Master Surgeon Research Articles

John C. Goligher Memorial Lectureship. Traditions, trials, and treatises.

I t is indeed a special privilege to have been asked to present this lectureship in honor of a master surgeon, an insightful and prolific author, an indefatigable investigator, and a treasured fr iend--John Cedric Goligher (Fig. 1). I thought that as the first in what I hope will become a traditional lectureship at this meeting I would speak of the man himself. This was an easy decision for me to adopt, actually, because without any false modesty I do not have the temerity to stand at this podium and to speak in his name about my work or the work of our department. I am still haunted by the recollection of mypalpable intimidation at succeeding him to the lectern at a meeting. With his enormous personal experience, his clarity of thinking and expression, and his ability to convey authority without conceit, one was left with the realization that his successor would be anticlimactic and redundant. When John Goligher rose it was not merelyan opportunityfor him to explain, to clarify, or to express himself. His speech was musical, spoken with the measured grace of a Bach dtude. He understood the critical import of the use and abuse of the English language, He knew well the consequences of Sir Francis Bacon's aphorism, The Ill and Unfit Choice of Words Wonderfully Obstructs the Understanding. How can one adequately present the individual who has inarguably been described as the preeminent clinical investigative surgeon in the world? I will try. John Goligher was born in Londonderry, Northern Ireland, March 13, 1912, and educated there at Foyle College. He entered the University of Edinburgh Med-

The history of neurological surgery at Northwestern University.

The residency program in neurological surgery at Northwestern University was founded in 1924 by Loyal Davis and was formally accredited by the American Board of Neurological Surgery in 1946. Allen Kanavel, mentor to Davis, was one of the original members of the Society of Neurological Surgeons. Five individuals have served as chief of neurosurgery at Northwestern: Davis, Paul Bucy, Anthony Raimondi, Albert Butler, and H. Hunt Batjer. Davis was the first surgeon west of the Appalachians to limit his work to neurosurgery. Between 1954 and 1963, there were two independent neurosurgery residency programs at Northwestern, one headed by Davis and the other by Bucy. A master surgeon and superb teacher, Bucy trained more than 65 residents and became one of the greatest authors and leaders in the field of neurosurgery. Neurosurgical training at Northwestern has traditionally emphasized excellence of patient care, strong resident and student teaching, and basic science research. Through the years, a major strength of the program has been its clinical volume and diversity. Four hospitals have played major roles in the program: Northwestern Memorial Hospital (created by the merger of Chicago Wesley Memorial Hospital and Passavant Memorial Hospital), Children's Memorial Hospital, Evanston Hospital, and the Veterans Administration Lakeside Hospital. This article traces the development of neurological surgery at Northwestern, with an emphasis on its historical background and the contributions of Kanavel, Davis, and Bucy. The present philosophy and structure of the training program and the program's future under the direction of Batier are also described.

Landmarks in the development of coronary artery bypass surgery.

For you to find the truth, in the first place, you have to believe in the truth with all your heart and with all your soul, and believing in the truth with all your heart and with all your soul means saying what you think is true wherever and whenever, but, most especially, at the least opportune moment. (…) Whenever wisdom is found in a scientific work, there cannot be the slightest doubt it is passion’s doing, a painful passion much deeper and dearer than simple curiosity. Miguel de Unamuno Since my training as a resident in general surgery at the University Hospital in La Plata, I have been attracted by thoracic surgery. As soon as I graduated, I started traveling every Wednesday 44 miles to the Rawson Hospital in Buenos Aires, where the Finochietto brothers had organized a postgraduate program, mainly to learn lung and esophageal resections. As a resident, I lived in the hospital, where I witnessed the early attempts in thoracic surgery. In 1949, Professor Clarence Crafoord was invited by the head professor, Jose Maria Mainetti, to give lectures and operate on patients in our institution. I was extremely lucky to participate as his second assistant. Crafoord was indeed a master surgeon. I still remember today my happiness at being so close to one of the most important pioneers in thoracic and cardiovascular surgery. I was also impressed by his anesthesiologist. With a small machine (he brought his own equipment) and high doses of curare, the operation went smoothly, and certainly we learned enormously. In those days, I thought only about my work and an academic career that I had started earlier as a student assistant professor in anatomy. I was convinced that my future would be connected exclusively to the university, because I realized that teaching …

Conservative subtraction-addition rhinoplasty

The deviated external nose remains a difficult technical challenge to even the most masterful rhinoplastic surgeon. The classic septorhinoplasty approach to the deviated nose demonstrated a 9.8% revision rate in this study. During a 2-year period, the conservative subtraction-addition rhinoplasty procedure was developed, which subsequently reduced the revision rate to 1.3%. Conservative subtraction-addition rhinoplasty foregoes aggressive septal surgery and equalizes and enhances the airway through asymmetric turbinate volume reduction. Minimal bony and upper lateral work through rasping, soft tissue removal, and/or cartilage grafting allows for external nasal alignment. Both internal and external conservative subtraction-addition rhinoplasty components thus maintain perioperative structural stability and ensure long-term nasal symmetry. (Otolaryngol Head Neck Surg 1997;117:330-7.)

