgeon. Boston in those days was indeed the gateway to cardio-thoracic surgery. The Deaconess, as well as the Children's and Peter Bent Brigham Hospitals, were in walking distance and the M.G.H. only a short subway trip away. The second generation pioneers who in the late 1930s and during the war had established modern cardio-thoracic surgery, Churchill, Overholt, Sweet, Gross, and Harken, were all there to watch. 4.1. Resection for tuberculosis Furthermore, with all respect and admiration due to the teachers I was going to meet in Boston, we have to realize that the explosive development of cardio-thoracic surgery in our time was not only due to the coming of age of anesthesiology but also to the more favorable and frequent indications for operation, above all in the new field of TB-resection. Before tuberculosis the most common indication for resection was bronchiectasis, but here also the decision to operate was made earlier. Therefore, instead of the dreadful cases Lilienthal operated between 1910 and 1920, surgeons took on the kind of cases Churchill (Fig. 12) and Belsey described in their 1939 paper on segmental resection for bronchiectasis. Tuberculosis has indeed played a key role in the development of thoracic surgery. In the wake of two world wars the flare up of this last worldwide epidemic before AIDS left thousands of chronic TB-patients in sanatorium-isolation for years. Even before the discovery of streptomycin in 1944, i.e. before antibiotic protection, many of these chronic patients were eager to take the still considerable risk of operation in order to escape the frustrating sanatorium atmosphere so well described in Thomas Mann's ‘Magic Mountain’. I had myself been an assistant in a sanatorium before streptomycin in 1946. By the time I started my training with Overholt we already had streptomycin and the number of cases with improved results increased dramatically. Even though tuberculosis played a key role in the rise of pulmonary surgery, TB-resection remained highly controversial for many years. When the first papers on TB-resection appeared in the programs of the AATS meetings between 1935 and 1940, they were greeted with skepticism and outright condemnation. Freedlander, at the 1935 meeting, had the courage to report an, as a matter-of-fact, unsuccessful case. During the discussion John Alexander of Ann Arbor, the uncontested authority for the medico-surgical treatment of pulmonary tuberculosis, expressed doubt ‘that lobectomy will ever be widely accepted for uncomplicated cavernous TB’. Five years later, at the 1940 meeting, Dolley and Jones idem presented another paper on the same topic. It is highly significant that during the ensuing discussion as many as 18 surgeons reported their experiences. In the 19 pneumonectomy cases mortality was 40.2% with only nine patients ‘improved’ or doing well. For the 31 lobectomies mortality was 20.5% with 16 patients improved. Due to the influence of a few farseeing pioneers – Overholt, Chamberlain and others – against the reprobation of many conservative physicians arguing that TB was a disseminated disease unsuitable for surgical treatment, resection for pulmonary tuberculosis turned out to be the breakthrough of the 1940s and 1950s. Even though fairly soon streptomycin and other powerful antituberculous drugs replaced surgery, hundreds of young thoracic surgeons, among them future pioneers in cardiac surgery, such as Russel Brock (1903–1993), Harken and Bailey, had learned their trade by performing resections for pulmonary tuberculosis.
