MODERN SURGERY- 1st HALF OF THE 20TH CENTURY

There is an informal survival rule amongst surgical residents passed from one generation to the next:

1. Eat when you can
2. Sleep when there is an opportunity
3. Above all, never fool (polite form) with the pancreas

None of the greats, including Halsted, touched the pancreas. But one man did.

Allen Oldfather Whipple reported a two-stage operation for pancreatic cancer to remove the head of the pancreas in 1936, which evolved into a one-stage operation, and is essentially the same now as it was nearly 90 years ago. Pancreatic cancer is difficult to diagnose as the organ is so sheltered in the back of the abdominal cavity. It remains perhaps one of the most difficult of operations. Only 1 in 5 fortunate patients is a candidate for this major operation. It takes most surgeons that are capable of doing it, five to eight hours to accomplish it, and still has higher operative mortality than most operations, namely 2-3%. It also has a complication risk of a disappointing 30 to 40%, with a rather dismal prognosis of 20% five-year survival, making pancreatic cancers one of the most feared of all cancers.

Whipple gets all the credit, and indeed, he deserves a good bit of it, but history has a way of eventually recording what really happened. There was, however, a predecessor to Whipple. Walther Carl Eduard Kausch (1867-1928), another one of Jan Mikulicz-Radecki trainees and also son-in-law, had come up with a very similar operation in 1909, some 27 years before Whipple. His original drawing demonstrates the concept.

The operation used to be called by both names: Kausch-Whipple Pancreaticoduodenectomy, but like so many things got abbreviated to just Whipple.

KARL LANDSTEINER 1868-1943

Blood transfusions are described in the Old Testament and are the basis for prohibitions against “partaking” of someone else’s blood by some religions. Some accounts of ancient Egyptians using reeds to transfuse animal blood were not successful. The famed architect of St. Paul’s Cathedral in London, Sir Christopher Wren, described injections of blood intravenously to the Royal Society. Robert Boyle (of Boyle’s law, P ∝ 1/V) reported arterial to vein transfusion.  But all of these early attempts failed to recognize that blood from an animal source, and even blood from a human source, was not in the best interest of the patient, because of the antibody-antigen phenomenon that was yet to be discovered. That would be the contribution of the Austrian pathologist, Karl Landsteiner,   honored on the 1000 Shilling note, the last currency that Austria printed, before converting to the Euro. He identified that serum of some people agglutinated the red cells of other people, and from that followed the three blood types A, B, and O (the universal donor). One year later he found the rarer 4th blood type, AB (the universal recipient), which garnered him a Nobel Prize for Medicine in 1930. Without that knowledge, blood transfusions more likely harmed and even killed the recipient most of the time.

All the major operations we now do depend on the technology of typing, and crossmatching, donor blood to the recipient. Landsteiner gave the surgeon the ability to replace blood lost during surgical procedures. His other achievements were isolating the Poliovirus, as well as the first to culture Rickettsia prowazekii, the causative agent of typhus. He also identified the other blood factors, the minor blood types M, N, and P used in paternity identification, and in 1940 the Rh Factor, which led to the subsequent discovery of hemolytic disease of the newborn (HDN) by others. He discovered the dark field identification of syphilis. He came to the US in 1923 and accepted a post at the Rockefeller Institute in New York. He achieved Emeritus Professor status but continued working. He had a heart attack in his lab, with a pipette in hand, and died two days after that in 1943.

In 1894 the French President Marie François Said Carnot was assassinated in the streets of Paris. At surgery, the surgeon found that the portal vein was severed, an injury that was not deemed survivable in the late 19th century.

A young surgical resident studying in Paris at that time was greatly influenced by that event and set his mind thinking about how to repair arteries and veins. That man’s name was Alexis Carrel.

He copied a triangulation technique he had learned from an embroideress. It worked in the lab, and subsequently in the operating room, a feat that won him the Nobel Prize in medicine in 1912, eighteen years after that fateful assassination, and set the path for a new surgical specialty, vascular surgery.

World War I, from 1914 to 1918, known then as “the war to end all wars” was a killing factory. Twenty-three million military and seventeen million civilians died in that conflict, making it among the deadliest of human conflagrations, just the perfect situation that in the past has always made for surgical advances, having a large laboratory at one’s disposal. Carrel was a busy surgeon while also developing his surgical talents. But wound care was still in need of improvement. Carrel worked with an English chemist, Henry Drysdale Dakin, to create an improved and safe antiseptic solution, the Carrel-Dakin Solution, still in use today. Again, if you wish to be historically accurate in writing wound dressing orders,    you should write for Carrel-Dakin Solution, and not just Dakin Solution. Carrel was also involved with inventing the very first ventricular assist pump. He associated with an inventor from a totally different field, aviator Charles Lindberg, to bring it into reality. The two became lifelong friends and even lived on adjoining islands in the Atlantic.

Carrel was a very religious man and became an alleged witness to a Lourdes miracle. This cast a shadow on his scientific credentials, and he could not get a hospital appointment. Alexis left France and got a research appointment at the Rockefeller Institute. He conducted experiments in cellular senescence, and was able to keep chicken cells alive for twenty years, much longer than the lifespan of a chicken. Some of his other ideas were not PC, especially in the realm of improvement of the human species. His support of the eugenics policies of the Vichy government, a Nazi puppet government of France during World War II, caused him to be named a Nazi collaborator but he died before his trial.

