- Email: [email protected]
A Chinese thoracic surgeon and his two decisions
OUR SURGICAL HERITAGE
A Chinese Thoracic Surgeon and His Two Decisions Song Wan, MD, PhD, and Anthony P. C. Yim, MD Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
Doctor Wu Ying-Kai is known to many in the thoracic surgical academia worldwide. This article focuses on the two decisions he made at the ages of 33 and 70 that profoundly influenced the development of thoracic and cardiovascular medicine in a country with one quarter of
the world population. His successful career was gauged not so much by the position he achieved, but by the obstacles he had to overcome to achieve it. (Ann Thorac Surg 1999;67:1190 –3) © 1999 by The Society of Thoracic Surgeons
1933 to 1941: Initial Steps
case reports of Samuel Marshall from Boston [4] and Adams and Phemister from Chicago [5]. Loucks and Wu were impressed by the Adams approach and decided to carry it out in China. A male patient in his fifties with known carcinoma of the lower thoracic esophagus was soon scheduled for surgery. Unfortunately, Dr Loucks got a severe cold the day before the operation and had to stay at home. Dr Wu called him and proposed postponing the operation. Much to his surprise, the answer came: “Go on, Ying-Kai, since the patient is ready. I am sure you can do the job. I wish you all the best.” Doctor Loucks was correct. Although it lasted for more than 7 hours, the operation was uneventful. Through a left thoracotomy, Dr Wu excised an apple sized tumor and did a two layer end to side esophagogastric anastomosis below the aortic arch. The patient, Mr Feng, was discharged 3 weeks after surgery. Every team member was invited to dinner to celebrate. Doctor Wu was glad to pay the bill, which came to one third of his monthly salary. Within the following year, Wu and Loucks (Fig 1) performed 10 more cases with only 3 early deaths. It was certainly not just beginner’s luck. In August 1941, PUMC decided to send a few promising staff members, including one surgeon, to the United States for further training. Logically, the surgeon of choice was Dr Wu. The initial arrangement for him, however, was to study plastic surgery at Barnes Hospital in St. Louis, Missouri.
Doctor Wu Ying-Kai’s long surgical career started in 1933 with a major setback. He was diagnosed with tuberculosis three months into his surgical internship at Peking Union Medical College (PUMC), after having just completed his medical education at Moukden Medical College in northeast China. Streptomycin was not available then, and the young Dr Wu was sent to a sanatorium to recuperate. Under such circumstances, one may be persuaded to give up medicine, or at least choose a career less physically demanding than surgery, but Dr Wu decided to repeat his one year surgical internship after spending 9 months in the sanatorium. PUMC was established by the Rockefeller Foundation in 1917 and was designed to promote research in addition to clinical excellence. Doctor Wu was chosen to be the research fellow immediately after his internship. Only the most promising intern out of a dozen could obtain such an honor each year. He was referred to as Y.K. instead of Dr Wu, and was invited to join the afternoon tea every day with the professors. During his 1-year fellowship, Dr Wu had two articles published in English [1,2]. The first one, interestingly, happened to be related to tuberculosis. He went on to become the Chief Resident of Surgery in June 1938 and, one year later, instructor of surgery at PUMC. On April 26, 1940 (12 days before his 30th birthday), Dr Wu performed the first successful resection of cancer of the esophagus with intrathoracic esophagogastrostomy in China [3]. There were earlier attempts at esophagectomy by the former chief of surgery at PUMC, but there were no survivors. The next chief, Dr Harold H. Loucks, together with a group of investigators including oncologists, pathologists, radiologists, and ENT surgeons, continued the task. As Loucks’ assistant, Dr Wu joined this team of investigators as soon as he completed his residency. At that time, they were encouraged by isolated Address reprint requests to Dr Yim, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong; e-mail: [email protected].