4.2. Anesthesia Anesthesia – which I had already admired at the Mayo Clinic – was no doubt the other decisive element for the development of cardio-thoracic surgery. As we have to remember, farseeing surgeons such as Sauerbruch, Elsberg, Matas, Crafood, to name only some of them, made important contributions to the progression of modern anesthesia. On the other hand, unfortunately, in my time there was a definite ambivalence in the relation between anesthetists and surgeons. While most continental surgeons remained definitely adepts of nurse-anesthesia and much later accepted physician anesthetists only as subordinates to their department, institutions like the Mayo Clinic or the Lahey Clinic and the M.G.H. in Boston had established anesthesia departments with prominent chiefs such as Lundy, Eversole or Beecher. As an unpaid visiting fellow at the Overholt Clinic I was able to occasionally visit other hospitals such as the M.G.H. or the Children's Hospital, to watch Churchill, Sweet or Gross doing a lobectomy, an esophagectomy or a patent ductus. Churchill was broad-minded and farsighted enough to understand the necessity of physician anesthesia early on. Henry K. Beecher, chief of anesthesiology at the M.G.H. was one of the foremost pioneers in his field and he thought rightly that ‘anesthesia had altered the practice of medicine, perhaps more than any single other advance’. Beecher was a great teacher and leader of men, with a passion for promoting his specialty. During my visits to the M.G.H. operating theater he noticed my interest in thoracic surgery and consequently invited me – to my surprise – for lunch at the Ritz Carlton, a place until that day beyond my habits. In fact, this generous teacher offered a fellowship for 1 year in his department to any interested Swiss physician. My Lausanne chief, to whom I passed on this tempting offer, was opposed to any such development and naturally declined this unique opportunity. Beecher proposed the fellowship to Professor R. Nissen in Basel who had spent some time in Boston during the war. Nissen, open-minded as he was, sent one of his assistants, Werner Hugin (1918–), who later became the first president of the Swiss Society of Anesthesiology and the first Swiss Professor in the field. It was unfortunate for the Lausanne Hospital where we had to work with a very good but still ‘makeshift’ nurse-anesthesia for several more years. Even when Professor Decker accepted, much later, the necessity of a professional physician anesthetist there was never an independent department of anesthesiology at the Lausanne University Hospital before his retirement in 1960. I must repeat that many continental surgeons had the same attitude and that in Switzerland, Germany and Austria anesthesiology as a special discipline was only accepted as late as in 1952, the year Societies for Anesthesiology were finally founded in these three countries. This unfavorable picture is of course in contrast to the evolution in the USA and Scandinavia where many surgeons took the initiative in the advances of anesthesia. C.A. Elsberg (1874–1948), a young New York surgeon, developed what was probably one of the first anesthesia-machines for clinical use based on the Meltzer research and in 1910 gave the first endotracheal insufflation anesthesia for one of Lilienthal's early thoracic operations. I think that Alexis Carrel, himself a surgeon, working next door to Meltzer at the Rockefeller Institute, understood the potential of Meltzer's work for clinical anesthesia and suggested it to his surgical colleagues. Clarence Crafoord and Overholt, long before one-lung anesthesia, both devised methods to prevent the much feared spilling of septic secretion from the diseased to the healthy lung in the lateral thoracotomy position. Crafoord, in his 1938 thesis ‘The Technique of Pneumonectomy in Man’, suggested to close off the diseased bronchus by a gauze tampon placed by bronchoscopy. Overholt, for the same reason, had abandoned lateral thoracotomy in favor of the ‘face down prone position’ (Fig. 13). As one of his trainees I operated for several years on all my patients in this position by postero-lateral thoracotomy. Even before one-lung anesthesia, however, I switched back to the lateral thoracotomy allowing a much better access to the entire chest cavity. So much for the ancient history of anesthesia.
When I arrived in Boston in 1946 Overholt still operated with ‘nurse-anesthesia’. During my second term with him he had switched to physician anesthesia. In 1946 the patients were intubated by the residents before the nurse took over. As every experienced anesthetist can confirm today—50 years later—tracheal intubation can be a very difficult maneuver. In the beginning Willy Meyer, the promoter of the Sauerbruch chamber in the USA, thought that intubation as a routine clinical method was not a practical procedure. Even in the late 1930s surgeons regarded intubation as a maneuver needing more than average skill. Overholt's residents, themselves eager to learn, were kind enough to let me intubate occasionally. I knew that this training was fundamental for starting thoracic surgery at home and when I came back in early 1947 before every thoracotomy I had to intubate myself before turning the anesthesia over to our nurses. I will never forget the many difficulties of my ‘learning curve’ in thoracic surgery, one of them being tracheal intubation. Only 4 years later in private practice was I able to rely on the first Swiss anesthetist, Charles Bovay, who was trained like myself some years before at the Deaconess Hospital in Brookline-Boston.
