Innovation and Discovery on Surgery, History, and Humanities

v a d e m e c u m

Innovation and Discovery on Surgery, History and Humanities Luis H. Toledo-Pereyra

Michigan State University Kalamazoo Center for Medical Studies Western Michigan University Kalamazoo, Michigan, USA

LANDES BIOSCIENCE

Austin, Texas USA

VADEMECUM Innovation and Discovery on Surgery, History and Humanities LANDES BIOSCIENCE Austin, Texas USA Copyright ©2009 Landes Bioscience All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Printed in the USA. Please address all inquiries to the Publisher: Landes Bioscience, 1002 West Avenue, Austin, Texas 78701, USA Phone: 512/ 637 6050; FAX: 512/ 637 6079 ISBN: 978-1-57059-706-0 Library of Congress Cataloging-in-Publication Data Toledo-Pereyra, Luis H. Innovation and discovery on surgery, history, and humanities / Luis H. ToledoPereyra. p. ; cm. -- (Vademecum) Includes bibliographical references. ISBN 978-1-57059-706-0 1. Surgery--History. 2. Medical innovations. 3. Creative ability. 4. Inventors. I. Title. II. Series: Vademecum. [DNLM: 1. General Surgery--United States. 2. Diffusion of Innovation--United States. 3. History, Modern 1601---United States. 4. Humanities--history--United States. WO 11 AA1 T649i 2009] RD21.T65 2009 617--dc22 2009011103 Cover Art: Thomas Eakins. Portrait of Dr. Samuel D. Gross (The Gross Clinic). 1875. Philadelphia Museum of Art. Used with permission. While the authors, editors, sponsor and publisher believe that drug selection and dosage and the specifications and usage of equipment and devices, as set forth in this book, are in accord with current recommendations and practice at the time of publication, they make no warranty, expressed or implied, with respect to material described in this book. In view of the ongoing research, equipment development, changes in governmental regulations and the rapid accumulation of information relating to the biomedical sciences, the reader is urged to carefully review and evaluate the information provided herein.

Dedication To those surgeons and physicians not afraid of committing to the exciting world of innovation and discovery. To Remington Rose, with love and hope.

Contents Dedication ..................................................................iii About the Editor ........................................................ vii Contributors ............................................................... ix Preface ........................................................................ xi Acknowledgements ................................................... xiii

Section I. Innovation and Discovery 1. Innovation .................................................................... 3 Luis H. Toledo-Pereyra

2. Elements of Discovery .................................................. 8 Luis H. Toledo-Pereyra

3. Cushing as an Innovator ............................................. 13 Luis H. Toledo-Pereyra

4. Discovery According to Blalock.................................. 17 Luis H. Toledo-Pereyra

5. Innovation According to C. Walton Lillehei ............... 22 Luis H. Toledo-Pereyra

6. Discovery According to Huggins ................................ 32 Luis H. Toledo-Pereyra

7. Lessons from Thomas Alva Edison —The Greatest American Inventor— To Surgical Investigators............................................. 35 Luis H. Toledo-Pereyra

Section II. Art, Literature and Cinematography 8. The Four Doctors ....................................................... 43 Luis H. Toledo-Pereyra

9. Diego Rivera and His Extraordinary Art of Medicine and Surgery ............................................. 48 Luis H. Toledo-Pereyra

10. In the Cemetery of Forgotten Books ........................... 57 Luis H. Toledo-Pereyra

11. Medicine, Gabriel García Márquez and Love in the Time of Cholera ................................................. 62 Luis H. Toledo-Pereyra

12. From Hell ................................................................... 67 Luis H. Toledo-Pereyra

13. Something the Lord Made .......................................... 73 Luis H. Toledo-Pereyra

Section III. Biography, History and Criticism 14. William and Charles Mayo: Their Influence on American Medicine ............................................... 81 Roberto Anaya-Prado and Marisol Godinez Rubi

15. The History of Surgery According to Owen Wangensteen ................................................ 90 Luis H. Toledo-Pereyra

16. Richard Selzer: Premier American Surgeon-Writer ........................................................... 97 Luis H. Toledo-Pereyra

17. Lessons from the History of Medicine ...................... 104 John Waller

Section IV. Philosophy of Surgery 18. The Social Transformation of American Surgery ....... 113 Luis H. Toledo-Pereyra

Section V. Virtues of Man 19. Humility .................................................................. 123 Luis H. Toledo-Pereyra

20. Embracing Greatness ................................................ 126 Luis H. Toledo-Pereyra

21. Good Men Live on and Never Fade Away .................. 131 Luis H. Toledo-Pereyra

Acknowledgements of Figures .................................. 137

About the Editor...

Luis H. Toledo-Pereyra Surgeon, Researcher and Educator. He is the author and editor of 21 books. His books, Vignettes on Surgery, History and Humanities, Origins of the Knife, A History of American Medicine and most recently Reminiscences on Surgery, History and Humanities, have been introduced as the standard textbooks for the course of the History of American Medicine that he has been teaching for 19 years at Western Michigan University. He lives in Portage, Michigan, with his wife Marjean and dog Zorro.

Contributors Roberto Anaya-Prado Health Research Division Hospital of Obstetrics and Gynecology Mexican Institute of Social Security Guadalajara, Jalisco, Mexico Marisol Godinez Rubi Health Research Division Hospital of Obstetrics and Gynecology Mexican Institute of Social Security Guadalajara, Jalisco, Mexico Luis H. Toledo-Pereyra Michigan State University Kalamazoo Center for Medical Studies Western Michigan University Kalamazoo, Michigan, USA John Waller Lyman Briggs College Michigan State University East Lansing, Michigan, USA

Preface Great advances in a medical or surgical discipline originate from courageous and unabashed, committed professionals who are fearless in exploring new avenues of management or treatment. Great advances in the chosen field are dependent on those who think and practice innovation and discovery. Great advances in selected or wide areas of medicine or surgery are the response of long-term, dedicated professionals who believe in principles of innovation and discovery. To innovate or to discover can become a more frequently sought out process if surgeons or other specialists advance their knowledge to include novel concepts throughout their professional exercise. Awareness of innovation or discovery represents the most important step toward reaching the heights of these conceptual ways of viewing the practice of medicine or surgery. To think of innovation or discovery is to begin the path of accepting challenges and new developments when practicing medicine or surgery. The advice for young and mature surgeons alike would be to innovate whenever you can, to discover wherever possible. Advance your knowledge and maintain your innovative spirit. Keeping your activities in tune with innovative or discovery ideas creates the right spirit for advancing medicine or surgery. Innovation and discovery are unique and worth pursuing. Creating the environment for them to flourish is the responsibility of the clinical or basic science specialist. Innovation and discovery are in our minds. Do not let time pass by and start innovating and discovering today. There is no time to waste. Enjoy your path as the innovator and/or discoverer of the future! Luis H. Toledo-Pereyra Editor

Acknowledgements The material for this book was previously published in the Journal of Investigative Surgery. We appreciate their generous permission to use the Journal’s contents for this publication. The dedicated help of Sarah Staples, MA on the review of the whole text, selection of many of the pictures and overall editorial support was greatly appreciated.

SECTION I

Innovation and Discovery

CHAPTER 1

Innovation Luis H. Toledo-Pereyra The ability of someone to change old ideas, to modify wellestablished principles and to challenge the ordinary. Peter F. Drucker (b. 1909), the talented Austrian-born writer, judicious observer and teacher of management techniques, extensively reviewed the principles of innovation in Innovation and Entrepreneurship, published in 1985.1 In this book, he emphasizes and analyzes knowledge-based innovation and expands on the key ideas of advancement of knowledge and application of technology. In as much as he believes in the “unsuccessful attempts to identify the personal traits, behavior, or habits that make for a successful innovator,”1 he proposes simplicity and focused-oriented activities as essential principles associated with effective innovation.1,2 We follow

Figure 1.1. Peter Drucker. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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these ideas and search for better means to teach innovation as a way 1 to maximize our ability to transform the ordinary in the surgical sciences into the extraordinary. One of our advanced and thoughtful senior surgical residents had finished his daily rounds and was chatting with Dr. Mackey, his surgical career mentor. The young trainee had recently attended a national surgical congress where he incredulously witnessed the emphasis placed on the necessity of being a practical and common sense surgeon rather than an innovator. Even though it was clear to him that practicality and innovation were not antagonistic in principle, he sought the perspective of his admired mentor, surgeon Mackey. After hearing of this experience, Mackey deliberately turned to the resident with surprised eyes and exclaimed, “Innovation is everything! Let me explain what I mean. Not infrequently, you will hear that surgeons need to concentrate on what we do well and eliminate thoughts of grandiose, innovative ideas. What an incongruent, irrational, irritating thought! On the contrary, I believe surgeons need to think and practice innovation whenever possible. Innovation should be part of our daily activities; innovation is everything!” The smart resident whole-heartedly agreed, finding his mentor’s confirmation both reassuring and uplifting! Now, the difficult task—how to teach innovation to surgical residents and faculty, how to exalt its virtues and how to proceed in the effective practice of innovation? The great enthusiasm of surgeon Mackey, admittedly a fictional character, should be contagious and worth imitating.3 In the past, creative and innovative surgeons have been a frequent source of our writings. Indeed, we can refer to many inspiring examples, in particular to the Nobel Laureate Surgeons.4-6 This dedicated group of individuals demonstrate a whole range of innovative abilities and exemplify a life of innovation. For a brief moment, consider the unique qualities of these Nobel surgeons. Certainly, innovation is one of them together with commitment, determination and focus.3 These qualities, each important on its own, require the others to reach the potential climax of success so evidenced by these accomplished surgeons. Charles Huggins, one of the nine Nobel surgeons, would remind his students daily of the importance of discovery by asking, “What did you discover today?”7 From a practical point of view, what is the most effective way to teach innovation so everyone participates in the experience? How do we excel through innovation? How do we improve our professional practice by using innovative principles? There are no simple answers, but being part of the experiment justifies the effort. First, an

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annual course of theoretical lectures dealing with innovation should be instituted. Second, a series of books and papers about innovation, 1 obtained from the business literature, should be included in the curriculum. Third, during rounds, in conferences and in the operating room, innovation should be a topic of frequent discussion. Finally, residents should be required to write a paper or present a lecture dealing with innovation. If these suggestions were incorporated into residency programs, our residents would be better prepared to serve as the innovative surgeons of tomorrow. It is feasible that our residents would develop habits of change and improvement. It is feasible that our residents would be agents for enhanced operative techniques and surgical management. Before concluding, we could receive some lessons from the greatest innovator of all time, Leonardo da Vinci (1452-1519). Can da Vinci teach us some practical and applicable lessons? Was he seeking innovation continually? Did he cultivate some principles that allowed him to innovate effectively? The most plausible answer is yes for each of these questions. Yes, da Vinci qualifies as a competent teacher of innovation, inasmuch as he pursued it throughout his lifetime. Yes, he cultivated solid principles to reach heights of excellence in innovation and pure knowledge. Da Vinci was his own man, unafraid to challenge authority. He questioned old and new principles that did not conform to his expectations. His continual quest was to reach the truth. He was a consummate experimenter with wide-ranging curiosities. He acted based on knowledge and experience.8-10 According to one of the great students of da Vinci, Michael Gelb, the master considered himself a discepolo della esperienza (disciple of experience).10 Though da Vinci was not a scholar or academician, he occupied himself in gathering knowledge and actively searching for answers to critical questions. His guiding principles were independence, curiosity, originality, quest for knowledge and determination. Da Vinci’s life and virtues demonstrate how we can improve our innovative skills in daily professional practice. Thomas Alva Edison (1847-1931) embodies the classical example of American innovation.8-14 He and another distinguished American, Benjamin Franklin (1706-1790), were the most notable heroes of innovation on the American continent. Both of them produced many works of great significance. For this writing, I concentrate on the good deeds of “The Wizard of Menlo Park,” as Edison was known in New Jersey where he lived.11-14 Starting with the telegraph, the phonograph, the Dictaphone and the electrical lamp (incandescent light bulb), he

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completed 1093 successful patents in his lifetime, an unmatched record. 1 Edison was an innovator’s innovator all his life. He lived and breathed innovation. He was a practical man who saw needs and took advantage of the opportunities to fill them. His virtues were those of perseverance, full commitment, dedication, focused planning and the desire to succeed at all cost. These significantly special characteristics distinguished Edison as “the innovator of the millennium.”1,2 As a way to continue the extraordinary legacy of Thomas Edison, the Edison Preservation Foundation organizes the annual Edison Innovation Conference, where the Edison Innovation Awards are given to those especially gifted individuals who have pursued and demonstrated “Edison’s legacy of entrepreneurship and innovation.”11-14 Given Edison’s unique life and superb accomplishments, it is not hard to admire the man who is considered to be the “inventor of the 20th century” and the “father of modern invention.”1,2 Without doubt “his genius paved the way for the development of the computer, cell phone and compact disk.”12,13 His brilliant example capitalizes on the best virtues a person can possess as a dedicated innovator. Like surgeon Mackey and the interested resident, we can ponder the potential benefits of this especially important and infrequently cultivated virtue of innovation. We, like they, attempt to define and characterize innovation as it differs from creation and discovery. One way to separate the three qualities of innovation, creation and discovery is to consider innovation as an agent of change, creation as an agent of developing something new and discovery as a mechanism to encounter something that was not known to exist before. In this form, you can be an innovator, creator and discoverer simultaneously, or you can be an innovator and not necessarily a creator or discoverer. Each one, I believe, has its special characteristics and well-defined boundaries. Today, we are talking about the possibilities of incorporating only innovation into professional activities. Surgeon Mackey would claim there is much more to discuss. Still, he and his younger colleague could depart having explored new and enhanced possibilities for integrating innovation into surgical practice.

References

1. Drucker PF. Innovation and Entrepreneurship. New York: Harper Collins, 1985. 2. The Business World According to Peter F. Drucker. (Accessed May 30, 2006. Available at http://www.peter-drucker.com/). 4. Toledo-Pereyra LH, Martinez-Mier G. Maestros Nobel de la Cirugia. Mexico: JGH Editors, 2000.

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5. Toledo-Pereyra LH. Nobel Laureate surgeons. J Invest Surg 2006; 19(4):207-209. 6. Toledo-Pereyra LH, ed. Vignettes on Surgery, History and Humanities. 1 Georgetown: Landes Bioscience, 2005. 7. Toledo-Pereyra LH. Discovery in surgical investigation: The essence of Charles Brenton Huggins. J Invest Surg 2001; 14:251-252. 8. Toledo-Pereyra LH. Leonardo da Vinci: The hidden father of modern anatomy. J Invest Surg 2002; 15:247-249. 9. White M. Leonardo: The First Scientist. New York: St. Martin’s Griffin, 2000. 10. Gelb MJ. How to think like Leonardo da Vinci. New York: Delta Trade Paperback Edition, 2004. 11. Thomas Edison. (Accessed May 30, 2006. Available at http:// en.wikipedia.org/wiki/Thomas_Edison). 12. Edison innovation awards. (Accessed May 30, 2006. Available at http:// www.edisoninnovationawards.com/). 13. McCormick B. At Work with Thomas Edison. Canada: Entrepreneurship Press, 2001. 14. Toledo-Pereyra LH. Lessons from Thomas Alva Edison—The greatest american inventor—To surgical investigators. J Invest Surg 2003; 16:185-188. 15. Christensen CM. The rules of innovation. Tech Review 2002; 105:32-39. 16. Peterson AJ. Leading the way across generations. Med Bull 2004; Fall:15-19.

CHAPTER 2

Elements of Discovery Luis H. Toledo-Pereyra If you would be a real seeker after the truth, it is necessary that at least once in your life you doubt, as far as possible, all things. —René Descartes (www.lucidcafe.com/library/96mar/descartes.html)

I see discovery as the essence of thinking man, or to paraphrase René Descartes (1596-1650), the famous French philosopher and mathematician, “I think, therefore I discover.” Descartes concentrated on “Cogito, ergo sum” or “Dubito, ergo cogito, ergo sum” from the Latin, meaning, “I think, therefore I exist” and after that, “I doubt, therefore I think, therefore I exist.”1 For anyone who knows the significance of these statements, it is not hard to believe that they represent the foundation of Western philosophy. The foundation of modern science should be, “I think, therefore I discover.” The objective of this writing is to characterize discovery and define the stages or elements present in its evolution.

Figure 2.1. René Descartes, 1596-1650. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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Doubt in the Cartesian Method

Descartes utilized doubt as a method that would allow him to reach certainty. He believed that thinking was the only element that could 2 not be doubted.2 Skepticism constituted a unique component that could bring truth to the front. Among the Greeks, skeptics were those individuals who sought examination, who searched through inquiry and special consideration to recognize the wisdom of truth. Descartes doubted everything! He questioned the physical and mathematical world. He attentively raised doubts as concerns of inquiry and analysis appeared. The French philosopher was a firm defender of doubt, a convinced believer in skepticism, a decisive student of certainty. Cartesian methods and beliefs are still prevalent and practical today, especially when we consider that doubt is at the center of scientific reasoning. Doubting is the language of the serious scientist, the currency of those dedicated researchers who believe in challenging old and new principles and accepting only well-tested hypotheses.

Stages of Discovery

Discovery is a way of being. Discovery is also a way of thinking. Discovery is inclusive, encompassing all the positive elements of a thinking mind. Discovery is action associated with thinking. One could easily say, “Think and act and eventually you will discover.” Here are what I consider to be the six stages or elements in the evolution of discovery. 1. 2. 3. 4. 5. 6.

I I I I I I

Six Stages of Discovery have an idea. (concept) believe in it. (belief) can do it. (ability) support it. (support) can prove it. (proof) will protect it. (protection)

Each one of these stages or elements of discovery is unique. Each one requires a different frame of mind. Each one permits the others to advance the discovery process. Each one would not function without the aid of the other elements, since the idea by itself can only reach maturity in concert with the other five phases. Discovery is an idea, belief, ability, support, proof and protection all together. Let’s review each one of these six elements within the context of discovery.

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Stage 1: I Have an Idea (Concept)

Having an idea is perhaps the most important element of discovery. With the idea everything starts, with the idea the engine begins func2 tioning, with the idea discovery becomes real. How, then, can we generate the idea or ideas within our working environment? How, then, can we actively be seeking ideas worth pursuing in our disciplines? How, then, can we be beacons of new ideas and sources of discovery in our daily professional lives? We need pragmatic answers for these worthwhile questions. Let me address these questions first by using examples of medical discovery in the 20th century. This century produced many extraordinary examples of discovery in medicine and science and we will focus on two of them: the discovery of insulin and the discovery that heart transplantation could be performed in humans. The first, the discovery of insulin, came about through the superb work and ideas of Banting and Best, who, in 1921 in the laboratory of Dr. Macleod at the University of Toronto, demonstrated that the material called insulin, extracted from the islets of Langerhans in dog pancreases, could significantly lower blood sugar in diabetic dogs. Incredible feat! And one that was faced with great skepticism, especially from Dr. Macleod, the biochemist in charge of the laboratory. In the surgical arena, we have a unique example from Dr. Christiaan Bernard (1922-2001). On December 3, 1967, he opened the doors of heart transplantation by giving a normal heart from a brain-dead donor to his patient, Louis Washkansky, who was on the brink of death from incurable heart disease.3 Dr. Barnard’s idea, aided by his commitment and seasoned with considerable temerity, made this milestone possible. Some purist students of discovery may claim that Barnard did not discover; rather he innovated, since he was following ideas and concepts previously studied by other giants of the field of heart transplantation, such as Norman Shumway (1923-2006). Even though I do not disagree with this observation, I remain confident of Barnard’s contribution, whether we call it discovery, innovation, or simply advancement of an old idea. In any event, Barnard turned the medical and surgical world upside down with his outstanding contribution, performing an operation that had never been done before!

Stage 2: I Believe In It (Belief )

To take an idea, even an extraordinary one, to the next sustainable level, we must believe in it. Belief is at the foundation of discovery. Barnard would not have carried out a heart transplant if he had not

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believed in the operation and the possibility of performing it successfully. That unshakeable confidence is required! One needs to believe in the idea and defend it tenaciously. 2 In the same way, Banting would not have discovered insulin if he had not stood behind the belief that an extract of the pancreas could restore insulin metabolism. Believing can advance or revolutionize the desired field of knowledge. Many more examples abound in medicine and surgery, examples that can guide us as we remain active on the exciting frontiers of medical discoveries.

Stage 3: I Can Do It (Ability)

Great discoverers are not only individuals with excellent minds, but people who can do the task at hand: who have the ability to complete all necessary enterprises: those who can think, believe and act! In no area is this more obvious than in surgery, where ability is of paramount importance. Only those who can perform surgery capably reach the pinnacle of discovery, since implementation advances any task toward the final goal. As a matter of record, all disciplines require the ability to act, the ability to reach, the ability to create, the ability to take an idea to its well-justified conclusion. The message should be one of acting as well as one of thinking creatively. Advancing progressive and newly found ideas must be followed by shepherding the idea through the discovery cycle.

Stage 4: I Support It (Support)

The development of the idea, the belief in it and the ability to act on it are not enough if we do not find means to uphold it. Supporting the idea becomes the next critical step towards securing the discovery. The strategy necessitates thinking, believing, doing and upholding to secure the completion of the discovery process. Many times, in many ways, researchers or professionals assume that the only step worth emphasizing is the creation of the idea. Not necessarily. Other stages conducive to implementation of the idea are as important within the advancement of discovery as other elements. Remaining supportive of the research idea constitutes the basis for making discovery a firm and worthwhile endeavor. No professional formulating discovery plans would be taken seriously unless capable of demonstrating his or her ability to carry through and support the new idea, the unique idea that has never been considered before.

Stage 5: I Can Prove It (Proof )

Having the idea, of course, is good; having faith in it, acting on it and supporting it are as good or even better when undertaken together.

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Showing the proof that the idea works is the best! The initial evidence can be corroborated and confirmed again in future attempts. Nothing is more exhilarating than when the investigator says, “I can 2 prove it!” Proof enjoys a special position at the heart of every discovery. Without proof there is no discovery; without the demonstration of research facts, discovery is far distant or non-existent; without defined and positive results, discovery cannot be considered. Proof, facts, results—all are part of the discovery enterprise. Their positions are worth emphasizing. In order to claim discovery, we need to demonstrate and substantiate the proof of the experiment or idea under consideration.

Stage 6: I Will Protect It (Protection)

It is not enough to have an idea, to believe in it, to act on it, support it and prove it; it is also necessary to protect it. Protection goes to the intellectual property level. Discovery alone lacks heft without intellectual property safeguards. Discovery without intellectual property is inconceivable these days. How can you best protect your ideas, your products, your methods and so forth? Very simply, I guess. Secure the services of an attorney and search for advice in obtaining a patent. If economic constraints prevent hiring a patent attorney at the time, you must submit a temporary patent or provisional filing, or present a notice of disclosure to the patent office. Protecting your ideas is one of the fundamental necessities in the process of discovery and needs to be addressed in the early stages of research development.

Conclusions

It is clear that the most important elements or stages of discovery can be summarized through six elements. The concept, belief, ability, support, proof and protection of the idea together represent the critically needed principles of discovery. Clinicians and researchers or clinical researchers need to embrace these elements to secure the highest standards of discovery.

References

1. Cottingham J, ed. The Cambridge Companion to Descartes. Cambridge: Cambridge University Press, 1992. 2. Doney W. Descartes: A Collection of Critical Essays. New York: Doubleday Co., 1967. 3. Barnard C, Pepper CB. Christian Barnard One Life. Toronto: The MacMillan Co., 1969.

CHAPTER 3

Cushing as an Innovator Luis H. Toledo-Pereyra There are few American surgeons who have reached the amazing medical pedestal secured by Harvey Cushing’s (1869-1939) accomplishments. He was a man of dedication, commitment and untamable driving force. He took the problems encountered in the young field of neurosurgery and defined them one by one, until firm answers were clearly evident to patients and surgeons. Crisp intelligence and persevering determination were his overwhelming raw traits, later refined into qualities. Since many biographical studies circulate pertaining Cushing’s life and results,1-5 today I will emphasize the characteristics of his extensive and infrequently deciphered innovation.

Status of Neurosurgery Prior to Cushing’s Active Participation

Even as late as the early 20th century, high mortality and morbidity were the rule for many neurosurgical patients and in particular those

Figure 3.1. Harvey Cushing, circa 1900. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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Innovation and Discovery on Surgery, History and Humanities

undergoing surgery of the brain. In brain operations, desperation and lack of effective treatment were the frequently observed effects. No good technique existed for preventing the intense hemorrhaging that occurred at the opening of the skull or surrounding the pathological lesions as they 3 were dissected. Europeans and the few Americans who were operating on the brain were not focusing on solutions that would diminish intra-operative bleeding, an overwhelmingly difficult problem. It appeared that compression and instrumental clamping were not eliminating this desperate situation. Stanching the flow required a frontal attack directed at the bleeding surfaces and tiny blood vessels covering the brain and at the underlying diseased tissue. Cushing decided to undertake this fight, for which he needed a meticulous and painstaking plan. Another area of serious concern, as Cushing observed the operating clinics in Europe and the United States, was the lack of good monitoring of the patient during surgery. Neurosurgical patients were not being evaluated in regards to their general vital signs during the surgical procedure. There was no way to determine the general status of the patient as the anesthetic drug was exerting its effect, particularly in patients who had added complications or other morbidity factors, such as hemorrhage and cardiovascular pathology. A solution was increasingly evident, but was not incorporated until Cushing and his friend Ernest Amory Codman (1869-1940) introduced ether charts for general surgery cases at the Massachusetts General Hospital in 1894.6 Cushing introduced this incredibly innovative development into neurosurgical cases so that pulse, respirations and temperature were incorporated into the monitoring done in the neurosurgical operating room. The ether chart—an underestimated, practical and important prognostic tool—aided evaluation of patients undergoing long and exhaustive neurosurgical procedures. Another interesting, unique and innovative development was applying findings of the experimental laboratory to the neurosurgery clinic. This practice was practically unheard of until the very late 1800s or early 1900s. European surgeons were not attending the animal laboratory to obtain answers for their clinical problems. They were approaching the patient directly and considered learning in the human operating room as the best way to advance. Cushing, under the tutelage of the legendary William Halsted (1852-1922), established the animal Hunterian Laboratory at Johns Hopkins in 1905. From here on, Cushing had a direct line of approach from the human to the laboratory and back to the human. This excellent equation helped improve the disastrous results once seen in the clinic. It made remarkable sense to aid clinical findings by using animal laboratory observations. Three years before,

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in 1902, Cushing had started teaching a course of operative surgery for medical students in the animal laboratory. This course was very successful and many students asked to attend it even after they had completed the medical school requirement. In 1912, when Cushing moved to the 3 Brigham Hospital, he integrated a similar surgical research laboratory into his practice, with the same success as enjoyed at Hopkins.

Cushing Takes Over

Early in the 1900s Cushing realized, especially after his initial trip to Europe, that the neurosurgical field was in dire need of a savoir, or better yet, a creator. No one was actively leading and he decided, with the support of Professor Halsted, that it was time to do just that. Cushing armed himself during an extensive European tour that permitted him to visit the most important British, German and Swiss clinics, among others. He attended the most respected academic centers of the time and spent an extended visit with his favorite European surgical professor and that of Dr. Halsted, Emil Theodore Kocher (1841-1917), winner of the 1909 Nobel Prize for his extraordinary work on thyroid disease and its implications in reducing morbidity and mortality after thyroid surgery.7 Cushing appreciated the meticulous and effective operating techniques of Master Kocher and quickly, when he could, Cushing applied them to his neurosurgical cases. Kocher and Halsted believed in or had the same principles, based in strict antisepsis, hemostasis and slow and deliberate operating techniques. Cushing learned everything he could from these superb surgical masters. He absorbed all nuances of their techniques and introduced them, in an effective manner, to surgeries on high-risk patients. Immediately after returning from his first visit to Europe, in 1901, Cushing asked Dr. Halsted to be assigned to develop a new Neurosurgery Service, the first in America. Cushing planned everything and his results began to show significant differences from those previously obtained. Patients started to do better and to survive more often, a big difference from the results usually observed in neurosurgical patients. Cushing was the first surgeon to be fully devoted to neurosurgery in America. He was the neurosurgery master, the first professor of surgery dedicated to neurosurgery. He was the American neurosurgery pioneer and creator of the field in this country. He was the first one to establish and define neurosurgery throughout the rest of the world in the way we know it today. Harvey Cushing was synonymous with excellence, with perseverance, with the best we could aspire to in the field of neurosurgery. He was the creator of a new specialty. He alone brought it into being!

