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Ann Thorac Surg 2000;70:1746-1752
© 2000 The Society of Thoracic Surgeons
a Department of Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada
Address reprint requests to Dr MacLean, Royal Victoria Hospital, Room S-8:45, 687 Pine Ave W, Montreal, PQ H3A 1A1, Canada
e-mail: lloydm{at}citenet.net
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Abstract |
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 Top Abstract IntroductionEdward ArchibaldNorman BethuneCommentReferences |
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Introduction |
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TopAbstractIntroductionEdward ArchibaldNorman BethuneCommentReferences |
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Edward Archibald |
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TopAbstractIntroductionEdward ArchibaldNorman BethuneCommentReferences |
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Archibald took his surgical training at RVH in Montreal and with Professor Johannes Von Mikulicz in Breslau. He returned to a staff position in Surgical Pathology at RVH in 1901, but developed pulmonary tuberculosis and was hospitalized at the Trudeau Sanatorium. In a cured and stable state, he was appointed Assistant Surgeon at RVH in 1904. He was the third surgeon on the staff and was in charge of the ward service, ie, all admitted patients without means to pay, the vast majority of hospitalized patients at the time. The two senior surgeons had first call on the operating room for their private patients.
Surgical research
In 1929, the year Archibald (Fig 1) became Surgeon-in-Chief, a Department of Experimental Surgery was established with the financial support of the Rockefeller Foundation. The goal was to introduce an atmosphere of scientific inquiry into the teaching hospital and a spirit of cooperation between basic scientists and clinicians.
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Studies on shock
Archibald spent 18 months in France during World War I, 4 months of which were in a casualty clearing station close to the front lines. During the summer and fall of 1915, he and one other surgeon cared for 3,500 combat casualties with a lower death rate than any other frontline facility in the district [2]. He recognized shock in combat casualties who presented with a weak pulse, rapid shallow breathing, pallor or cyanosis, carelessness of manner, clear but lethargic thought processes, low temperature, and low blood pressure. Of the 17 patients with a blood pressure less than 75 mm Hg whom he described at the 1917 meeting of the American Surgical Association (ASA), only 3 rallied with treatment and all 3 later died of infection [3]. Intravenous saline and blood helped, but operations did not. He used and recognized the value of hypertonic saline at that early date. He emphasized the difference between hemorrhage only and shock due to trauma. The former responded to transfusions and saline, but traumatic shock did not, and he thought that this was due to capillary trapping. The classic experiments of Brooks and Blalock [4] 20 years later supported his early observations.
Thoracoplasty in America
The surgical treatment of tuberculosis was the central endeavor of Archibald’s life. He was present (1909) when P. L. Friedrich [5] of Marburg, Germany, presented for the first time in North America, a report of radical thoracoplasty. Friedrich removed ribs one or two through ten. Sauerbruch, a student of Friedrich, developed a two-stage operation to decrease the risk. Archibald [6] adopted this technique with removal of varying lengths of rib and wrote a landmark paper summarizing his experience in 172 patients, which was presented to the Clinical Congress of the American College of Surgeons in 1929. In this state-of-the art lecture, he defined favorable cases as those patients with unilateral disease who were systemically well but with positive sputum. Thoracoplasty achieved an impressive cure rate (66%), ie, conversion to negative sputum with observation over 1 year after operation and with a low mortality. Doubtful cases showed progression in the recent past, intermittent systemic signs (markedly positive sputum), and enlarging cavities but with recent stabilization. These patients responded with a much lower cure rate (38%) but acceptable mortality (4.2%). The unfavorable cases exhibited definite progressive disease, extensive cavitation, and bilateral involvement. No one was cured in this group and the mortality rate was 26%. Archibald, at the time Bethune joined him in 1929 at RVH, had firm, evidence-based concepts concerning which patients should be treated by thoracoplasty.
Although selection of patients was of primary importance, Archibald also had firm ideas on technique. He favored general anesthesia, nitrous oxide, and oxygen with supplemental local. He supported a two- or three-stage operation starting with the lower ribs. He removed a greater length of each rib than Sauerbruch to achieve a more complete collapse and higher cure rate. He emphasized the use of apicolysis to more effectively collapse the upper lobe and frequently used vascularized flaps of pectoralis major and minor muscles to fill the extrapleural space. He was among the first (1912) to perform thoracoplasty in North America and his lifelong interest in the procedure contributed to its establishment as a treatment that was lifesaving for many and freed many more from a sanatorium existence.