Some notable American spine surgeons of the 19th century.

In the 19th century, American physicians were drawn to the renowned medical centers of Europe, beacons of excellence in all areas of clinical science, to complement and supplement medical education and training. Such Old World master surgeons as Victor Horsley and William Macewen constantly reported novel and innovative operative procedures, including a significant number of operations on the spine and spinal cord. In this same era, a number of American surgeons made important contributions to the emerging specialty of spine surgery. The lives and work of Alban Smith, Berthold Hadra, DeForest Willard, and Robert Abbe are submitted in this report as examples.

A Miracle and a Privilege: Recounting a Half Century of Surgical Advance, and: A Tale of Two Citadels: Memoirs of a Surgeon and His Times (review)

Reviewed by: A Miracle and a Privilege: Recounting a Half Century of Surgical Advance, and: A Tale of Two Citadels: Memoirs of a Surgeon and His Times C. Rollins Hanlon Francis D. Moore. A Miracle and a Privilege: Recounting a Half Century of Surgical Advance. Washington, D.C.: National Academy Press, 1995. xii + 450 pp. Ill. $29.95. Kenneth C. McKeown. A Tale of Two Citadels: Memoirs of a Surgeon and His Times. Edinburgh: Pentland Press, 1994. xiv + 276 pp. Ill. £17.50. These two surgical autobiographies provide contrasts more arresting than their similarities. Each deals with a half century of experience in surgery, one from the viewpoint of an American academician, the other from that of a senior consultant surgeon at a district general hospital in England. McKeown chronicles a distinguished operative surgical career, from his origins in Belfast through medical school at the local Queen’s University and clinical education in London. In the metropolis he saw at first hand the workings of a consultative system that gave priority to the patients of Harley Street physicians, as criticized by Cronin in his classic book, The Citadel (1937). McKeown grants a certain validity to Cronin’s picture of medical practice as an edifice for the protection of professional privilege, but he looks much more scornfully at the new Citadel of the evolving National Health Services (NHS). In his view the bureaucracy of state control has placed market forces ahead of traditional medical ethics. He fears that harsh criticism, as pictured in Cronin’s book, might well bring down on a practitioner today such personal reprisals as the termination of short-term contracts in the new Citadel of the NHS. Preceding McKeown’s own introduction are three “appreciations” by colleagues in Great Britain and Canada. They attest to his status as a master surgeon—especially in esophageal resection, which McKeown brought to a level [End Page 182] of technical excellence that matched or surpassed the results achieved in any of Britain’s academic teaching hospitals. His achievement grew out of more than forty years of developing his team concept of surgery, leading to a reputation that attracted patients and surgical observers from around the world. In later years he received many honors, traveling widely to demonstrate his methods. Predictably, he proudly lists the greatest attainment of the National Health Service as the establishment of centers of excellence other than the provincial university teaching hospitals. His own Consultant Surgical Service in Darlington was obviously a vast improvement over the hospital surgical services previously provided there only by general practitioners. McKeown’s extensive surgical travels provide interesting vignettes of experiences around the world. In the United States a short visit left him impressed with the country’s “youthful or perhaps immature outlook” (p. 187) and engendered a frank disbelief in the mortality figures for esophagectomy by a “very well known American surgeon.” Reticence to mention names did not extend to the Chicago professor who cut short McKeown’s lecture to accommodate the overall program, and who is properly dressed down for this lèse-majestè. Better editing of this fascinating, narrowly focused account of global surgical experiences, listing well-merited recognition of McKeown’s many achievements, might have elided these sour animadversions on his American professional cousins. In sharp contrast to McKeown’s story is the broad-ranging, gracefully written account by Francis D. Moore, Moseley Professor of Surgery Emeritus at Harvard and former chief of surgery at what was then “the Brigham” Hospital. Starting with an admittedly “privileged childhood” on Chicago’s North Shore, and working through anthropology, philosophy, and chemistry at Harvard College, Moore’s intellectual and artistic capabilities were expanded by studies in musical composition and by foreign travel. Research that began in medical school progressed rapidly from a single case report through more extended work on thyrotoxicosis and vagotomy for duodenal ulcer. But it was his fellowship of the National Research Council that provided the stimulus, the skills, and an entry to isotope research that would soon make him a world leader in the study of body composition and the metabolic response to injury. Active in clinical practice but increasingly seen as professorial timber because of his research...