© 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1943: The First Decision Doctor Wu Ying-Kai would have become a plastic surgeon if Dr Evarts A. Graham, then chairman of the Department of Surgery at Washington University in St. Louis, had not called on him during the third month after he joined the plastic surgery unit at Barnes Hospital. One day, Dr Graham showed Dr Wu a letter from Dr Loucks, saying that the chief thoracic surgeon at PUMC had just resigned and it would be better for Dr Wu to learn thoracic surgery abroad. To the young surgeon, it was like a dream come true to learn a trade he was interested 0003-4975/99/$20.00 PII S0003-4975(99)00097-1
Ann Thorac Surg 1999;67:1190 –3
HERITAGE WAN AND YIM A CHINESE THORACIC SURGEON
1191
One day I went to Dr Graham and told him about my wish to return to China soon. At first he said, “Wu, you better stay here. We are allies and fighting the same war. You can make your contribution here just as well as in China.” I said, “Thank you, Dr Graham, but I feel I should be in China while my country is at war.” Doctor Graham understood and promptly said, “Yes, that is true. I am sorry we cannot keep you longer. What can I do for you before you go?” So I asked for his advice concerning a study tour through some surgical clinics before I left the United States for home. About 1 week later, Miss Hanvey, Dr Graham’s capable secretary, gave me more than 30 letters of introduction. Armed with these letters, I visited many famous surgical clinics during the next 4 months[11]. Fig 1. Doctor Wu visited Dr Loucks’ home near Philadelphia in May 1979. (Reprinted from Wu YK. Reminiscence of personal association with American thoracic and cardiovascular surgery. Am J Surg 1980: 139: 765–70 with permission from Excerpta Medica Inc.)
in, under a world-renowned expert [6]. Doctor Wu then started to work in the chest service at Barnes Hospital. Two weeks later, two cases of carcinoma of the esophagus were presented at the weekly surgical pathology meeting. The operations, just done by Dr Graham, were believed to be among the first few in the United States. Doctor Lischer recalled the following incident: Toward the end of the conference, in a very modest and quiet manner, Dr Wu said, “I just happen to have a couple of slides.” So, he got up and discussed his own personal experience with some 10 patients. From then on, Dr Graham had the highest admiration for Dr Wu, who always went about his work in a quiet, modest way [7].
Doctor Wu was then invited to a St. Louis Surgical Society meeting to give a more detailed account of his work on esophagectomy [8]. That report was subsequently published in The Journal of Thoracic Surgery [9], of which Dr Graham was the founding editor. After 10 months of training at the chest service of Barnes Hospital, Dr Wu went on to become the chief resident of thoracic surgery at Robert Koch Hospital, a 700 bed municipal tuberculosis hospital in St. Louis, when the previous chief resident, Dr Thomas Burford, left for the war. Doctor Wu and his colleague Dr Mario Pianetto, a surgical fellow from Argentina, were soon sharing almost all the cases. This proved to be a great opportunity for them. They set a record for not having a single wound infection in 150 consecutive stages of thoracoplasty [8,10], which was an outstanding improvement compared to an infection rate of 12% only 10 months earlier [10]. In March 1943, Dr Wu decided to return to China to fight in the war against the Japanese. This was certainly not an easy decision. Many may have chosen to stay in the United States where the standard of living was much higher and research facilities far superior than in China. However, as a patriot, Dr Wu did not hesitate before returning home. This decision, in fact, had a major impact on the development of thoracic and cardiovascular surgery in China for the next 50 years.
More than 100 patients at Robert Koch Hospital presented Dr Wu with a wristwatch as a farewell souvenir (Fig 2). Doctor Wu has been wearing that watch ever since [8].
1943 to 1980: Unique Achievements in a Unique Time Doctor Wu Ying-Kai left Philadelphia in August 1943. It took him 6 weeks to arrive in India by a British ordnance ship, and another 2 weeks to catch a plane for China. Despite the poor working conditions during wartime, Dr Wu struggled and made his contribution to thoracic surgery in his own country. In 1944, soon after he became the head of the Department of Surgery at Central Hospital in Chongqing, Dr Wu performed the first ligation of
Fig 2. Wristwatch presented to Dr Wu by the patients of Robert Koch Hospital on March 23, 1943. On the back of the watch was the following inscription: “3-23-43, Y.K. Wu, from patients of Koch Hospital” (Reprinted from Wu YK. Reminiscence of personal association with American thoracic and cardiovascular surgery. Am J Surg 1980:139;765–70 with permission from Excerpta Medica Inc.)