Pulmonary resection
Archibald [7] did the first successful pneumonectomy using individual ligation of the hilar vessels and bronchus on July 7, 1933 (Fig 2). The patient was a 31-year-old man with a sarcoma of the left upper lobe and was the fourth patient to undergo a successful pneumonectomy. Two weeks later, William Reinhoff, Jr, of Baltimore performed the first of two successful pneumonectomies, also using hilar dissection and individual ligation of vessels and bronchus [8].
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Widespread use of resectional surgical procedures followed rapidly and training programs were developed to meet the need for surgeons expert in this new field.
Higher standards in training
Archibald, by 1935, when he was President of the ASA, was convinced that the advancement of surgery depended upon a group of master surgeons, a "corps d’élite." He deplored the foolhardy adventurer whose self-confidence was uncontrolled by knowledge. Others agreed and said that the crying need was for more surgeons and fewer operators [10]. He wanted a recognition of expertise, a higher degree in surgery to advance the specialty. He thought Fellowship in the Royal College of Surgeons (FRCS) of England, Edinburgh, and Ireland neglected to assess the candidate’s operative experience and competence.
The American College of Surgeons had made an important contribution to continuing education of surgeons and emphasized the candidate’s moral and ethical standing in the community, which Archibald ranked highly but did not consider to be a measure of training. He found the German system not strict enough and the French system too exclusive.
Archibald favored an apprentice system in which a candidate would train under a master surgeon, demonstrate a sound knowledge of the basic sciences, and by instruction and thorough examination become, in turn, a master surgeon. He concluded his presidential address to the ASA, "Higher Degrees in the Profession of Surgery," with the following: "We must continually strive for our posterity, as well as for ourselves, towards higher standards in that profession, which is at once our anxiety, our pride and I trust, sometimes, our glory" [11].
At that time, only 15 of 59 medical schools in the United States offered training programs of at least 5 years duration. Nine schools offered advanced degrees in surgery. Members of the ASA at the time agreed that "the great mass of surgery is being done by men who have been inadequately trained." They also agreed that comprehensively trained (5 to 8 years) surgeons should be placed in the community to elevate standards. Those qualified surgeons should be identified by a special certification and by an independent board. The American Board of Surgery was formed in 1937 with enormous benefits to patients over the subsequent decades of phenomenal expansion of surgery.
Archibald the man
Archibald was a kind and considerate master surgeon. He prepared his presentations and manuscripts with meticulous care. He stressed each logical point with eloquence and cogent philosophy. He reported his failures as well as his successes and had the ability to ask the pertinent questions in research. In 1929, at the age of 56 years, Archibald was appointed Surgeon-in-Chief of RVH to the delight of everyone. Even though quite deaf, and clearly absentminded, he was extremely effective. One student, Rocke Robertson, later Chairman of Surgery at McGill University, recalled that Archibald would arrive for a 9 AM lecture at least 20 minutes late. He would spend the next 20 minutes discussing the news of the day, but would end up giving the students some real pearls in the last few minutes before rushing off to another 9 AM appointment. The head nurse in the operating room recalled that more than once Archibald would show up at 10 AM for a 9 AM operation but a day late. His anesthetist, Dr William Howell, once sent a nurse to Archibald’s office with the inquiry, "Is this patient posted for surgical operation or anesthesia only?" The same Howell wrote a poem about Archibald which exalted his many accomplishments but ended with the line, "Oh, Edward, you would be sublime, if only you could be on time." I (L.D.M.) gave mementos of Archibald which I had found in my office, including the gown he wore when he received an honorary degree from the University of Paris, to the archives of the hospital. An elderly pediatrician who had known Archibald asked me if I had ever found his watch.
Despite these shortcomings, or maybe because of them, Archibald was able to focus his thoughts and ignore distractions, allowing him to make contributions of lasting value. He published a popular monograph on neurosurgical care for patients in 1908 [12] and was instrumental in recruiting Wilder Penfield to Montreal. He was the father of surgical research in Canada. He formed a successful thoracic surgery training program. He published widely on many unrelated topics, meeting the needs of the day. He made a fundamental contribution to training and certification of surgeons and he fostered a truly academic atmosphere that crossed departmental barriers. He did it all without fanfare and without ever raising his voice, but, compared with Norman Bethune, he remains an unsung hero.