The library of Thomas Kincaid, a seventeenth-century Scottish surgeon.

In 1709 the library of the Incorporation of Surgeons of Edinburgh (now The Royal College of Surgeons of Edinburgh) received a donation of approximately 230 books. They had belonged to Thomas Kincaid, a master surgeon who lived and worked in Edinburgh in the second half of the seventeenth century. Little is known about Kincaid; however, he was not unimportant in both burgh and Incorporation affairs in the 1640s and 1650s. Reconstructing the collection to allow us to peer along Kincaid’s bookshelves, therefore, will shed some light on this otherwise obscure surgeon.

Report of the 1992–93 Sterling Bunnell Traveling Fellow

I feel especially honored and grateful to have been chosen as the 1992-1993 Sterling Bunnell Traveling Fellow. In the space available, it is impossible to fully convey all my experiences and mention every individual who was so kind to me during my travels. I am deeply grateful to all those who through guidance, advice, and hospitality enabled me to travel to Asia and Europe to study many aspects of hand surgery and be exposed to a wealth of knowledge and the expertise of many master hand surgeons while studying and evaluating a variety of health care delivery systems. Over approximately 3 months I visited 23 hand centers in 17 cities. My travels began in March 1993 in Sapporo, Japan. Here my hosts, Professors Toshiko Ogino, Seiichi Ishii, at the Sappora Medical College Hospital and Michio Minami at the Hokkaido Orthopaedic Memorial Hospital provided me with an excellent introduction to Japanese hand surgery at their institutions respectively. Professors Ryogo Nakamura and Takayuki Miura demonstrated their techniques of three-dimensional computed tomography imaging for carpal reconstruction and management of Kienbrck 's disease during my visit in Nagoya. In Niigata, Professor Tatsuya Tajima shared with me many of his accomplishments and techniques for reconstruction of congenital hand deformities and trauma and for brachial plexus repair at the Niigata Hand Surgery Foundation. I must pay a special trib-

Surgical Scripts: Master Surgeons Think Aloud About 43 Common Surgical Problems

Problem solving and problem correction or amelioration are what a surgeon does. This book is about how a surgeon thinks when presented with a specific problem. Learning has a nonmeasurable end point and is a continuum throughout the surgeon's active life and experience. Commencing with medical school and progressing through residency and other postgraduate training, the surgeon acquires a tremendous mass of information. Judgment, however, demands not only textbook knowledge but repeated exposure to similar situations with memory of what did and did not work. As pointed out in this book, "efficient knowledge aggregation is developed through repeated experience" and "this fact makes organization of knowledge pragmatic." The authors' intention is to demonstrate how experienced clinical surgeons use pattern recognition in decision making, supplemented by comments from a trained cognitive psychologist on the surgeons' expressed thoughts. The material is presented using 43 surgical scripts encompassing a wide variety of problems

The Remarkable Surgical Practice of John Benjamin Murphy

Members of the staff of Mercy Hospital and Medical Center, Chicago, Ill, have collaborated to publish a summary of the life and work of J. B. Murphy, 1857-1916, the legendary master surgeon and teacher. His writings and operations were so prodigious in number and extent that the editors, R. L. Schmitz, MD, professor emeritus, University of Illinois, and T. T. Oh, chief librarian, Mercy Hospital, wisely have chosen to summarize Murphy's accomplishments in a series of chapters devoted to general surgery, gynecology, neurosurgery, orthopedics, thoracic surgery, urology, vascular surgery, and infectious disease. In addition, there are brief accounts of his life and the Chicago setting in which he flourished. Perhaps only a skilled librarian could collect and record Murphy's enormous output of written material, which is clearly and comprehensively presented at the end of this volume. The reader gains an immediate feeling for the spellbinding performances of Murphy as he

The death of Henry II of France.

On June 30, 1559, King Henry II of France (1519-1559), against the advice of his court ministers, participated in a fateful joust. The wooden lance of his younger opponent pierced the King's headgear, shattered into fragments, and penetrated his right orbit and temple. The King survived for 11 days following the mortal wound and was treated by two of the most distinguished physicians of the Renaissance: Ambroise Paré (1510-1590), the master surgeon, and Andreas Vesalius (1514-1564), the great anatomist. The unfortunate event, the nature of the injury, and the medical consultation between these eminent physicians should all be of interest to neurosurgeons. The historical consequences of this event are briefly reviewed.