1192
HERITAGE WAN AND YIM A CHINESE THORACIC SURGEON
Fig 3. Doctor Wu Ying-Kai at Fu Wai Hospital in 1962. (Reprinted from Wu YK. Seventy years in medicine (1927–1997): learning, practicing, and teaching. Beijing, China Science & Technology Press, 1997 (in Chinese) with permission from the China Science & Technology Press.)
patent ductus arteriosus in China [12]. In 1947, Dr Wu and colleagues performed the first successful pericardectomy in China for chronic constrictive pericarditis [13]. Doctor Wu returned to PUMC in May 1948, as an associate professor of surgery. Doctor Loucks left China two years later and Dr Wu was soon appointed Chief of Surgery. Major political and economic changes took place after the founding of the People’s Republic of China in 1949. This was followed by the Korean War and the so-called Cultural Revolution. Communications between China and the United States essentially ceased during the next two decades. In 1974, Dr Lyman Brewer III, a former fellow under Dr Graham and the 54th president of the American Association for Thoracic Surgery (AATS), invited Dr Wu to join the Association’s annual meeting. The trip was, unfortunately, not possible for Dr Wu due to political circumstances. Few who know the modern history of China would deny that the Cultural Revolution of 1966 to 1976 was a disaster for many. Dr Wu was not an exception. His clinical practice was totally stopped during this period. He was even forced to do some labor work unrelated to medicine for 4 years, despite being the founding president of the Military Thoracic Hospital and the Cardiovascular Institute of Chinese Academy of Medical Sciences. The latter institution is also known as Fu Wai Hospital, the biggest cardiovascular medical center in China where Dr Wu (Fig 3) and his associates had carried out some pioneering cardiac and thoracic projects some years earlier. Open heart surgery with the use of hypothermia and extracorporeal circulation started early in 1960 at this institution [14,15], but was almost discontinued for ten years afterwards. Despite the setback, the work initiated by Dr Wu on carcinoma of the esophagus has gained momentum. Doctor Wu once said, “The only systematic scientific research I have done is the study on carcinoma of the esophagus.” It indeed represents a long journey in his
Ann Thorac Surg 1999;67:1190 –3
professional life, step by step, since 1940. In fact, Dr Wu and his colleagues had performed close to 1,000 operations for patients with esophageal cancer between 1948 and 1958. Doctor Wu noticed that many patients came from the Taihang Mountain Range in North China. From April 1959 to August 1961, a survey of the prevalence and mortality of esophageal cancer was conducted in Beijing and four provinces of North China. Populations totalling 17 million were studied. The incidence and mortality in some regions were found to be exceptionally high. For example, in Linxian of Henan Province, a county with a population of a half million, more than 500 cases of this malignant disease were diagnosed each year and fourfifths of those patients died. This means that more than one patient died each day from esophageal cancer in that small county. Based on epidemiologic, pathologic, and clinical investigations, Dr Wu and colleagues, including Drs Huang Guo-Jun, Shao Ling-Fang, and Zhang Yu-De, proposed that the natural history of esophageal cancer consists of initial, developing, overt, and terminal phases. They concluded that emphasis should be directed to the first two phases: prevention in the initial phase and early detection/surgery in the developing phase. The first part includes the avoidance of carcinogenic substances such as nitrosamine, changing harmful habits such as eating food that is too coarse, hard, or hot, and swallowing hastily [16]. The use of a cytologic screening technique, which was developed by the pathologist Dr Shen Qiong, has been the most effective method for early detection of esophageal cancer in the high incidence region and contributed to the improved long-term survival of Stage I patients. In the hands of an experienced team in Linxian of Henan Province, headed by Dr Shao, the 5-year survival rate had reached 90% in more than 200 Stage I patients by 1977 [16,17]. The political situation in China had improved by the late 1970s. Doctor Wu was now able to accept the invitation of another president of AATS, Dr Thomas B. Ferguson, to deliver an honored lecture at the association’s Sixty-Second Annual Meeting in Phoenix, Arizona, on May 4, 1982. The topic, naturally, was the 40-year Chinese experience on surgical treatment of esophageal cancer [16].