At the time, I found in Brookline just as before in Rochester, the same small town atmosphere I was used to in Switzerland. Everything, the prestigious hospitals as well as boarding houses and cafeterias were in walking distance. The three Boston surgeons who impressed me most and permanently all through my surgical life were R.H. Overholt, Richard Sweet, and Robert Gross. Of course there was also the chief, Frank Lahey (Fig. 14), whose international reputation as a surgeon I do not have to stress. Occasionally I watched him ‘do a thyroid-resection’ more elegantly than anybody else. His second in command, Richard Catell, a prestigious surgeon second to none who specialized in biliary and pancreatic surgery, had repaired the common duct of Anthony Eden (1897–1977), the British foreign minister. Unfortunately, on my second visit in 1950, I watched this brilliant surgeon, afflicted by Parkinson's disease at the early age of 50, trying to overcome his terrible handicap by pure willpower, helped by two of the best residents – a tragic spectacle.
Of the three, Overholt, Sweet and Gross, we will meet the latter two in the chapters on esophageal and heart surgery. As for Overholt (1901–1990) (Fig. 15), he was our chief and has remained my role model as a surgeon as well as a man all through my surgical career. He was a charismatic personality, a great teacher and a lifelong friend. We visited each other regularly whenever one of us crossed the Atlantic. One of my lasting and special souvenirs is our 1951 car ride all the way up the Italian Peninsula, along the south of France – Menton, Nice and Cannes – up to Marseille airport for Overholt's flight home. We had attended the meeting of the American College of Chest Physicians in Rome and as the young surgeon that I was, I still only owned the smallest possible car, a ‘Topolino’, a vintage automobile, today the equivalent of the still existing Fiat ‘500’ Cinquecento. Who today would make such a long return trip in such a small vehicle? I remember our frequent stops, not so much to stretch Overholt's long legs, cramped in the small compartment, but to let him take pictures of the many wonderful views.
Some years later, in 1956 or 1957, he came to the mountains to watch me do a lobectomy in one of our sanatoria. As it had to happen with the ‘chief’ behind me, I tore a segmental artery. In order not to pull the short segmental stump off the main artery I tied only two knots instead of three or four of my linen ligature (still the usual ligature material) as it is less apt to slip. Relieved I said ‘le mieux est l'ennemi du bien’, a local French expression that Overholt liked so much as to write it down. It means ‘The better is the enemy of the good’. I sometimes wonder if I would ever have succeeded in introducing thoracic surgery in my part of our country without this first training period at the Overholt Clinic. It was then that I learned the delicate and precise techniques of total or partial lung resection, especially segmental resection for bronchiectasis or TB. As a technician Overholt was absolutely unsurpassed and unsurpassable. His 1949 book ‘The Technique of Pulmonary Resection’ (of which I cherish an autographed copy) (Fig. 16) remains even today one of the best teaching manuals in our field. Without going into the details of his biography, which can be consulted elsewhere, let me just recapitulate that he was born and raised in Ashland, Nebraska, a small farm town, went on to medical school at the University of Nebraska and surgical training in Philadelphia before being appointed as a thoracic surgeon to the staff of the Lahey Clinic in Boston-Brookline. As an independent personality by nature, he soon established his own private practice, rising to worldwide reputation. In the early 1930s, when operating on tuberculosis patients he observed that the lungs of non-smokers recovered faster than the smokers’ lungs. He became a literally fanatic crusader against cigarette smoking and the tobacco companies. He always told his story of the 1934 convention when he reported his anti-tobacco observations. He remembered that he was actually laughed off the podium ‘They thought I was crazy’ he said... He definitely was also convinced that a surgical solution was the best treatment for many diseases—tuberculosis, bronchiectasis, asthma and many more.
He was a convinced and undoubting surgeon and when, in advanced years he himself needed a triple coronary bypass and a colon resection he never flinched and was a totally disciplined patient. Some surgeons have a feeling that operations are only good for their patients—not so much for them or their families. He was not one of them. All in all, as a personality and a surgeon, Overholt was an outstanding pioneer to be remembered.