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Norman Bethune |
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TopAbstractIntroductionEdward ArchibaldNorman BethuneCommentReferences |
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From early boyhood, Henry Norman Bethune expected to become a great surgeon and wanted to be called Norman, after his great grandfather, who was a physician and surgeon and a founding member and early dean of the medical faculty of Trinity College in Toronto. He interrupted his medical school training twice, the first time to become a laborer-instructor of lumber jacks in a remote camp in Northern Ontario and the second time to serve in World War I as a stretcher bearer. He was wounded and returned to medical school. After graduation, he served as a medical officer in the Royal Canadian Navy.
Bethune’s surgical training was at West London and Great Ormond Street Hospitals. He obtained an FRCS of Edinburgh and spent a short time at the Mayo Clinic before entering practice in Detroit in 1924. This was not a good period for Bethune. His wife left him in 1925 and in 1926 he entered the Trudeau Sanitorium with moderately advanced tuberculosis.
During his stay at Saranac Lake, Bethune initiated the beginning of a huge volume of writing and art. His most important art of the period was a multipaneled mural entitled the TB’s Progress. Drawn in color, the 5-ft-high and 60-ft-wide continuous panel covered the walls of his cottage. Below each of the nine drawings was a poem that described the drawing. The ninth drawing depicted the angel of death holding Bethune in her arms. The following is the poem for this drawing [13]:
Sweet death, thou kindest angel of them all.
In thy soft arms, at last O let me fall;
Bright stars are out, long gone the burning sun
My little act is over and the tiresome play is done.
Making little progress by October 1927, Bethune insisted that artificial pneumothorax be performed. Progress was spectacular and by December 1927 he was sputum negative and able to leave the hospital. Of his four companions in their cottage, two died in the 1930s as predicted in the final mural. Two others, Alfred Blalock and John Barnwell, went on to distinguished careers in surgery and pulmonary medicine. Blalock also underwent artificial pneumothorax at a later date.
Bethune, who experienced wide swings in mood throughout his life, passed from a deep state of depression expressed in his murals to a state of euphoria and conviction that he should devote his life to salvage those afflicted with tuberculosis. His crusade was against tuberculosis but also the social conditions that caused it.
Bethune wrote to Archibald for a training post and it was suggested that he spend a preliminary period with Dr David T. Smith, later Head of Bacteriology at Duke University, at Ray Brook. Doctor Smith said later that Bethune learned more about bacteriology in 3 months than most graduate students learned in 3 years. Bethune was with Archibald first as a trainee and then as a colleague from 1928 to 1932.
Enthusiastic informed teacher
Wendell MacLeod [15], a medical intern from 1930 to 1932, recalled how Bethune, a dashing figure, would arrive on the medical wards at RVH and insist on a wider search to unveil the cause of a pulmonary abnormality. Bethune had a warm and considerate manner. He sat on patients’ beds and frankly discussed the odds for improvement with or without surgical procedure. He spoke to relatives and took personal interest in the welfare of patients. He was informal, outgoing, dynamic, and cheerful. In the words of MacLeod [15], "a breath of fresh air." He was a gifted teacher using the small group approach based on a specific patient. He was interested and listened to what the students found on examination and thought before he expressed himself unequivocally. He enjoyed ridiculing standard practice. His energetic pursuit of new approaches was especially refreshing to young trainees who had endured what they considered to be excessively formal instruction. A case in point was the successful use of maggots to heal chronic empyema resistant to standard drainage procedures [16].
Archibald supported Bethune but regarded his surgical technique as "quick but rough, not careful, far from neat and just a little dangerous." When Dr G. E. Mignon, Chief of Surgery of Sacré Coeur Hospital in Montreal, asked Archibald to help him find a qualified thoracic surgeon, Archibald recommended Bethune. Bethune eagerly accepted, but it took 1 year to convince the Archbishop that a Protestant anglophone should be appointed to a senior post in their Roman Catholic francophone hospital. The sisters of the hospital also had reservations, having heard he led "une vie de bohème."
By the time of his appointment at Sacré Coeur, Bethune was well known among the thoracic surgeons of Canada and the United States. He performed 300 operations during the year after his appointment, many on advanced bilateral cases of tuberculosis. His frank presentations at meetings of the American Association for Thoracic Surgery were well received by the younger surgeons, but his manuscript on "Twenty-Five Errors I Have Made in Thoracic Surgery" was never published. Around this time Bethune invented or devised replacements for many of the instruments he used. The most enduring are his pneumothorax apparatus and rib shears. The table-mounted scapula retractor (the iron intern) was a forerunner of automatic table retractors now used widely in abdominal and thoracic surgical procedures.