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Cushing Moves Fully into Neurosurgery

The tremendous ability and enhanced endurance Cushing exhibited at Hopkins and the Brigham were in themselves the sustaining force of the 3 specialty. Cushing had begun an incredible enterprise that was going to revolutionize the surgical and medical world. Cushing was ahead of many who believed this achievement was not possible. Cushing was charting new and unexplored territories, serving as the Columbus of this field. Once Cushing recognized that it was possible to overcome the dangers associated with operating on the brain, he attacked all the well-known pathological enemies of the specialty by offering a well-characterized plan and well-defined objectives. He was the man in charge, he was creating the rules, he was devising the protocols. Cushing fiercely represented constancy of purpose, supporting the development and direction of the field. Through meticulous and perfectly planned efforts, Cushing began accumulating positive results in gasserian ganglionectomy for trigeminal neuralgia, all kind of brain tumors, pituitary tumors and other frequently occurring neurosurgical clinical problems. By the time Cushing moved to Boston in 1912, the neurosurgical specialty was very much on its way. Cushing had clearly demonstrated the value of the surgical approach to the central nervous system. And, more than anything, the neurosurgical specialist had confirmed the safety of operating on the brain or any other portion of the central nervous system. Neurosurgery had been integrated into existing medical practice and was moving forward.

Cushing as an Innovator Throughout His Career

Many and varied were the principles and details of innovation introduced by Cushing. From beginning to end, he decided to be a practical innovator. He translated many laboratory findings into the clinical arena. He absorbed the clinical needs of neurosurgery and produced improved results through innovation. Starting from ganglionectomies to brain and pituitary tumors, Cushing introduced better surgical techniques and achieved better results after surgery. Cushing developed improved methods for better hemostasis with the use of muscle fragments, silver clips and electrosurgery. He and Dr. W. T. Bovie introduced a special device for electrocauterization of bleeding areas.1 Cushing made discoveries regarding the movement and origin of the central spinal fluid, known as The Third Circulation. He developed surgical techniques for the removal of meningomas and acoustic neuromas. He and Bailey developed the classic method for classifying brain tumors.1,5

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Cushing recommended the use of physiological solutions during surgery. He favored the use of the transsphenoidal approach for pituitary tumors. Years later, he supported the intracranial approach. Before these developments, Cushing had innovated first for the general surgery patient 3 in the use of intra-operative monitoring, particularly by tracking blood pressure, pulse, respirations and temperature. This special discovery was extremely helpful for improving management of the neurosurgical patient, decreasing mortality and improving neurosurgery results overall. Cushing was motivated in his innovative ideas by finding practical solutions to clinical problems. As he encountered difficulties, he immersed himself in searching for a response that would positively affect patients. Cushing was innovative in the research laboratory as well. At the Hunterian Laboratory, he conducted investigations using dogs, which further clarified the role of the hypophysis within the context of the rest of the body. With a group of associates, including Samuel Crowe and John Homans, he entertained surgical techniques that included experimental hypophysectomy and hypophyseal transplantation.9 While in Europe, together with scientists working at Kocher’s laboratories, he studied the use of increased intracranial pressure, which they were performing at the time of his long visit. These are only a few examples illustrating the innovative genius of Cushing.

Cushing and the Strong Qualities of an Enduring Innovator

Cushing’s commitment to solving problems for the betterment of patients was the first distinctive trait of an enduring innovator. He was a practical innovator and today would be considered the first to introduce technology transfer from the patient to the laboratory and back again. Like his teacher William Halsted, Cushing utilized the laboratory to help answer the clinical questions presented by patients. Cushing’s competitive nature to advance surgery, science and medicine was the second quality of an enduring innovator. His desire to reach the pinnacle before others must have been the enduring force in discovering new pathways to improved clinical results. Enduring quality number three was Cushing’s “hard-driven intellect,” which favored his attempts to move forward in the yet unknown field of neurosurgery. Quality number four was Cushing’s ability and skills to realize the best means by which innovative techniques could be implemented. Cushing’s appreciation of detail and his intense personality were in many ways the background against which he pushed forward his ideas and sought out principles. At the same time he was studying, he was

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exploring the possibility of solving problems. There was no question he was a problem solver. He encountered, observed, objectively analyzed, studied the problem and tried new paths in his search for solutions. I must return to the strong interest Cushing had in helping his 3 patients. And, obviously this presents an important and critical question for us. Was this, his strong interest for patient care, the number one quality for innovation for Dr. Cushing? Or was his inner desire to be number one the most important consideration? It is very hard to accurately define this point. Suffice it to say that probably Cushing possessed a combination of both of these traits, generosity on one side and selfishness on the other, sense of commitment on one side and competitive spirit on the other, willingness to serve the profession on one side and a fearless, driving force on the other. In summary, Cushing should be considered one of the great neurosurgical innovators of all times and in the words of noted surgical historian Sherwin Nuland, when reviewing the outstanding book by Michael Bliss, Cushing is “one of the greatest medical innovators ever produced by the United States—or any other country.”1 In spite of his many personal drawbacks of being “hard-driven, egotistical and mean,” Cushing excelled in making a wealth of contributions to the development and establishment of a new field of medicine—neurosurgery as we know it today. His name will be remembered for generations to come.

References

1. Bliss M. Harvey Cushing. A Life in Surgery. New York: Oxford University Press, 2005. 2. Cushing, Harvey Williams. (Accessed April 2008. Available at www. whonamedit.com). 3. Jay V. The legacy of Harvey Cushing. Arch Pathol Lab Med 2001; 125:1539-1541. 4. Hanft S. Har vey Cushing : A life in surger y. FASEB J 2006; 20:1951-1953. 5. Cyber Museum of Neurosurgery. (Accessed April 2008. Available at http:// www.neurosurgery.org/Cybermuserum/tumorregistryhall/whal.html). 6. Horwitz NH. Harvey Cushing (1869-1939). Neurosurgery 1996; 39:617-621. 7. Toledo-Pereyra LH. Nobel laureate surgeons. J Invest Surg 2006; 19:275-277. 8. Toledo-Pereyra LH. Harvey Cushing: Father of American neurosurgery. J Invest Surg 2002; 15:115-116. 9. Crowe SJ, Cushing H, Homans J. Effects of hypophyseal transplantation following total hypohysterectomy on the canine. Q J Exp Physiol 1909; 2:389-400.

CHAPTER 4

Discovery According to Blalock Luis H. Toledo-Pereyra Discovery fascinated Alfred Blalock (1899-1964) and it fascinates me as well. The point is not that Blalock and I are the same, but that the great Hopkins master praised discovery all his life and made a special effort to realize the highest achievement of this unique and special quality. I have respected and supported his stance since the early years of my medical academic studies. In fact, Blalock’s focus on discovery makes his principles as relevant for the next generation of surgeons as they were for mine. In 1956, at the regular meeting of the American Surgical Association in White Sulphur Springs, West Virginia, Professor Blalock delivered the inspiring presidential address of the year.1 At this sophisticated event, the august surgeon selected as the topic for his dedicated address,

Figure 4.1. Alfred Blalock at his office of Johns Hopkins Hospital during his tenure of Chief of Surgery. The pictures of his teachers serve as background. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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Innovation and Discovery on Surgery, History and Humanities

The Nature of Discovery.1 He expounded clearly and convincingly on the qualities and attributes of promising surgical researchers and brought forward the essence of discovery. For Blalock, discovery existed in four general categories: the first associated with chance or accident; the second dependent upon 4 intention or design; the third characterized by intuition or imagination; and the fourth integrated by a combination of two or all of the previous categories.1 From his previous early surgical experience in Nashville, Blalock had a clear idea of what research encompassed and how to direct himself towards future “fountains of knowledge,”1,2 towards sipping from the streams of science, towards reaching the wellsprings of discovery. For a moment it would be extremely enlightening and very instructive to hear Blalock’s own words:1 For many years I have been interested in the background or the nature of discoveries in medicine and this is the subject of my address. Discovery may be defined as the act of finding out what was unknown, such as Harvey’s discovery of the circulation of the blood. One discovers what already exists but was unknown previously, such as the applicability of steam to the purposes of locomotion. On the other hand, one invents what did not exist before, such as the machinery necessary to use steam for locomotion. It must be admitted, however, that the distinction is often a close and debatable one. Whereas we usually give the name ‘discovery’ to the recognition of a new fact, Claude Bernard maintained that the idea is what really constitutes the discovery. He said: ‘The idea is the seed; the method is the earth furnishing the conditions in which it may develop, flourish and give the best fruit according to its nature. But as only what has been sown in the ground will ever grow in it, so nothing will be developed by the experimental method except ideas submitted to it.’3 We should clearly define, if at all possible, the boundaries among discovery, innovation and creation. Even though professor Blalock entirely emphasized discovery, I have the impression he was implicitly including innovation or was using the term “discovery” to sometimes explain innovation. The reason for this assumption is that around 1956, when Blalock’s address was delivered, the term “innovation” was infrequently used and therefore, the esteemed surgeon did not use this word at all in his address.1 After the 1980s4-11 and in present times,

Discovery According to Blalock

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“innovation” has become more common in the scientific and popular vocabulary, necessitating its separation from discovery and even more from creativity. In a recent work on Innovation,4 I attempted to separate and in some ways to define each one of these qualities or functions of life 4 in the following way. I will let the fictional character of surgeon Mackey speak:4 Like surgeon Mackey and the interested resident, we can ponder the potential benefits of this especially important and infrequently cultivated virtue of innovation. We, like they, attempt to define and characterize innovation as it differs from creation and discovery. One way to separate the three qualities of innovation, creation and discovery is to consider innovation as an agent of change, creation as an agent of developing something new and discovery as a mechanism to encounter something that was not known to exist before. In this form, you can be an innovator, creator and discoverer simultaneously, or you can be an innovator and not necessarily a creator or discoverer. Each one, I believe, has its special characteristics and well-defined boundaries. Today, we are talking about the possibilities of incorporating only innovation into professional activities. Surgeon Mackey would claim there is much more to discuss. Still, he and his younger colleague could depart having explored new and enhanced possibilities for integrating innovation into surgical practice. In many ways, discovery, innovation and creativity can intermingle, with lines of real separation that appear so thin and frequently nebulous as to blur the case for separate definitions. I could summarize my view again by saying that creativity is the basis for innovation (which is change) and this often leads to discovery (which is finding something new, unknown). Returning to Blalock’s savvy ideas on discovery, he offered excellent examples to illustrate each one of the categories he selected. For instance, for the discovery by chance or accident, he utilized Edward Jenner (1749-1823) as the discoverer of planned vaccination in 1798 to prevent smallpox, Walter Dandy (1886-1946) as the discoverer of pneumoventriculography in the late 1910s at Hopkins12 and Graham (1883-1957) and Cole (b. 1898) as the discoverers of oral cholecystography in 1923,13 to name only a few.1 For the category of discovery by design or intention, Blalock considered Wangensteen (1898-1981)

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Innovation and Discovery on Surgery, History and Humanities

as the discoverer of duodenal suction, Dragstedt (1893-1975) as the discoverer of bilateral truncal vagotomy and Huggins (1901-1997) as the discoverer of hormonal control of prostatic cancer.5,6,8 For the category of discovery by intuition, imagination, or hunch, Blalock suggested Fred Banting (1891-1941) as the discoverer of insulin in 4 1921.14,15 In the last section of Blalock’s address, the illustrious professor proffered the most significant advice for young surgeons. He noted:1 In concluding, I will enumerate a few general principles that may be helpful to young scientists applying themselves to research in experimental medicine. Contrary to popular belief, there is nothing magical about science or scientific investigators. The conception of the scientist as an intellectual superman, achieving important results through sheer mental brilliance, is quite unfounded. Too often in talking to a bright young surgeon I have heard the statement that he does not wish to go into academic work because he has no originality, when as a matter of fact he has not had the opportunity or the inspiration to demonstrate his ability. The only way an interested person can determine whether or not he has aptitude in research is to give it a trial. Some who were previously uninterested in investigative work become fascinated if exposed to it. Please understand I do not think that every young surgeon should be encouraged or expected to go into research. My point is that he should not shy away from it because of a misconception and the fear that he does not have originality. As a medical student I felt pity for the investigator, but later this changed to admiration and envy. Blalock admired immensely the life and accomplishments of great investigators, of great men of science such as Claude Bernard, Walter Cannon and Otto Loewi.3,16,17 He respected the unique wisdom of their uplifting writings. Each one of them produced books of enormous help to young and mature investigators of their and our time. Their teachings should serve as a perennial source of knowledge and advice. In the end, Blalock’s intense quest for discovery represented his firm desire to encourage young investigators to reach high levels of science and surgical research. His own personal discoveries in shock and cardiovascular disease prove his dedicated effort to improve the basic principles and practice of surgical pathology. His writings and

Discovery According to Blalock

21

teachings about the evolution of surgery and emphasis on discovery should remain alive in the minds of current and future investigators in the field of surgery, as well as in medicine generally.

References

1. Blalock A. The nature of discovery. In: Ravitch MM, ed. The Papers of 4 Alfred Blalock. Baltimore: Johns Hopkins Press, 1966. 2. Longmire WP. Alfred Blalock: Personal Reflections. Pasadena: Castle Press, 1964. 3. Bernard C. An Introduction to the Study of Experimental Medicine. New York: Macmillan, 1927. 4. Toledo-Pereyra LH. Innovation. J Invest Surg 2006; 19:207-209. 5. Toledo-Pereyra LH, Martinez-Mier G. Maestros Nobel de la Cirugia. Mexico: JGH Editors, 2007. 6. Toledo-Pereyra LH. Nobel laureate surgeons. J Invest Surg 2006; 19:211-218. 7. Toledo-Pereyra LH, ed. Vignettes on Surgery, History and Humanities. Georgetown: Landes Bioscience, 2005. 8. Toledo-Pereyra LH. Discovery in surgical investigation: The essence of Charles Brenton Huggins. J Invest Surg 2001; 14:251-252. 9. McCormick B. At Work with Thomas Edison. Canada: Entrepreneurship Press, 2001. 10. Toledo-Pereyra LH. Lessons from Thomas Alva Edison—the greatest American inventor—to surgical investigators. J Invest Surg 2003; 16:185-188. 11. Christensen CM. The rules of innovation. Tech Review 2002; 105:32-39. 12. Dandy WE. A method of detecting intestinal perforation: an aid in abdominal diagnosis. Ann Surg 1919; 378:70. 13. Graham EA. The story of the development of cholecystography. Am J Surg 1931; 12:330. 14. Harris S. Banting’s Miracle. Philadelphia: JB Lippincott, 1946. 15. Platt W, Baker RA. The relation of the scientific “hunch” to research. J Chem Education 1931; 8:1969. 16. Cannon WB. The Way of an Investigator. New York: WB Norton, 1945. 17. Loewi O. From the Workshop of Discoveries. Lawrence, Kansas: University of Kansas Press, 1953.

CHAPTER 5

Innovation According to C. Walton Lillehei Luis H. Toledo-Pereyra Experience is a great teacher. Good judgement comes from experience and experience comes from bad judgement.

—C. Walton Lillehei

C. Walton Lillehei (1918-1999) is without a doubt the greatest surgical innovator of our time and because of his noteworthy contributions, he is considered to be the father of open heart surgery.1-9 He intensely valued the force of innovation and discovery and forever defended the “minds of the young” as the best source of creativity. One could almost hear him saying that to stall the young’s creative energy would be equal to derailing the progress of humanity.10 In this writing, I concentrate on and emphasize the noteworthy concepts on innovation that Lillehei put forward in the field of scientific inquiry.

Figure 5.1. C. Walton Lillehei. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

Innovation According to C. Walton Lillehei

Brief Biographical Remarks

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Walt Lillehei, as he was frequently called by his friends and family, was a Minnesotan through and through. He was born, raised and except for a short stint in Europe during World War II and New York for a few years, lived and worked all his life in Minneapolis and St. Paul. He epitomized the Midwest and Minnesota spirit of being open, courte- 5 ous, friendly and generous. He accepted others’ ideas but challenged established dogma. The real soul of an innovator! Lillehei was an educational and academic product of the University of Minnesota, where he received his bachelor’s degree (BS, 1939), medical degree (Alpha Omega Alpha, 1942), master’s in physiology (MS, 1951) and doctorate in surgery (PhD, 1951). Owen Wangensteen (1898-1981) represented the caring surgical mentor and best example for the young Lillehei. Both of them established a trusting and loyal relationship which lasted throughout their lives. After finishing an internship in 1942, Lillehei answered the call for his services in World War II with the mobile Army Surgical Unit that he commanded with honors. He received a Bronze Star upon completion of his tour of duty. In 1946, Lillehei began his surgical residency under Chief of Surgery Wangensteen. At the University Hospital, he was able to work with the noted surgical teachers whom Dr. Wangensteen had so creatively assembled. Dennis and Varco in surgery and Visscher in physiology were frequent communicators with the upcoming surgeon. The university atmosphere was highly conducive for innovative work. Lillehei thrived in this positively charged creative environment. In 1951, Lillehei entered the ranks of the surgery professorial staff of the University of Minnesota, first as an instructor, then rapidly advancing to professor by June 1956. During this period, many significant developments in cardiac surgery occurred at Minnesota and in every one Lillehei was a decisive participant, especially on the cross-circulation cases. What a time of great excitement for the Surgery Department and the entire cardiac world. On September 2, 1952, Lillehei assisted Dr. John Lewis in the first successful surgical repair of the malformed heart under hypothermia. This incredible case stimulated the 34-year-old, fresh and motivated young surgeon to pursue cardiac surgery during a long and fruitful career. The issues involving successful cardiac surgery were many and realistically implausible to solve in the immediate or very distant future. Lillehei applied himself with intense commitment to finding solutions for the seemingly unsolvable and difficult problems associated with performing any meaningful cardiac surgery at the time.

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5

Figure 5.2. Dr. Lillehei’s pacemaker featured on the cover of the “Saturday Evening Post.”

After a long road of challenging laboratory work at the University of Minnesota, Morley Cohen, Herbert Warden and Walt Lillehei came out with an unexpected response.11,12 From ideas generated in Lillehei’s laboratories, pertaining to the main culprit of poor blood oxygenation, the Minnesota team elegantly proceeded to study the azygos flow system and thereafter utilized the concept of cross-circulation, where a human donor (generally a parent) would provide the oxygenation and blood pump effect to the recipient undergoing heart surgery.9,10,13-16 A tremendous feat for that time and for any time under any circumstances at any point in history! This absolutely incredible discovery offered the best to patients with congenital heart defects and the world of cardiology and cardiac surgery.9,11-16 After the feat of cross-circulation in 1954 in a child with ventricular septal defect, many more patients received attention in operating rooms at the University of Minnesota.13-16 In 1955, Lillehei together with Richard DeWall, introduced the bubble oxygenator as a replacement for cross-circulation.10,16 In 1957, Lillehei used a myocardial electrode as a pacemaker for the first time in a human.16 By 1960, Lillehei was using portable pacemakers introduced by Earl Bakken, a notable Minnesota engineer and collaborator on this project.16,17 A great number of operations followed with incredible success for those times.15 In November 1967, Lillehei left Minnesota and accepted the position of Lewis Atterbury Stimson professor and chairman of surgery at the stellar New York Hospital—Cornell Medical Center.1-9 The scientific

Innovation According to C. Walton Lillehei

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and innovative hopes of Lillehei did not progress as expected in New York. The move did not offer the august cardiac surgeon the opportunities he had frequently seen in Minneapolis1-9 and did not result in the best opportunity for the surgeon-scientist. In between Minneapolis and New York, Lillehei created three prosthetic heart valves: The Lillehei-Nakib toroidal disc (1966), the Lillehei-Kaster pivoting disc (1967) and the Kalke-Lillehei rigid bileaf- 5 let prosthesis (1968).18 An incredible odyssey under any conditions and under any appreciable measure for anyone! In 1975, the distinguished cardiac surgeon returned to Minnesota, actively joining the emerging cardiovascular technology start-up, St. Jude Medical, as the medical director of the cardiac valve division. He successfully held this position until his unfortunate death in 1999. During Lillehei’s tenure at St. Jude Medical, he participated in the development of his fourth valve, the St. Jude mechanical heart valve, perhaps the best valve produced through Lillehei’s collaboration and probably one of the best cardiac valves in the world. A constant during all of Lillehei’s professional life was his resilient and courageous fight to overcome the struggles and devastating effects of cancer. In February 1950, one day after completing his surgical residency, the young surgeon recognized a tumor in his neck. Without further delay, he took this matter to the consideration and advice of his distinguished mentor, Dr. Owen Wangensteen. Recognizing the serious possibility of a malignant growth, Professor Wangensteen recommended a biopsy and subsequent radical surgery, depending on the findings. A 12-hour operation, including radical neck dissection, mediastinal exploration and left parotidectomy followed the diagnosis of parotid gland lymphosarcoma.1 Months of recovery ensued but the Minnesota surgeon never gave up his dreams and aspirations. Regardless of the outcome, Lillehei was determined to fight for every inch of productive life. Even a subsequent course of radiation therapy did not deter the attitude of this valiant future surgical pioneer.

Evolution of a New Idea

Lillehei’s career brilliantly illustrates the most important steps in the evolution of the researcher-scientist-clinician. First, an idea needs to be born! Second, the idea needs to be nurtured. Third, the surgeon-researcher needs to be prepared to stoically defend his/her idea. Lillehei, in a brilliant way, summarized the “Seven Ages of the Evolution of an Idea”10,14 with particular reference to the critics. It would be very instructive to repeat exactly what he first published in 1982:14

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Table 5.1. The seven ages of the evolution of an idea with particular reference to the critic I. Idea stage

“Won’t work” “Been tried before”

5 II. Successful experiments “Won’t work in man”

(in animals)

III. After one successful clinical patient

“Very lucky” “Doubt if patient really needed treatment” “Too bad, a tragedy, really, because now they’ll continue”

IV. After four or five clinical successes

“Highly experimental” “Too risky, immoral, unethical” “I understand that they’ve had a number of deaths they’re not reporting”

V. After ten to fifteen patients

“May succeed occasionally in carefully selected cases, but most patients with this defect don’t need operation anyway”

VI. After a large series of successes

“So and so in Shangri-La has been unable to duplicate their results” “I hear that a number of their patients are now dying late deaths”

VII. Final stages

“You know, this is a very fine contribution” “A straightforward solution to a difficult problem” “I predicted this” “In fact, in 1929, I had the same idea” “Of course, we didn’t publish anything—nor did we have penicillin, cortisone and fine anesthesia in those days”

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27

Remaining loyal to a new idea and, as we indicated before, defending the concepts and rationale associated with it represent elements of great importance for the upcoming and/or well-seasoned surgeon investigator. I could well hear the famed cardiac specialist emphasizing these two important virtues and possibly adding that an extraordinary degree of commitment is necessary to advance the idea. In short, to have a new idea represents the first step that needs a complete continuation and 5 follow through to make the most of an initial and seminal consideration. Other surgical greats, such as Halsted and Blalock, would pursue Lillehei’s principles in their careers.19,20

Resistance to a New Idea

According to Lillehei, new ideas face resistance as part of a natural process of evolution.10 I would add, new ideas are created to be resisted. New ideas stimulate opposition. New ideas constitute the origins of the opposition battle. Master surgeon Lillehei would reflect upon these concepts in the following way:10 Open heart surgery—now regarded as one of the most important advances of the 20th Century—went through an intense barrage of criticism. It was surrounded by controversy and opposition which even threatened to delay its acceptance and application. The experienced heart surgeon would then add some other critical concepts regarding the acceptance or rejection of new ideas:10 Nonetheless, the acceptance of new ideas, new concepts, new theories, has virtually always been surrounded by opposition and controversy. Many have developed this, but familiarity with history clearly and repeatedly has indicated that disapproval or opposition from established authorities in high places frequently has had a strong retarding influence upon the acceptance of new information. It seems almost a normal risk which innovators must recognize and even expect and go forward undeterred. The researcher must learn to thrive upon opposition. Also, the successful innovator needs to recognize that the intensity of the opposition may be a good measure of his success and thereby, gain added confidence. It is evident, according to the advanced wisdom of Dr. Lillehei, that following the path of the innovator requires one to remain calm and ready to receive the unwarranted criticism with a positive attitude, with

28

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an added interest in the advancement of science and in the progress of humanity. Criticism is gaining advantage, opposition is moving forward, disapproval is progress. Each one of these principles is to be repeated to the young investigator, is to be solidified in the mind of the developing surgeon-scientist, is the evidence and support to the mature and accomplished researcher.

Examples of Intolerance in the World of Science and Medicine According to Lillehei

Noted surgeon and innovator Lillehei saw surgery as the great opportunity to generate new ideas, to bring new principles to bear and to advance the knowledge of the discipline. The unique and classical example of the development of open heart surgery through cross-circulation is just one of many monumental advances he and his colleagues accomplished. In this discovery and in others his group introduced, he admitted some intolerance as the concepts were being presented to the medical world.10 The pioneer Minnesota surgeon cited selected examples of scientific and layman intolerance toward the contributions of acclaimed scientists. He considered Roger Bacon (1214-1294) from the 13th century, followed by Galileo Galilei (1564-1642) four centuries later, Ignaz Semmelweiss (1818-1865) and Joseph Lister (1827-1912) from the 19th century and Werner Forssmann (1904-1964) from the 20th century. History finally accepted the great developments made by these personalities, but Lillehei highlighted the notion of slow acceptance of their ideas and principles.10 Bacon, a great philosopher, scientist and reformer of the Middle Ages, sought scientific explanations of natural phenomena and opposed the belief that science was dangerous.10 He challenged orthodoxy and was confined to prison for half of his life. Galileo, another great scientist like Bacon, remained truthful to his principles and theories when advancing the knowledge that the sun and not earth was the center of the universe. For this idea, he was punished with prison by the Inquisition and persecuted in the last years of his life.10 Semmelweiss, a great medical contributor, was at the center of medical controversy when he dramatically decreased puerperal infection by washing the hands prior to pelvic examinations of parturient ladies. A number of continuous objections about hand washing contributed to him losing his job and thereafter dying in an asylum at the age of 47.10 Lillehei offered the distinct examples of Bacon, Galileo and Semmelweiss as clear evidence of the difficulty of accepting challenging concepts at the time of their discovery.10

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29

The noted surgeon also presented two more distinguished and controversial figures at the time of their discoveries, Lister and Forssmann. The first one introduced antisepsis on August 12, 1865, at Glasgow Royal Infirmary and the concept took more than 15 years before receiving full acceptance.10 The second suffered ridicule and ostracism for refusing to back down from his idea of catheterizing the right heart. In 1929, he realized this feat and Professor Sauerbruch fully ignored 5 him and “orthodoxy banished Forssmann from the academic scene.”10 Lillehei felt that these well-defined examples represented the intolerance that the world in general and the world of science in particular, showed toward the introduction of new concepts and new ideas.10

Life of an Innovator

Lillehei carried with pride the designation of innovator. He pursued his ideas with enthusiasm and dedication. Every task was significant for him, every idea was worthwhile, every principle was considered, every surgery became the center of new advances. His career as an innovator represented a lifelong commitment! The accomplished thoracic surgeon felt that “determination, persistence and stubbornness were the most important components of research.”10 He also felt that persistence was “the single most important element in successful discovery.”10 If one closely follows Lillehei’s professional life, innovation was a way of living, innovation was the essence of his thinking, innovation centrally occupied his life and work. As radical as this commitment might appear, what I have just described encompasses the life of any innovator. Such commitment is a solitary and challenging stage, which represents full dedication to the life of the surgeon-innovator, to the work of the surgeon-researcher, to all the required elements of the scientist participating in the field of innovation. Lillehei had all these qualities, demonstrating them convincingly throughout his professional career.

Conclusions

C. Walton Lillehei was the most important and advanced surgeon-innovator of the 20th century and without a doubt in the annals of American surgery. Trained under professors Wangensteen, Varco, Dennis and Lewis at the University of Minnesota surgical program, he quickly progressed through the professorial ranks without difficulty and advanced with intense dedication up the ladder of science and innovation.

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His discoveries were many and he is considered the father of open heart surgery because of his unique contributions to the field through the initial and essential steps of cross-circulation using the azygos flow principle. With others on his team, he introduced the DeWall-Lillehei bubble oxygenator, total intracardiac repair of tetralogy of Fallot, use of myocardial electrodes for the chronic treatment of complete 5 heart block and many others innovations, such as the cardiac valves described previously. Walt Lillehei, as he was called by his friends and family, represented the cardiac surgeon par excellence, the innovative cardiac surgeon and one who would be a continuous example for surgeons and students alike.