Bertram M. Bernheim: A southern vascular surgeon

Bertram M. Bernheim: A southern vascular surgeon

Entre Ancien Régime et Révolution : les chirurgiens vus par eux-mêmes (1790-1791)

Jean-Pierre Goubert : Between the old regime and the Revolution, how surgeons saw themselves. At the end of 1790 the French sanitary committee launched an investigation into the practice of surgery, the hundred or so replies to which are the source of this article. An analysis of these replies shows how master surgeons, a relatively heterogeneous profession, saw the question of their autonomy at a crucial time which was favourable to far-reaching reforms. A small minority of them called for reforms but the great majority simply rejected a number of long-standing obvious "abuses" and wished to improve the standard of training and enhance the profession's status. These replies provided the sanitary committee with material for debate, and arguments for the champions of "change".

The Surgical Residency

When the job description no longer fits the job, it is time to reexamine the task and its purpose. The residency in surgery is a good example. The description, as presented in the booklet of information of the American Board of Surgery (ABS), no longer fits the job. The job, of course, is training general for the future, surgeons who can provide proficient care for patients with vascular disease, endocrine problems, cancer, and diseases of the alimentary tract and yet can be experts in transplantation, the management of trauma, and critical care. It is a big order. There may still be a few master surgeons who can do it all, but for most of us the times of the compleat surgeon are gone. General surgery has become too complex, and all indications are that this complexity and sophistication will continue to increase. This expansion of surgery

Les saisonniers de l'écriture. Régents de villages en Languedoc au XVIIIe siècle

« L'école paroissiale, au XVIIIe siècle, est l'une des manifestations les plus vivantes des communautés d'habitants ». Ainsi débutait dans les Annales ESC, il y a quinze ans déjà, un article pionnier sur « Les petites écoles en Languedoc au XVIIIe siècle ». Tranchant avec les innombrables monographies suscitées par la querelle scolaire des premières années de la Troisième République et rompant pour le Languedoc un silence brisé depuis peu ailleurs, son auteur participait à î'éclosion d'une série de travaux dont la bibliographie ne cesse de s'enrichir. L'utilisation simultanée de documents fiscaux, de visites pastorales, de correspondances et de délibérations lui a permis de dresser une carte de l'implantation scolaire et d'en analyser les conditions de manière suggestive pour l'ensemble de la province. Est ainsi soulignée l'importance du lien entre l'école et l'orthodoxie dans le Languedoc protestant où les écoles sont les plus nombreuses. Mais la demande d'école va bien au-delà des seules exigences de la Contre-Réforme. Sa présence semble témoigner partout d'un même « humanisme » villageois.

Chiron Speaks: What Was the Genesis of the Fellowship for Advanced Training in Head and Neck Oncology?

During the mid-1950s, it became apparent to the leaders in otolaryngology that training beyond the standard three-to four-year residency was necessary to keep abreast of the rapid surgical advances taking place in the treatment of head and neck neoplasms. This was particularly true in the treatment of laryngeal cancer. Heretofore, early cancers of the larynx had been treated by irradiation or laryngeal fissure (cordectomy). Supraglottic laryngectomy, hemilaryngectomy, and radical neck dissection in continuity with laryngectomy were just developing as possible alternatives for control and cure. Other neck and throat procedures, such as incontinuity jaw-neck excision and preservation of the facial nerve in parotid surgery, were considered extreme, technically difficult, and outside the purview of the standard otolaryngological, general surgical, or plastic surgical programs. Hence, several preceptor arrangements with master surgeons flourished, each with its advantages. However, there were shortcomings, ie, formal university affiliation lacking, small case loads, little hands-on experience,