 

 

ERNST SAUERBRUCH 1875-1951

 

Sauerbruch was the protégé of Jan Mikulicz-Radecki. He was most interested in thoracic surgery and developed a negative pressure chamber with Mikulicz where the patient’s head was outside of the chamber, and the rest of the patient was inside the chamber with the surgeons. This allowed the chest to be opened with the continuous oxygenation of the lungs. His most favorite, and talented student, Rudolph Nissen, used it to perform the first successful pneumonectomy in 1931. Sauerbruch knew Hitler, and even treated him as a patient, commenting that he had “the potential to become the most insane criminal in the world.” Truer words have never been spoken!

 

Sauerbruch was the most known surgeon in Germany, at the time, and tried his best to avoid the political turmoil.

He managed to help several of his Jewish friends to escape Germany, including Rudoph Nissen, who went to Turkey, by way of Switzerland, with his family.

Among Sauerbruch’s surgical achievements were the sensational plication of a large cardiac aneurysm, also esophageal surgery, as well  as inventing several instruments related to thoracic surgery.    

EVARTS GRAHM 1883 – 1957

Graham is credited with the first pneumonectomy done in the United States for cancer of the lung in 1933.   Dr Grahm and Dr. Cole were co-originators of the oral cholecystogram (Graham-Cole test). Iopanoic acid is administered orally, absorbed by the intestine, and excreted by the liver, and concentrated in the gall bladder, just like bile. If the gall bladder did not visualize it was evidence of a diseased gall bladder, and a reason to do a cholecystectomy, of course currently superseded by the gall bladder ultrasound. Dating myself, Dr. Waren Cole was still the Dean of the University of Illinois Medical School when I entered that institute in 1963.

Graham was a co-founder of the American Board of Surgery and edited several journals in thoracic as well as general surgery. I recall as a teenager going to medical meetings with my father, where the room was dense with smoke, as most doctors smoked at that time. In 1950 Evarts Ambrose Graham and Ernst Wynder published a large study in the Journal of the American Medical Association (JAMA) linking cigarette smoking to lung cancer. This convinced him, and many other doctors, including my father, to quit smoking. Alas, it was too late for Dr. Graham, he died of lung cancer in 1957. Ironically, Dr. James Lee Gilmore, Graham’s first pneumonectomy patient in the US done for cancer (Nissen’s operation was for infection)  outlived him.

 

The Improper Bostonian, ERNEST A. CODMAN

He was a surgeon, and like all humans made mistakes, but unlike most, he made it his life’s mission to continually evaluate what he called “The End Result.” He followed every patient on whom he operated for at least a year postoperatively and recorded important events in their course of recovery on a 3 x 5 card. Why was he considered “improper” then? He insisted that all errors be reported, studied, presented, and become lessons from which we can benefit. Most of us find that painful, especially when we are discussing our own mistakes. But as it turns out, it is the best way to learn how not to make that mistake again.

He was the originator of the Morbidity and Mortality Conference (M&M), which is now incorporated into every teaching hospital’s weekly conference. In 1914 Massachusetts General Hospital turned down his plan for evaluating a surgeon’s competence, and they took away his hospital privileges. His response was to open his own hospital, the “End Result Hospital.” He helped to lead the founding of the American College of Surgeons and the Hospital Standardization Program, which eventually evolve into the Joint Commission on Accreditation of Healthcare Organizations.

A review of complications is so essential for learning that it is demanded by the reviewing organization of residency programs, and is immune from legal scrutiny. It must, therefore, be held outside of the public domain as a strictly “professionals only” conference. Without the M&M we would be half the surgeons we are.

 

LUISA GARRETT ANDERSON & FLORA MURRAY

These women physicians completed their medical education before World War I. Six weeks after Britain entered the war in 1914, the two women doctors were on their way to Paris to assist in the care of the wounded. They were immediately very busy taking care of the injured. The volume, however, was so overwhelming that the RAMC (Royal Army Medical Core) offered the two women a 1000 bed hospital, but back in London, which they accepted. The Endell Street Military Hospital in London was staffed entirely by women.  The initial response of the all-male soldiers was to ask for a transfer to another hospital.

By the time the men were to be moved, to a man, they all refused, preferring to stay where they were. The female physicians broke the taboo of only men caring for injured male soldiers and proved themselves the equivalent of the male physicians. It also propelled the medical profession into accepting more women into medical schools and subsequent further training.  This was all before women got the vote!    It was a significant advance for the equality of women.

 

 

HARVEY WILLIAM CUSHING 1869-1939

Harvey Cushing did a surgery residency with William Halsted. He also spent time with Theodor Emil Kocher, where he described what is called the Cushing reflex, which occurs when raising levels of pressure intracranially, the heart slows down, and blood pressure increases. Cushing introduced the recording of blood pressure using a device called the sphygmomanometer, which he brought back from Italy, and added it to the routine vital signs. He was the first o describe an adenoma of the pituitary that stimulated the adrenal gland to produce cortisol, Cushing’s Disease. During World War I, Cushing developed an extraction technique for removing metal foreign bodies from the brain using a magnet. Cushing attended Lieutenant Edward Revere Osler, the son of Sir William Osler, who was mortally wounded in the third battle of Ypres, Belgium. Later Cushing wrote a Pulitzer Prize- winning book, Life of Sir William Osler. Cushing was also the first to use and later popularize the Bovie Electrocautery.

 

 

 

 

William Bovie was a Ph.D. of plant physiology at the University of Michigan when he worked on his invention of an electrocautery that could cut and cauterize. “The Bovie” is an instrument now present in every operating room.

Without it, surgery would be back in the Halsted days, tying every capillary. You will note the colors of all Bovies, blue and yellow, the colors of the University of Michigan.

 

 

 

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