References

1. Cooley DA. In memoriam: C. Walton Lillehei, the “Father of open heart Surgery.” Circulation 1999; 100:1364. (Accessed July 17, 2006. Available at http://circ.ahajournals.org/cgi/content/full/100/13/1364). 2. Black S, Bolman RM. C. Walton Lillehei and the birth of open heart surgery. J Card Surg 2006; 21:205-208. 3. C. Walton Lillehei. C. Walton Lillehei: Information from answers.com. (Accessed July 17, 2006. Available at http://www.answers.com/c.%20 walton%20lillehei). 4. Shake JG. Farewell to a surgical giant: A tribute to C. Walton Lillehei, M.D., Ph.D. Minnesota Medicine 1999; 82. (Accessed July 17, 2006. Available at http://www.mmaonline.net/Publications/MnMed1999/ December/Shake.cfm). 5. Shirley R. Permission to think!: Great thinkers: Dr. C. Walton Lillehei. WorldWideLearn. (Accessed July 17, 2006. Available at http://www. worldwidelearn.com/great-thinkers/walton-lillehei.htm). 6. Hoffman W. A heart operation: Perspective from a playground. The Doric Column. (Accessed July 17, 2006. Available at http://mbbnet.umn.edu/ doric/lillehei.html). 7. Gott VL, C. Walton Lillehei, M.D., Ph.D. 1918-1999. The Cardio Thoracic Surgery Network. (Accessed July 17, 2006. Available at: http:// www.ctsnet.org/doc/3531). 8. Knatterud M, C. Walton Lillehei. Lillehei Heart Institute at the University of Minnesota. (Accessed July 17, 2006. Available at http://www.med.umn. edu/lhi/AboutLHI/cwl.html). 9. Lillehei CW. The birth of open-heart surgery: Then the golden years. Cardiovas Surg 1994; 2:308-317. 10. Lillehei CW. New ideas and their acceptance as it has related to preservation of chordae tendinea and certain other discoveries. J Heart Valve Dis 1995; 4(Suppl II):S106-S114.

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11. Warden HE, Cohen M, Read RC et al. Controlled cross circulation for open intracardiac surgery. Physiologic studies and results of creation and closure of ventricular septal defects. J Thorac Surg 1954; 28:331-343. 12. Cohen M, Lillehei CW. A quantitative study of the “Azygos Factor” during vena caval occlusion in the dog. Surg Gynecol Obstet 1954; 98:225-232. 13. Lillehei CW, Cohen M, Warden HE et al. The direct vision intracardiac 5 correction of congenital anomalies by controlled cross circulation. Results in 32 patients with ventricular septal defects, tetralogy of Fallot and atrioventricularis communis defects. Surgery 1955; 38:11-29. 14. Lillehei CW. A personalized history of extracorporeal circulation. Amer Soc Artif Inter Org 1982; 28:4-17. 15. Lillehei CW, Varco RL, Cohen M et al. The first open heart corrections of ventricular septal defect, atrioventricular communis and tetralogy of fallot utilizing extracorporeal circulation by cross circulation: A 30-year follow up. Ann Thorac Surg 1986; 41:4-21. 16. Weirich WL, Gott VL, Lillehei CW. Treatment of complete heart block by the combined use of a myocardial electrode and an artificial pacemaker. Surg Forum 1958; 8:360-363. 17. Lillehei CW, Gott VL, Hodges PC et al. Transistor pacemaker for treatment of complete atrioventricular dissociation. JAMA 1960; 172:2006-2010. 18. Lillehei CW, Nakib A, Kaster RL et al. The origin and development of three new mechanical valve designs: Toroidal disc, pivoting disc and rigid bileaflet cardiac prosthesis. Ann Thorac Surg 1989; 48:535-537. 19. Toledo-Pereyra LH. William Stuart Halsted: Father of american modern surgery. J Invest Surg 2002; 15:59. 20. Toledo-Pereyra LH. Discovery according to Blalock. J Invest Surg 2007; 20(3):145-147.

CHAPTER 6

Discovery According to Huggins Luis H. Toledo-Pereyra Surgical investigation, like investigations in many other disciplines, begins with an idea which is fortified and fully nurtured with knowledge and determination. The advancement of the initial idea, as simple as it may be, requires diligence and a well-structured plan. Now, how and when this plan is executed pertains to the territory of the commitment and dedication of the surgical investigator. Discovery in surgical investigation is vital to the enterprise, that is, to the progress and development of the surgical sciences. Charles Brenton Huggins (1901-1997) was a classical surgical investigator who clearly focused on advancing pure surgical knowledge. With work developed in his laboratories at the University of Chicago on the hormonal treatment of prostatic cancer, he secured the Nobel Prize for Physiology and Medicine in 1966. Professor Huggins had a noble and incredible motto: Discovery is our business. This sentence reflected his deeply ingrained appreciation of discovery in the surgical arena.1 His students had to endure frequent questioning in regards to their discoveries each day. “What did you discover today?” the professor would ask his students. It was wise

Figure 6.1. Charles Brenton Huggins. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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for him to ask since we need, seek and require a discovery every single day. Our attitude towards discovery is then vital to the enterprise. How can we teach discovery to our students? It is not that simple to impart this particular quality since discovery is a combination of attitudes and influence. Yet discovery is at the core of the sciences. We learn, we discover, we do science and in the end we publish. Discovery goes hand in hand with knowledge, discovery reaches for answers, discovery is by itself what the investigator dreams of. Teaching discovery includes 6 a discovering personality supported by infrastructure to transform ideas into real products. The senior investigator educates the younger pupil about scientific advances, already aiming at their translation into practical application. Discovery requires that all steps of science be rehashed with dedicated enthusiasm. The surgical discoverer is on the verge of the future. Think if it this way: Discovery = knowledge + innovation + findings. In the early 20th century, a new breed of American surgeon-investigators/surgeon-scientists dedicated themselves zealously to answering perennial surgical questions. They planted the seed and aspired to find fundamental critical answers. They fit the bill as discoverers, innovators, creators. In this group were William Halsted (1852-1922), William Mayo (1861-1933), George Crile (1864-1943), Evarts Graham (1888-1957), Owen Wangensteen (1898-1981), Walt Lillehei (1918-1999) and so many others. America provided, during this time, a great number of accomplished surgeon-scientists/investigators. Their common denominator was desire, intrepidness, unquestionable work-ethics and willingness to challenge the unchallengeable and to reach for uncharted territories. Unlimited commitment and perseverance characterized their intense desire. They embarked on a mission of discovery dedicated to finding the best cures possible. They conquered and put forward a new therapeutic approach. They revolutionized surgical practice. Charles Huggins understood the young minds of his time and cultivated their relationship under all circumstances. He believed a mentor’s obligation was to feed the immature mind of beginners, to offer truths to their important questions and to maintain their enthusiasm.1 He quoted Emerson, “It came to him business, it went from him poetry.” His position on scientific endeavors was clear, he understood that one should improve experimentation with thoughtful experience and that deeper knowledge was obtained from continuous research.1 He also understood that recognition of a problem was crucial in obtaining the definitive answer. He preached that science was ruled by idea and technique and that the investigator discovered truth by activity alone.1

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Another great scientist, transplant immunologist Peter Medawar, friend and mentor of young surgeons and future surgical investigators, explained his concepts about scientific creativity as dependent on previous work, unexpected findings followed by definitive experiments and a certain degree of serendipity.2 In their research, one would assume from those characteristics, that the most knowledgeable and dedicated investigators are those with the most opportunities to reap the benefits 6 of scientific creativity. Surgeon-investigators, through history, have introduced innumerable important advances to medicine. Their discoveries enriched cardiac surgery, transplantation, vascular surgery, total parenteral nutrition, metabolic response to trauma, hormonal control of cancer, angiogenesis and genetics, to mention several of them. Clyde Baker, dedicated surgeon-investigator/scientist has recently summarized important developments in the history and philosophy of surgical research.3 He emphasized the obstacles the surgeon-investigator must overcome before reaching a stable career, namely, time, economics and discrimination, as well as the inherent factors associated with the surgical persona. Surgeon-discoverers have in common the innovative spirit reinforced by time commitment and an urgent need for accomplishment. As we reach the end of this writing, let us return to Charles Huggins’ philosophical thoughts and leave his words as a constant reminder of his wisdom and personal views: Discovery is quite different from development. Discovery is science. It is for the few who enjoy meditation and reflection even during the activity of experimentation. Development is for the practical man and the big team. In discovering one becomes emotionally bound up in his problem. In the beginning of discovery there is nothing—only void. Then, comes the dream and its high quality is the genius of research. The dream is a fantasy—a creation of the imaginative faculty.4

References

1. Huggins CB. The business of discovery in medical sciences. JAMA 1965; 194:1211-1215. 2. Medawar PB. Pluto’s Republic. Oxford: Oxford University Press, 1992. 3. Baker FC. History and philosophy of surgical research. In: Souba WW, Wilmore DW, eds. Surgical Research. San Diego: Academic Press, 2001:1261. 4. Huggins CB. On medical investigation. Surg Clin North Am 1969; 49:455-457.

CHAPTER 7

Lessons from Thomas Alva Edison —The Greatest American Inventor— To Surgical Investigators Luis H. Toledo-Pereyra If surgical investigators were privileged enough to be addressed and advised by the Wizard of Menlo Park, Thomas Alva Edison (1847-1931), undoubtedly, his words would contain the following advice: Dear Surgical Investigator: Your profession is a unique one, reflecting the intense dedication of individuals committed to the investigation of surgical problems. Dealing with diseases that affect the human body and attempting

Figure 7.1. Thomas Alva Edison. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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to discover cures—clearly beyond my area of expertise—as well as studying why certain therapies work and why certain procedures are better than others, together create a complex situation that requires an extraordinary commitment from anyone involved. Though what I convey to you may not be unique, still let me try to express my principles associated with innovation and research. Let me begin with my life and experiences, hoping to stimulate within your spirit those same feelings that uplifted and compelled me. 7 I did not go to school for very long, since my teachers could not tolerate my inquisitive and rebellious attitude. My dear mother, Nancy Elliot, taught me at home everything I knew. I was born in a midwestern town, Milan, Ohio, near Lake Erie in 1847.1-3 Inventions were few during this time of headlong westward expansion. A few years later in 1854, we moved to Port Huron, Michigan. There I began working at the age of 12, selling snacks and newspapers on the Grand Trunk Railroad, which made the roundtrip to Detroit.4 I learned a great deal from this experience, particularly regarding the importance of punctuality and responsibility. In the winter of 1860, I began reading my father’s copy of Thomas Paine’s (1737-1809) The Age of Reason.4,5 This was, without a doubt, the best book I have ever read and I would recommend it to you without hesitation. This book reflects Paine’s revolutionary views on religion and society and reveals a better view of the philosophers of the Enlightenment. Truly, this book is one to be cherished. From 1863 to 1867, I worked as an itinerant telegrapher, a trade that would be to my advantage in the years to come. In your case, sustained interest in all knowledge pertaining to surgical investigation is the key to your future success. In 1867, immediately after the Civil War, I moved to Boston, where I experienced the tantalizing intellectual life of a great cultural center. Just months later, I moved to New York, the greatest metropolis in the country, where I was given the permanent position of telegraph operator at the Western Union Company.1-5 My life was quiet and without any major developments up to this point, even though I continuously pondered ways to improve our daily function in society. My advice at this point concerns your dedication to thinking. “The brain can be developed just the same as the muscles can be developed, if one would only take the pains to train the mind to think. Why do so many men never amount to anything? Because they do not think.”4,5 I believe this applies clearly to surgical investigation, a discipline in which thinking is of paramount importance. Think all the time; in fact, do not stop thinking at any moment.

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My apologies for persisting in this topic of thinking, but I consider it to be the most significant aspect of my advice. “The man who doesn’t make up his mind to cultivate the habit of thinking misses the greatest pleasure in life. He not only misses the greatest pleasure, but he can not make the most of himself.”5 Failure without thinking is as bad as failure without trying. Failure with thinking amounts to something that with hard work and perseverance will ultimately lead to success. For the surgical investigator to be successful, he/she needs to remain faithful to the thinking process. Do not hold your thinking at anytime, 7 but instead, continue to build your powers of observation and one day you will have a highly trained brain that will be able to see everything, to see it all. In 1869, in the preludes to industrialization and the Gilded Age, when I was 22 years old, I obtained my first patent for an electronic vote recorder and entered my first partnership with Frank Pope. I had to learn not only the applicability of science, but also the best means by which to do business. Self-education and dedication contributed a great deal in my daily working endeavors. The same will remain true in your experiments dealing with surgical problems: the more knowledge and commitment you profess to the elected field of surgical investigation the more rewarding the results. It has not escaped my notice that I have been categorized as ambitious, aggressive, rebellious, single-minded, self-centered and imaginative, along with so many other characteristics.4 I accept these charges with the condition that I be considered an independent thinker, someone whose only purpose was to invent and invent. In order to be independent and be able to invent, a researcher needs a facility that can offer the best for proficient laboratory work. Get your own laboratory, if you can, one that you can use anytime with any ideas you might have. In 1876, near the end of Ulysses Grant’s presidency and the year of the invention of the telephone by Alexander Graham Bell, the Menlo Park Laboratory opened its doors, so I could tinker with any idea that crossed my mind.4 I was the only inventor with a research facility of this magnitude. No one else had anything similar. If you are interested in research as a surgical investigator, it is vital to participate in a laboratory that offers the best available in research equipment and laboratory personnel. Never settle for less! Some have questioned the 1093 patents that were issued to me alone or jointly in the course of my lifetime. I did not plan to obtain so many patents. They originated from my interest in the various fields of innovation. The greatest number were in the field of the electric light

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and power (389), followed by those associated with the phonograph (195), the telegraph (150), the storage battery (141) and so many other fields of life and industry. Do not let these accomplishments or those of others derail your path of consistent research. If you are to reach the answers you need to improve health and overcome disease, you must maintain a vigilance for obtaining the best results under the best possible conditions. Remain alert to new advances in your field and to those of your research competitors. 7 Advance your knowledge constantly, visit other laboratories and form special coalitions with other researchers in the field. Identify your friends, as well as those who do not support your causes and findings. Do not overemphasize the role of the latter in your life. Focus attentively on all facets of your research and make progress by carefully following details and threads of evidence. Work constantly and nap sometimes. Work at night, if you can. Working hard keeps your mind crisp and your spirit high. Do not overlook the benefit of dedicated labor. I failed to mention to you thus far that at an early age, I lost a great deal of my hearing. This tragedy became a blessing as I began enhancing other senses as a substitute for my poor hearing. My ability to concentrate considerably increased, my distractions significantly diminished and I became an excellent reader.5 I am not recommending to you to lose your hearing to replace it for higher senses, but the qualities mentioned could be continuously exercised so your research can consistently improve. Not surprisingly, my approach to life was unorthodox. I had an adversarial relationship with many people, I did not conform to established order, I was brash and undiplomatic. I had my own ethics and standards and I followed my own advice.4,5 I do not recommend this same path for you and let me explain why. Since I did not have a superior above me, it was not that risky to act as I did. Given today’s job market, I would understand that it would be prudent to follow a different approach. Remember, what is important is to remain free in spirit and thought as much as you can, while at the same time considering the critical role of regulations and authority. In this way, you can continue being employed for a long time. Under these or any conditions, never sacrifice your honesty and integrity over the job you possess, whatever it might be! It is noteworthy to mention to you, that there were always two characteristics to my inventions. One, the invention must be practical and intended to make money5 and two, the invention must correlate with current interest so that people realize its importance.5 Briefly stated, “Anything that won’t sell, I do not want to invent. Its sale is

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proof of utility and utility is success.” “A scientific man busies himself with theory. He is absolutely impractical. An inventor is essentially practical.”5 Though these thoughts accurately reflect my own personal experience, I realize that they won’t apply absolutely to all research. You might be able to apply part of these truths to your surgical investigations, attempting to reach practicality while still recognizing some theoretical advantages for your experiments. I have already alluded to the role of long and patient labor. Nothing is as important as this concept. Invention does not come from luck; 7 it comes from long and committed hours, days, weeks and months of intense sacrifice. Do not allow yourself to become discouraged under any circumstances.5 Charge ahead without excuses. There are none! I made many mistakes in my life and perhaps the most significant is the one associated with the complete resistance I had for second-generation improvements of my inventions.5 In spite of being the first to invent the phonograph, electrical system and motion picture, I did not realize the importance of new additions to the initial inventions. Instead, I stubbornly persisted in maintaining intact the first-generation invention and because of this others realized the benefit of improved additions. What a serious mistake. My clear advice to you is to actively participate in any changes in research, so you can continue advancing your initial developments. Again, don’t do what I did. I regret not being able to offer you all the lessons and instructional experiences derived from the wisdom of my long existence. However, I hope that those I could provide were helpful to you in improving your ability to succeed in your career and your life as a whole. In closing, I would like to leave you with the final statement expressed by Robert Conot, one of my most accomplished biographers:4 “Edison succeeded because he was an eternal optimist who would not let himself or others consider the possibility of failure; because he was an unconventional thinker, who accumulated the resources that enabled him to transform his ideas into reality; because he charged ahead when others hung back; because he demolished the opposition and bowled over impediments … he was the product of a unique conjunction of talent, ambition and opportunity. There was never anyone like him before. And, in the hundred years since, the world has changed so radically it is highly improbable that there will ever be anyone like him again.” With my best consideration for a successful life of extraordinary developments in surgical investigation. Thomas Alva Edison

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References

7

1. Israel P. Edison. A Life of Invention. New York: John Wiley & Sons, 1998. 2. Baldwin N. Edison. Inventing the Century. New York: Hyperion, 1995. 3. Millard AJ. Edison and the Business of Innovation. Baltimore: Johns Hopkins University Press, 1990. 4. Conot R. Thomas A. Edison. A Streak of Luck. New York: Da Capo Press, 1979. 5. McCormick B. At Work with Thomas Edison. Canada: Entrepreneur Press, 2001.

SECTION II

Art, Literature and Cinematography

CHAPTER 8

The Four Doctors Luis H. Toledo-Pereyra In 1906, the Florentine-born American painter John Singer Sargent (1856-1925) completed the extraordinary painting The Four Doctors in his London studio. This work captured one of the most significant periods of American medicine: the development of the pre-eminent Johns Hopkins medical system, dedicated to science, bedside care and laboratory medicine. In this work, the great painter, at the request of a dedicated Hopkins benefactor, Mary Elizabeth Garrett, and in agreement with the Board of Trustees, paid tribute to the four founders of Johns Hopkins Medical School.1-3 Miss Garrett was not unknown to Sargent since he had painted her earlier when the Board of Trustees wanted to recognize her donation to the medical school. She realized then the enormous virtues of the artist and suggested to the Board and financially supported a painting representative of the best of the faculty of the new medical school. The

Figure 8.1. The Four Doctors. From the Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions, Baltimore. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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work took almost a year to paint and it was clear that the lofty goals of this painting were fully satisfied. The clients, the Hopkins Board, were captivated by the extraordinary aptitudes of this singular artist and by the sublime depiction of the fictitious encounter of the four great doctors. At the time of executing this legendary painting with a medical theme, Sargent was 50 years old and clearly at the top of his well-respected realistic art. He had already produced many of his most appreciated canvases: El Jaleo (1880), The Daughters of Edward 8 Darley Boit (1882), Portrait of Madame X (1884) (considered by Sargent to be his best), portraits of beautiful models Rosina Ferrara and Carmen Bertagna, three paintings of Robert Louis Stevenson and his wife (1885), Claude Monet Painting (1887), Frederick Law Olmsted (1895), Mr. and Mrs. Isaac Newton Phelps-Stokes (1897) and United States presidents Theodore Roosevelt (1903) and Woodrow Wilson. This list names just a few of the good and distinctive samples of his exemplary art. In his active career, he produced approximately 900 oil paintings, 2000 watercolors and a great number of charcoal drawings and other works.1-3 So by the time he was commissioned to create The Four Doctors, he was a well-established and recognized artist throughout Europe and the United States. How Sargent was selected as the best artist for the medical masterpiece is not well known, except that Mary Garrett had direct contact with him as she had been a previous client. Garrett never doubted that Sargent was the ideal candidate. The Board went along and the issue became how to convince the great painter to realize a special piece of art to commemorate the excellence of Hopkins medical teaching and research. That was not difficult since Sargent’s acceptance implied the representation of Hopkins as a unique place in the medical world. Who decided to utilize the four most distinguished Hopkins doctors as the consideration of the institution’s ascendancy to medical heights? I believe Sargent was asked by Garrett and the Board to paint the four founders of the medical school: the dean and professor of pathology, William Welch (1850-1934), the chief and professor of medicine, William Osler (1849-1919), the chief and professor of surgery, William Halsted (1852-1922) and the chief and professor of gynecology and obstetrics, Howard Kelly (1858-1943).1-6 Everything else was Sargent’s creation, the artistic expression, the appropriate setting, content in addition to the founders. In short, all artistic development, as expected, was Sargent’s.

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The four founders, as they were openly considered at Hopkins, were members of the first clinical faculty of Baltimore’s Johns Hopkins Medical School. The exceptional surgeon writer, Sherwin Nuland so elegantly articulated how Hopkins achieved great levels of excellence. He accurately wrote:1 The success or failure of the Hopkins undertaking would depend entirely on the quality of the faculty. By a combination of wisdom, luck, philanthropic support and the magnetic force of an exciting new environment, Hopkins attracted an assortment of laboratory and clinical innovators whom many historians regard as the most talented young biomedical scholars ever assembled in one place. Next, Nuland reviewed the importance of the four founders and considered their influence within the context of the medicine of the day and their contributions to the world medical scene:1 It would have been impossible to overestimate the influence that these four men would have in medical education and patient care, not only in the United States, but throughout the world. Their work and the work of their students, as well as the brilliant contributions made by Hopkins people, … soon began to eclipse that of the German-speaking schools that had preceded them. I can add that the remarkable contributions of Hopkins’ four founders, Welch, Osler, Halsted and Kelly, to American and world medicine went without comparison. These four leading personalities, on their own, carried extremely well the weight and development of four specialties, pathology, medicine, surgery and gynecology, respectively. Without their astute and unique contributions, the clinical science of medicine would not have been as mature as we see it today. Residents’ education reached special levels of advancement that would not have occurred otherwise. The essence of the work of each one of Hopkins’ four founders can be summarized briefly. In this regard, William Welch should be considered the modern father of American pathology and the modern father of American medical deans; William Osler, the modern father of American internal medicine; William Halsted, the modern father of American surgery; and Howard Kelly the modern father of American gynecology and obstetrics. Therefore, their legacy should remain unquestioned as history moves forward.

8

46

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How did Sargent conceive of and paint The Four Doctors? Each one of the four founders went to London to pose for Sargent during the elaboration of the portrait. Sargent decided to place the four professors in the positions observed in the canvas, three sitting and one standing. Why is Halsted standing and the others sitting? We do not know. Why are the professors gowned and posing in a manner that appears more European than American? We do not know. Or is it because Sargent was more accustomed to European ways? Here, an anecdote introduced by the talented Sargent biographer Charles Merrill Mount can shed some light:7 When in 1905, Miss Elizabeth Garrett, the founder of Johns Hopkins Medical School, sent over her four best doctors for a group portrait, they were very famous men indeed–Drs. Welch, Halsted, Osler and Kelly. Dr. Welch was soon complaining he called them all “Kelly” with remarkable lack of discrimination. However eminent they were in the field of medicine, to Sargent they were no great beauties. He worried over posing them and when Dr. Osler asked if he might wear his red Oxford gown he set off an oration. “No. I cannot paint you in that. It won’t do. I know all about that red. You know, they gave me a degree down there and I’ve got one of those robes.” His words were coming forth with that well-known muffled manner: “I’ve left it on the roof in the rain. I’ve buried it in the garden. It’s no use. The red is as red as ever. The stuff is too good. It won’t fade.” Then for a moment it seemed that a bright idea had struck him and he went on in better spirit. On another matter, why is a large Venetian globe behind the figures? Because the master painter felt that the portrait was missing something important that the huge European globe supplied to the artistic piece. It was complete now! It is said that Sargent after seeing the globe exclaimed, “We have got our picture.” 3,7 Immediately thereafter, he added to the background of the painting a replica of El Greco’s St. Martin and the Beggar done by Jorge Manuel Theotocopouli, El Greco’s son.3 Sargent was clearly pleased with the effect that these two elements contributed to the painting and he felt it was completed then. The immense oil on canvas (10 feet, 9 inches high and 9 feet, 1 inch wide) is currently hanging in the West Reading Room of Hopkins Welch Medical Library. Medical students, medical faculty and other visitors to the library can enjoy this very special and outstanding medical icon of artistic endurance. This incredible canvas, which

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recently completed 100 years of existence, is showing some effects of age, according to Nancy McCall, Hopkins archivist of the Alan Mason Chesney Medical Archives. “The painting has darkened considerably over the years,” she said.3 “The work needs help; you can barely make out the full figure of St. Martin, looking at it today,” she added.3 An intense effort to restore this work is in progress in Baltimore.3 This superb painting of The Four Doctors is one of America’s unique and especially admired medical art works on canvas. The artist reflected the immense quality of his art and brought to bear the history behind the new wave of medical innovation and research. The four doctors 8 were the best-qualified practitioners of their time. They constituted the essence of the new medicine and surgery. They were the origin of modern medical sciences. They began new fields in their own specialties. In 1906, they were what was good and particularly superb about the new American medicine starting to be introduced to the world. Welch, Halsted, Osler and Kelly were the outstanding representatives of this new medicine, the medicine of accurate diagnosis, appropriate caring, advanced laboratory testing and improved surgical techniques. This canvas should be the example of what four doctors might be able to accomplish in a system of integration, cooperative assistance and innovative medical and surgical principles.

References

1. Nuland SB. Medicine. The Art of Healing. New York: Hugh Lauter Levin Associates, Inc., 1992:98-99. 2. John Singer Sargent. (Accessed Dec. 12, 2006. Available at http:// en.wikipedia.og/wiki/John_Singer_Sargent). 3. The Johns Hopkins Gazette. (Accessed Dec. 22,2006. Available at http:// www.jhu.edu/~gazette/2001/jan2901/29doctor.html). 4. Toledo-Pereyra LH. William Stewart Halsted: father of American modern surgery. J Invest Surg 2002; 60:59-60. 5. Toledo-Pereyra LG, ed. Vignettes on Surgery, History and Humanities. Georgetown: Landes Bioscience, 2005. 6. Toledo-Pereyra LH. A History of American Medicine from the Colonial Period to the Early Twentieth Century. Lewiston: Edwin Mellen Press, 2006. 7. Mount CM. John Singer Sargent. A Biography. New York: WW Norton & Co. Inc., 1955. 8. Hills P. John Singer Sargent. New York: Harry N. Abrams, Inc. Publishers, 1987. 9. Ratcliff C. John Singer Sargent. New York: Abbeville Press Publishers, 1982. 10. Ormond R. Sargent John Singer in the Dictionary of Art. Vol. 27. Jane Turner, ed. New York: Grove, Oxford University Press, 1996:839-842.

CHAPTER 9

Diego Rivera and His Extraordinary Art of Medicine and Surgery Luis H. Toledo-Pereyra The classical Mexican muralist Diego Rivera (1886-1957) was neither a scientist, physician nor surgeon. Diego Rivera did not study science, medicine, or surgery in a formal way. Yet Diego Rivera masterfully painted the world and its unique surroundings, clearly recognized society and all of its iconoclastic characters and conceived the art of medicine in a way not represented by any other artist before.1-18 The purpose of this writing is to emphasize Diego Rivera’s extraordinary creativity, expressed in his art of medicine and surgery, to demonstrate the unique knowledge of the Mexican master about the medicine and surgery of previous and current times.

Figure 9.1. First surgical sketch by Diego Rivera while in Paris (1920). Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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From Guanajuato, Mexico, where Diego Rivera was born in 1886, to Mexico City where his family finally settled, facilitating in this way his art studies at the San Carlos Art Academy, Rivera demonstrated superb ability in his artistic work.4,7,10,11,17,18 His teachers were highly impressed with his initial sketches and from the early steps of his career he was a source of admiration from anyone who came in contact with his work. Rivera had an innate capability to draw the human figure. Faces became natural to him, as if he did not have to realize a significant effort in their creation. Rivera was incredibly able to express nature and 9 its related environment. For Rivera, drawing nature and the human figure was a single endeavor. Both communicated a special and uniquely singular development. There is no doubt that the classes at San Carlos enhanced Rivera’s artistic dimension. There is no doubt that Rivera began to see the world with different eyes. There is no doubt his teachers stimulated the dormant genius inside. Given the value of his previous training, the artist was not pleased that he had not completed his educational sojourn. For this reason, Rivera continued his training elsewhere at the first opportunity and he pursued that welcomed chance with intense desire, particularly in Europe.11,17,18 Nothing was going to stop the culmination of his dream. Without any delay, the artist received great news. The Government of the State of Veracruz in Mexico was offering a scholarship to him for four years to carry on his work in Europe. Without a minute to spare, the trip was planned and Rivera readily embarked on the first ship that could take him to the old continent. Without any sentimentality, Rivera was eager and quite fearless to temporarily exchange his beloved Mexico for European soil. His imagination, which under normal circumstances did not recognize any boundaries, began to present extraordinary scenarios to him. Grandiosity was not one of Rivera’s limitations! Once in Europe, Madrid was the first stop in 1907 and Eduardo Chicharro was Rivera’s mentor. The artist traveled around Europe until he settled in Paris on 1911, where he remained in this exciting city for 7 years until 1918.8,10,17,18 During this time, he acquired a great deal of knowledge, witnessed the emergence of Cubism (1907-1914) and closely followed the works and school of Paul Cezanne and the group of artists of Montparnasse, including Amadeo Modigliani, Ilya Ehrenberg, Max Jacob and many others.17 He visited Italy as well, an obligatory destination for the expansion of his especially creative art.