1980: The Second Decision As the president of the Cardiovascular Institute of the Chinese Academy of Medical Sciences and Fu Wai Hospital, Dr Wu spared no effort to promote open heart surgical projects in the late 1970s, inasmuch as the development of cardiac surgery was severely baffled during the years of the Cultural Revolution. However, he was forced to retire in 1980 when he approached his 7th decade. Many might have been happy to do so having worked all their lives, but not Dr Wu. “I was not prepared,” Dr Wu recalled, “I was still full of energy and, most importantly, I wanted to make good for the loss of more than 10 years” [8]. Despite being forced to retire at Fu Wai Hospital, he decided to start all over again and found a new center of cardiovascular medicine, which would provide not only clinical services, teaching, and
Ann Thorac Surg 1999;67:1190 –3
scientific research, but also community health care and preventive care, as well as international exchange. The Beijing Heart Lung Blood Vessel Medical Center was inaugurated in September 1981 at Chao Yang Hospital. Two years later, the center moved to its current location and became the Anzhen Hospital. Aiming at high standards from the very beginning, Dr Wu organized an international symposium on cardiothoracic surgery in October 1981. Supported by the Chinese Medical Association and the Lyman A. Brewer International Surgical Society, it was the first dedicated meeting in China for exchanging knowledge on cardiothoracic surgery among more than one hundred experts from all over the world. Moreover, the meeting became a foundation of continued collaboration. Four years later, the second international symposium on cardiothoracic surgery was held at Anzhen Hospital to celebrate the publication of a 111 chapter textbook entitled “International practice in cardiothoracic surgery” [18]. Edited by Drs Wu and Richard Peters, with contributions from 157 distinguished authors in 12 countries, this book immediately became, and has remained, a classic reference for many Chinese cardiothoracic surgeons. With the importance of teamwork in mind, Dr Wu sent some of his assistants, including cardiac surgeons, anesthesiologists, intensivists, and perfusionists, for training abroad. The first open heart operation by this young team was done on December 27, 1982, and marked the launching of the cardiac program at Beijing Heart Lung Blood Vessel Medical Center. This program grew rapidly thereafter at Anzhen Hospital: 528 open heart operations were performed in 1986, and the annual pump cases has exceeded one thousand since 1994. Doctor Wu was also instrumental in developing a national cardiovascular community control program [19], which he called “my second specialty.” A collaborating study, as part of the multinational monitoring of trends and determinants in cardiovascular disease, the MONICA project of the World Health Organization (WHO) has been carried out in 16 provinces in China since 1982, with a total population over 5.5 million being monitored. The data collected from this study are of particular importance since few other Asian countries were involved in this kind of epidemiologic study. Although the trend in cardiovascular disease is increasing in this part of the world, the patterns of coronary heart disease and stroke in China are quite different from many western countries and these are probably related to the different ways of life [20]. Such a timely investigation also provided a reliable database for future internal evaluation as well as international comparison. The quality control of this project was ranked No. 1 by WHO in 1987, among 39 collaborative centers from 27 countries. A comprehensive program in the prevention of hypertension, stroke, and coronary heart disease for a population of more than 50,000 was established in 1987 in Beijing. Doctor Wu and his associates have also vigorously fought for an anti-
HERITAGE WAN AND YIM A CHINESE THORACIC SURGEON
1193
smoking campaign since 1984. “Where there is a will, there is a way” remarked the septuagenarian. A 1-week exhibition was held at the Chinese Revolution Museum in Beijing in June 1996, in honor of Dr Wu Ying-Kai’s 70-year dedication to medicine. Doctor Wu was asked, regarding his two decisions in 1943 and 1980, whether he would do it all again if given the choice. The answer was a predictable yes. Irrespective of being 34 or 70, his prime concerns in life have been for his patients and his country, and not for himself.