There was only one other pulmonary surgeon who impressed me just as much and that was J. Maxwell Chamberlain of New York. I first met him when I arrived on my second trip to New York in October 1949. Remembering him also gives me the occasion to review my very interesting impressions of surgery and surgeons in other North American centers, foremost New York and Chicago. These impressions go back to my first two prolonged residencies in 1946 and 1950, as well as to later passages. Chamberlain, as I will describe, played an important role in my discovery of tracheobronchial surgery because it was during one of his operations that I saw the first bronchial anastomosis, and Chicago was a milestone in the field because that was where I met Bob Jensik, one of the early pioneers in that field. Sleeve lobectomy and tracheobronchial reconstruction were the ultimate success stories for thoracic surgeons before turning to early cardiac surgery. The amazing and definitely challenging field of plastic reconstruction of the tracheobronchial tree is a striking example of the revolutionary speed of mid-century advances in our field. While 10 years before, in the 1940s, surgeons struggled to advance from crude tourniquet operations, little different from 19th century general surgery, by 1950–1960 sleeve lobectomy was the topic of the day. A historical review of this development is fascinating but before that I would once more like to turn to two related personal souvenirs. For my second residency with Overholt in 1949–1950 I crossed a stormy Atlantic Ocean in October on the French luxury liner ‘Ile de France’, another absolutely memorable episode of my surgical career. Compared with a monotonous routine flight from Geneva to New York in a crowded Jumbo jet, my first 1949 boat trip – considerably less expensive – was indeed something very special. Before going on to Boston I visited some of the prominent New York surgeons, in particular Max Chamberlain who had been recommended to me by Overholt. J. Maxwell Chamberlain (1908–1968) (Fig. 17) was a truly charismatic personality whose relentless drive and juvenile enthusiasm had a great impact on the professional career of his many friends and colleagues. Having trained with Churchill at the M.G.H. he moved to New York and established himself as the number one thoracic surgeon. Somehow I had developed an almost friendly relationship with him and he took me along to assist during his operations in several New York hospitals, some as far out as the Sea View sanatorium on Staten Island. Whenever I came to New York in later years we got together, sometimes with Crafoord, one of his best friends. On one of these visits in the late 1950s he wanted to show me a new posterior approach to the hilum for lower lobectomy. As it sometimes happens when a surgeon wants to show one of his special techniques to a colleague, that 1 day Max Chamberlain, by mistake, cut the intermediate instead of the lower lobe bronchus. Because the patient had a very limited respiratory reserve Chamberlain wanted to save the middle lobe and performed a technically perfect anastomosis between middle lobe and intermediate bronchus. That was my first look at tracheobronchial surgery, a field which was going to be one of my main interests during several years. When in the late 1950s I had to choose if possible an original topic for my inaugural lecture as Associate Professor at the Geneva Medical School, everything had been said about resection for tuberculosis or bronchiectasis, etc. The only original development I considered of actual interest was tracheobronchial surgery and, obviously in preparation for my lecture, I started doing more and more sleeve lobectomies and bronchoplasties. Today's reader should, however, realize that developing a new technique, with our at the time limited infrastructure in instrumentation and anesthesia, meant every operation was a hard-won struggle. Surgery was still a one-man show with the surgeon carrying total responsibility almost alone; a situation even more dramatic in the early days of closed, blind cardiac surgery.