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Diego took advantage of any circumstance that appeared along his way. He visited all the art museums, attended lectures and seminars, developed friendships with those in similar circumstances, reviewed new art directions and, if possible, interacted with the masters of European art stationed in Paris or those who were visiting the city for extended periods of time. Thus he encountered Pablo Picasso, Henri Matisse, Juan Gris and Georges Braque.8,17,18 Rivera had seen it all, but he was still not fully satisfied since he had not examined the buon fresco technique of the Italian master Giotto before returning to the Mexican capital. A new visit to Italy in 1920 9 calmed Rivera’s intense and persistent quest for knowledge of the mural technique. He was now fully prepared to begin his incredible and prodigious professional career, one that would incorporate 235 painted frescos and a total surface area of 15,000 square feet.11 No other artist in the history of the world has painted such a massive amount of wall canvases, which now occupy “universities, palaces, banquet halls, ministry of public education”11 and other important locations. The well-versed art historian David Lomas accurately summarizes the legacy of the artist by saying, “Rivera is the 20th century’s greatest exponent of fresco painting.”12 I would like to advance even further the possibility that Rivera is the greatest exponent of fresco painting ever.

The Science of Diego Rivera

Rivera appreciated science a great deal and particularly how science evolved through the years. Biology was a prime concern of his, because it represented the best means to characterize human life. In the mural at the Detroit Institute of Arts, Detroit Industry (1932-1933), the highly qualified Mexican master depicted not only the automotive industry at the Ford Rouge complex in Dearborn, but utilized this unique opportunity to introduce other important concepts of science, medicine and surgery. The mural offers ideas and details that could only be mastered by someone who knew and/or constantly studied science and its accompanying disciplines.4,7,9 In the Detroit murals, Rivera analyzed with restrained patience the interrelationship between science and technology, between realism and mysticism, between dynamic symmetry and linear perspective.9 Within the scientific arena, Rivera approached a long list of scientific disciplines, which included ecology, geology, geometry, astronomy, chemistry, botany, bacteriology, pharmacology, reproduction, therapeutics, biology and surgery—all in all, 12 well-defined fields of separate scientific

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expertise. Rivera encompassed a great number of scientific disciplines that had not been considered in this magnitude by other painters.4,7,10 Rivera took the challenge of science personally and pursued the study of all scientific endeavors with intense passion. Rivera saw science as the overall most significant field of knowledge ever possessed by human beings at any point in time. In evaluating the creative ability of Rivera and his expression of the science of the day, Dorothy McMeekin does an especially good job in portraying the artist’s work.9 McMeekin elegantly elaborates in her book, Diego Rivera: Science and Creativity in the Detroit Murals, 9 providing a clear picture of Diego Rivera:9 The creativity in Rivera’s work will not be determined by how well he depicted automobile production—it is difficult to find an automobile in the murals—but by his ability to convey and enhance some of the major themes in art, science and philosophy: harmony, coherence, continuity, unity, structure, good and evil, chaos and order. A study of the murals indicates that he was illustrating these themes and presenting a cohesive picture using the mechanistic and materialistic ideas that underlie the biological, physical and cultural world. His choice of subject matter and artistic style reflect these objectives. The murals depict the positive and negative aspects of applied science: the conquest of disease, automobile manufacture and warfare. The smaller panels are statements about the origin and function of living systems.

The Medicine of Diego Rivera

When Rivera left Mexico for Europe in 1907, he did not know anything about medicine; nor was he interested in medicine. Rivera knew he wanted to do something special. He wanted to absorb all and everything from European soil. His thirst for knowledge was unquenchable, but his appreciation for medicine was not yet evident. Apparently the great French capital presented the first real opportunity to satisfy Rivera’s inquisitive medical interest.8,9,11,13,17,18 The first time Rivera demonstrated his intense desire to draw medical or surgical objects was in 1920, when he attended the surgical clinic of doctor Jean Louise Fauré in Paris.17 The French art historian, Elie Fauré, brother of the surgeon and good friend of Rivera, facilitated the artist’s attendance at the clinic, which offered a wonderful opportunity for the talent of the eager and ascendant Rivera.17

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The next significant medical work of Rivera was located in Detroit, where many medical themes were incorporated into the automobile industry frescos (1932-1933). He focused on exposing areas of great medical concern, such as the development of vaccination and the three giants of microbiology, Pasteur, Koch and Metchnikoff. It is not known why Rivera did not attempt to introduce their faces as known from existing photographs. The healthy human embryo is introduced as another small mural underneath vaccination. In the south wall of the Detroit murals, Rivera presents a panel depicting the pharmaceutical industry, as well as a panel illustrating surgery. On the east wall, Rivera introduces 9 another embryo originating from the soil or germ cell.7,9,18 In 1934, Rivera worked on the mural Man at the Crossroads in New York at the Rockefeller Center. Rivera began but was not allowed to complete the mural at the request of “Mr. Rockefeller,” who felt that the inclusion of Lenin was unacceptable. Rivera, proud of his accomplishment and well-respected artistic freedom, secured an even more historic spot at the National Palace of Arts in Mexico City, where he painted an identical and perhaps better mural with the title of Man, Controller of the Universe.18 In this work, in one of the ellipses, to the right of the man controlling the universe, Rivera cleverly introduced disease-causing cells as a negative implication to the influence of capitalism and the wealth of the world. Towards the left of the viewer, Rivera emphasized technology and the introduction of X-rays for the good of humanity.18 On April 18, 1944, Rivera finished one of the most extraordinary murals he realized with a medical historical perspective. The famed Mexican cardiologist Ignacio Chavez had invited the noted muralist to incorporate The History of Cardiology in two large panels, measuring 6 × 4 meters each, at the premises of the newly founded National Institute of Cardiology in Mexico City. Rivera eagerly accepted the challenge and with the historical help of master cardiologist Chavez, he painted the most informative and historical of murals, a work that can hardly be compared to any other painting of the same genre. Rivera utilized every possible element to enhance and sustain the grandiosity of this work.10-13,17,18 The history of cardiology, from distant antiquity before the Christian era to the early 20th century, was presented in a very real and precise manner. With the initial aid of Professor Chavez, no distinguished contributor to the specialty was missed. All the outstanding personalities in the development of this unique field of medicine were included. At the bottom of the panels, the artist exalts the medicine of the past, even paying homage to Aztec medicine with the use of Yoloxochitl for internal maladies.12,17,18

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In 1953, four years before his death, Rivera painted his last superb medical mural at the Hospital de la Raza in Mexico City. In it the Mexican artist exemplifies “modern medical science and technology”18 on the left and the evolution of Aztec medicine on the right. In the middle, as if dominating the mural, is the figure of Tlazolteotl or Ixcuina (goddess of repulsive things).18 She represents “one of the major deities of earth in the Aztec pantheon.”18 It is interesting to see how the Aztec deity is defined and interpreted in Diego Rivera: A Retrospective (1990):18 The figure of Tlazoltéotl is taken directly from a facsimile of an early 16th-century pictorial manuscript, the Codex Borbonicus, now in the Bibliothèque de l’Assemblée National, Paris. The codex shows her with her typical attributes: cotton headdress and ear pendants, flayed human skin as a covering and blackened nose and mouth. Her central position in the composition is in keeping with Rivera’s habit of using human images as axial motifs in many of his other murals. The special prominence given here to an Aztec deity, in a literal transcription of the indigenous pictorial style, reinforced by an itemized graphic catalogue of native plant specimens used for ancient medicinal purposes, is indicative of a new kind of emphasis on native roots in Rivera’s art, which invites explanation in the context of contemporary (now historical) events.

The Surgery of Diego Rivera

Medicine in general was not the only technological area of attention for Rivera; surgery occupied his dedicated attention as well. Diego pursued the anatomy and physiology associated with surgery. He attended operating rooms and observed human dissections. He studied surgical techniques as they pertained to the development of his art. He admired the technology of medicine and surgery. As noted before, the Clinic of Dr. Jean Louis Fauré (1920) represented the first artistic excursion of Rivera into surgery or medicine. He attended the operation performed by Doctor Fauré in Paris and even though he did not draw organs or tissues this time, he clearly demonstrated his keen interest in this medical specialty.17 More than a decade later, while working on the Detroit murals, Rivera assigned a complete panel to Surgery. His admiration for the surgical world is evident through this small mural facing the south wall of the courtyard. In this unique artistic work, two hands are in the

9

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middle, one dark and the other one whiter. The darker one is extracting a brain tumor, while many hemostatic clamps are controlling the bleeding and a skull X-ray above depicts the growing mass. The small bowel with partial obstruction, the pancreas and the reproductive organs are introduced within the panel as well.9,17,18 Why in the panel Surgery did Rivera only outline the skull and the digestive and reproductive systems? Why did Rivera not pay attention to the heart or excretory systems? Where did Rivera obtain his information? These and many other questions can be referred to Dorothy McMeekin:9 One very plausible answer is that the “Surgery” panel reflects the influences of the pioneer physiologist Claude Bernard, author of Experimental Medicine and Emile Zola, the prolific author of many books including The Experimental Novel. The similarity in the titles is not coincidence; Bernard and Zola were friends … The choice of organs to be represented in the “Surgery” mural can be traced to Emile Zola whose philosophy is presented by Mathew Josephson in Zola and His Time (1928). Josephson indicated that Zola’s “heightened senses resulted in a certain mysticism about physical experiences …” Zola’s and Rivera’s emphasis on the reproductive and digestive systems was probably a response to the tremendous advances made by physiologists like Claude Bernard in our understanding of the organs of the abdominal cavity … In the “Surgery” mural Rivera includes the pancreas to commemorate the control of diabetes with insulin, the intestine to symbolize many advances in our understanding of nutritional diseases (i.e., Pellagra and the B vitamins) and the reproductive organs to represent the discovery of hormones. Years later, in the unique mural of The History of Cardiology (1944) previously described, Rivera touched on topics interrelated with surgery. In this case, he introduced Galen (130-200), noted surgeon of antiquity14,15 and anatomists/physiologists of the eminence of Andreas Vesalius (1514-1564), Marcello Malpighi (1628-1694), Raymond Vieussens (1641-1716), Michel Servet (1509-1553) and William Harvey (1578-1657).14,15,18 All of them made fundamental contributions to understanding the structure and circulation of the heart and the human body, including their physiology. Although these findings

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were not directly related to surgery, they permitted the clear advance of the surgical disciplines. The last great medical mural of Rivera, completed in 1953 as The History of Medicine in Mexico: The People’s Demand for Better Health at De La Raza Hospital, elegantly conveys several surgical scenes. These scenes represent surgery with images of wound care and suturing, bandaging of wounds, as well as birthing and a C-section occurring in a formal operating room with a team of five medical and nursing professionals, including an anesthesiologist. In general, this particularly impressive mural represents “a visual homily and celebration of medical science.” It is evident through this work that Rivera clearly cultivated 9 and propagated the fine art and science of medicine and surgery. In conclusion, the art and work of Rivera, within the confines of science, medicine and surgery, attained the highest level of accomplishment compared to the works of any one of the great master painters. Rivera reached the pinnacle of art in the medical and surgical themes of his well-recognized murals. The medical and surgical works of the noted Mexican master should be excellent examples for teaching the virtues of art and science to future generations of medical and surgical specialists.

References

1. Bernard C. Experimental Medicine. New York: Macmillan, 1865:1927. 2. Bronowski J. On art and science. In: Summerfield JD, Thatcher L, eds. Creative Mind and Method. Austin: University of Texas Press, 1960. 3. Koenigsberger D. Renaissance Man and Creative Thinking. Atlantic Highlands: Humanities Press, 1979. 4. McMeekin D. The historical and scientific background of three small murals by Diego Rivera in the Detroit Institute of Arts. Michigan Academician 1983; 15:5-12. 5. Miller SL. A production of amino acids under possible primitive earth conditions. Science 1953; 117:528-529. 6. Netter FH. The Ciba Collection of Medical Illustrations, Vol 2: Reproductive System; Vol 3: Digestive System; Vol 4: Endocrine System. Summit: Ciba Pharmaceutical Products, 1972. 7. Rivera D. Dynamic Detroit—An Interpretation. Creative Art 1933; 12:289-295. 8. Wolfe BD. The Fabulous Life of Diego Rivera. New York: Stein and Day, 1963. 9. McMeekin D. Diego Rivera: Science and Creativity in the Detroit Murals. East Lansing: Michigan State University Press, 1985. 10. Rochfort D. Pintura Mural Mexicana. Mexico City: Limus Editores, 1993.

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11. Ciok AE. Diego Rivera. Acad Med 2002; 77:64. 12. Lomas D. Painting the history of cardiolog y. Brit Med J 2005; 331:1533-1535. 13. Diego Rivera. (Accessed April 23, 2007. Available at: http://en.wikipedia. org/wiki/Diego_Rivera). 14. Toledo-Pereyra LH, ed. Vignettes on Surgery, History and Humanities. Georgetown: Landes Bioscience, 2005. 15. Toledo-Pereyra LH. Claudius Galenus of Pergamum: surgeon of gladiators, father of experimental physiology. J Invest Surg 2002; 15:299-301. 16. Toledo-Pereyra LH. The art in surgery: the relevance of artistic expression in the surgeon’s life. J Invest Surg 2003; 16:53-54. 17. Hamill P. Diego Rivera. New York: Harry N. Abrams, Inc, 1999. 18. Founders Society Detroit Institute of Arts. Diego Rivera: A Retrospective. New York: W.W. Norton & Company, 1986.

CHAPTER 10

In the Cemetery of Forgotten Books Luis H. Toledo-Pereyra It is exactly what the title proclaims, a Cemetery of Forgotten Books. Carlos Ruiz Zafón (born 1964), the literary sensation and newly acclaimed Spanish writer, conveys with great clarity in his first adult novel, The Shadow of the Wind (2001), a story very much worth telling.1 The main protagonist of this novel is little Daniel, a 10-year-old boy, who at the request of his father visits his intriguing bookshop. While wandering in the various aisles and hidden places within the confines of thousands of shelved books, his father brings him to a special room where he will face those works of art and love that have been forgotten by the unappreciative public. He is about to enter the Cemetery of Forgotten Books.

Figure 10.1. Carlos Ruiz Zafón. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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Let Daniel tell you what he saw: “I still remember the day my father took me to the Cemetery of Forgotten Books for the first time. It was the early summer of 1945 and we walked through the streets of Barcelona trapped beneath ashen skies as dawn poured over Rambla de Santa Mónica in a wreath of liquid copper. ‘Daniel, you mustn’t tell anyone what you’re about to see today,’ my father warned. ‘Not even your friend Tomás. No one.’”1 As Daniel moved close to the man who was guarding the select and enigmatic room, he was greeted with no initial response. Then the story resumes: “The man called Isaac nodded and invited us in. A blue-tinted gloom 10 obscured the sinuous contours of a marble staircase and a gallery of frescoes peopled with angels and fabulous creatures. We followed our host through a palatial corridor and arrived at a sprawling round hall, a virtual basilica of shadows spiraling up under a high glass dome, its dimness pierced by shafts of light that stabled from above. A labyrinth of passageways and crammed bookshelves rose from base to pinnacle like a beehive woven with tunnels, steps, platforms and bridges that presaged an immense library of seemingly impossible geometry. I looked at my father, stunned. He smiled at me and winked. ‘Welcome to the Cemetery of Forgotten Books, Daniel.’”1 “So how does this story relate to medicine or surgeons?” asked the advanced senior surgical resident. “I do not mean to be rude, sir, but I don’t see much application to our current surgical curriculum,” he added. “Aren’t we supposed to review and analyze surgical techniques or critical management steps in the care of surgical patients?” asked the impatient and right-to-the-point, future surgeon. John Mackey, the star surgeon educator, a patient and humane individual who was always attentive to the needs of residents, offered a rational response to the eager and inconsiderate resident. Mackey, always calm and well-composed, settled into the ample and comfortable sofa where he was sitting and addressed the resident. “Peter, what bothers you so much? Why can’t you relate this interesting story, ‘The Shadow of the Wind,’ to the surgical discipline?” The assertive surgical resident had great respect for Dr. Mackey but couldn’t understand his position on this unusual and not applicable book. The mature surgical specialist recognized he needed to dedicate some time to the explanation of this complex book. “I believe the Cemetery of the Forgotten Books alluded to in ‘The Shadow of the Wind’ represents a very positive lesson for surgeons the entire world over.” “How is that,” replied the senior resident.

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“The thing is that in surgery, medicine or any other learned discipline, we have a great number of forgotten books, which are left in the Cemetery of Forgotten Books,” said Dr. Mackey, revealing his increased interest and commitment to surgical historical appreciation. “The situation is so sad,” he continued, “because it reflects lack of interest in historical matters and more importantly in historical surgical matters.” “I do feel, Peter, that few trainees and a similar small number of faculty surgeons are really interested in books dealing with the history of surgery,” emphatically continued Dr. Mackey. “Let me give you some figures from a survey performed during Grand Rounds last Thursday morning. Only 40% of the faculty and residents responded and the results reflected 10 minimal to no interest in surgical historical events or the development of surgery. I am referring to a mere 20% of those who responded positively. What do you think, Peter?” said the senior specialist. Peter did not know what to say, especially when he began to comprehend the problem, which was more extensive and complicated than initially anticipated. “I understand now, Dr. Mackey,” he admitted with a gesture of serious contrition. “I extended my survey, Peter, to include, I felt, a more probing question. I plainly asked the audience, and there were 70 faculty and residents, ‘How many of you have read any surgical books that were 50 years old or older?’ You will be very surprised that the answer was zero,” remarked the senior surgeon. “The state of affairs, therefore, is grim and with no evidence towards improvement,” said Dr. Mackey. “I am somewhat skeptical about those poor figures, sir,” responded Peter and then he added, “How can that be? What kind of surgical books are you talking about?” It was impossible to believe, in Peter’s mind, that the surgical profession did not dedicate ample time to the study of problems within the surgical historical context. But, reality was different, reality indicated that this was the case, reality was very clear on this point. Senior attending surgeon Mackey repositioned himself on the sofa, sat straighter, began to talk more authoritatively. “Peter, I understand your degree of frustration and state of uncertainty before this precarious response of many of our colleagues and mentors of yours. Let me get to the specifics. When I asked them about who had read, owned or seen any books written by Francis Moore (1995),2 Ira Rutkow (1993-1988),3,4 Sherwin Nuland (1989),5 Claude Organ (1987),6 Mark Ravitch (1981),8 Owen Wangensteen (1978),7 or Allen Whipple (1963),9 only three individuals out of 70 present (4.2%) responded

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positively. Their reaction, Peter, made me feel like I was entering into the Cemetery of Forgotten (and this time) Surgical Books. I felt that I was living the moment when little Daniel first saw his father’s Cemetery of Forgotten Books. I felt that all these extraordinary historical surgical books had been consigned to oblivion since most of our friends and colleagues in the surgical field had not read, owned or seen them at any point in their lives. What can we do about this state of neglect, Peter?” asked the frustrated Dr. Mackey, while he directed his attention back to the story of Daniel in “The Shadow of the Wind.” He turned to the following passage: 10

This is a place of mystery, Daniel, a sanctuary. Every book, every volume you see here, has a soul. The soul of the person who wrote it and of those who read it and lived and dreamed with it. Every time a book changes hands, every time someone runs his eyes down its pages, its spirit grows and strengthens. This place was already ancient when my father brought me here for the first time, many years ago. Perhaps as old as the city itself. Nobody knows for certain how long it has existed, or who created it. I will tell you what my father told me, though. When a library disappears, or a bookshop closes down, when a book is consigned to oblivion, those of us who know this place, its guardians, make sure that it gets here. In this place, books no longer remembered by anyone, books that are lost in time, live forever, waiting for the day when they will reach a new reader’s hands. In the shop we buy and sell them. But in truth books have no owner. Every book you see here has been somebody’s best friend. Now they have only us, Daniel. Do you think you’ll be able to keep such a secret?1 “Now, Peter, I have presented my case through the story of Daniel and have underlined the application of it to our Cemetery of Forgotten Surgical Books. Our next step should be to convince our surgical colleagues of the unique and special importance of history in the understanding and teaching of surgery. We need to determine how to bring history to the daily practice of surgery, to energize Grand Rounds, to fortify learning in the operating room and to improve surgical activities overall. The plan should be to introduce a series of lectures on the history and evolution of surgery worldwide and in the United States, including the surgeons’ personalities, contributions, surgical techniques and ways of treatment. Surgical residents would be tested on the details of these lectures and faculty would be available to further enhance the

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teaching of the history of surgery.10 The cycle would then be completed, in that the history of surgery is not only important but is being taught in the best form possible and the Cemetery of Forgotten Surgical Books would be resuscitated to bring those great surgical books to life.” Master surgeon Mackey smiled at the thought. While this story has fictional characters, they illustrate the significance of respecting those surgical books that have been condemned to be forgotten. The lesson is simple—these works deserve to be rejuvenated. Many long-neglected works on the history of surgery could elevate our profession by showing us how to treat patients more comprehensively, more effectively and more humanely.

References

1. Ruiz Zafon C. The Shadow of the Wind. New York: Penguin Group (USA) Inc., 2004. Translated by Lucia Graves. 2. Moore FD. A Miracle and a Privilege. Washington D.C.: Joseph Henry Press, 1995. 3. Rutkow IM. The history of surgery in the united states. Vol. 1, Textbooks, Monographs and Treatises. San Francisco: Norman Publishing, 1988. 4. Rutkow IM. Surgery. An Illustrated History. St. Louis: CV Mosby, 1993. 5. Nuland SB. The Doctors. A Biography. New York: Penguin Press, 1989. 6. Organ C, Kosiba M. A Century of Black Surgeons: The USA Experience. Norman, OK: Transcript Press, 1987. 7. Wangensteen OH. The Rise of Surgery. From Empiric Craft to Scientific Discipline. Minneapolis: University of Minneapolis Press, 1978. 8. Ravitch MM. A Century of Surgery, the History of the American Surgical Association. Philadelphia: J.B. Lippincott, 1981. 9. Whipple AO. The Evolution of Surgery in the United States. Springfield: Charles C. Thomas, 1963. 10. Toledo-Pereyra LH. The history of surgery according to Owen Wangensteen. J Invest Surg 2007; 20:5.

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CHAPTER 11

Medicine, Gabriel García Márquez and Love in the Time of Cholera Luis H. Toledo-Pereyra You might be wondering why I am writing about Gabriel García Márquez (born 1927) in a surgical research journal, or in any medical journal for that matter. Well, your concern is legitimate. But after you explore the wonders of the Nobel-winning author, Gabriel García Márquez and Love in the Times of Cholera (1985), your mind will certainly change. Indeed, in this outstanding novel, the recognized Colombian writer introduces, in addition to the sublime love affair of Fermina Daza and Florentino Ariza, a well-respected and European-trained physician with postgraduate training in medicine and surgery, Dr. Juvenal Urbino.1 Through Gabriel García Márquez and the extraordinary deeds of Dr. Urbino, surgeons and physicians in training and practice can learn the lessons of medical humanism presented by the Nobel laureate.

Figure 11.1. Gabriel García Márquez. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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Gabriel García Márquez—The Author

Gabriel García Márquez won the Nobel Prize in literature in 1982, three years before his book Love in the Time of Cholera was published in 1985.1 His fame had reached other continents, his books were being translated into other languages and he was readily recognized as the most prominent individual representing magic-realism; in fact, he could be considered the creator of this literary genre. Magic-realism gives the author the opportunity to “trace an exceptional half-century study of unrequited love”1 and in my estimation the great opportunity to introduce the medical sciences to the literary world. Gabriel García Márquez presents the unique medical figure of Dr. Juvenal Urbino, dissects his personality, his way of practicing, his thoughts, his emotional well-being, his professional and human char- 11 acter and his life. Dr. Urbino, as the primary character in the writing of the prestigious author, is the principal personality in telling our story. Dr. Urbino is the most knowledgeable and distinguished physician and surgeon practicing in San Juan de la Ciénega, the colonial city on the Caribbean coast of the country of Colombia. He dedicates his life to medicine, civic affairs and family, in that particular order. He encompasses the way that Gabriel García Márquez is using to discern the life and practice of a physician and surgeon living in the late 19th century and early 20th century in the Caribbean world. In this work, our intention is not to explore the extensive and fruitful literary career of Gabriel García Márquez, but rather to concentrate on the marvels of one novel, Love in the Time of Cholera. I will specifically review the crucial developments on the life and accomplishments of Dr. Juvenal Urbino.

Doctor Juvenal Urbino—First Developments and Medical Training

Juvenal Urbino was a Colombian Caribbean product in all his persona. Born around 1843, he grew up in the Caribbean region of Colombia, known as San Juan de la Ciénaga, near to Cartagena de Indias. Juvenal Urbino proceeded from good family background and lived in the District of the Viceroys, the opulent part of the city where his father had been a distinguished doctor who died of cholera when Urbino was still a young student. Urbino attended local schools and medical school in the area. After obtaining his medical degree, he moved to Paris, France, where he received the most sophisticated medical training of the era under the direction of the great medical and surgical professors of the times.1

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Charcot, Trousseau and probably Peán, were Parisian mentors actively involved with young doctors taking postgraduate specialization in both medicine and surgery. The year was approximately 1868 when young Juvenal Urbino started making his rounds in Paris, a very exciting and advanced town in the medical and surgical scene. The dedicated Colombian doctor began his studies at the Hôpital de la Salpêtrière as an intern. From there, he moved on to other noted Parisian medical institutions. He saw and worked with the luminaries of French medical and surgical societies, absorbing important medical principles and well-accepted theories. Urbino was attending the best surgical clinics when the antiseptic methods introduced by the British surgeon Joseph Lister (1827-1912) were published in 1867.2 Juvenal 11 Urbino grasped the concepts developed by the exceptional faculty of Paris, by the leading medical doctors of France and the rest of Europe and by the best teachers available in the world of medicine. These were the medical mentors of Juvenal Urbino!

Dr. Juvenal Urbino Disembarks onto the Caribbean Coast of Colombia

In about 1871, after three years in Paris, Dr. Urbino returned to his native Caribbean port city. He was extremely well-prepared to manage any contemporary medical issue. Most importantly, he had learned to deal with cholera-related matters, which appeared to be a distinct and fatal problem of epidemic proportions in his sea-bound city. Dr. Urbino had attended many lectures in Paris given by the eminent doctor Adrien Proust, who was an established genius in epidemics and particularly in cholera. Dr. Urbino carried this knowledge back to his port city and the people of Colombia. “Impure water was not all that alarmed Dr. Juvenal Urbino. He was just as concerned with the lack of hygiene at the public market.”1 “Dr. Urbino wanted to make the place sanitary.”1 “Cholera became an obsession for him.”1 “No one doubted that the sanitary rigor of Dr. Juvenal Urbino, more than the efficacy of his pronouncements had made the miracle possible.”1 The control of cholera had been attained. The control of cholera was a reality along most of the Caribbean coast.1 The control or establishment of special measures to prevent cholera were functions of great deal of repute for the late 19th century physician. Surgery occupied a second level of attention, inasmuch as anesthesia had been implemented in 1846 in Boston and antiseptics had been used in 1865 in Glasgow.3 Dr. Juvenal Urbino practiced both medicine and surgery, but with more dedication to sanitary and public health issues.

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Dr. Juvenal Urbino—Daily Activities and Civic Duties

Daylight hours were not long enough to contain the activities of Dr. Urbino. He started very early in the morning, prepared for his medical school class, delivered his instructive lessons to students, attended civic duties, had lunch, took a siesta, read and at four o’clock began seeing patients until early evening.1 Dr. Urbino was a man of detail, methodical, well-organized and someone his wife could readily find because of his invariable routine.1 Dr. Urbino was loved by his patients, who respected his dedication and commitment to medicine. The doctor filled his busy day not only with medical matters but with civic activities as well. He dedicated a great part of his morning to attending volunteer functions. Volunteerism was high on his agenda and certainly held special meaning for him. Helping society and particularly 11 the underserved, were matters of supreme consideration for his beliefs. One could almost imagine that his motto was: “Work, help others and your life would be fully engaged.” Among his many civic functions, he generously attended “his catholic service, or his artistic and social innovations.”1 He participated in every corner of social life. “He organized the construction of the first aqueduct, the first sewer system and the covered public market that permitted filth to be cleaned out of Las Animas Bay … He gave active encouragement to every religious and civic society in the city and had a special interest in the Patriotic Junta, composed of politically disinterested influential citizens who urged governments and local business to adopt progressive ideas that were too daring for the time.”1 As if that were not enough for Dr. Juvenal Urbino, or anyone else, he restored the Dramatic Theater, led the Poetic Festival and actively launched a superb opera initiative.1 His degree of collaboration for public events was legendary. He was matchless in his civic spirit and leadership support. He was the consumate achiever, setting an example for successive generations of physicians and surgeons to follow.

Dr. Juvenal Urbino—Significant Thoughts

Dr. Urbino, at the young age of 81, still actively practicing medicine and unwilling to retire, offered great help for “only hopeless cases” and gave us some worthwhile advice. Let’s take him at his word and transcribe some of his significant thoughts:1 1. “He could tell what was wrong with a patient just by looking at him.” 2. “He grew more and more distrustful of patent medicines.” 3. “He viewed with alarm the vulgarization of surgery.”

