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Ann Thorac Surg 2006;82:1567-1569
© 2006 The Society of Thoracic Surgeons
Mayo College of Medicine, Jacksonville, Florida
* Address correspondence to Dr Odell, Mayo Clinic Section of Cardiothoracic Surgery, 4500 San Pablo Rd, Jacksonville, FL 32224 (Email: odell.john{at}mayo.edu).
On September 9, 2005, Andrew Logan, a pioneer in cardiothoracic surgery and an honorary fellow of the American Association for Thoracic Surgeons, died at the age of 98 years. Hereafter follows a description of my exposure to this fine man who will be missed by me and by others who knew him.Figure 1
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Those who were training could not have chosen a better place to train and to later work. We worked out of two hospitals [1, 2]. At Wentworth hospital there were approximately 100 cardiothoracic beds of which half were for cardiac surgical patients; King George V hospital (our other hospital) was a 1,700 bed tuberculosis hospital where more chronic infected patients were lodged. Here there were 110 thoracic surgical beds including a 30-bed ward for chronic empyema patients and a 30-bed male ward for the 20 new patients with carcinoma of the esophagus who were admitted weekly. We were all extremely busy. Two bronchogram lists of as many as 5 to 8 patients each were done at each hospital and were reviewed at our weekly Saturday morning roentgenogram meeting. Tuberculosis, bronchiectasis, pleuropulmonary amebiasis, the ravages of rheumatic fever, and the Belsen-like images of patients with esophageal cancer were what we saw and dealt with every day. Initially we functioned as surgeons and pulmonologists, as there were no such local specialists. Ward rounds took place daily at 4:00 PM when the work done was reviewed. If patient activities were complete, then one joined Le Roux and Logan for tea beforehand. They would often discuss current and previous patients, names of patients, and their details, even recalling details from 15 years beforehand in Edinburgh. Le Roux was an unbelievable administrator. How else would such a unit have run so efficiently? He culled the interesting roentgenograms, and he dictated the letters and summaries, which would never be more than two sentences long. A typical example follows: Mr X, with an indeterminate nodule, found at uneventful lobectomy to be a carcinoma is returned to your care.
A brief picture of the clinical environment with the spectrum of patients has been painted, but the overwhelming personal influence was Logan, who was in his late sixties when I first met him. He was a tall, somewhat aloof man, bald on top with some gray hair surrounding the baldness. He was extremely well qualified and had a master's degree and fellowships in surgery and internal medicine.
He had seen thoracic surgery develop and in fact had been part of its growth. He initially trained in Newcastle where George Grey-Turner (blunt esophagectomy fame [3]) and George Mason were colleagues. Mason had also been influenced by O'Shaughnessy, one of Sauerbruch's trainees, and Mason was regarded by Logan as the best surgeon he had worked alongside. O'Shaughnessy unfortunately was killed at Dunkirk during the evacuation. Mason, a fellow registrar suggested that Logan join him in doing a pulmonary resection on a dog. Anesthesia was introduced by ether, administered through an apparatus modeled on Sauerbruch's Uberdruk system, and lobes were sequentially removed. This was his introduction to thoracic surgery. His role, at the first bronchoscopy he assisted, was to hold the patients head and place his thumb protected by a thimble between the teeth. The operation for removal of a foreign body took all day; unfortunately the adolescent being operated on had died with extensive surgical emphysema. He knew Sauerbruch, Crafoord, Nissen, and Dubost, and he regularly traveled in Europe to watch them operate.
Logan assisted Mason in 1934 (a year after Evarts Graham) with the first pneumonectomy in Britain, on a 15-year-old boy with bronchiectasis. Mackewn's pneumonectomy in 1893, regarded by some as the first, was essentially the scooping out of necrotic lung. Logan's description of the operation follows in his own words: "When the lung had been mobilized to the hilum a rubber catheter was wound tightly around the hilum and tied in that position, the procedure advocated by Sauerbruch. The lung was surrounded by gauze mops and the chest wall was closed. The patient, as used to be said, ‘stood the operation well' and on the following day Mason went on a skiing holiday in Switzerland, leaving me the duty of re-opening the chest and taking out the lung on the tenth day" [4]. The inevitable empyema was managed by dressing the open chest wound daily and the fistula and empyema eventually healed.