Now, coming back first to Chamberlain and then to the history of sleeve lobectomy, it is important to remember that Chamberlain, more or less simultaneously with Overholt, was already the foremost and earliest promoter of segmental resection for tuberculosis. His first publications with Klopstock date back to 1949 and 1950. At the time economic segmentectomy for TB was, right or wrong, still a very controversial approach and could only be successful in the hands of the best technicians. Both Overholt and Chamberlain were of course outstanding technicians. Segmental resection was in fact one of the important steps toward precision lung resection. Chamberlain was also instrumental in the foundation of the Society of Thoracic Surgeons in 1965 and invited me to be one of the founding members. Although himself a highly respected member of the somewhat exclusive elite of thoracic surgeons, he wanted to start a new forum for young surgeons who were prevented from belonging to the American Association for Thoracic Surgery because of its limited membership policy. In honor of its founder every annual meeting of the Society of Thoracic Surgeons starts with the ‘J. Maxwell Chamberlain Memorial Lecture’. I do not quite agree with Ralph Alley who, although one of Max Chamberlain's best friends, thought that ‘following his tragic and premature death in an automobile accident on his way from work in New York to home in Boston, he became a legend that may have grown progressively larger than the man’. To me he was a unique person and he belonged to the small group of truly great surgeons that I had the privilege to meet. New York, although always a metropolis, was an altogether different city from what it is today, less overbearing, less crowded, with fewer or no tourists, a city which lived at a somewhat slower pace. Still, for someone who grew up in small Swiss towns, New York was then, as today, a definitely exciting city, medically and otherwise. In 1950 I lived uptown at the International House for Students, one of those typical New York red brick buildings, near General Grant's tomb overlooking the Hudson River (Fig. 18). Aside from medicine and surgery my two everlasting memories are ‘The Death of a Salesman’ by Arthur Miller, and an evening with Ella Fitzgerald and Louis Armstrong. I have always loved the theater and went to see a play whenever the occasion presented itself, but I have never been more impressed by any other play since then. A few years earlier though, during my student years in Paris (1938), the extraordinary actor Louis Jouvet impressed me just as much. In the New York play I do not recall the names of the actors in 1950/1951, but I have seen the play on several occasions since then, always remembering that first performance in the 1950s. Ella Fitzgerald and Louis Armstrong have of course few equals in jazz history and later both of them could only be heard at big shows in huge theaters like Radio City Hall. During that first New York visit in 1950, walking down Broadway I happened to notice a small advertisement announcing the two famous musicians. They performed in one of those small walk-down clubs on Broadway, a room holding 100–150 spectators at the most. I walked down the few steps, paid a certainly modest entrance fee and spent an unforgettable evening with these unique performers. Life in New York was then so different that today's visitor would find himself there in an entirely other world.
During the few days I stayed in New York in 1950 I also visited Andre Cournand at Belleview, Herbert C. Maier at Lenox Hill and Harold Neuhof at Mount Sinai Hospital. Cournand, of French origin, became world famous as the inventor of cardiac catheterization in 1941. My visit with him revealed what was for me a quite new field of cardiopulmonary physiology. From a historical point of view cardiac catheterization was performed much earlier, in 1929, when Forsemann, a young German physician in his famous ‘auto-experiment’ pushed a ureteral catheter through a vein in his own arm into his heart, wanting to prove that it was possible to inject medication directly into the heart. Herbert C. Maier was another New York surgeon who impressed me very much, not by his operations but by his encyclopedic culture in thoracic pathology, radiology, and diagnosis in general. He was President of the AATS meeting in 1966 in Vancouver. The Mount Sinai team has always been in the forefront of the field of thoracic surgery. At the time, I visited Harold Neuhof who as early as 1933 had already published a paper on the surgical treatment of lung cancer, which puts him definitely in the pioneer generation. With his junior colleague Arthur Touroff he was also the expert in the surgical treatment of a then frightening, often deadly disease, putrid lung abscess. The Mount Sinai team had published a long series of cases describing the draining of the abscess in two stages and obliterating the residual crater with a pedicled pectoralis muscle graft. I remember that on my return to Lausanne I treated several such cases according to the Neuhof principles. Finally returning to tracheobronchial surgery and leaving New York I would like to pay tribute to another brilliant surgeon, Robert Jensick in Chicago, who performed, whenever possible, sleeve lobectomies for cancer at a time when most surgeons throughout the world still resorted to total pneumonectomy, for purely technical reasons. Several other leading surgeons, Hermes Grillo, Griff Pearson and others, whom we will come back to in the historical paragraph, played a crucial role in the development of these techniques. They, as well as Jensik, were to remain close friends and colleagues throughout my entire surgical career. The first time I visited Chicago in 1950 I intended to watch Willis Potts operate. He had conceived the Aortic Potts clamp for the direct aorto-pulmonary shunt in blue babies. Another highly informative visit was the one with Paul Holinger, after Chevalier Jackson the most renowned expert in the growing field of endoscopic diagnosis and therapy. Chicago, different from New York, was also a stimulating and, at least near the lake, beautiful city. I took many pictures of the lakefront and the impressive elevated drawbridges. I stayed at the Stevens Hotel, a massive brick building on Michigan Avenue, today replaced by the modern buildings of the 1970s and 1980s, right across from the famous Aquarium (Fig. 19). On one of my later visits during the early 1960s, walking along Michigan Avenue one evening, I came upon a queue in front of the Chicago Civic Opera. Realizing that George Solti was conducting the Chicago Symphony that evening, an already then famous conductor and famous orchestra, I stood in line and obtained one of the last tickets. I was overwhelmed by a splendid rendition that I still remember of some Beethoven and probably a Brahms or Debussy symphony; an overwhelming experience on a surgical tour.