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4. He would say “The scalpel is the greatest proof of the failure of medicine.” 5. “He thought that, in the strict sense, all medication was poison and that seventy percent of common foods hastened death.” 6. “He would say in class, the little medicine we know is known only by few doctors.” 7. He would say: “Each man is master of his own death and all we can do when the time comes is to help him die without fear of pain.” These thoughts clearly indicate the doctor’s philosophy. Inasmuch as other thoughts remain and could not be analyzed in total, this is a reflection of the doctor’s standing on many significant issues. We owe to Gabriel García Márquez a debt for bringing to real life the character 11 of this unique and especially gifted Caribbean physician.

Conclusions

The life and accomplishments of Dr. Juvenal Urbino (approximately 1843-1924), through the incredible pen of noted author Gabriel García Márquez, brings to us the life of a dedicated professional, committed to patients, medical students and social causes; the life of a medical humanist who utilized literature, theater, poetry, opera and other humanities to enhance his existence and that of others; the life of a generous, kind and responsible human being who brought happiness and well-being to many patients, students and citizens of his Caribbean colonial city. Dr. Urbino should serve as a vivid example of how to be a good doctor, as he attended his patients in the most meaningful manner. Only one thing might have improved his medical practice—unintentionally he did not serve the poor as often as he did the rich. Had he done so, his shining example would be even more admirable. Despite this shortcoming, his life and practice are certainly worth imitating.

References

1. García Márquez G. Love in the Time of Cholera, translated by Edith Grossman. New York: Vintage Press International, 2003. 2. Francoeur JR. Joseph Lister (1827-1912). In: L.H. Toledo-Pereyra, ed. Vignettes on Surgery, History and Humanities. Georgetown: Landes Bioscience, 2005:62-66. 3. Toledo-Pereyra LH, Toledo MM. A critical study of Lister’s work on antiseptic surgery. Am J Surg 1976; 131:736-744.

CHAPTER 12

From Hell Luis H. Toledo-Pereyra From Hell. Well, at least he got the address right.

—Sergeant Peter Godley reading the return address on a package sent by Jack the Ripper

When I received an invitation from Western Michigan University Honor History College students to attend and critique the film, “From Hell” (2001, Metro Goldwyn Mayer), I must admit that I was not terribly enthusiastic. As I inquired with my colleagues about the film, none of them were knowledgeable about it either and they did not realize that the film was based on the well-written and exceptionally graphic novel by Campbell and Moore.

Figure 12.1 From Hell. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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The students provided me with some additional details on the film and the audience the film was addressing. Even though I have enjoyed some of the excellent work of Johnny Depp, a gifted actor and recognized the name of the two talented directors, brothers Allen and Albert Hughes, I was still not convinced of the social and historical value of this eviscerating film. At this point, if I decided to accept this invitation, I wanted to address the positive aspects of this work. What I did value was the possibility of a historical review of 19th century England and the status of medicine at the time. These two reasons alone convinced me that I should integrate myself into this project and provide my limited expertise to the students. Once I had accepted the invitation, I began my quest for reviewing all information pertaining to this film, which portrayed the misadventures 12 and horrible events associated with the crimes perpetrated by Jack the Ripper. My main attention for this film was focused on finding possible benefits within the context of humanism and medical history to transmit to the students and later on to surgical residents. Before analyzing the emotional message provided by this cinematic experience, we must understand and study the full extent of the educational part of this film. We must review this film in its entirety. We must persist in corroborating facts, truths and untruths in order to examine the impact of this bold film. The film opens in 1888 London, in the Whitechapel district, where extreme poverty, unsanitary conditions, a filthy environment and a perilous and untrustworthy atmosphere was the standard for the area. Many characters appear on screen, including the victims who were sacrificed by the fury of the surgical knife, equivalent in those times to the knife of Liston, great British surgeon of the Crimean War. The film continues with the opening of the abdomen and the extraction and stealing of many organs, including the ovaries and uterus, among others. As the movie progresses, it becomes apparent that the perpetuator of these crimes had to be “somebody with a working knowledge of dissection,” someone who had possibly used an amputation kit or was knowledgeable through other trades such as “a veterinarian or an educated butcher or somebody with knowledge of human anatomy.”1-3 Throughout the course of the movie, Inspector Abberline, expertly portrayed by Depp, shows us that his dreary laudanum (opium) dreams give him some of the answers related to the “unfortunate” ladies’ crimes of Whitechapel. Mary Kelly, played by Heather Graham, is a lady of the street. She grows close to the absinthe opium-saturated inspector and gives him reason to believe that she will be the last of Ripper’s

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horrendous crimes. At the end of the film, she is in fact murdered and Abberline commits suicide through one of his incredible dreams. Two eminent surgeons enter the scene, Sir William Gull, the old master and physician to Queen Victoria and Prince Edward and Dr. Ferral, the young star, who is performing the extraordinary surgeries of the brain, called lobotomies, for the treatment of insanity. The whole operation of lobotomy is clearly presented to us, including patient selection, anesthesia with chloroform, patient’s restrictions and the actual surgery. According to Sir William, this surgery is a revolutionary operation that could alleviate human suffering. Sir William implies that, because of lobotomy, the treatment of insanity is a problem of the past, violence can be controlled and the lives and futures of these individuals are secure. In reality, that was not the case since lobotomized patients remained in a vegetative state and could hardly be active members of 12 society. Instead, they were restricted to a prison-like life. In the middle of the whole story, we have the critical involvement of the Free Masons. Gull, Ferral, the police chief and many of the most prominent personalities form an integral part of the order. They help and protect each other. In multiple ways, they exert an extraordinary influence in the lives of many members of society. They swear secrecy and full respect to the aspirations of the group. In the final scene, Gull, the distinguished surgeon and elevated royal professor, is discovered to be the Ripper, the assassin of innocent human beings. Once considered a noble citizen and a preserver of life through the practice of medicine, Gull is now seen as a destroyer, a killer and a robber of the precious gift of life. When he faces the Free Masons’ Court, the following exchange takes place:1 Masonic Governor: You stand before your peers, masons and doctors both. Sir William Gull: I have no peers present here. Masonic Governor: What? Sir William Gull: No man amongst you is fit to judge …the mighty art that I have wrought. Your rituals are empty oaths you neither understand nor live by. The Great Architect speaks to me. He is the balance where my deeds are weighed and judged … not you. Moments before, Sir William had proudly indicated, “One day men will look back and say I gave birth to the twentieth century.”1-3 Immediately after the intense interaction with the court, he is condemned to be treated by lobotomy. We next see him in an isolated room,

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in a curled position, in a permanent vegetative state. Meanwhile, Mary Kelly, the secret love of Abberline, is found dead. As the last victim of Sir William Gull, her body is completely destroyed. A continuous and extended tragedy; a tragedy without compare; a tragedy that should remain nameless; a tragedy that can not be described. Now, in a practical way, what can we learn from these events and personalities? How can we convert the events described on film into something real? Can we find hope and understanding? Up to what point can we use the lessons of this story to teach and learn? Is it possible for us to transfer these developments to the medical and surgical world? I believe we can and let me explain how. These bizarre and absolutely disgusting murders are beyond any rational explanation. No individual with any sense of decency and 12 understanding could explain the evolution of these disastrous events. It would be extremely hard to learn from their abnormal presence. What, then, can we learn? We can find value in discussing the behavior of the characters. Let’s take for example, the young and accomplished surgeon Ferral. As he is introduced in the movie, we are informed that, “he suffered from the surgeon’s malady of vanity.” We respond by saying that vanity is not a virtue under any circumstances but it is often seen in the surgeon’s world. We must encourage our young faculty and still forming residents to view their surgical efforts with patients and colleagues as the sacred temple where they can exert humility and understanding. They need to evolve to a level where the virtue of patience, thoughtfulness and humility are practiced and understood. They need to advance positive and worthwhile causes to the caring of the individual. They need to respect everyone in the surgical arena. Now, let us turn for a minute to the old but intensely perturbed surgical master, Sir William Gull, the most arrogant human character, the annihilator of precious lives, the proud criminal who understands no good and proclaims distorted causes. Under these circumstances, our surgical students can certainly learn how not to be, how arrogance, self-importance, vanity, self-love and similar distorted negative traits of humanity can be harmful to life, family and work. A well-assured professional is good but not someone who is imperious, presumptuous and disdainful. All are negative qualities which do not have a place in the world of medicine. Surgeons of the likes of William Gull are not welcome in a field dedicated to professionalism, decency and caring.4-6 Another significant happening in this movie is the use of lobotomy to overcome violent behavior. In the cinematographic London, 1888 is the year in which lobotomy is carried out by the upcoming and

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intrepid Dr. Ferral. The actual operation in humans began in 1890, performed for the first time in six schizophrenic patients by the audacious Swiss neurologist Dr. Burckhardt. Two patients did not survive the lobotomy procedure and no one else thereafter attempted the already controversial surgery until 1935. In 1935, the American Jacobson, from Yale, realized that frontal lobotomies produced calmer chimps. A crucial piece of information was discovered that same year by the hands of the noted Nobel neurologist Antonio Egaz Moniz from Portugal, who found that if the nerve connections between the frontal cortex and the thalamus were severed, the patients improved their already altered behavior. This work stimulated the inquisitiveness of Walter Freeman and James Watts in the United States. From their first operation performed in 1936, thousands of lobotomies followed thereafter. In a period of 20 years, from 1930-1950, it is estimated that 12 approximately 50,000 operations were performed in the United States alone. Because of the unreliable results associated with this surgery and the potential for worsening findings in one third of patients, the operation was progressively abandoned.7-9 What can we assimilate from the lobotomy cases performed in the movie and thousand of patients who received lobotomies in real life? What we learn is that a surgical technique, performed without sufficient validity, was recommended for mental cases because no other appropriate therapeutic alternative existed. What we learn is that lobotomy was more harmful to patients than if surgery had never been performed. What we learn is that lobotomy should not have been applied for any kind of behavioral disorder. What we learn is that no systematic study was ever performed in lobotomized versus nonlobotomized individuals with psychiatric disorders. Near the end of the movie, the master surgeon-villain, William Gull, appears again. He is seen receiving a lobotomy as penalty for the incredibly horrendous crimes that he perpetuated. Hours or days later, we see him suffering the degrading mental consequences of lobotomy. He is then reduced—as he did to many human beings—to no emotional human life. He is nobody. He cannot exhibit a rational thought process. For all practical purposes, William Gull ceases to exist. “From Hell” teaches a surgeon what not to be and what not to do. This movie presents a sad evaluation of the human spirit. It basically “uncovers the view from hell.” The movie shows the malice of man and it leaves no doubt as to the frightful conditions of these unexpected and heinous crimes. In a lucid moment, Gull ironically characterizes the doings of the young and astute Ferral by saying “he

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knows all about anatomy and nothing about the soul.”1-3 This maxim, taken positively, points to the importance of the soul as the fiber of man, to the significance of the intellect as opposed to the materialistic views, to the relevance of the spirit compared to the weak flesh of man. What is difficult to accept is that the perverse William Gull gives advice as to the importance of the soul when he does not have one of his own to show. It is evident that the Western Michigan University Honor History students, who invited me to attend and review this movie and the surgical residents of our program would obtain many pertinent observations, as presented above, which will enhance their ability to be better students, better residents and, of course, better human beings. And, finally, it is fair to say that the initial reservations that I 12 had with attending this film discussion were completely unfounded. This dark and provocative film provided me with an excellent opportunity to review the historical significance of lobotomies, reflect on the way a surgeon should portray him/herself among patients and peers and recognize that to be a superb surgical technician is not the sole criteria for defining an excellent surgeon. Genuine concern for the human race, compassion and humility are key criteria for defining an excellent surgeon, characteristics that were clearly lacking in Sir William Gull.

References

1. From Hell (2001). (Accessed December 18, 2006. Available at http:// www.imdb.com/title/tt0120681/). 2. From Hell. (Accessed December 18, 2006. Available at http://www. fromhellmovie.com/flash_site/index.html). 3. From Hell—Wikipedia, the free encyclopedia. (Accessed December 18, 2006. Available at http://en.wikipedia.org/wiki/From_Hell). 4. Toledo-Pereyra LH. Respect. J Invest Surg 2005; 18:281-4. 5. Toledo-Pereyra LH. Loyalty. J Invest Surg 2006; 19:275-277. 6. Toledo-Pereyra LH, ed. Vignettes on Surgery, History and Humanities. Georgetown: Landes Bioscience, 2005. 7. Lobotomy—Wikipedia, the free encyclopedia. (Accessed December 18, 2006. Available at http://en.wikipedia.org/wiki/Lobotomy). 8. Boeree CG. A brief history of the lobotomy. (Accessed December 18, 2006. Available at http://www.ship.edu/~cgboeree/lobotomy.html). 9. Lobotomy.info. (Accessed December 18, 2006. Available at http:// lobotomy.info/).

CHAPTER 13

Something the Lord Made Luis H. Toledo-Pereyra This is the story of two men—an ambitious white surgeon and a gifted black carpenter turned lab technician—who defied the racial strictures of the Jim Crow South and together pioneered the field of heart surgery. —From Something the Lord Made, HBO Video/DVD, 2004.

“Why is it that you always say, this is like Something the Lord Made, when a surgical case is difficult and increasingly complicated but the outcome is good?” The uninitiated surgical assistant posed this question to the accomplished surgeon-mentor. The mature professional responded briefly, “It is because I marvel so at the realization of intricate surgical problems and I see those positive developments as evidence of the hand of the Lord.” But, I will be honest with you, that particular sentence was introduced to me by a surgeon trained under the great Hopkins surgeon, Alfred Blalock (1899-1965).1-14

Figure 13.1. Something the Lord Made. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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The story goes back to 1943 when chief surgeon Blalock had been challenged by chief pediatric cardiologist, Helen Taussing (1898-1986), to solve the blue baby dilemma. In the children’s wards at Johns Hopkins Hospital, there were many children suffering from the ravages of a congenital malformation called tetralogy of Fallot, which produces, among other clinical signs, a blue color of the skin because of the lack of oxygenated blood reaching the whole body. The critical question that thoughtful cardiologist Taussing presented to elite surgeon-researcher Blalock concentrated on how to eliminate the blue skin and blue body (known as cyanosis), or in other, more physiological words, how to improve the oxygenation of the body. Blalock did not shy away from studying and attempting to resolve this abnormal condition, even though Robert Gross (1905-1988), the famed Boston Children’s Hospital surgeon-in-chief had chided Taussing years before about her unrealistic quest to find a 13 solution for patients with tetralogy of Fallot. The problem was not a simple one. It represented a rather complex anatomical and physiological maze. Four entities characterized Fallot’s tetralogy: 1. interventricular septal defect, 2. stenosis of the pulmonary artery, 3. aorta overriding the septum and 4. right ventricular hypertrophy.1-5 The anatomy proved so uniquely complicated that it had never been treated before, as demonstrated by an exhaustive review of the Index Medicus by Clara Bell, who was specifically assigned by Professor Blalock to search the medical literature.1 Blalock immediately realized that he needed to include his gifted surgical technician, Vivien Thomas (1910-1985), in the process of discovering the best means to develop an acceptable experimental surgical model of tetralogy of Fallot. Then, of course, they could find the best treatment for the condition.1-5 As if this challenge were not demanding enough, Blalock had incomplete investigations of crush shock syndrome and coarctation of the aorta under way in his surgical laboratories, as well as a demanding and active surgical practice. Knowing that Professor Blalock did not have the time to dedicate himself to the laboratory and that Thomas had been running the surgical experiments for several years already, the only solution could arise exclusively from Thomas’s hands and mind. As a consequence, he entrusted himself with dedicated effort to reflect on the best tetralogy model he could arrive at in the old Hunterian Laboratories. Thomas reviewed pathological specimens with Dr. Taussing, analyzed the

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anatomical anomalies seen in Fallot patients and began to structure a series of experiments for a reproducible cyanotic surgical model in dogs.1 Thomas soon comprehended that the four anatomical deficiencies seen in Fallot patients were not accessible to duplication under experimental conditions. He attempted, however and successfully replicated oxygen desaturation of arterial blood by using various kinds of pulmonary arteriovenous fistulae in dogs.1 In 1938 in Nashville,1 he had technically achieved subclavian artery-to-pulmonary artery anastomosis in dogs, when he and Blalock wanted to produce pulmonary hypertension, although they failed in that endeavor. The technique, nevertheless, allowed more blood to arrive at the lungs without difficulty for a different reason. The solution for circumventing the blue coloration of these seriously handicapped children was finally at hand. Chief surgeon Blalock utilized the surgical accomplishments of his 13 eminent surgical technician to save the lives of countless patients suffering from the cyanotic diseases of the heart.1-14 Professor Blalock, the august and noted surgeon, recognized the particularly special value of his esteemed and advanced technician. On one occasion, Blalock had the opportunity to carefully review the technique Thomas had utilized to suture the pulmonary artery. After doing so, the surgeon asked, “Vivien, are you sure you did this?” Thomas answered in the affirmative and then after a pause, Blalock said, “This looks like something the Lord made.”2-4 Years later, this statement was used as the title of the award-winning HBO movie on the life of Vivien Thomas and his relationship with his distinguished boss and mentor, Alfred Blalock. Blalock and Thomas, the chief surgeon and the surgical technician, the academic specialist and the uninitiated high schooler, the teacher and the receptive student, had immense respect and admiration for each other. Blalock and Thomas had known one another for many years. Blalock and Thomas had built a relationship of mutual understanding and dedicated trust. One could readily predict the other’s response at any point in time. One could readily project the other’s feelings at any given moment. One could readily assume the other’s professional goals without a doubt. Blalock and Thomas were both committed to one another in all their surgical-research endeavors. They had a personal foundation of understanding and support. Many years later, Something the Lord Made became a well-written, produced and acted film featuring the writing of Peter Silverman, the direction of Joseph Sargent and the acting of Alan Rickamn, who

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superbly played Dr. Blalock and Mos Def, who recreated the enlightened life of Mr. Thomas.2 Each one of these elements brought joy and character to the silver screen and likely serve as a good example for future generations of surgeons and technicians alike. Examples such as this are worth preserving and exalting. Examples such as this need to reach new generations of physicians and students. On November 29, 1944, the day arrived on which Dr. Blalock was scheduled to operate on Eileen Saxon, a 15-month-old, nine-pound baby with severe symptoms of the blue baby disease or tetralogy of Fallot. Operating Room 706 had been prepared. The surgical instruments had been selected. Assistants Dr. Longmire and Dr. Colley were scrubbed. Anesthesia personnel were ready and Dr. Blalock entered the room to attend the surgical operation involving this sick child. As the professor prepared to make the incision, he noticed Thomas was 13 not behind him. Immediately, he unscrubbed and frantically began to look for him (as the movie conveys the scene). The noted technician was found and asked to remain behind the professor. The operation began with increased tension and some bleeding of blue blood, which was readily apparent. The vascular sutures were located, but let me stop here and allow Thomas to give us the full account:1 The chest was entered through an incision in the left fourth interspace. The mediastinal pleura observed to have numerous collateral vessels giving it a dark bluish red appearance. There was moderate oozing of blood from the mediastinal pleura when it was incised. There were very few specific bleeding points, these numerous vessels being almost capillary in size. Dr. Blalock exposed and then dissected free the left pulmonary artery and passed an umbilical tape beneath it. The pulmonary artery was then temporarily occluded to determine if the patient would tolerate the occlusion. The full length of the left subclavian artery was dissected free. A bulldog clamp was placed at its origin from the aorta and the vessel ligated as far distal was possible. It was divided proximal to the ligature. The adventitia was stripped from the end of the vessel. The patient’s vessels were less than half the size of the vessels of the experimental animals that had been used to develop the procedure. A bulldog clamp was placed proximally on the pulmonary artery. There was a pause to check again the tolerance of the patient to the occlusion of the vessel. A second bulldog clamp was placed distally on the pulmonary artery, isolating a segment of the vessel. The patient was tolerating

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the occlusion. A small transverse incision was made in the isolated segment of the pulmonary artery—the point of no return. Dr. Blalock asked if I thought the transverse incision was long enough; I said I thought it was, if not too long. He began suturing the vessels, starting with the posterior row, which was the most difficult and tedious. This continuous everting mattress suture was placed loosely. In such small vessels, it was necessary to place each stitch less than one millimeter from the last and very close to the edge of the vessel. When the stitches were in place across the posterior third of the suture line, they were pulled taut by simultaneous traction on both ends of the suture material, thus everting the edges of this segment on the suture line. Stay sutures were placed at each end of the segment and the continuous mattress sutures tied to them. A third stay suture was placed in the center of the anterior segment. With slight traction on this, the suturing continued; each stitch was tightened as placed and anchored to the third stay suture, continuing on to the first stay suture, still in place, to which it was tied. With this, the anastomosis of the left subclavian artery to the left pulmonary artery was completed … The occluding bulldog clamps were removed. There was practically no bleeding. Dr. Blalock was concerned that no thrill was present on palpation of the pulmonary artery. (A thrill results from turbulence when blood from a high or systemic pressure area, such as the subclavian artery, enters a low pressure are, such as the pulmonary artery. It is a sort of buzzing sensation that one can feel with a finger on the vessel. In the closed chest with the use of a stethoscope, it can be heard as a loud noise called a bruit.) He thought the absence of a thrill might have been due to a low systemic blood pressure or to the viscosity of blood from the increased number of red blood cells. The patient was so small that no effort was made to determine blood pressure. Anxiety in the operating room was somewhat relieved. The chest was closed. Everyone present was pulling for Eileen, the first patient to have the Blue Baby operation and for Dr. Blalock. The case was closed, history had been made and most importantly, a new way of treatment for alleviating the blueness of these babies was readily at hand. Similar operations continued to be performed at Hopkins and later on around the country and the rest of the world. People trained under Mr. Thomas and Dr. Blalock spread throughout the nation and made out of this procedure (subclavian-to-pulmonary

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artery shunt) a daily, uneventful surgical event. In 1950, Dr. Blalock, Hopkins and Thomas celebrated the one thousandth blue baby operation and members of the surgical staff and his trainees commissioned a distinguished Canadian photographer, Yousef Karsh, to capture Professor Blalock in a photo that became legendary in Hopkins’ annals of history. Before closing the curtain on this story, it is important to note that Thomas accomplished his great contributions to medicine as a black surgical technician, when race represented a significant obstacle in a medical world dominated by white professionals. Courage, determination and intelligence contributed to the realization of his great medical discoveries, an example for all to follow. One could clearly state with Dr. Blalock, Thomas viewed his work as Something the Lord Made. 13

References

1. Thomas VT. Pioneering Research in Surgical Shock and Cardiovascular Surgery: Vivien Thomas and His Work with Alfred Blalock. Philadelphia: University of Pennsylvania Press, 1985. 2. Something the Lord Made. [DVD]. HBO, 2004. 3. American Experience: Partners of the Heart. [DVD]. Boston: WGBH Boston, 2003. 4. McCabe K. Like Something the Lord Made. The Washingtonian, 1989. 5. Toledo-Pereyra LG. Alfred Blalock. Surgeon, educator and pioneer in shock and cardiac research. J Invest Surg 2005; 18:161-165. 6. Blalock A. Experimental shock: the cause of the low blood pressure produced by muscle injury. Arch Surg 1930; 20:959. 7. Blalock A. Acute circulatory failure as exemplified by shock and hemorrhage. Surg Gynecol Obstet 1934; 58:551. 8. Blalock A, Cressman RD. Experimental traumatic shock—role of the nervous system. Surg Gynecol Obstet 1939; 68:278. 9. Duncan GW, Blalock A. The uniform production of experimental shock by crash injury. Surg Gynecol Obstet 1942; 115:684. 10. Blalock A, Park EA. The surgical treatment of experimental coarctation (atresia) of the aorta. Ann Surg 1944; 119:445. 11. Ravitch MM. The Papers of Alfred Blalock. Baltimore: Johns Hopkins Press, 1966. 12. Hanlon CR, Blalock A. Complete transposition of the aorta and the pulmonary artery: experimental observations on venous shunts as corrective procedures. Ann Surg 1948; 127:385. 13. Kay JH, Thomas V, Blalock A. The experimental production of high interventricular septal defects. Surg Gynecol Obstet 1953; 96:529. 14. Kay JH, Thomas V. The experimental production of pulmonary stenosis. Arch Surg 1954; 69:561.

SECTION III

Biography, History and Criticism

CHAPTER 14

William and Charles Mayo:

Their Influence on American Medicine Roberto Anaya-Prado and Marisol Godinez Rubi

The Birth of a New Era in Treating Ailments

William Worrall Mayo (1819-1911) came to the United States in 1845 from England. He had a degree in chemistry and pursued his interest in medicine by enrolling for the 1849-50 session at Indiana Medical College. He married in 1851 and ultimately settled in Rochester, Minnesota, where he and his wife had a daughter and two sons. In a short time, he became the physician of Rochester and had a steady practice.1,2 Dr. W.W. Mayo was a devoted physician and his growing sons were a common sight on the visits he made to patients.

Figure 14.1. The Mayo brothers in surgery. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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He involved his sons in all aspects of his work: whether he needed help giving ether to remove a tumor or dressing a wound. The two boys were immersed in healing and, like their father before them, they never strayed from their calling to become doctors.3,4 William James Mayo (1861-1939), the eldest son, was born on June 29, 1861. He was a quiet, intelligent boy and these traits carried him throughout his amazing career. His aptitude for observation and his patience guided him toward forceful advocacy of new surgical concepts. He went to medical school at the University of Michigan and graduated in 1883. After receiving his degree, he returned home to help his father in an extensive practice. The same qualities also applied to the youngest Mayo son. Charles Horace Mayo (1865-1936) was born on July 19, 1865. Charles was the jovial, personable son. In 1888 he received his medical degree from Chicago Medical School.5-8 The Mayos decided that he should not go to the University of Michigan, because they felt 14 that it was important to be exposed to different theories. After finishing his studies in medicine, Charles returned home to join the family practice, which had become increasingly busy with three physicians. They all had good reputations, but were increasingly frustrated with the prevailing individuality in the practice of medicine.

The Evolution of Hospital Care

Today hospitals are at the forefront of meeting medical needs. Most doctors are affiliated with a specific hospital and ailing people find doctors there. Major surgeries are now performed either at university hospitals or large hospital centers. They are a place to get help and, hopefully, cure. People are confident that they will receive excellent care from the staff and that they will leave of their own volition with the hospital’s blessing. This, however, wasn’t always the case. People had a negative view of hospitals until the 1900s. They were seen “as a last, deathbed resort.”9 The poor were the most common frequenters of medical facilities, which were perceived as a refuge for dependents rather than a place to heal. Average citizens refused to consider hospital care for these reasons; they preferred house calls and physicians practiced at the patient’s home. They would be summoned to the person’s house and any medical procedures that were needed were performed there. The doctor carried a bag with all the supplies he or she commonly used; physicians were not affiliated with hospitals at all and had no standard operating room or office. The main reasons for home visits and fear of hospitals was medical in nature. People felt they would be less likely to die at home where they were comfortable and enjoyed familiar surroundings.

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Before the 1800s, medical care in the Western world changed very little.10 Doctors rarely performed surgeries because of the immense pain to the patient, who had no anesthesia. If surgery was performed, it was on the extremities and minor in essence and the chances of the patient dying were higher than the chances of healing. Germs were still undiscovered and procedures were performed with bare hands and in less-than-sanitary conditions. People hoped they would have more luck at home rather than surrounded by degenerates in a hospital. Once bacteria were accepted and anesthesia was invented, however, practices began to change more rapidly within a few years than in the two preceding millennia. The germ theory became more popular and sterilization and sanitation were more accepted. Soon anesthesia gained much attention and excitement from physicians and patients alike. Death rates dropped dramatically because of preventive measures. Thus, surgeries became more thorough and extensive. The previous association between high death rates and hospitals was clearly changing and people became 14 less judgmental of hospitals.