Social consciousness
As Larry Hannant [13] has stated, Bethune’s life was a journey from apolitical exuberance to political intensity. The change occurred abruptly during the period from 1935 to 1936. He was then 45 years of age, twice divorced from Frances Campbell Penny, restless, and seeking new challenges. He felt strongly that if poverty could be eliminated, then tuberculosis would disappear. This was the depths of the depression in Canada and after a trip to Russia to attend a physiological congress he reported to a distinguished medical-surgical society in Montreal that "Russia presents today the most exciting spectacle of the evolutionary emergent and heroic spirit of man" [17]. Bethune joined the Communist Party in Montreal in November 1935.
His thoughts on health care were well before their time. He recognized that good care depended on a team effort, which demanded cooperation among physicians, surgeons, nurses, and others. He thought protection of the people’s health was the prime responsibility of the state and formed a group, "For the Security of the People’s Health," to study possible options for Quebec. He thought the current system was unjust, inefficient, wasteful, and completely outdated. He wanted health security for the people and economic security for the profession. This struck the profession at the time as dangerously close to socialized medicine. He responded that 25 years ago it would have been thought contemptible to be called a socialist. Today, he said, it is ridiculous not to be one. He enjoyed speaking on this subject and was to lay audiences an especially popular, engaging, lively, well-informed performer.
Bethune was an accomplished artist (Fig 3). He organized an art school for children in his home in Montreal which attracted the participation of many distinguished local artists. He wrote plays, poetry, short stories, and was an avid correspondent all his life.
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Bethune arrived back in Montreal in June 1937 after an absence of 8 months to a triumphant welcome. One thousand met him at Windsor Station in Montreal and 8,000, a capacity audience, heard him speak that night without notes on the bravery of the Spanish people, the failure of the international community to assist them, and the likelihood of an antifascist world war. He continued his crusade across Canada to small gatherings in hamlets or to record crowds in major cities. By the end of the tour in September 1937, the opening salvo of the second Sino-Japanese War had just occurred. Bethune decided to continue the battle against fascism in China.
Bethune in China
As in Spain, Bethune upon arrival in China got a quick fix on his destination. He would not serve the Nationalist Party but wished to join the forces opposing fascism, the Eighth Route Army under Mao Tse-Tung in Northern China. Again his troupe was small; in addition to himself there was only Jean Ewen, daughter of a prominent Canadian communist and a registered nurse who had practised in a Shantung Hospital for 2 years and spoke Chinese. They flew from Hong Kong to Hankou, the temporary capital of China, and met Chou En Lai, later premier of China. From there to the Eighth Army headquarters was a distance of 800 miles through enemy-held territory. They arrived in Yan’an 5 weeks later having treated combat casualties on the way and narrowly escaped capture. After midnight on their day of arrival, a messenger arrived and announced that Mao Tse-Tung wished to meet them. Mao had heard of Bethune’s experience in Spain and was eager to learn to what extent he could duplicate his effort in China.
During his 19 months in China, Bethune taught the Chinese skills and gave them hope. He performed near miracles by taking peasant boys and young workers and making doctors and nurses out of them. He treated patients individually but instituted public health measures that transformed the lives of everyone. He won the admiration of the Chinese by accepting their customs, sleeping in their homes, donating his own blood to their wounded, and suffering hardships equally with them.
Bethune had found his mission in life. For the first time he believed he was working together with the people in a united effort. With feverish devotion Bethune started a medical school (The Barefoot Doctors), wrote a basic medical text with emphasis on treating the trauma of warfare, operated around the clock for long stretches, and created a model hospital but emphasized treatment close to the front lines. He devised a model operating unit consisting of Bethune, two Chinese doctors, an interpreter who he had trained as an anesthetist, a cook, and two orderlies. Their equipment included a collapsible operating table designed by Bethune, surgical instruments, antiseptics, 25 wooden splints, sterile gauze, and medicine, all carried on three mules. He became commander of all Chinese Communist medical forces, part of an army of 200,000 with 25,000 wounded in 1,000 battles during Bethune’s tenure. Near the end he was 49 years of age and looked 65 (Fig 5). Bethune died from streptococcal septicemia after operating on a combat casualty with an infected head wound. His team carried his body for 4 days along icy mountain paths to a place of relative safety. On January 5, 1940, 10,000 people silently shuffled by the frail gaunt corpse. Among Chinese only the name Mao Tse-Tung was more familiar than Pai-Ch’iu-En (White One Sent).
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Comment |
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TopAbstractIntroductionEdward ArchibaldNorman BethuneCommentReferences |
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References |
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TopAbstractIntroductionEdward ArchibaldNorman BethuneCommentReferences |
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