I should also remember my best Chicago friend, Thomas W. Shields, Professor at North Western University, a world-renowned cancer specialist and editor of a 2000-page, two-volume textbook on thoracic surgery. The 1994 fourth edition of this excellent, comprehensive textbook, to which I contributed the historical introduction, remains an absolutely up-to-date compendium. The last of my very good Chicago relations was C. Rollins Hanlon, an amazing personality with whom I was going to be in frequent contact when, after my retirement from active surgery, I was appointed to start and direct a department for the Swiss Medical Association for continuous medical education. Hanlon was going to be from 1969 Director of the American College of Surgeons in Chicago. I had met him as Blalock's resident in 1946 and through a common friend, Francis Woods, Overholt's associate. They were originally both from Cincinnati where I had mutual friends from before the war. Rollins Hanlon is one of the unique personalities, academic surgeon and an invaluable administrator. Before 1969 he was a highly respected academic surgeon, Associate Professor at Hopkins, and Professor and Chairman at St. Louis University. As Blalock's resident he established the fact of increased longevity in transposition patients having large septal defects and consequently developed the atriseptostomy as a treatment for these patients. Rollins Hanlon should definitely be remembered as an outstanding scholar and professional politician. During the almost annual trips to the AATS meetings I visited many other institutions and brought back new inspirations: Cleveland, San Francisco, Ann Arbor and Saranac Lake, the sanatorium resort, America's ‘Magic Mountain’, a small and charming country town, which reminded me of our TB-resorts Davos and Leysin. In the excellent and supposedly beneficial spring climate I was reminded of the early history of sanatorium cure in the US. The history of the young New York physician Edward L. Trudeau (1843–1915), who promoted ‘open air treatment for tuberculosis’ and established the first sanatorium in this small town in the Adirondack Mountains in 1884, is too well known to be repeated once more, but it was one more interesting experience to have gone there in 1946 or 1949, shortly before resection and antibiotics transformed the sanatorium world into an almost forgotten historical curiosity. 6.1. Tracheobronchial reconstruction In fact tuberculosis played an important role in the history of tracheobronchial reconstruction, when the salvage of healthy lung tissue distal to a posttuberculous bronchial stricture was important. The names of many leading surgeons – Price Thomas, Philip Allison, Paulson and Shaw – are attached to the development of these function-sparing techniques. Straightforward end-to-end bronchial anastomosis was of course still a difficult task before one lung anesthesia with a double lumen tube. The next best solution was the Gebauer technique of bronchoplasty. Paul Gebauer, whom I met in 1952, was predominantly a TB-surgeon in Honolulu. As he explained, he had many patients, especially small Hawaiian women, who developed posttuberculous stenosis of their already small bronchi. In order to save healthy lung, distal to the stricture, Gebauer had developed the technique of restoring a normal bronchial lumen by a dermal patch-graft, stabilized by a serpentine of stainless steel wire (Fig. 20). By an extraordinary coincidence I happened to sit next to him on our flight to San Francisco from the 1952 AATS meeting in Dallas. During that flight at still low altitude, I was able to admire the splendid scenery of the Grand Canyon for the first time, and I obtained first-hand detailed information concerning the Gebauer technique. Back home I used this technique for one of my first tracheoplasties. After a semi-circumferential palliative resection of a carcinoma of the cervical trachea, I repaired the long defect with a pedicled Gebauer-graft.