During the Second World War, Logan rose in rank to lieutenant-colonel and was in charge of a thoracic unit based in Egypt and Palestine. After the war he started a thoracic surgical unit in Edinburgh and ran it with an autocratic, dictatorial style. He describes his first 11 patients, all with chronic empyemas, and in each the bronchus was found at bronchoscopy to be obstructed by tumor. Stories about his demanding approach and acrid comments can still be heard in the Royal Infirmary of Edinburgh today. When one of his registrars who had not left the hospital for 3 months asked if he could leave a little bit early on a slack day so that he could have a haircut, he was challenged: "Are you losing interest?" When a registrar apologized for inadvertently removing a clamp from the aorta during a coarctation repair he replied, "I should be the one apologizing; I am the one who employed you." If the anesthetized patient moved during the incision he would state loudly, "Thank goodness he has a tube down his throat, otherwise we'd hear him scream." Surprisingly his demeanor was completely different in Durban where he joined Le Roux to start the unit. He accepted that Le Roux was the boss and deferred to him. He was extremely unassuming. Although eminently suitable, the world of publications and higher positions was not for him. There are, in fact, very few surgeons working in cardiothoracic surgery, who know of Logan's contributions. In review articles he tended to never cite his own work [5]. With persuasion we were able to coax Logan to tell the stories of our pioneers. I spent many enjoyable evenings with him and his wife discussing all manners of subjects, and my interest in the history of our specialty was kindled and remains.
Logan was an aggressive surgeon who knew his anatomy well. He developed the transventricular mitral valve dilator for mitral stenosis [6]. He was aware of the work of Bailey, Harken, and Brock, but was nevertheless frustrated by the current approaches to the stenotic mitral valve through the left atrial appendage. While visiting Dubost in Paris in 1954, Logan saw him dilate a stenotic mitral valve using a dilator inserted through the atrial appendage. This prompted Logan to develop a dilator that was inserted through the left ventricular apex and positioned across the stenotic valve by the index finger within the left atrium [6]. Later, watching Logan do a combined aortic and mitral valvotomy through a small incision at the apex of the left ventricle, Tubbs was prompted to add a screw, which modified the size that the dilator could be opened. Currently, older surgeons will remember the dilator by Tubb's name, rather than Logan's. Tubbs, in describing what he did to Logan's dilator commented, "Never in the field of cardiac surgery has a surgeon become so famous for so little." We used the Logan dilator frequently in Durban and regularly four or five closed mitral valvotomies were done in a morning. When asked what it was like those early days he stated, "Experience was built on a pile of corpses." He did the first lung transplant in Britain (ie, the fifth worldwide) in 1968 for a patient with paraquat poisoning [7].
Logan is also known for his aggressive operation for esophageal cancer. To a lesser degree, Skinner and DeMeester advocated his principles. Logan's operation entailed a left thoracolaparotomy with en-bloc excision of the esophagus, the adjacent pleura, diaphragmatic hiatus, the spleen, and the distal pancreas. The aortic sheath was opened to the celiac artery, and all tissue surrounding the left gastric artery was removed. Watching an expert do such an operation was a delight as all the anatomical features were rapidly exposed. The procedure in his hands only took a few hours. For an obvious reason, this massive operation has few proponents today.
With time Logan did less and less surgery, but became more and more involved with assisting, visiting outpatients, and teaching. Much of our teaching involved the interpretation of chest roentgenograms. Le Roux, his protégé and later boss, wrote two books on chest roentgenograms. Both Logan (who had studied Latin, philosophy, and French at St Andrews) and Le Roux (whose father was professor of classics at the University of Cape Town) loved the English language and correct usage was necessary. A resident who used "consolidation" instead of "opacification" when describing a radiographic abnormality never used that word again. An operation was done, not performed (ie, "only clowns perform!"). Logan finally retired in 1986 for the second time at 80 years of age. At the time of his second retirement in Durban he was persuaded to describe the beginnings of thoracic surgery. This he did in an amusing style, which covered his personal exposure to thoracic surgery [4]. He concluded with a disapproving paragraph of the fragmentation of thoracic surgery into cardiac surgery and general thoracic surgery. He returned to Edinburgh and kept active intellectually and obtained a degree in Italian. I visited him whenever I was in the United Kingdom, and we would have a meal at his favorite Italian restaurant where all knew and loved him. Sadly with time he became blind and this tall imposing figure was noticeably shorter due to vertebral collapse, yet his keen intellect remained.
His memories and contributions remain fondly in the mind of all those who came in contact with him.
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