Winds of Change

Most hospitals in the United States were founded between 1880 and 1920.11 The Mayo brothers joined the medical field at the beginning of this boom and were hands-on participants in creating one of the nation’s first hospitals. The year William, or Dr. Will as he was referred to, graduated from medical school, a tornado tore through his hometown, killing and wounding many of the people there.8 There were no hospitals, so the injured were cared for in a barn. Some of the women volunteered their help as nurses, but this posed problems for Dr. W.W. Mayo. The nurses had to leave in the evening to take care of their own families, forcing the “hospital” to compensate for the lack of help. Dr. W.W. Mayo then considered asking nearby nuns, who were visiting their summer convent, for help. He wasted no time in asking the mother superior, Mother Alfred Moes, if she could spare some of her women to help the sick. She agreed and this began one of the most influential medical relationships of modern times.12,13 Mother Alfred saw what the disaster had done to the town and the benefits of a hospital were noted. She then approached Dr. W.W. Mayo with her idea for a hospital in Rochester. Dr. Mayo hesitated because of the immense cost, but said that if she built one he and his sons would support her. That was all the encouragement she needed and four years later, after a lot of hard work and money saving, St. Mary’s Hospital was a tangible dream come true.6,8,13 Opposition came from Catholics who

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wanted the hospital to treat only Catholics. Mother Alfred dispelled this notion when she hired a protestant priest as director. The hospital would accept anyone in need regardless of race, religion, class or gender. This was a new practice and it went over very well with the patrons. It is important to note that the Mayos were not directly involved with the creation of this hospital, but their encouragement of the endeavor, their willingness to perform procedures there and their talents as doctors were the reasons why the hospital was so quickly accepted and used by the sick and wounded. The Mayos approved of the hospital wholeheartedly and agreed to perform all of their surgeries in its specially designed operating rooms. The Mayos were well respected and their support encouraged visits from those in need of medical attention. It took a few years to lay the groundwork for the hospital’s success, but, after its reputation was established, visitors soon exceeded the number of beds. Only a few years 14 after the hospital was opened an addition was needed. The popularity of the hospital was due to many factors, though mainly the reputation of the Mayo brothers. They were well liked and respected physicians and their death rate was lower than that of most other physicians. The Mayos often traveled to learn the latest techniques in surgery and this instilled confidence in those who dealt with them. The Mayo brothers always seemed to champion new advancements and their vision did not go unnoticed.14 Simultaneously, traditional views of the nature of disease were beginning to break down and the hospital was at the very center of this trend.15 Gowns and gloves were becoming a common sight in the operating room, as was thorough cleaning of surfaces, including hands and tools. The dressings covering wounds were now changed at least once a day rather than “once a stay.” Drs. Will and Charlie encouraged these practices and the medical world took note that their success rates were much higher than most other physicians. The techniques adopted by the Mayos were still in the experimentation phase, but Lister’s new method of aseptic surgery was the reason for increased practice of the art.3,6,16 Another reason for hospital popularity was advancements in transportation. Before long, there was a train station in Rochester that made it possible for people from afar to visit the hospital. People were eager to have the Mayos help after hearing news of their work and dedication to the patient. The train increased visitation to the hospital, which was a blessing and also aided the Mayos personally. They were frequent travelers to check out medical news and the train made their trips

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easier, longer and more fulfilling. With increased comfort in going to the hospital, confidence in receiving competent medical care and leaving the hospital healthy, visitation soon exceeded the abilities of the three doctors. It became evident that the men needed to bring in other physicians to add to their practice. “It has become necessary to develop medicine as a cooperative science: the clinician, the specialist and the laboratory workers uniting for the good of the patient,” explained Dr. Will. “Individualism in medicine can no longer exist.”6

Team Work, the Next Step

In 1892 the Mayos added the first of many partners. What the Mayos envisioned was a future of cooperative work. They felt that house visits and individual practices would soon be obsolete. They were confident in the positive results of group work. In addition, the men felt they could accomplish more good as a group, rather than meeting only yearly to share concepts and exciting advancements with 14 their peers. “Difficult medical and surgical problems are solvable when experts pool their talents,” said Dr. Will.17 What better way to pool talents than practice under one roof ? Group medicine, with total teamwork, was their goal. In fact, the world’s first, largest and most successful practice of group medicine was that of the Mayos. “This concept of interlocking talents and a mood of sharing is the fundamental reason why the Mayo Clinic is so respected today,” claimed Dr. Charles Mayo.18 The brothers looked for physicians with talents that paralleled their own. All the doctors were expected to practice general medicine, but it was a natural branching that had each man specializing in one area or another. Dr. Will was very talented in pelvic and abdominal surgery, while Dr. Charles was known for his talent in surgeries of the head, eyes, throat, brain and so on.19 Each new partner was encouraged to practice what interested him and it was not uncommon to have doctors study abroad learning the most current techniques in a field, such as new ways to administer anesthesia or remove tumors from different cavities of the body. The Mayos also added a laboratory and many new discoveries were made there. For example, a Mayo physician developed the process for freezing tissue samples in the operating room. This discovery revolutionized surgery, because the doctor was able to explore, diagnose and repair all in one operation. After Dr. William Mayo obtained his degree and through his initial practicing years, anesthesia was not widely used or even known. Slowly ether and chloroform became more common and by the time

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Dr. Charlie graduated, much more clinical use of these drugs was occurring. The brothers used anesthesia in all of their operations and they paid close attention to other new advancements. When a new tool was invented to administer anesthesia, they were eager to watch its use and judge for themselves. If they felt it was an improvement, they brought the technology home with them. The brothers had an anesthesiologist who specifically focused on administering the drug. And from this specialty came new ideas on how to deal with anxious patients. It was common practice to give the drug in a separate room and then wheel the patient into the operating room. The Mayo group noted that anxiety was much less and therefore less of the anesthesia was needed, if the patient was present in the operating room during preparation, was informed of what was going on and of what would happen. This method was noted by fellow physicians who came to watch the doctors perform surgeries and the concept ultimately be20 14 came common practice. Patients are still treated this way. Dr. W.W. Mayo influenced the practice of nursing with that first visit to the sisters. Nurses are irreplaceable in the practice of medicine. The sisters’ care of the sick eventually evolved into a nursing school, where fine women were taught to heal the sick. It was necessary that nurses know the fundamentals of medicine and working and living at the hospital launched this new, modern method of nursing. The doctors were not always at the hospital and the sisters learned to heal without immediate physician supervision. As stated earlier, the idea of sterilizing the operating room was seen as irrelevant in the 1800s. Only towards the end of that century was the idea of aseptic surgery accepted. The Mayo brothers became doctors during the beginning of this new trend and they quickly embraced it. The operating rooms at St. Mary’s were slanted to provide for a thorough cleansing. Latex gloves were gradually adopted and it was a standard practice that the body area to be operated on, as well as the tools and air surrounding the patient, be thoroughly cleaned. The Mayo’s death rates and instances of infection were noticeably smaller than those of most other practicing surgeons and the Mayos shared their beliefs freely with those who were interested in improving their own percentages.

The Aim of Hospital Practice

Education was the lifeblood of the Mayo’s practice. They were always traveling to see new advancements and reading papers written by other physicians. The brothers also believed in their hospital and the communication they had among the staff. All the doctors were able to discuss

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ideas and share new methods. One day, on a visit to the east coast, Dr. Will noted the presence of several interns at a hospital and observed the insignificant work they were required to do. He was disturbed by this and, after returning home, he approached the University of Minnesota to develop a partnership between the hospital and university. This new agreement created stature and permanence for Mayo Clinic. The hospital was now more than one facility—it was an educational department for the teaching of medicine. Dr. Will supported this change stating, “Training interns is the professional duty and social responsibility of members of the staff.”21 In 1915 the Mayo Foundation for Medical Education and Research was established with a gift of $1.5 million to the University of Minnesota. With this money, the world’s first formal graduate training program of physicians was created. It was called the Mayo Graduate School of Medicine and has participated in the postgraduate education of more than 13,000 doctors since its inception.17 The Mayo Clinic was opened just a year before the graduate school 14 was created. The Mayo Clinic was simply a medical practice group, which represented a gradual increase in staff and stronger unity that required a home office for this continued relationship. The Mayo Clinic should not be confused with the hospitals. It was a group practice, which was closely affiliated with hospitals. St. Mary’s Hospital started the trend of group medicine by employing the Mayos, but it could not accommodate the advancements they envisioned. So a separate organization evolved. Offices were built for the Mayo Clinic to house the clinical staff. Labs were organized and special departments gained notoriety separate from the whole. Dietetics became an area of great change. Experimentation at the Mayo Clinic spurred invention. And, of course, surgery had always been the strongest branch of the Mayo’s practice. The new clinic drew attention to what the Mayos and their partners were working towards in the medical field: unified medicine in group practice. The Mayo Clinic can now claim over 3 million patients for whom its staff have provided medical care. It has contributed over $250 million to medical research and programs. Today, the Mayo Clinic is almost a household name. Most people are familiar with its reputation for experimentation and groundbreaking surgeries. Mayo surgeons were among the first to perform successful open heart surgery. The first hip replacement in the United States was done at Mayo, paving the way for future joint replacements. These advances were in addition to the Mayo brothers contribution in changing from individual practices to hospital care and group work. People take the medical profession as it is today

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for granted. Most don’t realize that it hasn’t always worked like this, that hospitals have not always been so centrally involved in medicine. The Mayo Clinic was the model from which future practices mirrored their policies. The success of the group practice surpassed what physicians were attempting as individuals. After the Mayo example, what followed can only be characterized as a hospital boom. There were some people, however, who were doubtful that the clinic could carry on after the brothers died. What they didn’t realize was that because of the strong presence and stellar example the two men set, the practice they built would endure. This success was not due to the Mayos as celebrated doctors, but was due instead to the philosophy they instilled in their partners and predecessors. The enduring achievement was about their example and how the men and women who joined them learned from and added to the original idea of “comprehensive care at the highest standard, efficiency and the patients well-being.”22 If the Mayos had become farmers rather than physicians, they would 14 have excelled at that instead. The medical profession would probably have stalled for a few more years and it is doubtful that the caliber of treatment expected and received today would be as high. The Mayo brothers went above and beyond the expectations of most people. They not only became doctors, but specialized in surgery and encouraged the education of nurses and future doctors. They were forefathers of new medical techniques and built a lasting organization that is still a leading example for other group practices and hospitals alike. Without the advancements encouraged and started by Dr. W.W. Mayo and his sons and their affiliation with St. Mary’s, it is a safe bet that medical care would not be what we have today.

References

1. Clapesattle H. The Doctors Mayo. London: Oxford University Press 1941:26-35. 2. Nelson CW. Biographical update of Dr. William Worrall Mayo. Mayo Clin Proc 1995; 70:616. 3. Clapesattle H. The Mayo brothers: makers of history. Bull Med Lib Assoc 1959; 47(1):18-23. 4. Nelson CW. Dr. William Worrall Mayo’s legacy to his sons. Mayo Clin Proc 1996; 71:1130. 5. Kaufman et al. Dictionary of American Medical Biography. Greenwood Press, 1984; 508. 6. Nelson CW. The surgical careers of the Mayo brothers. Mayo Clin Proc 1998; 73:716. 7. Clapesattle H. The Doctors Mayo. London: Oxford University Press, 1941; 208.

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8. Beahrs OH. Contributions of the Mayo Clinic in World Wars I and II. Ann Surg 1995; 221(2):196-201. 9. Mayo CW. Mayo: The Story of My Family and My Career. New York: Doubleday & Company, Inc., 1968:19. 10. Rosen G. The Structure of American Medical Practice 1875-1941. Philadelphia: University of Pennsylvania Press, 1983:1. 11. Stevens R. American Medicine and the Public Interest. New Haven and London: Yale University Press, 1971:78. 12. Nagel G. The Mayo Legacy. Springfield: Bannerston House, 1966:22. 13. Nelson CW. Mother Alfred Moes and Mayo. Mayo Clin Proc 1998; 73:108. 14. Rutkow IM. Moments in surgical history: the doctors Mayo. Arch Surg 2001; 136(5):603. 15. Rosen G. The Structure of American Medical Practice 1875-1941. Philadelphia: University of Pennsylvania Press, 1983:11. 16. Rothstein WG. American Physicians in the Nineteenth Century, from Sects to Science. Baltimore and London: The Johns Hopkins University Press, 1972:258. 14 17. Martin FH. Fifty Years of Medicine and Surgery: An Autobiographical Sketch. Chicago: Lakeside Press, 1934:284. 18. Mayo CW. Mayo: The Story of My Family and My Career. New York: Doubleday & Company, Inc., 1968:23. 19. Clapesattle H. The Doctors Mayo. London: Oxford University Press, 1941:300. 20. Sarr MG, Van Heerden JA, Kendrick ML. William J Mayo’s vision a century later. J Am Coll Surg 2005; 201(3):324-326. 21. Nagel G. The Mayo Legacy. Springfield: Bannerston House, 1966:38. 22. Bowers JZ. An Introduction to American Medicine—1975. Washington, D.C.: Geographic Health Studies, 1977:156.

CHAPTER 15

The History of Surgery According to Owen Wangensteen Luis H. Toledo-Pereyra May the spirit of inquiry, the love of learning and appreciation of the History of Medicine create in our medical schools an intellectual atmosphere that will heighten greater medicine commitment and accountability in its service to mankind. —O.H. Wangensteen and S.D. Wangensteen, The Rise of Surgery: From Empiric Craft to Scientific Discipline

The legendary Minnesota surgeon, Owen Wangensteen (1898-1980), throughout his prominent surgical career frequently pondered the virtues of surgical history.1-10 He could not understand why some other surgeons, notable or otherwise, did not cultivate the benefits of utilizing history on the teaching of surgery and its well-developed principles. For him, the history of the discipline and the men or women who participated on its development were at the forefront of his teachings.

Figure 15.1. Owen Wangensteen. Used with permission from the Minneapolis Star Tribune. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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The Minneapolis surgical professor maintained that, “if all medicine from anatomy to zoology could be taught with special emphasis upon the historical approach, our medical students would be better prepared to cope with the problems of the future.”1 He was certainly on target and I clearly support his perspective. How can anyone eliminate or de-emphasize the value of history in the surgeon’s profession or in any other field of medicine or cultivated discipline? Yet history is ignored more frequently than might be expected. Wangensteen was fully aware of this state of affairs!

Brief Biographical Note

Owen Wangensteen began his life on the frontier of Minnesota agricultural land where he was born in Lake Park on September 21, 1898. Of Norwegian ancestors, he grew up on his father’s farm, where he supervised the care of all animals, particularly the pigs, which were abundant. His level of commitment and attention to the care of the animals oriented him toward a career in medicine. The University of Minnesota was his obvious choice for college and medical school. He 15 graduated at the top of his medical school class of 73 students.3 Dr. Arthur Strachauer, part-time chairman of surgery at the University, convinced young Owen that “surgery was where the action was.”3 However, in 1923, there were no surgical intern positions available at Minnesota. Therefore, he interned in medicine for one year and immediately thereafter moved to the reputable Mayo Clinic, just 70 miles southwest of Minneapolis. While at the clinic, he specialized in surgery during 1924-1925 and attended surgical cases with Dr. William Mayo and Dr. Judd. In addition, he spent some time discussing surgical research with Dr. Frank C. Mann.3 In 1925, when he returned to Minneapolis, he obtained a PhD and assumed the position of chief resident at the university hospital. A year later, he accepted a full-time job as an assistant professor of surgery offered to him by Dean Lyon. In 1927, Wagensteen traveled to Europe to continue his surgical studies. His wife and 2-year old daughter, Mary, accompanied him to Switzerland and Germany. Armed with a recommendation from the renowned Dr. William Mayo, Wangensteen received unequalled attention from all the European masters, Ferdinand Sauerbruch and Rudolf Wissen (Berlin), Martin Kirschner (Tubingen), Paul Sudeck (Hamburg) and Friedrich Voelcker (Halle) from Germany. Professors de Quervain and Ascher from Berne, Switzerland, were his last two important stops. This special European visit constituted one of the best experiences that Wangensteen could draw on later throughout his surgical life.3

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In 1928, Wangensteen and family returned to Minnesota and immediately he was promoted to associate professor of surgery. Two years later, in 1930, the initiated professor was elevated to chairman of the surgery department at the age of 32.3 Wangensteen concentrated on various surgical developments, on training surgical residents, on the development of new surgical techniques for use in gastrointestinal problems and on the exhaustive study of bowel obstruction and the means to solve this frequently fatal condition by introducing nasogastric suctioning. He also advanced the concept of aggressive radical surgery for cancer and utilized second-look operations for lymph node metastases. Above all, Wangensteen should be recognized as one of the great surgical mentors of the 20th century. During his tenure at Minnesota, an incredible number of disciples made subsequent discoveries in all surgical disciplines, which were recognized in the United States and eventually worldwide.5 Countless numbers of his surgical trainees were to occupy the most important surgical positions in the United States 3 15 surgical universe. The Wangensteen surgical tradition was a shining light for a great number of surgical trainees and continues through the great deeds performed by all the noted disciples of this unique Minnesota surgeon, teacher and researcher.3-10

How Did Wangensteen’s Interest in the History of Surgery Begin?

It is not a simple endeavor to define the origins of any specific task or interest in the life or accomplishments of anyone and Wangensteen is no exception. By all appearances, the young surgeon visiting Europe in 1927 developed a taste for the history of surgery. The great European clinics of the day, attended by well-recognized personalities like Sauerbruch, Kirschner, Sudeck and Voelcker in Germany, intensified his desire to review the contributions of earlier surgeons who had guided the emerging discipline. Later on, professor de Quervain in Switzerland reinforced Wagensteen’s initial desire for historical exploration. Many ideas in the fertile mind of Wangensteen were not going to be fully expressed until years later and perhaps some of the ideas waited until his historical career took full force after complete retirement as chief of surgery at the University of Minnesota in 1967.3-5 Since this European educational trip, it was evident that the surgical specialist had seen with open eyes and accepting spirit the many advances recognized throughout history on European soil. As much as previous European achievements impressed thousands of tourists, the wonders of that continent awed Wangensteen with regard to surgical feats.

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How Was Wangensteen’s Interest in the History of Surgery Sustained?

Curiosity is an important element in maintaining interest and Wangensteen’s curiosity was a prime example since his inquisitive nature never left him. In the same way, his interest for history, particularly the history of surgery, never abandoned him. The extraordinary combination of curiosity and interest guided professor Wangensteen throughout his life and frequently these are the forces that nurture all of us in many fields of endeavor as well. The prodigious memory of Dr. Wangensteen was an asset in recognizing and remembering many important historical facts. Th is innate ability sustained his appreciation and interest for the history of surgery.1-6 There were no facts that escaped his evaluation, whether they were close or distant in time. He recalled names without difficulty and analyzed events easily, as if they had recently occurred.3-5 At the top of his game, nothing escaped his attentive response, everything remained under consideration and, very importantly, all historical facts were 15 alive in his memory. In short, curiosity, interest and a gift for recalling significant events and personalities fed Dr. Wangensteen’s intellect and his enthusiasm and dedication to the history of surgery. No development in the history of the surgeon’s arena evaded his attention and consideration.

How Important Was the History of Surgery to Wangensteen?

Throughout his surgical career, teachings, research and postsurgical retirement years, Dr. Wangensteen considered the history of surgery as the most special, “profitable and enjoyable” discipline.2 He could not conceive of surgery without history and I would add that history could not be created without the benefit of surgery. Both are intertwined to the point of complete amalgamation, to the point of complete integration, complete union. History and surgery, though two disciplines, cannot exist independently, because neither can reach its pinnacle on its own. In one of his classic papers, Dr. Wangensteen addressed the following topic, “Has Medical History Importance for Surgeons?”2 The Minnesota specialist believed that “medical history” would make “the learning process invigorating and pleasurable.”2 He realized that “our greatest teachers are numbered among those we have come to know only through the pages of history.”2 He emphasized that teaching history would make “our medical students” more knowledgeable and involved

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in the whole surgical enterprise.2 He recognized the enormous value of surgical history when he stated in his own worthwhile manuscript, “I like to think of medical history as an invitation to learning. It is a temptation no surgeon should resist.”2 Professor Wangensteen continued to praise the meritorious value of surgical history, because “the social acceptance of the profession is determined in large measure by its accomplishments.”2 The writings and surgical conquests of the past were thoroughly acknowledged by the Minnesota surgeon and great student. In 1978, Dr. Wangensteen and his wife, senior medical historian, Sarah Davidson Wangensteen, produced their magnum opus on the history of surgery.1 With extraordinary diligence and overwhelming care, they both spent unthinkable numbers of hours in the planning, research, development, writing and rewriting of this unique and outstanding historical manuscript.1 The Wangensteens dedicated many years of arduous work to completing this special scholarly work. Once it was finished, no other work on the 15 history of surgery covered the extensive number of topics referred to in this encyclopedic treaty. The Rise of Surgery: From the Empiric Craft to Scientific Discipline constituted a seminal reference work written mainly from the historical point of view regarding the pathophysiological problems affecting surgical patients and the management of their diseases. From wound management in amputation to debridement, lithotomy, prostatic obstruction, intestinal obstruction, emphysema, ovariotomy, anesthesia, antiseptics and many more topics, this book analyzed in 785 pages the origins of surgery and related topics as well.1 The publication of this splendid treatise by the Minnesota couple left no doubt whatsoever of Dr. Wangensteen’s determination to position surgery, through its unique history, among the most revered and learned professions. No other American surgeon since the time of Samuel D. Gross (1805-1884) had accomplished so much as regards the history of surgery as Owen H. Wangensteen! As a dedicated labor of love and reverence towards the specialty, he traced the specialty he had served for so many years.

Personal Recollections

When I arrived to the University of Minnesota Surgery Program, on July 1, 1970, three years after professor Wangensteen had retired as chairman, the aura of his works and developments remained visible through the lives and deeds of his notable disciples. The then upcoming surgical star and now chairman of the department of surgery, Dr. John

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S. Najarian (b.1927), had allowed the Wangensteen tradition to flourish and in due time to amalgamate with his own, ascending Najarian tradition. The presence of Dr. Wangensteen at many Saturday Grand Rounds gave a sense of historical recollection of a long life dedicated so successfully to surgery. With a spirit of cooperation and understanding of his new position as retired chief, Dr. Wangensteen rarely spoke spontaneously unless asked for his opinion, at which time, he offered it with enthusiasm. Respect and camaraderie were the main tenets of the Wangensteen-Najarian academic relationship as I saw it. My years at Minnesota (1970-1976) permitted me to visit with Dr. Wangensteen many times. At this stage, he was fully dedicated to the study of the history of surgery and completing his superb work on The Rise of Surgery: From Empiric Craft to Scientific Discipline. I found him to be amiable, pleasant, willing to spend time with me and to help me on any matters that pertained to his area of expertise. He enjoyed researching topics unknown to him or those that were challenging to the understanding of the history of surgery. He was truly a scholar 15 and a kind individual: someone who was easy to work with and who understood the benefits of a deep scholarly discussion. In 1972, when I was advancing my interest on the history of medicine as an academic discipline, Dr. Wangensteen was extremely helpful in presenting interesting new avenues of scholarly historical pursuits. He recommended that I go and talk with Dr. Leonard G. Wilson, the founding chairman of the Department of the History of Medicine. Our informal discussions took me on many worthwhile and exciting roads through the history of surgery. I have always cherished this singular opportunity. During my surgical residency and studies into the history of medicine, I often visited with Dr. Wangensteen and frequently spoke with him in the Historical Biomedical Library (now named after him) on the fifth floor of Diehl Hall. Every visit was a great and distinct honor, an opportunity to discuss the history of surgery with this extraordinary man of American surgery. At the time, I did not have a well-defined appreciation of his towering presence in American medicine. With historical hindsight, I do now.

Conclusions

The life and surgical accomplishments of Owen H. Wangensteen remain as a lucid example of academic excellence. Of special interest was his commitment to the history of surgery. He delved into the surgical challenges of the day and offered a high-level resolution to

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surgical problems, such as the study and management of intestinal obstruction. He dissected the historical forces that shaped surgical treatment of many of the diseases which were creating high morbidity and mortality. Wangensteen lifted the history of surgery to levels not reached by others surgeons before, except in the writings of Samuel D. Gross. Both Wangensteen and Gross should be remembered as the most distinguished surgical historians of their times. Today we have the likes of Ira Rutkow, a noted surgeon-historian of our era who has followed in their footsteps.

References

15

1. Wangensteen OH, Wangensteen SD. The Rise of Surgery: From Empiric Craft to Scientific Discipline. Minneapolis: University of Minnesota Press, 1978. 2. Wangensteen OH. Has medical history importance for surgeons? Surg Gynecol Obstet 1975; 434-442. 3. Najibi S, Fykberg ER, Wangensteen OH. A surgical legend and the father of modern management of intestinal obstruction (1998-1981). Digest Surg 2000; 17:653-659. 4. Leonard AS. A tribute to Dr. Owen H. Wangensteen: the chief. Surgery 1981; 88:402-406. 5. Peltier LF, Aust JB, L’Etoile Du Nord. An Account of Owen Harding Wangensteen. American College of Surgeons, 1994. 6. MacLean LD. Wangensteen’s surgical forum: a legacy of research. Bull Am Coll Surg 1993; 78:9-16. 7. Wangensteen OH. Credo of a surgeon following the academic line. JAMA 1961; 177:559. 8. Wangensteen OH. The early diagnosis of acute intestinal obstruction with comments on pathology and treatment. West J Surg Obstet Gynecol 1932; 40:1-17. 9. Wangensteen OH. Historical aspects of the management of acute intestinal obstruction. Surgery 1969; 65:363-383. 10. Ravitch MM. A Century of Surgery. Philadelphia: Lippincott, 1981.

CHAPTER 16

Richard Selzer:

Premier American Surgeon-Writer Luis H. Toledo-Pereyra A stillness settles in my heart and it is carried to my hand. It is the quietude of resolve layered over fear. And it is this resolve that lowers, my knife and me, deeper and—deeper into the person beneath. —R. Selzer (Mortal Lessons, 1976, p. 92)

What does it take for a simple and unsophisticated instrument, the knife, to confess its advances, defeats, glories, difficulties and many more details of its life? It is not a simple task to be a rudimentary knife and at the same time to be entrusted with the care of the human body. If a knife could talk, what do you think it would say? I guess this could be a long story, since the many battles endured by this committed piece of

Figure 16.1. Richard Selzer. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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steel might be expressed as optimism, sorrow, virtue, caring and cure, 16 which can all occur in the full expression of its presence. No one conveys better than Richard Selzer (b. 1928) the spirit and grace of such a legendary instrument. Selzer represents today’s most prominent American surgeon-author, challenged only by the unique works of Sherwin Nuland (b. 1930), another distinguished surgeon-author also once affiliated with Yale University Medical School. Both surgeons share similar special abilities of excellence in writing. More recently, Atul Gawande (b. 1965) has shown qualities similar to his two distinguished colleagues by combining surgery and literary interests. In this essay, attention is dedicated to the works of Richard Selzer and in particular to his outstanding writings in Confessions of a Knife and other of his noted books.1-13 Attention is also given to the implications of his surgical writing career for a younger generation of surgical specialists.

Brief Biography

Selzer grew up in Troy, New York, where he was born. He attended Union College, also in New York, before beginning his medical studies at Albany Medical College, where he graduated with an MD in 1953. His surgical residency followed immediately thereafter at Yale University. His surgery studies were interrupted when he was drafted into the U.S. Army from 1955-1957. After his army stint, he returned to surgery at Yale, where he completed his residency in 1960. Selzer began his surgical practice at Yale the same year, where he continued until his retirement from surgery in 1986.5-10 Well into his surgical career, Selzer began cultivating his interest in writing. In 1968, he wrote his first story, dealing with the biblical tale of “Jonah and the Whale.” Other stories soon followed. In 1974, his first book of short stories, Rituals of Surgery,1 was published. In spite of the title, these essays contained no reference to the life and practice of surgery. In 1975, Selzer received the National Magazine Award from Columbia University for the Esquire Magazine essays dealing with “The Knife,” “Kidney Stones” and others. In the same year, his second book, Mortal Lessons: Notes on the Art of Surgery2 was published. A few years later, in 1979, his next book reached publication, Confessions of a Knife.3 As he was nearing his retirement from surgical practice in 1984, Selzer received a well-deserved and highly anticipated American Medical Writer’s Award.5,8,9 In 1988, the noted surgeon-writer received a Guggenheim National Endowment for the Arts Fellowship in recognition of his successful writing career. Several other books were published in the years to

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come. In 1992, he finished a revealing autobiographical work, Down From Troy: A Doctor Comes of Age (William Morrow & Co., 1992). 16 Two years later, another personal book appeared, Raising the Dead: A Doctor’s Encounter with His Own Mortality (Viking Press, 1994), published as a dedicated account of his own experience with Legionnaire Disease.5,9,10 The Doctor Stories,4 The Exact Location of the Soul (St. Martin’s Press, 2001) and The Whistler’s Room (Shoemaker & Hoard, 2004) followed.5,9,11 Selzer’s total literary output represents 7 books of collected works, 6 nonfiction books and 1 play, in total, 14 books of supreme literary expression. Selzer, the author, took the pen as he had the scalpel so many times utilized in the operating room, but this time slicing (as a reference to completing his writing work) the many pages of careful and thought-out description of characters, instruments, special occasions and circumstances; he also elegantly described the life of this mute yet uncompromising piece of steel, bronze or stone. The knife is an instrument of truth for the practicing surgeon and clearly one of hope for the eagerly awaiting patient.