Richard von Volkmann 1930-1889

Volkmann was born August 17, 1830, at Leipzig, the son of a professor of anatomy and physiology at the University of Halle. With this family background, it is not surprising that he embarked on a medical career. All his life was associated with the University at which his father taught. In 1856, he was appointed deputy to the surgical clinic of Professor Blasius and, in 1867, he achieved the Chair in Surgery. After a time in military service during the Franco-Prussian War, he returned to his own hospital to confront the ravages of sepsis, having been familiar with Lister's work (Dis Colon Rectum 1982;25:173–178). He was so successful in applying the Listerian method that it was to Volkmann's unit that surgeons came from throughout the world to learn his methods. Lister's concepts were received most enthusiastically in Germany. Volkmann's primary interests were in orthopedics and in general surgery. He emphasized the importance of open drainage and widening of wounds, and made other contributions to the management of hydatid cyst of the liver, intra-abdominal abscess, ulcer disease, tuberculous arthritis, joint dislocation, and compound fractures. His improved operation for excision of the rectum (the subject for this Classics presentation) is less familiar to surgeons than that of his pupil, Kraske (Dis Colon Rectum 1984;27:499–503). His name is recognized primarily because of his description of the esoteric entity of the pathophysiology of ischemic muscle contracture. Volkmann was a striking figure, with long “dundreary” whiskers. He was truly aristocratic in appearance. Besides being a master surgeon with an enormous private practice, he was a superb orator. He could lecture fluently in several languages, including Latin. He was also well-recognized and extremely popular throughout Germany as a published writer of poems and fairy tales for children. A visitor to the clinic that he designed commented in 1879 that the most striking feature was the terrazzo paving, constructed in such a manner as to permit efficient drainage. This was extremely important, since flushing the wounds with carbolic solution from gardening pots was always employed during the procedure. Sepsis was so pervasive a problem that it was routine to perform three or four excisions of the hip joint in children each week. Wolkman died of pneumonia on November 28, 1889, while accompanying a patient for a consultation to Jena, in what is now East Germany.

Dandy of Johns Hopkins

Early 20th-century neurosurgery in the eastern United States was high-lighted by the Boston and Baltimore schools of Harvey Cushing and Walter Both Midwesterners came to the Johns Hopkins Medical Center—first Cushing and then Dandy, who became one of Cushing's residents. The conflicts between these strong-willed master surgeons are explored in this biography by William Lloyd Fox. He has tried to fill what he considers to be a gap in American medical history. He has used personal interviews with the Dandy family and with scores of doctors and laymen who knew Walter Dandy well. His correspondents include Cushing's biographer, John F. Fulton; Fox has had access to Dandy's personal and professional correspondence and has obviously read much of Dandy's prolific output (160 papers and five books). The biography as such is straightforward and largely chronological and follows a brief introductory chapter entitled Neurological Surgery Before Walter E. Dandy. The reader

The Biliary Tract

For a decade, the formerly tidy, logical world of the biliary tract surgeon has been in intellectual turmoil, as efforts are made to digest and appropriately utilize revolutionary diagnostic and nonoperative therapeutic techniques. This book—the fifth in a series entitled Clinical Surgery International—is designed to give the practicing surgeon a good data base for evaluating new technology and learning how well-known clinical surgeons apply these techniques. The series editor could not have selected a better editor, for Professor Blumgart of the Postgraduate School in Hammersmith, London, is a master biliary tract surgeon, a scholar, and the epitome of an internationalist. The 17 chapters come from seven countries. Blumgart is far too canny (he once practiced in Scotland) to try to resolve the differences of his contributors and come up with a single answer in this evolving field. The value of the book lies in its tight editorship. The authors consistently

Jacques Lisfranc 1790-1847

Jacques Lisfranc was born in Saint-Paul-Jarrest (Loire), France, April 2nd, 1790, the son of a physician. Early in his youth he demonstrated a particular interest and aptitude for the field of medicine as he observed and commented upon his father's ministrations to his patients. He accomplished his preliminary studies at the Lyceum in Lyons and then went to Paris to continue his medical training at the Hôtel-Dieu. It was there that he came under the tutelage of Dupuytren. It was soon said that Lisfranc was at least as worthy as his superior. Later the two men developed a certain animosity toward each other which became manifest rather severely in the medical political arenas of the time. Lisfranc received his doctorate of medicine in 1812 at a time that France was involved in the Napoleonic wars. He was commissioned as a surgeon and distinguished himself in campaigns in Saxony and in France. Following the war he established his practice in Paris. Fortuitously, one day Lisfranc rescued a magistrate who fell from his horse. By this serendipitous meeting Lisfranc was invited to join the faculty of medicine at the Hospital of Pity. He rose rapidly to chief of surgery and developed the reputation of being extremely competent, truly a master surgeon. For over 20 years he was affiliated with that institution and wrote numerous articles on such diverse subjects as shoulder disarticulation, the application of the stethoscope in the diagnosis of fractures, and on diseases of the uterus. In addition, he wrote two books which were well received—one on Surgery at the Hospital of Pity and the other on Operative Medicine. This Classics presentation has been selected because it has been generally attributed that Lisfranc was the first person to remove a cancerous tumor from the rectum. The technique involves essentially a transanal approach. As was the custom of the day, the report appears as narrated presumably by one of his assistants. Among the many distinctions Lisfranc achieved, he was founding member and ultimately President of the French Academy of Medicine and Chevalier of the Legion of Honor. Lisfranc developed an enormous clinical practice, and in spite of many physical infirmities he persisted in his surgery until the day of his death, May 12, 1847, at the age of 57.