References 1. Wu YK, Miltner LJ. The operative treatment of tuberculosis of the knee joint. Chin Med J 1936;50:253– 8. 2. Wu YK, Miltner LJ. A procedure for stimulation of longitudinal growth of bone: an experimental study. J Bone Joint Surg 1937;19:909–21. 3. Wu YK, Loucks HH. Surgical treatment of carcinoma of the esophagus. Chin Med J 1941;60:1–33. 4. Marshall SF. Carcinoma of the esophagus. Successful resection of lower end of esophagus with reestablishment of esophageal gastric continuity. Surg Clin North Am 1938;18: 643– 8. 5. Adams WE, Phemister DB. Carcinoma of the lower thoracic esophagus. Report of a successful resection and esophagogastrostomy. J Thorac Surg 1938;7:621–32. 6. Ferguson TB. Evarts A. Graham — the man. J Thorac Cardiovasc Surg 1984;88:803–9. 7. Lischer CE. Discussion on: Wu YK, Huang KC. Chinese experience in the surgical treatment of carcinoma of the esophagus. Ann Surg 1979;190:365. 8. Wu YK. Seventy years in medicine (1927–1997): learning, practicing, and teaching. Beijing: China Science & Technology Press, 1997 (in Chinese). 9. Wu YK, Loucks HH. Resection of the esophagus for carcinoma. J Thorac Surg 1942;11:516–28. 10. Wu YK, Pianetto ME. The problem of wound infection in thoracoplasty. J Thorac Surg 1943;12:648–52. 11. Wu YK. Reminiscence of personal association with American thoracic and cardiovascular surgery. Am J Surg 1980;139: 765–70. 12. Wu YK. Ligation of patent ductus arteriosus. Chin Med J 1947;65:71– 6. 13. Wu YK, Huang KC. Surgical treatment of constrictive pericarditis. Chin Med J 1953;71:247– 86. 14. Chang TH, Wang YC, Wu YK. Open heart surgery under selective hypothermia and extracorporeal circulation. Chin Med J 1962;81:207–11. 15. Hou YL, Shang TY, Wu YK. Surgical treatment of aneurysm of thoracic aorta. Chin Med J 1964;83:740–9. 16. Wu YK, Huang GJ, Shao LF, Zhang YD, Lin XS. Progress in the study and surgical treatment of cancer of the esophagus in China, 1940 –1980. J Thorac Cardiovasc Surg 1982;84: 325–33. 17. Wu YK, Huang KC. Chinese experience in the surgical treatment of carcinoma of the esophagus. Ann Surg 1979; 190:361–5. 18. Wu YK, Peters RM, eds. International practice in cardiothoracic surgery. Beijing: Science Press, 1985. 19. Wu YK. Epidemiology and community control of hypertension, stroke and coronary heart disease in China. Chin Med J 1979;92:665–70. 20. Wu ZS, Hong ZG, Yao CH, et al. Sino-MONICA-Beijing study: report of the results between 1983–1985. Chin Med J 1987;100:611–20.
A Chinese Thoracic Surgeon and His Two Decisions Song Wan, MD, PhD, and Anthony P. C. Yim, MD Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong
Doctor Wu Ying-Kai is known to many in the thoracic surgical academia worldwide. This article focuses on the two decisions he made at the ages of 33 and 70 that profoundly influenced the development of thoracic and cardiovascular medicine in a country with one quarter of
the world population. His successful career was gauged not so much by the position he achieved, but by the obstacles he had to overcome to achieve it. (Ann Thorac Surg 1999;67:1190 –3) © 1999 by The Society of Thoracic Surgeons
1933 to 1941: Initial Steps
case reports of Samuel Marshall from Boston [4] and Adams and Phemister from Chicago [5]. Loucks and Wu were impressed by the Adams approach and decided to carry it out in China. A male patient in his fifties with known carcinoma of the lower thoracic esophagus was soon scheduled for surgery. Unfortunately, Dr Loucks got a severe cold the day before the operation and had to stay at home. Dr Wu called him and proposed postponing the operation. Much to his surprise, the answer came: “Go on, Ying-Kai, since the patient is ready. I am sure you can do the job. I wish you all the best.” Doctor Loucks was correct. Although it lasted for more than 7 hours, the operation was uneventful. Through a left thoracotomy, Dr Wu excised an apple sized tumor and did a two layer end to side esophagogastric anastomosis below the aortic arch. The patient, Mr Feng, was discharged 3 weeks after surgery. Every team member was invited to dinner to celebrate. Doctor Wu was glad to pay the bill, which came to one third of his monthly salary. Within the following year, Wu and Loucks (Fig 1) performed 10 more cases with only 3 early deaths. It was certainly not just beginner’s luck. In August 1941, PUMC decided to send a few promising staff members, including one surgeon, to the United States for further training. Logically, the surgeon of choice was Dr Wu. The initial arrangement for him, however, was to study plastic surgery at Barnes Hospital in St. Louis, Missouri.