The first sleeve-lobectomy in 1947 is attributed to Price Thomas. It was probably an on the spur of the moment decision because he did the operation for resection of an adenoma on a young man waiting to enlist in the Royal Air Force. Obviously the candidate was only accepted as a pilot because his surgeon had saved his upper lobe and normal respiratory function. Price Thomas published the history only 9 years later, in 1956, with 13 more cases. He said that Allison had done the first sleeve-lobectomy for carcinoma in 1952. In the US Paulson and Shaw were the first surgeons to publish their experience with broncho-plastic procedures in 1957. Once again the question of priority is unimportant since many of the avant-garde surgeons started doing function-sparing operations at about the same time, between 1950 and 1960. Price Thomas also performed a pneumonectomy for cancer on King George VI in an especially installed operating room at Buckingham Palace, on September 23, 1950. A heavy smoker, maybe in part due to the responsibilities and stress during the difficult war years, King George survived the operation for only a few months. His daughter, Elizabeth II is still Queen of Great Britain, 50 years later. Clement Price Thomas (1893–1973) (Fig. 21) was another of my heroes. In 1933 he started as clinical assistant of Tudor Edwards (1890–1946) (Fig. 22), the founder of thoracic surgery in Great Britain. After the premature death at the age of 56 of his chief, Price Thomas and Russel Brook, whom we will meet later as a cardiac surgeon, were the leading thoracic surgeons in Great Britain. Price Thomas, whom I visited the first time in 1948 and several more times in later years, was a most attractive personality, a very modest man with a great sense of humor. On my first visit, still a very young and unimportant resident from Switzerland, I was nevertheless treated with typical British courtesy. One day, along with the great Evarts Graham who was visiting his British colleague, I was invited to ride with them in Price Thomas's Rolls Royce. In those days surgeons had chauffeurs and a Rolls Royce or, like my chief in Boston, a Cadillac. One can imagine how impressed I was in 1948 riding in a Rolls Royce from one hospital to another, listening to these two famous surgeons, sitting in the back and smoking a cigarette. Another historically interesting detail was that Evarts Graham (1883–1957), the first surgeon to successfully perform a pneumonectomy for cancer, definitely curing his patient, himself died of metastatic inoperable carcinoma of the lung. Price Thomas, on the other hand, also developed lung cancer but was cured by a lobectomy performed by Charles Drew, his first assistant, the Charles Drew who later introduced profound hypothermia for cardiac surgery. So much for case histories.
As for surgery of the tracheobronchial tree during the late 1950s and early 1960s, three surgeons were the leaders in this field, Robert J. Jensik, whom I already mentioned, and first of all Hermes C. Grillo (Fig. 23) of the M.G.H. and F.G. Pearson of Toronto. They were indeed the leaders in this new field and due to our personal relationship I started doing more and more function-sparing operations in cancer patients. Another favorable element was my collaboration with Marcel Savary, our chief of the ENT department and a European pioneer in bronchial and esophageal endoscopy. It so happened that we had more and more benign cases of postintubation strictures. In these cases technical details, such as extensive tracheal mobilization from above and below, advocated by Grillo and Pearson, were of the utmost importance. Furthermore, we always left a slightly longer posterious membranous flap to take the tension off this most vulnerable spot and remained faithful to the resorbable catgut sutures we had used since our days with Rienhoff in 1946. At the 1969 meeting of the Society of Thoracic Surgeons in San Diego we presented eight such tracheal resections without complication or restenosis. Our most extensive resection was in the case of a 20-year-old Italian girl who, following an unsuccessful suicide, presented a two-level stricture at the tracheostomy level and way down at the tip of the canula. We had to resect 10 of a total of 17 rings, practically 60% of the trachea. The postoperative course was uneventful and the stenosis did not recur. At the time this was surely the world's most extensive tracheal resection. One year later we reported a still satisfactory result during the discussion on the same topic at the meeting of the AATS in Washington. Over the years, discussing our experiences at these meetings, we all, Jensik, Grillo and Pearson, became good friends. I owe a special debt to Griff Pearson who made me a honorary member of the AATS when, as its President in 1990, he invited me to give the ‘Honored Guest Lecture’ on ‘The Story of Thoracic Surgery’ – the beginning of a second career as a medical historian.