Life of a Surgeon-Writer

It is not simple to be a surgeon; it is not simple to be a writer; and it is, of course, even less simple to be both. Selzer solved this difficult equation by stealing time from his regular sleeping schedule. He went to bed early each night and then began each new day at 1 a.m. Stoically, he complied with his writing ambition every working day until attending his surgery cases at 7 o’clock in the morning. He kept this overwhelmingly and overreaching daily schedule for the many years of his dual professional undertaking. Let us hear from Selzer himself on this issue.10 I had been a surgeon for a good long time, when all at once the energy to write appeared. I was 40 years old when I began to write. It came to me late, like a wisdom tooth. I decided to teach myself the craft of writing. I gave up practically everything but my work as a doctor, my family and writing. I didn’t play bridge, go to the movies or to dinner parties. It was the life of a paramecium, only without the rapture of binary fission. I would finish my work as a surgeon, come home, visit with my family, have dinner and then immediately go to bed around 7:30 or 8 o’clock. I was the first grown-up in the state of Connecticut to go to bed and my children were humiliated by this. At 1 a.m., I would get up, make some tea and, with the rest of the world sound asleep and all the light in the universe directed on

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a blank sheet of paper, I wrote. I wrote dozens of horror stories in the dead of night, just as an exercise. You don’t need much psychological complexity or philosophical profundity, all you need to do is scare your reader and then you’ve succeeded After three or four years, the stories began to be published. So that’s how it started. But my family did have to accept the fact that I was launched on a different path and wasn’t going to lead my previous life. For me, the decision to write was not a frivolous thing; it was a passion from the beginning and I knew I had to do it. Selzer’s motivation for writing was unique. His dedication to literary works was uncommon. His commitment to combining surgery and writing was undeterred, particularly given the difficulties frequently seen in the practice of these two jealous fields of knowledge. After retiring from surgery in 1986 at the age of 58, the mature surgeon had free time to dedicate to his second professional ambition, that of the muses of literary circles. Now he had a way to please both of his parents; his father by having embraced medicine and his mother by attending the call of poetic license. He had responded extremely well to the most important developments of his life. He had proved himself as a committed and motivated surgeon-writer. On many fronts, he was providing a durable example to a new generation of surgeons and physicians as he searched for an added writing career.1-15

Confessions of a Knife

This particular book of Selzer’s presents, in 24 outstanding essays, the essence of the crisp lyrical quality of the author’s expression. I was taken by the imaginative force of this literary work. He extensively explores all emotions and brings the caring of humanity to our reach. He is a master of description, a professor of clear and brilliant explanations, a mentor of human understanding. Consider these examples of Selzer’s lyrical work.3 1. In the essay “An Absence of Windows,” the author explains the location of the hospital and operating room. “Part of my surgical training was spent in a rural hospital in Eastern Connecticut. The building was situated on the slope of a modest hill. Behind it, cows grazed in a pasture. The operating theater occupied the fourth, the ultimate floor, wherefrom huge windows looked down upon the scene. To glance up from our work and see the lovely cattle about theirs, calmed the frenzy of the most temperamental prima donnas.”3 What enormous grace and poetic advances emerge in this writing!

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2. To continue with the previous essay, Selzer describes some of the manifestations of the severe pain of pancreatitis. “The belly I lay 16 the flat of my hand upon was hot to the touch. The slightest pressure of my fingers caused him to cry out—a great primitive howl of bowel and diphthong. This kind of pain owns no consonants. Only later, when the pain settles in, long and solid, only then does it grow a spine to sharpen the glottals and dentals a man can grip with his teeth, his throat. Fiercely then, to hide it from his wife, his children, for the pain shames him.”3 It could not have been said so well by anyone else, with such elegance and descriptive intelligence. 3. The essay on “Alexis St. Martin” reflects the superior description of the founding of gastroenterology by two absolutely indispensable individuals. “At the very place where the waters of three Great Lakes, Huron, Michigan and Superior, come together, there humps the turtlish island called Michilimackinac. Here, in the year 1822, a shotgun was fired that blew open the body of a man and founded the science of gastroenterology. Aesculapius, the god of medicine, must have set all Olympus booming with laughter when he arranged that mayhem in Mackinac and set in motion this unlikely passion.”3 Then, the author proceeds to describe the two required heroes of this dramatic story, the shot-suffering Canadian fur trapper, Alexis St. Martin (1804-1881) and the obsessed army surgeon, William Beaumont (1797-1853), soon to be a surgeon-scientist, father of American physiology and gastroenterology.3 These two most opposite characters represent the essence of this well-told and highly refined story. 4. In the “Appendix” essay, Selzer introduces the innocent and at the same time dangerous role of this often-overlooked tiny organ. He masterfully describes the lowest of abdominal organs. “Other parts are expendable, the gall bladder, the spleen, the odd digit or tonsil, but none of these is so lacking in purpose as to be of no earthly use to the community of organs. Not so the appendix … Is it not ironic that the one part of the corpus most useless, most lacking in anatomical and physiological importance should be the one part most commonly diseased? Appendix is the evil dwarf who will cut any caper in order to get attention.”3 The surgeon-writer continues his magnificent exposé regarding the most important and significant elements of this “sausage balloon.” He literally gives life to the sometimes lifeless organ.

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Mortal Lessons: Notes on the Art of Surgery

Other works by Dr. Selzer can give us further insight into the writings of this exceptional surgeon-author. Mortal Lessons is a great example. In this case, nineteen classic essays describe the art of surgery, the human body and many other important themes. Of significance are the essays dedicated to “The Exact Location of the Soul,” “The Surgeon as Priest,” “Lessons from the Art,” other parts of the body and especially “The Knife.”2 When examining the unequaled literary piece “The Knife,” one realizes the immense value of its presence. Selzer approaches the subject with clear understanding and singular style. “What is it, then this thing, the knife, whose shape is virtually the same as it was three thousand years ago, but now with its head grown detachable? Before steel, it was bronze. Before bronze, stone—then back into unremembered time. Did man invent it or did the knife precede him here, hidden under ages of vegetation and hoof prints, lying in wait to be discovered picked up, used?”2 The full characterization of the noble surgical instrument is approached with gusto. Mortal Lessons contains many other important stories not described here.

More About Richard Selzer

Selzer offers a plethora of critical information in his uplifting essays. He uses surgery very effectively to convey the importance and dramatization of the surgical act. Selzer is spiritual and recognizes the “aura of the spirit in the wound.”10 He advances the concept of the sacred while being touched by the diseased body. He is not religious, inasmuch as he does not believe in God, even though he remains highly spiritual.10 Selzer is a man of principle and of a generous heart when attending to the needs and tribulations of his ill patients. One has the distinct impression that surgeon-writer Selzer lives and suffers through their distressing times. Selzer and his patients become a single unit in that each depends on the other for a successful relationship. Patients and doctor are conjoined until the treatment is completely resolved. It appears that Selzer extracted humanism not only from the effects of his bleeding knife but also from the inking strokes of this purposeful pen. Knife and pen were intertwined to reach higher heights for the good of the healing patients. The surgeon-writer cures effectively with knife and pen by offering patients the best solutions to their daunting problems.

Conclusion

Selzer is one of the premiere American surgeon-writers of today. His literary work extends from 1968 when he published his first story on

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a nonsurgical topic. Subsequent writing focused more frequently on surgically relevant issues. In particular, in 1975, Mortal Lessons: Notes 16 on the Art of Surgery appeared. Four years later, Confessions of a Knife reached bookstores. Both of these books reflect on the simplicity and grandiosity of the surgical art, celebrate the outreach of the profession and consider the intricate elements of surgical practice. Selzer produced many other important works of similar intentions. In total, 14 books have been published since he began studying medicine in New Haven at Yale Medical School. Selzer has produced a legacy of worthwhile surgical literary essays that should be a leading example of the uniqueness of the profession for new surgical practitioners as well as those of us who are established and seasoned surgeons.

References

1. Selzer R. Rituals of Surgery. New York: William and Morrow, 1974. 2. Selzer R. Mortal Lessons: Notes on the Art of Surgery. New York: Simon and Schuster, 1976. 3. Selzer R. Confessions of a Knife. New York: William Morrow, 1979. 4. Selzer R. The Doctor Stories. New York: Picador USA, 1998. 5. A Guide to the Papers of Richard A. Selzer (MS 60). Truman G Blocker, Jr. History of Medicine Collections, Moody Medical Library, University of Texas Medical Branch, Galveston, Texas. (Accessed September 23, 2007. available at www.lib.utexas.edu/taro/utmb). 6. Joseph P. The John Cheever story: a talk with Richard Selzer. Twentieth Century Literature 1991; 37:335-342. 7. Schuster CI. Confessions of a writer: the art of Richard Selzer. Rhetoric Review 1984; 3:84-98. 8. Stripling MY. Bioethics and Medical Issues in Literature. Westport: Greenwood Press, 2005. 9. Stripling MY. Medical Humanities. (Accessed September 23, 2007. Available at medical humanities.net/publications.html). 10. Setauket SK-E. Interview with Doctor/Writer: Richard Selzer. (Accessed September 23, 2007. Available at http://teenink.com/past/2000/ December/Interviews RichardSelzer.html. 11. Richard Selzer. (Accessed September 23, 2007. Available at www.fantasticfiction.co.uk/s/richard-selzer/). 12. (Accessed September 23, 2007. www.eric.ed.gov/ERICWebPortal/ recodDetail?). 13. Selzer R. Letters to a Young Doctor. New York: Simon and Schuster, 1982. 14. Toledo-Pereyra LH, ed. Origins of the Knife. Early Encounters with the History of Surgery. Georgetown: Landes Bioscience, 2006. 15. Anaya-Prado R, Toledo AH, Toledo-Pereyra LH. The surgeon as a scientific writer. J Invest Surg 2006; 19:335-339.

CHAPTER 17

Lessons from the History of Medicine John Waller What is the point of teaching the history of medicine? Many historians and clinicians find it regrettable that some medical students today will graduate knowing almost nothing of such “greats” of the past as Hippocrates, Galen, Vesalius, Harvey, Lister and Pasteur. But does this really matter? After all, traditional history of medicine curricula tended to distort medicine’s past, omitting the countless errors, wrong turns, fads, blunders and abuses, in order to tell the sanitized stories of a few scientific superheroes. Modern scholarship has seriously challenged most of these heroic dramas; few of our heroes were as farsighted, noble or obviously correct as once thought. Joseph Lister, for example, turns out to have had filthy wards, while William Harvey was devoted to the Aristotelianism he was long said to have overthrown.1,2 But as the history of medicine has become less romanticized, it has also become much more relevant, for it promises to impart useful lessons in the vital importance of scientific skepticism.

Always Question

In 2005 the Journal of the American Medical Association reported an elegant study by John Ioannidis.3 He had selected leading medical journals and traced what happened to the conclusions of their most highly cited studies involving the testing of different kinds of surgery or chemotherapy. Ioannidis found that when a therapy was claimed to be effective, in 32% of cases the claims were subsequently rejected or shown to have been exaggerated. In 44% the initial results had been replicated. Here, in a nutshell, we see the exceptional power of the experimental method: most of the time error and exaggeration are ruthlessly exposed. But reappraisal only happens because of the emergence of a culture, from the 17th century onwards, which rewards criticism and challenge.

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A relative latecomer, the experimental method relies on a mindset that needs to be cultivated and encouraged. The German physicist Max Planck famously remarked that, “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up that is familiar with it.”4 Planck exaggerated, but he recognized that people are by nature very slow to abandon received ideas. And, as Planck asserted, scientists too can be stubborn. They are often prone to stick doggedly to favored theories in the face of counter-evidence. They are also susceptible to passing fashions. This is precisely why studying medicine’s rich and convoluted history can be so worthwhile. There can be few better ways of warning students of the risks of dogmatism in science than delving into the history of surgery or medicine, for the vast majority of past medical ideas have turned out to be wholly or partly wrong.

Some Choice Errors from Medicine’s Past

Think only of the stock-in-trade of the surgeon over centuries of European and later American history: bleeding patients to restore humoral balance. Often patients were bled, whether by cupping, cutting 17 or the application of leeches, until they fainted. The procedure was still thriving in European and American hospitals into the mid-1800s. In the 1820s the pioneering French physician, Pierre Louis, had tested the procedure by bleeding some patients copiously and others moderately. Louis found that it made little or no difference if one took a lot or a little blood, but wedded as he was to a paradigm in which bleeding worked, he seems never to have considered the possibility that no bleeding would be best of all.5 Nor did surgeons of his day typically wonder if appalling rates of postoperative infection might be associated with hardly ever washing their hands or performing thousands of operations while wearing leather aprons impregnated with blood and surgical debris. Wholly committed to the idea that infections were the result of a combination of poisonous airborne fumes (miasmas) and climatic conditions, these practitioners looked no further. It would be decades before their successors discovered the microbial causes of hospital infection present on bed linen, aprons, beneath fingernails, on leeches, lancets, saws and reused bandages and dressings. Even those who survived operations were sometimes subjected to wholly unnecessary procedures. Numerous cliterodectomies were carried out in the mid-1800s by Isaac Baker Brown. An eminent British gynecological surgeon, Brown believed—in common with many of

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his contemporary physicians—that female masturbation was a grave threat to mental and bodily health. Women were brought to him by husbands perturbed by their wives’ nervous outbursts or lack of interest in marital sex. Irrespective of the woman’s feelings in the matter, Brown provided his surgical “solution.” It is worth mentioning that the records of European and US asylums of the 19th century show psychiatrists thought masturbation was the leading cause of insanity in around 30% of cases of serious mental illness.6 After the role of germs in causing disease was finally recognized, a brand new fad in surgical psychiatry emerged. Henry Cotton, medical director of the New Jersey State Hospital at Trenton in New Jersey between 1907 and 1930, formulated his “focal infection” theory, according to which toxins produced by bacteria float into the brain and there produce mental disturbance. From 1919 onwards he performed hundreds of operations to remove the alleged sites of infection. Cotton carried out scores of colon resections, removing large sections of the lower bowel. “Enucleating the cervix” was another common intervention. Uteruses were removed in the same speculative manner. And 17 testicles were removed “by excision.” These were highly invasive operations: as many as 30% of Cotton’s patients died of shock or infection following colon resection.7 Still, his patients’ obituaries spoke of a great pioneer. This is also how early advocates of leucotomy, like Egas Moniz and William Jackson Freeman, saw themselves, slicing through brain matter with little regard either to patient consent or their pitiful lack of follow-up data. Moniz won the Nobel Prize for medicine for developing an operation that would appall a later generation of psychiatrists. Only in old age did Freeman set about collecting the empirical data on the efficacy of psychosurgery which he could have gathered decades earlier.8 From the recent past the controversy over the significance of placebos stands out. Following a 2001 article in the New England Journal of Medicine by A. Hróbjartsson and P.C. Gøtzsche, serious doubts have been raised about the true magnitude of the placebo effect.9 Even if it turns out that there is indeed such a phenomenon, the fact remains that for decades the belief that placebos can have significant physiological effects drew heavily on a paper, published by anesthesiologist Henry Beecher in 1955, which is shot through with methodological flaws. These are not isolated cases. Open any medical textbook from, say, 50 or more years ago and many of the ideas will seem flawed or naïve. Only a minority of ideas stand the test of time and these do so only

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in heavily modified fashion. I make this point not to say that medical science is overrated, which I do not believe. (On the contrary, never before has medicine been so effective). Nor do I wish to belittle our predecessors, for like us they were doing their best with limited concepts and techniques. What I wish to emphasize is that medicine has always had to fight against tradition, faddishness and sometimes dangerous over-confidence. This is obvious to anyone who has studied science or who relies heavily on its findings. But a medical education consists in large part of learning scientific dogma. The knowledge students gain may be correct, but acquiring it does not always imbue an appreciation for the uncertainties of leading-edge science. In contrast, the wreckage of discarded medical theories and therapies provides the most powerful warning against dogmatism.

Why Things Go Wrong

From history we can also gain valuable insights into why medical science sometimes goes awry. Ioannidis identified several reasons why nearly a third of the highly cited studies he examined were later rejected or modified. He revealed, not surprisingly perhaps, that trials without control groups were highly likely to be invalidated. Likewise, 17 history provides many object lessons in the critical importance of proper method. For instance, reflecting on the popularity of bleeding over the centuries, students can learn to dissociate what seems to work from what has been clinically shown to work. And the necessity for careful study design is well illustrated by the gross methodological errors committed by Cotton, Moniz, Freeman and many others. Examples from the past also underscore the treacherousness involved in interpreting the data of cutting-edge science. A useful case study is provided by the disappointments of the Scottish naval surgeon James Lind. In 1747 he performed what may have been the first controlled clinical trial. He assigned 12 sailors dying of scurvy to six groups and gave each, aside from a basic diet, one of six supposed cures for this terrible and often fatal, disease. After a few days, he found that those who had been given the juice of lemons and oranges had recovered and were now able to nurse their shipmates. It seems obvious to us that Lind should have concluded, emphatically, that citrus fruit cures scurvy and convinced the British Admiralty of the fact. And yet over the coming decades he became convinced that citrus fruits offered no protection against scurvy. Why? A major reason is that in later studies Lind dispensed to seamen small blocks of boiled-down orange syrup for them to take on long voyages. Tragically, they died.

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There were in fact at least two interpretations of Lind’s later results: (a) that citrus fruits do not cure or prevent scurvy and (b) that somehow he had damaged the curative component by vigorous heating. Knowing nothing of vitamins or molecules, Lind simply did not consider the second possibility. And so he made the implicit assumption that if citrus fruits worked when fresh, they should work just as well when boiled for a day or two. He had done everything as the famous philosopher of science, Karl Popper, would have: he had formulated hypotheses, tested them rigorously and abandoned his theory when the evidence went counter to it. Unfortunately for both Lind and thousands of seamen, even sound method does not guarantee success.10 Today, too, data are frequently misinterpreted because of what a scientist cannot know. As most of the greatest medical scientists have found, rarely is new experimental data decisive. Most data sets are open to multiple interpretations: nature rarely offers up her secrets willingly and is apt to mislead.

Conclusion

The Victorian philosopher John Stuart Mill brilliantly extolled the

17 importance of skepticism. “If even the Newtonian philosophy were

not permitted to be questioned,” he wrote in his classic On Liberty, “mankind could not feel as complete assurance of its truth as they do now. The beliefs which we have most warrant for have no safeguard to rest on, but a standing invitation to the whole world to prove them unfounded.”11 The fact that Newton’s ideas later had to make room for those of Albert Einstein adds still greater weight and poignancy to Mill’s words. Errors of the past should not be covered up, buried or forgotten. This is partly because it needs to be acknowledged that progress comes through recognizing mistakes and from extracting the truth from failed paradigms. More importantly, learning about past errors teaches us about the frailties of the human mind, how readily we can come to believe in ideas or treatments that are plausible but incorrect. In the process we come to appreciate Mill’s insistence on the need for a keen spirit of skeptical inquiry.

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1. Granshaw L. Upon this principle I have based a practice: the development and reception of antisepsis in Britain, 1867-1890. In: Pickstone JV, ed. Medical Innovations in Historical Perspective. London: Palgrave Macmillan; 1992:17-46. 2. Pagel W. New Light on William Harvey. New York: Karger, 1976. 3. Ioannidis JPA. Contradicted and initially stronger effects in highly cited clinical research. JAMA 2005; 294:218-228. 4. Planck M. Scientific Autobiography and Other Papers. Trans F. Gaynor. New York: Philosophical Library 1947:33-34. 5. Bynum WF. Science and the Practice of Medicine. Cambridge: Cambridge University Press, 1994:43-44. 6. Allen PL. The Wages of Sin: Sex and Disease, Past and Present. Chicago: University of Chicago Press, 2002. 7. Scull A. Madhouse: A Tragic Tale of Megalomania and Modern Medicine. New Haven: Yale University Press, 2007. 8. Valenstein ES. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books, 1986. 9. Hróbjartsson A, Gøtzsche PC. Is the placebo powerless? an analysis of clinical trials comparing placebo with no treatment. N Engl J Med 2001; 17 344:1594-1602. 10. Waller J. Leaps in the Dark. Oxford: Oxford University Press, 2004. 11. Mill JS. On Liberty and Other Essays. Oxford: Oxford University Press, 1998:26.

SECTION IV

Philosophy of Surgery

CHAPTER 18

The Social Transformation of American Surgery Luis H. Toledo-Pereyra In 1982, Paul Starr (b. 1949), the noted Harvard sociologist, published his highly praised and Pulitzer prize-wining book, The Transformation of American Medicine.1 In this work, Starr clearly presents his brilliant assessment of the social history of American medicine. He strategically covers the evolution of American medical events from the 1760s to 1980. He advances the knowledge of professional sovereignty in American medicine, he contends with various forces, political and otherwise, in the shaping of the medical enterprise and

Figure 18.1. Typical operating room setting during the American Civil War. From the collection of Melinda and Paul Johnson, MD. Used with permission. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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he introduces the role of culture and social organizations in medical development and the comprehensive scope of its sublime goals. This essay attempts to incorporate some of Starr’s principles and premises on the social transformation of American surgery. The critical questions that resonate in my mind regarding this work deal with: • How surgery was able to transform itself from an unsophisticated mechanical discipline to a profession worth pursuing. • How surgery proceeded from primitivism to objective assessment of facts. • How surgery replaced the lack-of-respect label with one of appreciation and consideration. • How surgery convinced the public to seek improved medical treatment. • How surgery represents the positive force that is sought by patients and doctors to overcome disease. • How surgery ascended to medicine in its ability to cure and remove maladies from all. • And how surgery enhanced the world of possibilities and radically increased the level of expectations and valid concerns for the sick. These are some of the basic tenets that create the understanding 18 and transformation of surgery on American soil. Our intention is to review the above-mentioned points and to offer plausible and practical explanations as we progress through time and history.

Surgery of the 1760s

In the 1760s, the American surgical profession was limited in scope and knowledge. Surgeons were not fully accepted as respectable and many entered the discussion of surgeons’ value in society. Surgery was, by necessity, a discipline of minorities, whose main source of work and related income was amputations and tumor removals.1-8 If the U.S. person of the revolutionary 1760s required antibiotics or a surgical anesthetic, they were not available. Surgeons battled the incredible foes of infection and pain along the way to full recovery and recognized sovereignty. Surgeons stood alone with no complete legitimization of their trade. When medical schools came to America in Philadelphia (1765), New York (1767), Boston (1783) and Dartmouth (1796), surgeons had the unique opportunity to begin legitimizing their profession. This would occur in tiny steps compared to advances during the middle of the 19th century, at the time of the introduction of anesthesia and antisepsis, the two great saviors of the surgeon’s work.

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Surgery Transformation from Unsophisticated Discipline to Something Worth Pursuing

The surgeons’ knowledge during the 1700s and their ability to cure others were restricted to an environment that distilled ignorance and shunned science. Early surgery, of the 1760 era in America, lacked any degree of sophistication, which hampered its image and application in this country and the rest of the world. Many in society recognized the faulty results observed in the patients needing surgery beyond amputations and external tumor resection. The authority of the surgeon was trivial since he could not bring about a continuous flow of successful clinical cases that justified his moral presence.1-8 Not until the latter part of the 19th century, when scientific surgery embraced the germ theory of disease and introduced pain control and antiseptic wound care, did the surgeon begin to gain respect and the profession become a discipline worth pursuing.

Surgery Proceeding from Primitivism to Objective Evaluation of Facts

At the dawn of the 1800s, in 1809, American surgeon pioneer 18 Ephraim McDowell (1771-1830) performed in Danville, Kentucky, the first successful abdominal surgery in the world by removing an ovarian tumor, even before the discovery of anesthesia and antisepsis. In spite of this extraordinary case, surgery remained in a state of almost primitive despair. Besides McDowell, no one else attempted to open the abdomen electively again for more than 50 years.2,5 Surgery in America had not changed its childish face even up to the 1860s when the Civil War flared up. American surgeons were basically following elementary principles of surgery that the great Ambroise Paré (1510-1590) had expounded in his European theatre of operations three centuries before. The royal surgeon to four French kings and distinguished apprentice at the Hôtel-Dieu in Paris, he introduced improved means to treat war wounds with egg yolk, oil of roses and turpentine and advanced the use of ligatures for arterial bleeding during amputation.2 Where was American surgery before the discovery of anesthesia in 1846? The answer would be very simple: It had not advanced a great deal and remained idle during this period of time. American surgeons, just as their colleagues in other parts of the world, were taking care of external wounds, setting broken bones, excising readily accessible tumors, suturing disrupted flesh and amputating limbs. This was the basic realm of opportunities for the practicing surgeon of 1846, American or not.2,9

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One could also ask, where was American surgery prior to the discovery of antisepsis, according to Lister, in 1865? The answer again would be very simple: Surgery had not advanced a great deal and the bulk of American surgeons continued to perform the same procedures mentioned for the 1846 era. Society, therefore, continued to be extremely reluctant to subject any of its members to the surgeon’s care unless an emergency or death was imminent. The surgeon’s arena of care was then restricted by definition and the profession still lacked authority. Once more, one could ask where American surgery was at the time of Halsted’s ascendance to the newly created position of professor and chief of surgery at Hopkins in 1892? The answer clearly would be more extensive, since American surgeons had already begun their outstanding contributions to the modern and new scientific field of surgery.2,9,10 Among these personalities, Charles McBurney (1845-1913), a New York professor at Columbia University, made a monumental discovery and contribution in 1888 to the operative treatment of acute appendicitis.11 American surgeons were now surging as competitors to their European counterparts and the objective evaluation of facts was becoming a clear reality in the reporting and assessment of surgical events. 18

Surgery—From Lack of Respect to Appreciation and Consideration

In 1860, lack of respect for the surgical profession was not difficult to understand, given the unacceptable operative results pertaining to high morbidity and mortality at the surgeon’s hands. Patients were too alarmed to subject themselves to surgical procedures that otherwise might be managed by conservative means. Society was not forthcoming in the acceptance of the unsuccessful surgeon. These conditions represented overwhelming threats faced by a profession that could not reach levels of appreciation and consideration until the early 20th century, when American surgeons received better training, acquired more knowledge and found improved science at their disposal. In the 1900s, surgeons became more confident and society began a process of acceptance and consideration for those professionals who were clearly aware and highly committed to the best of their surgical function. Anesthesia, antisepsis and better techniques transformed the surgeon’s work into a more effective and appreciated discipline and the lack of respect evolved into enhanced sensitivity for the surgeon’s activity and better long-term results. As the 20th century progressed, surgeons applied all scientific advances to the betterment of their patients in a way that was clear to

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society and the organizations dealing with the support of patient care, hospital expenses and surgeon’s fees began to thrive.1-4,9 A real transformation from lack of respect to appreciation and consideration!

Surgery Convinces the Public to Seek Its Pathways of Improved Treatment

As 1922 came to a close, a new era of surgical history started. The great American surgical master, William Halsted (1852-1922) had just passed away and, therefore, his prominent surgical school and well-thought-out residency program were sources of considerable positive influence on American surgery.9-12 Halsted and excellent surgery were synonymous. No one could challenge the enormous contributions of the superb Johns Hopkins surgeon. With infection under significant control and surgeons now receiving an excellent training, the public commenced to accept the results that the surgical professionals were achieving. Their treatments required no explanation since well-devised procedures were clearly outlined and the majority were based on laboratory or clinical evidence. The years of lack of knowledge and unpreparedness were past. Now the surgeon was a distinguished professional sought out by the public for advice 18 and recommendation regarding treatment.

Surgery Changes Its Image from Brutishness to Gentleness

Brutishness was the essential element of the surgery of the old days, the surgery before anesthesia, the surgery of the American Civil War, the surgery before antisepsis, the surgery before effective analgesics and sedatives. As the demons of surgery, particularly pain and infection, were all dominated, the discipline became better accepted by patients and professionals alike. Control of pain represented the welcoming turn to gentleness. Surgery, by the late 1880s, had fewer significant drawbacks; surgeons could perform the operative procedure at a leisurely pace and the surgery of safety, proposed by William Halsted a few years later, was conducive to treating both tissue and patient gently.2,7,9,10 The surgical world now needed a plan for maintaining the best surgical techniques for all patients undergoing new and/or traditional procedures. Morbidity was required to be in check and mortality could not increase when assessing new procedures. Technology could not replace gentleness; on the contrary, both needed to work together for the good of the patient and the surgeon as well.

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Surgery Becomes the Positive Force Sought by Patients and Doctors Alike

18

Better results postsurgery equated to a positive force related to patient believability and satisfaction. Bad results were oriented to distrust and patient dissatisfaction. Still, in late 19th century America, the constant truth was that results varied widely. Results after surgery frequently could not be predicted, except for minor undertakings. Major procedures remained under the spell of a great number of variables, such as the surgeon’s ability, the patient’s general condition, the patient’s tolerance of anesthesia and the use of antiseptic and/or aseptic procedures. When surgeons utilized the well-accepted principles of asepsis, which had previously been practiced and perfected in the late 1870s and early 1880s, the surgical outcome appeared as a positive force for patients and doctors alike. Society began to expect demonstrated consistency and improved clinical findings. This response appeared more frequently as the first third of the 20th century came to an end. Surgeons, patients and society received good surgical news, promoting a positive attitude and promoting a positive future.