One may estimate that with tracheobronchial reconstruction at the beginning of the 1970s the mid-century revolution, at least in the field of pulmonary surgery, was over and nothing really new happened for decades. Nevertheless, as a final event or, if you want, as the conclusion we have to tell the story of the foundation of the ‘International Association for the Study of Lung Cancer’ and the birth of the Cliff Mountain TNM-Staging. It all happened in 1972–1973 and, as so often in the course of two intimate, small, get-togethers, ‘The Coventry Conference’ and the ‘Airlie House Conference’ of the N.I.H. To both select groups of maybe 50 physicians I was invited as the Swiss representative to present our experience in tracheobronchial reconstruction in cancer patients. While the ‘Coventry Conference’ on July 10–11, 1973, organized by Roger Abby-Smith, was devoted to the ‘Surgery of the lung: from bullous emphysema to carcinoma and transplantation’, the ‘Airlie House Conference’ in Washington, on October 16–20, the year before in 1972, dealt only with the theme ‘Cancer of the lung’ directly leading to the foundation of our new Society presided by the TNM champion Clifton F. Mountain of the M.D. Anderson Institute. The Coventry Conference was an intimate, very British ‘get-together’ including an evening reception in ‘tuxedo’ with the ladies wearing long dresses. Nevertheless, we did intensive work and had stimulating discussions during the 2 days and, after the meeting I had the occasion to watch our host Roger Abby-Smith operate; a superb surgeon in a class with Overholt, Chamberlain and, in their field, with Kirklin and Lillehei. For him, even during operations of far advanced cancer, there was never any difficulty, be it the hilar vessels, or even the auricular wall. I think it was Abby-Smith or maybe Chamberlain who said ‘Operability is a state of mind’. But, he was not only a surgeon and a charming personality, but also an authentic British gentleman. Following his retirement he never operated again and devoted himself entirely to his many hobbies, photography and alpine flora, which he collected roaming Scotland and even our Swiss Alps. A man who should be remembered. In Coventry I also became a friend of another important, very British surgeon, Jack Belcher. He was the number one pupil of another great pioneer, Holmes T. Sellors, whom I had visited in the 1950s. Jack Belcher was one of the 18 honest British surgeons, members of the ‘Charly's Club’, an original, typically ‘fair play’ club. Following a surgical error – he inadvertently had cut the main bronchus during a lobectomy – J. Belcher had the idea to present the case at a staff meeting, from which originated the idea that at every yearly meeting the 18 surgeons presented their errors instead of their successes: very British. It was also Jack Belcher who told me the anecdote that Norman Barret not only succeeded Price Thomas as chief surgeon at the Brompton Hospital but that he also inherited his famous Rolls-Royce. The Airlie House Conference on the treatment of lung cancer was due to the ‘Anti-Cancer Program’ of Richard Nixon, the 51st US President who had declared a war against cancer, one of the important, highly advertised programs financed by millions of official dollars. Organized by the N.I.H. it was a much more comprehensive and international meeting, with Scandinavian, French, Italian and even Russian pathologists, oncologists, immunologists invited besides British and American surgeons. We were three Swiss – two oncologists, Alberto of Geneva and Brunner from Berne, as well as myself. One incident I remember was the already frequent ‘overbooking’ of airline companies with the result that Alberto and myself for the first time in our life, crossed the Atlantic in the luxury of first-class passengers. However, in a more serious veine, the Airlie House Conference was an incredibly enriching experience, every attending member learning from the other, obtaining an all-round view of surgical, pathological, immunological facets of this same terrible disease. I can only say, from a very personal point of view, that I never learned more about lung cancer than during these 3 days (and nights) listening to Oleg Selawry, t |
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