Surgery Reached Medicine and Surpassed its Roots in the Ability to Cure and Remove Maladies from All

The basis for improved surgical outcomes resulted from the consistent use of surgical research. The continuous investigation of important surgical problems opened the door for advancing the surgical sciences. Surgery ascended to medicine as a discipline, surpassing its roots in the ability to cure and remove maladies because of its dedication and improved attention to solving problems through surgical research. From the latter part of the 19th century and especially at the beginning of the 20th century, a great number of medical developments were carried out by surgeons committed to surgical research.2-5,9 Advances in surgery were forthcoming as a powerful response to investigations occurring in the surgical laboratories of noted academic institutions. Discoveries pertaining to better surgical practices, new and improved surgical techniques, the best anesthetic methods, enhanced monitoring of patients intra- and post-operatively and better means for mitigating pain were only a few of the areas investigated. Entering the 1950s, immediately after World War II, American surgeons proceeded with intense research, which allowed them to become more knowledgeable and productive in newly advancing surgical specialties. It was evident and well-accepted by then that kidney

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transplantation and other organ transplants, open heart surgery, surgical nutrition and effective management of trauma and shock originated from the laboratories of dedicated surgical researchers. Years before, at the Hunterian Laboratories at Johns Hopkins, upcoming and noted neurosurgeons of the likes of Cushing and later on Dandy, effectively used these facilities to aid in the development of their specialty.9 Here was evidence once more of the great impact of surgical research on the practice and evolution of surgery.9 In 1970, when I had the great fortune of attending the surgical program of the University of Minnesota in Minneapolis, I personally realized the importance of animal laboratory research in surgery. In 1972, when I moved for more than 2 years to the superb laboratory of the distinguished academician and professor and chairman of surgery, John Najarian (b. 1925), my research ambitions and opportunities were more than fully satisfied. During those few years, I completely understood how far American surgery had traveled, how important research was for the surgical sciences and how fast surgery was progressing beyond the walls of the surgical laboratories. This unique opportunity, given to me by the Minnesota school, I have cherished all my life.

Surgery Radically Changes Patients’ Expectations and the View of the Sick

According to renowned surgical historian Ira Rutkow (b. 1947), American surgical supremacy can be traced to the period of 1946-1974.2 In this era, Americans demonstrated that science was at the core of surgical gains. The first support generally came from private funds, with later participation and engagement from public institutions. I entirely subscribe to the thesis of Rutkow, who provides an excellent explanation as to how surgery radically changed patients’ expectations and the view of the sick. At the center of the discussion was the consideration and reaffirmation of the surgeon-scientist and his/her incredible role on the supremacy of American surgery. Let the words of surgical historian Rutkow tell the story:2 It was clear in the late 1950s that surgery had arrived as a medical specialty and that the public and patients, in particular, had realized their expectations, viewing many operable conditions with a more positive and optimistic character. As we moved from the 1950s to 2007, surgery has not diminished its ability to cure; in fact, the surgical act has become safer and in some ways less demanding for patients and hospital personnel. Society appears enchanted with minimally invasive surgery and short-term hospitalization. Out-patient surgery clinics have become

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the centers of the day and are substituting for large hospital enterprises. It is fair to say that surgery has radically changed patients’ expectations and the view of the sick.

Conclusions

The social transformation of American surgery represents a long and convoluted process that required—from the 1760s until the late 1800s—improved knowledge, better means of anesthesia, antisepsis, asepsis, the availability of better analgesics and the continuous and careful use of objective observations during surgery. The incorporation of science and surgical research into American surgery permitted an elegant and effective transition from an untested discipline to one of proven facts and systematic application of the scientific method. By the early 1900s, society had begun to incorporate surgical means of treatment into the usual thinking of the American patient. The works of great American surgeon-leaders of the time paved the way for full acceptance of surgery as a scientific and mature medical discipline.

References 18

1. Starr P. The Social Transformation of American Medicine. New York: Harper Collins, 1982. 2. Rutkow IM. American Surgery: An Illustrated History. Philadelphia: Lippincott-Raven, 1998. 3. Rosenberg CE. The Care of Strangers: The Rise of the American Hospital System. Baltimore: Johns Hopkins University Press, 1987. 4. Leavit JW, Numbers RL. Sickness and Health in America. 2nd edition. Madison, Wisconsin: University of Wisconsin Press, 1985. 5. Wangensteen OH, Wangensteen SD. The Rise of Surgery: From Empiric Craft to Scientific Discipline. Minneapolis: University of Minnesota Press, 1978. 6. Talbott JH. A Biographic History of Medicine. New York: Grune & Stratton, 1970. 7. Halsted WS. Surgical Papers, Volumes I and II. Birmingham: Classics of Surgery Library, 1984. 8. Warner JH, Tighe JA. Major Problems in the History of American Medicine and Public Health. Boston: Houghton Mifflin, 2001. 9. Toledo-Pereyra LH, ed. Vignettes on Surgery, History and Humanities. Georgetown: Landes Bioscience, 2005. 10. Toledo-Pereyra LH. William Stuart Halstead: father of American modern surgery. J Invest Surg 2002; 15:59. 11. McBurney C. Experience with early operative interference in cases of disease of the vermiform appendix. New York Med J 1889; 50:676-684. 12. Toledo-Pereyra LH. Harvey Cushing: father of American neurosurgery. J Invest Surg 2002; 15:115-116.

SECTION V

Virtues of Man

CHAPTER 19

Humility Luis H. Toledo-Pereyra Humility is the virtue all preach, none practice and yet everybody is content to hear. —John Shelden (Humility, Wikipedia)

Let me begin by saying that according to Kant, Gandhi and many Western and Eastern religions, humility is a central virtue.1-3 Christian texts, particularly those of St. Thomas Aquinas, refer to humility as the center of spiritual life annexed to the prime virtue of prudence.1 Apart from being a basic religious tenet, humility is a virtue especially helpful to all human beings, to all of us. How can we specifically bring this virtue to the consideration of surgeons to aid in the betterment of patient care? Surgeons do not typically exude humility in their undertakings, either in the operating room or in their practice, probably because of the perceived necessity of demonstrating self-assurance, self-command, poise, confidence and the recognition of possessing superior knowledge in the performance of the operative act. Surgeons are not trained to be humble by design. They are trained to prize their skills and solve problems. How can we then modify this overconfident culture and still demonstrate the positive elements of the surgical persona? How can we effectively introduce humility in the surgeon’s career without eliminating qualities necessary for superior care? All these questions, though important enough, do not have a readily available answer. One thing we do know is that humility is an essential virtue to possess and nurture.1-5 We also know that humility can be taught by example as many other virtues have been taught in the past.6-11 Finally, we know that humility will bring a fuller and more accomplished professional and personal life to the practicing surgeon. To understand the value of humility, consider the following clinical scenario, though fictional, to reflect the origin and value of humility in the life of the practicing surgeon. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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Many were gathering around the main office of Chief Surgeon, Peter Hansicker. He was to report on the findings of the greatest development that one could ever expect, the transplantation of a human brain. Could that be possible? A great number of great surgeons had tried before with no success! The Chief was eager to present his findings and those of his surgical team of 25 professionals, who had connected the blood circulation to the whole brain successfully. The patient, a perfectly healthy 25-year-old adult male, had suffered multiple strokes with extensive brain damage due to associated unresectable brain tumors. The prognosis was grim, even devastating, until a unique, normal brain from a 30-year-old with an irreversibly damaged heart and severely injured abdominal organs, which did not permit his realistic survival, became available for brain organ donation. Appropriate arrangements had been made, the donor brain was successfully transplanted and the recipient had begun to show some muscle movement. Initial recognition of preliminary positive advances was at hand. As Chief Hansicker moved out into the press room to describe the latest developments regarding the case, he fully realized that this case was too premature to present to the rest of the world. The worried and conscientious surgeon turned around and returned to his office without 19 facing the attentive, eager journalists. His reasons were clearly dependent on something he believed was not ready for public consumption. There was no doubt that happiness was abundant without arrogance. Here the virtue of humility was very much in evidence. Was the surgeon right in claiming modesty? Was his attitude of humility correct? Should he actually have told the world what he had done? Should he have succumbed to the pressure of the hospital’s public relations team to claim the first case of brain transplant? Should he have waited until knowing whether or not the patient had responded to therapy and was able to walk out on his own? Should he have waited until several of these cases had made brain transplantation a reality? In answering some of these critical questions, I think the Chief Surgeon was right when he refused to face the press under the circumstances previously mentioned. I think his attitude was correct and reflected the strength of his principles. I think he was correct in applying modesty to his patient’s care and not allowing glittery lights to overshadow his view. I think he defended his presence and well-being by not succumbing to the continuous harassment of the department

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of public relations. I think it would be right to wait until the patient had responded to treatment. Finally, I think he was conservative and attempted to study the role of the physician in the support of all the personalities involved. How would you present your findings to the public in an era where lack of humility and increased visibility are the norm? A combination of common sense and modesty should be the common denominator. The first-of-anything event is not always the best moment to convey news that might be premature in nature. Time and judgment associated with humility are the best advisors under these conditions. Humility is not only reflected in the appearance of extraordinary cases, such as the one referred to here. Humility is more frequently expressed in common life events. Humility is a virtue of daily life, one that is exhibited in every aspect of the professional career. How can we teach young generations of practicing surgeons the positive trait of humility? It is not an easy task, but it can be done if examples are presented as ways to anchor and cement the good will of this important behavioral quality. If young, aspiring specialists see that the mature professional respects others, gives them their place in society and presents his/her findings in a realistic and unpretentious way, these actions will carry enormous support to engender humility as part of their daily work. Let’s approach life in this manner and expect 19 a positive and highly human return from all involved.

References

1. Humility. Humility—Wikipedia, the free encyclopedia. (Accessed February 26, 2007. Available at http://en.wikipedia.org/wiki/Humility). 2. Lewis JJ. Humility Quotes. Humility Quotes, Humility Quotations, Humility Sayings, Wisdom Quotes. (Accessed February 26, 2007. Available at http://www.wisdomquotes.com/cat_humility.html). 3. Humility. (Accessed February 26, 2007. Available at http://www.twopaths. com/humility.htm). 4. Murray A. Humility. (Accessed February 26, 2007. Available at http:// www.worldinvisible.com/library/murray/5f00.0565/5f00.0565.c.htm). 5. Ribeiro BF. Claude Organ, Jr. MD. Arch Surgery 2005; 140:1047-1048. (Accessed February 26, 2007. Available at http://archsurg.ama-assn.org/ cgi/reprint/140/11/1047.pdf ). 6. Toledo-Pereyra LH. Respect. J Invest Surg 2005; 18:281-284. 7. Toledo-Pereyra LH. Loyalty. J Invest Surg 2006; 19:275-277. 8. Toledo-Pereyra LH. Gratitude. J Invest Surg 2006; 19:137-140. 9. Toledo-Pereyra LH. Compassion. J Invest Surg 2005; 18:157-160. 10. Toledo-Pereyra LH. Trust. J Invest Surg 2006; 19:69-71. 11. Toledo-Pereyra LH. Integrity. J Invest Surg 2006; 19:1-3.

CHAPTER 20

Embracing Greatness Luis H. Toledo-Pereyra Greatness is on the “Way of Being.” Embracing greatness is everything. Know your “Way of Being” and you will know your soul. There is nothing better than feeling good about yourself. And feeling good does not necessarily come from good health but from a good mind and good emotions and why not from good attitude? My intention is to demonstrate that we all have a great deal of greatness within ourselves and we should discover it and embrace it to the betterment of our well-being. How does this apply to surgeons? How can this make us better professionals? Is there any program that can enhance our own abilities by stimulating greatness in us? Let’s begin our quest.

What Is the Embracing of Greatness?

Embracing greatness, I believe, is the emotional state that permits us to accept ourselves and others at the highest esteem level possible. Recognition from our peers does not enter into the equation. Embracing greatness is special, unique and the basis for a better life. I say, then, believe in greatness, believe in yourself and be ready for a new life. It is not being great that we should necessarily strive for, but having greatness in our souls and in our values. And there is a big difference! For some people, being great is innate, but more frequently greatness is acquired and demonstrated through exemplary deeds. Embracing greatness is the desire or state of mind that recognizes and accepts personal values, as well as those of others and converts them into a superior sensitivity. In being great, usually you focus on yourself; in embracing greatness, you readily accept not only your own virtues and aptitudes but also those of others who deserve recognition.

Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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There is no substitute for practicing the embracing of greatness in your life. Yet practically speaking, how do we achieve or maintain an attitude of acceptance and optimism rather than rejection and pessimism? Not an easy task, but certainly a goal to pursue, reach and maintain. By now, I think, you have a better view of the essence and value of embracing greatness. In practice, embracing greatness means: 1. Understanding what embracing greatness is all about. 2. Believing in the virtues of the state of embracing greatness. 3. Reaching awareness of its value. 4. Accepting its presence throughout your life. 5. Maintaining a positive attitude towards its continuous practice. A fictional example illustrates how these principles might apply. Since I am a surgeon and have been writing about surgeons, I will concentrate on our profession, even though the principles could apply to any other field of human endeavor. A mature surgeon, trained at Michigan State University, possessed incredible knowledge and experience in all types of inguinal hernia repair. He was about to take a patient with bilateral hernia whom he had refused before. The patient had been referred to many outpatient centers, surgeons and important hospitals, all to no avail since no consultation had been secured. The surgeon, knowing the severity of the case, proceeded to accept 20 the suffering patient into his clinic. The challenge: a 50-year-old male patient, morbidly obese at 500 pounds, with severe liver failure and aortic insufficiency. As if that were not enough, the patient had undergone six previous unsuccessful inguinal hernia repairs, four on the left and two on the right. The chances for a curative treatment were unbelievably small under these conditions. The surgeon accepted the challenge, not because he felt he was the greatest surgeon alive, but because he knew he could help this unsatisfied patient. In a way, the caring surgeon embraced greatness in his own manner. That is because the surgical specialist was confident of finding the best treatment for his patient. He reached greatness by effectively evaluating the patient, the disease and the therapy. The opportunity for being an excellent source of treatment presented to the surgeon and his patient a special condition comparable only to embracing greatness. It is as if someone said, ‘‘Be good, believe in yourself and begin to embrace greatness, the greatness you already have in your values and in yourself. Begin helping your patient!” Inasmuch as the concerned surgeon wanted to operate on this patient, at the end of the evaluation, he recommended observation and

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no surgery at this time. It was evident that the dedicated specialist was seeking the best treatment for this complicated condition. Greatness came, then, in caring for his patient, in offering sound advice, in studying the case as if it were the last he would ever do, in providing knowledge, support and compassion for his patient. In this respect, greatness is represented at each step we ever take, professionally or personally. One could appropriately agree that “greatness is a state or condition of being above the ordinary”1 and includes “nobleness of character.”2

Why Embracing Greatness Can Make Us Better Professionals

To my knowledge, there are no prospective, randomized studies indicating that embracing greatness would make us better professionals or better human beings. Therefore, we should rely on common sense as a way to explain the positive underpinnings of embracing greatness.3,4 If the principles of embracing greatness are clear, what lasting characteristics of embracing greatness will benefit us all. I have been pondering some thoughts that perhaps might be useful in conveying why the embracing of greatness is good:

20

Embrace greatness in your life Let’s recognize it We barely do it at times! Let’s accept it It is a routine development But we do not do it every day! There is no substitute For practicing embracing of greatness in your life You need greatness at all times And you do not even know it! Do not be afraid of it! Embracing greatness should be a way of life Let’s recognize it We do not do it enough! Embrace the best of yourself Celebrate your mind and spirit Do it every day! The value of embracing greatness is unique and of enormous proportions. Surgeons who consider embracing greatness, as well as individuals who care about this principle, have an added advantage when accept-

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ing greatness in their lives or professional activities. Why? Because embracing greatness is based on understanding human beings, on caring for them with special interest and on accepting and tolerating others as we do ourselves. Greatness gives us life by providing self-respect and awareness. Several other thoughts come to mind when attending the principles and values of this unique “way of life.” Greatness should be a “Way of Life” We do it all the time! It is a routine development! Do it every day Greatness is on the “Way of Being” Embracing greatness is everything Know your “Way of Being” and You will know your soul Greatness is all You need the embracing of greatness to survive You do not even know it! Embrace greatness every day!

Is Embracing Greatness the Opposite of Humility?

I do not believe embracing greatness is the opposite of humility. On the contrary, greatness and humility can be complementary if appropriately utilized. How is that? Well, embracing greatness allows us to recognize our values and the virtues of others and to fully appreciate our and their commitment to life. This is in tune with humility, since we emphasize the accomplishments of others as much as our own. In the same way, embracing greatness permits us to evaluate, in some form, the best of human conduct. Accepting greatness and humility revitalizes the depth of our human souls and orients us towards better defining the general perspective of our careers. In sum, embracing greatness first will bring us closer to recognizing humility as an important force behind human behavior and professional attitude. As mentioned before, it is important to differentiate embracing greatness from accepting yourself as being great. These are two completely different and separate entities. Be aware of remaining humble as you embrace greatness and celebrate the acceptance of such an important behavioral attitude. Consider always the importance of celebrating greatness in your life, in your virtues and don’t be afraid to walk away from ordinary thoughts and actions!

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Conclusion

The value of celebrating or embracing greatness in our personal or professional lives should be of unique importance since it will give us a positive sense of ourselves not attained before. For a surgeon, embracing greatness brings about a worthwhile and improved state of mind because of the acceptance of essential values and traits not recognized previously. In other words, embracing greatness presents surgeons with opportunities of great significance for helping patients and themselves as well. I will add, celebrate greatness and enjoy your profession more fully! And finally, embrace greatness as you believe in yourself.

References

1. Covey SR. Everyday Greatness. Nashville: Thomas Nelson Publs, 2006. 2. Compact Oxford English Dictionary, 3rd ed. New York: Oxford University Press, 2005. 3. Toledo-Pereyra LH. Integrity. J Invest Surg 2006; 19:5-10. 4. Toledo-Pereyra LH. Respect. J Invest Surg 2005; 18:281-4.

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CHAPTER 21

Good Men Live on and Never Fade Away Luis H. Toledo-Pereyra The point is that good men and women to be exact, never fade away, they live on for years to come. I would say that good men who produce good deeds cannot just fade away, but continue to create an example, a perennial wisdom and the desire of exploring new frontiers. As I apply these statements to good men, who in reality could be good surgeons, it becomes explicitly clear that the good deeds of these professionals will never fade away. The great American general, Douglas McArthur (1880-1964), as he was saying good-bye to the American people before a joint session of Congress on April 19, 1951, finished his speech to the whole august group by using a refrain of the most popular barrack ballads of the times: “Old soldiers never die; they just fade away.”1 Paraphrasing the great quote of the admired general, I would say: “Good men live on and never fade away.” The specific area of stark contrast with the general’s comments has to do with the unique value of good deeds in our lives. Good deeds go beyond any particular profession or individuals and readily search for the best in human beings. In defense of the military star, he was using the quote intact as it pertained to a familiar war ballad of that time. So, as much as we appreciate his statement, it applies differently to our consideration of good men who are good surgeons and good human beings.

Defining Our Position

The purpose of our position is to orient our attention to excelling at developing good and long-lasting deeds in our lives. There are many ways in which deeds appear. Some might see a real deed wrapped in a scientific cover. Others might consider the opportunity to help human beings in any way possible. Another group might be represented by Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

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individuals helping others by mentoring in their field of expertise. For surgeons, the characteristic would be using the profession to enhance their ability to help others, being in the clinic, the laboratory, the operating room, or as a simple human being. Sometimes I think that being a good human being is more difficult than being a good surgeon since humanity is more varied and complex than the most complicated operation. I would advise the surgeon then, first attempt to be a good human being before you excel at being a good surgeon, or attempt to be both at the same time, or do it at any point in your life but always with fervor and dedication.

The Universe of Good Deeds That Make Good Men

There are many possibilities we can pursue in climbing the universe of good deeds. There are no ends in this endeavor. There are many examples and many sources of enlightenment. How can we secure the good path for the good deeds that are out there waiting for us? There is no clear answer for this concern, except we need to follow the advice and career of good individuals and well-meaning surgeons in our case. What specifically are the good deeds we are talking about? The Good Deeds Organization has identified the values that are worth considering in our lives, whether we are professionals or not. These values are associated with: love, kindness, generosity, honesty, respect, growth, harmony and unity.2 The difficulty in reaching the 21 ideal level for each one varies in intensity and dedication. The value of each one is different as well. I consider that certain deeds are scarcer than others and subsequently not easy to obtain. With the strong possibility of being considered biased in this regard, let me show you my perception anyway. For some time I have been pondering if love is innate or comes to you without a specific request—that is, you either have it or not. My question is: Can you develop love for a person or area you never considered particularly likeable? You can, but it will be hard to attain and sometimes unattainable. Regarding the other values of kindness, generosity, honesty, respect, growth, harmony and unity, they are completely different from love in the sense that we can acquire, in bits and pieces, all of them. Not so for love. Now, is it possible we can respect someone without ever having or currently loving that person? Yes, I think we can and very frequently we do. Respect is rarely tagged to love. Respect is associated with many other considerations, like professional excellence, ability to accomplish, erudition and many other personal qualities. I think the other deeds are self-explanatory.

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The Value of a Good Deed Is in the Good Deed Itself

The value of a good deed is good no matter what. The value of a good deed should not be diminished because the purveyor of the deed does not have the most uplifting or lofty intentions. The value of a good deed is extraordinary by itself. A good deed should be taken into consideration based in the good deed itself. Of course, it would be ideal to have a good deed responsive to good intentions or, as presented elsewhere, “genuine good deeds start with genuine good intentions.”3 For surgical professionals, the deeds could take the form of attending to the extra needs of their patients, spending more time discussing surgical outcomes, introducing acts of kindness beyond their surgical expertise, favoring attitudes of respect and generosity and why not, if necessary, charging patients less or helping them to overcome their financial crisis. Surgeons should present themselves as human beings first, with the intention to help their patients far and beyond the emotional and practical threshold.

All Good Deeds Are Important

It is so true that deeds speak for themselves. The importance, then, is not the type of deed but rather conveying and producing a good deed by itself. Good individuals, good surgeons and other professionals attempt to realize as many good deeds as possible. Whether in their career, life or civic duties, they should direct themselves to the possibilities where they might offer a better means to help others. And the help should not only 21 come with performing surgery but also with entertaining more avenues of generosity, understanding and caring for the surgical patients. Good deeds should extend to mentoring residents and students as well, since where one finds desire and willingness it would not be hard to find good and excellent professionals. Teaching those who would be taking over the helm makes perfect sense. The more we expose our young surgeons to understanding their future careers and to emphasizing their premiere qualities and values worth preserving, the more we will be doing our job in an effective manner.

Classical Examples in the Surgical Literature

Many are the surgeons who can introduce us to the world of good deeds. From American surgeons, such as Ephraim McDowell (1765-1843), who attended a lady with a massively enlarged ovarian tumor and provided to her the best attention of the time, to current surgical professionals who give daily care to their patients, we can learn the skills needed to maximize our ability to do better as calming and understanding professionals.4

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Patients have benefited from caring individuals throughout history, whether they are surgeons, nurses, or paramedical personnel. To establish a continuous avenue for embracing the soul and body of seeking patients, we need to utilize the best good deeds available. Good deeds do not necessarily produce better surgeons, but good surgeons can certainly produce good deeds. Good surgeons who produce good deeds are good men. Good men are the ideal individuals we are searching for. Surgeons of antiquity, such as Galen (129-200), surgeon to the Roman gladiators, offered good evidence of good patient care according to the principles accepted by the epoch. Galen cultivated the Roman emperors and protected their families by his healing hand and established techniques. Galen exhaustively studied anatomy and physiology, even though mainly in animals since dying humans were not available for study.5 Galen dominated the medical world in the years until the late Middle Ages and the early Renaissance, when new physicians and surgeons took over as leaders of the changed world. Under these conditions, Leonardo Da Vinci (1452-1519) and especially Andreas Vesalius (1514-1564), advanced the medical beliefs of the time when Vesalius challenged Galen’s anatomical findings. It was clear that a new and open world had begun! At the time of the American Revolution, the father of American surgery, Phillip Physick (1735-1814) and the father of American anatomy, William Shippen, Jr. both contributed a great deal to the care 21 of the American soldiers as well as the care of the American colonial patients.6 Their good deeds were represented by their kindness, generosity, respect and unity. They were excellent examples to follow. Similarly, other surgeons around them and throughout the colonies offered signs of bravery and commitment to the medical cause. In summary, good men live on and never fade away, that is, their principles and example endure. Good surgeons who are good men would be the best representatives of our history of surgery. The maxim would be, be a good man, produce good deeds as you are a good surgeon and help society and patients throughout your life.

References

1. Douglas McArthur. (Accessed April 2008. Available at www.americanrhetoric.com/speeches/douglasmacarthurfarewelladdress.htm). 2. G o o d d e e d s . ( A c c e s s e d Ap r i l 2 0 0 8 . Av a i l a b l e a t w w w. TheGoodDeedsOrganisation.com). 3. Genuine good deeds start with genuine good intentions. (Accessed April 2008. Available at www.TheGoodDeedsOrganisation.com).

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4. Ephraim McDowell. In: Toledo-Pereyra LH, ed. Reminiscences on History, Surgery and Humanities, Georgetown: Landes Bioscience, 2007:92-95. 5. Galen. In: Toledo-Pereyra LH, ed. Vignettes on History, Surgery and Humanities. Georgetown: Landes Bioscience, 2005:32-34. 6. Toledo-Pereyra LH, Toledo Zimmerer SE. Colonial American medicine. J Invest Surg 2005; 18:212.

21

ACKNOWLEDGEMENTS

FOR

FIGURES

Figure 1.1. Pe t er D r u c ker. Fr o m w w w. c g u . e d u / i n c lu d e / PeterDrucker017.jpg. Courtesy of Drucker Institute, Claremont Graduate University. Figure 2.1. Rene Descartes. From www-groups.dcs.st-and. ac.uk/~history/PictDisplay/Descartes.html. Figure 3.1. Harvey Cushing. From http://www.neurosurgery.org/ cybermuseum/index.html. Figure 4.1. Alfred Blalock. From the Alan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions. Figure 5.1. C. Walton Lillehei. From www.lww.com. Figure 5.2. Dr. Lillehei. From http://www.mbbnet.umn.edu/firsts/ historic.html. Figure 6.1. Charles Huggins. From http://nobelprize.org/nobel_prizes/medicine/laureates/1966/huggins-bio.html. Figure 7.1. Thomas Alva Edison. From Listverse.com/Edison. Figure 8.1. The Four Doctors. From http://www.hopkinsmedicine. org. Figure 9.1. A sketch by Diego Rivera. From Hamill P. Diego Rivera. New York: Harry N. Abrams, Inc.; 1999. Figure 10.1. Carlos Ruiz Zafon. From http://cache.daylife.com/ imageserve/0dPz20t30of0S/340x.jpg. Figure 11.1. Gabriel García Márquez. From http://letras-uruguay. espaciolatino.com/aaa/garcia_marquez/gabo.h1.jpg. Figure 12.1. From Hell. From http ://en.wikipedia.org/wiki/ From_Hell_(film). Figure 13.1. Something the Lord Made. From www.teachwithmovies. org. Figure 14.1. The Mayo brothers in surgery. From http://www.mayo. edu/cme/images/educational-heritage.jpg. Figure 15.1. Owen Wangensteen. From http://ww2.startribune.com/ news/variety/influential2k/10.html#SUBHED9 with permission from the Minneapolis Star Tribune. Figure 16.1. Richard Selzer. From www.aachonline.org. Figure 18.1. Civil War surgeons. From the collection of Melinda and Paul Johnson, MD. Used with permission. Innovation and Discovery on Surgery, History and Humanities, edited by Luis Horacio Toledo-Pereyra. ©2009 Landes Bioscience.

Additional Books by Luis H. Toledo-Pereyra and Published by Landes Bioscience Vignettes on Surgery, History and Humanities explores the evolution of surgery and its masters. It’s principal objective is to reach the minds and hearts of all students of surgery. This encompasses medical students interested in surgery, surgical residents learning the discipline, faculty surgeons teaching young generations of future specialists, and the practicing surgeons who are making a difference in the community. ISBN-13: 978-1-57059-657-5

Origins of the Knife: Early Encounters with the History of Surgery searchs for the early encounters with the history of surgery. It reviews the most important surgical events and analyzes the role of man, society, and medicine in the creation of the temple of surgery. The knife directs the story of surgery, as it matures from a blunt and erratic stone to a steady—but not sterile—scalpel.It explores the influences of religion and culture, as well as the creation of anatomical and physiological principles, throughout the development of surgery. ISBN-13: 978-1-57059-694-0 Reminiscences on Surgery, History and Humanities follows the same guidelines utilized for Vignettes on Surgery, History and Humanities. This book expands on the author’s desire to reach students of history in general and those interested in the history and philosophy of surgery in particular. ISBN-13: 978-1-57059-697-1

To order: please go to www.landesbioscience.com, email [email protected], or call 1-800-736-9948

Section II. Art, Literature and Cinematography

Section IV. Philosophy of Surgery Section V. Virtues of Man

It includes subjects generally not covered in other handbook series, especially many technology-driven topics that reflect the increasing influence of technology in clinical medicine.

Innovation and Discovery on Surgery, History and Humanities

Section III. Biography, History and Criticism

V ad eme c um

Section I. Innovation and Discovery

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BIOSCIENCE

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