Doctor Wu Ying-Kai’s long surgical career started in 1933 with a major setback. He was diagnosed with tuberculosis three months into his surgical internship at Peking Union Medical College (PUMC), after having just completed his medical education at Moukden Medical College in northeast China. Streptomycin was not available then, and the young Dr Wu was sent to a sanatorium to recuperate. Under such circumstances, one may be persuaded to give up medicine, or at least choose a career less physically demanding than surgery, but Dr Wu decided to repeat his one year surgical internship after spending 9 months in the sanatorium. PUMC was established by the Rockefeller Foundation in 1917 and was designed to promote research in addition to clinical excellence. Doctor Wu was chosen to be the research fellow immediately after his internship. Only the most promising intern out of a dozen could obtain such an honor each year. He was referred to as Y.K. instead of Dr Wu, and was invited to join the afternoon tea every day with the professors. During his 1-year fellowship, Dr Wu had two articles published in English [1,2]. The first one, interestingly, happened to be related to tuberculosis. He went on to become the Chief Resident of Surgery in June 1938 and, one year later, instructor of surgery at PUMC. On April 26, 1940 (12 days before his 30th birthday), Dr Wu performed the first successful resection of cancer of the esophagus with intrathoracic esophagogastrostomy in China [3]. There were earlier attempts at esophagectomy by the former chief of surgery at PUMC, but there were no survivors. The next chief, Dr Harold H. Loucks, together with a group of investigators including oncologists, pathologists, radiologists, and ENT surgeons, continued the task. As Loucks’ assistant, Dr Wu joined this team of investigators as soon as he completed his residency. At that time, they were encouraged by isolated Address reprint requests to Dr Yim, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong; e-mail: [email protected].
© 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1943: The First Decision Doctor Wu Ying-Kai would have become a plastic surgeon if Dr Evarts A. Graham, then chairman of the Department of Surgery at Washington University in St. Louis, had not called on him during the third month after he joined the plastic surgery unit at Barnes Hospital. One day, Dr Graham showed Dr Wu a letter from Dr Loucks, saying that the chief thoracic surgeon at PUMC had just resigned and it would be better for Dr Wu to learn thoracic surgery abroad. To the young surgeon, it was like a dream come true to learn a trade he was interested 0003-4975/99/$20.00 PII S0003-4975(99)00097-1
Ann Thorac Surg 1999;67:1190 –3
HERITAGE WAN AND YIM A CHINESE THORACIC SURGEON
1191
One day I went to Dr Graham and told him about my wish to return to China soon. At first he said, “Wu, you better stay here. We are allies and fighting the same war. You can make your contribution here just as well as in China.” I said, “Thank you, Dr Graham, but I feel I should be in China while my country is at war.” Doctor Graham understood and promptly said, “Yes, that is true. I am sorry we cannot keep you longer. What can I do for you before you go?” So I asked for his advice concerning a study tour through some surgical clinics before I left the United States for home. About 1 week later, Miss Hanvey, Dr Graham’s capable secretary, gave me more than 30 letters of introduction. Armed with these letters, I visited many famous surgical clinics during the next 4 months[11]. Fig 1. Doctor Wu visited Dr Loucks’ home near Philadelphia in May 1979. (Reprinted from Wu YK. Reminiscence of personal association with American thoracic and cardiovascular surgery. Am J Surg 1980: 139: 765–70 with permission from Excerpta Medica Inc.)
in, under a world-renowned expert [6]. Doctor Wu then started to work in the chest service at Barnes Hospital. Two weeks later, two cases of carcinoma of the esophagus were presented at the weekly surgical pathology meeting. The operations, just done by Dr Graham, were believed to be among the first few in the United States. Doctor Lischer recalled the following incident: Toward the end of the conference, in a very modest and quiet manner, Dr Wu said, “I just happen to have a couple of slides.” So, he got up and discussed his own personal experience with some 10 patients. From then on, Dr Graham had the highest admiration for Dr Wu, who always went about his work in a quiet, modest way [7].
Doctor Wu was then invited to a St. Louis Surgical Society meeting to give a more detailed account of his work on esophagectomy [8]. That report was subsequently published in The Journal of Thoracic Surgery [9], of which Dr Graham was the founding editor. After 10 months of training at the chest service of Barnes Hospital, Dr Wu went on to become the chief resident of thoracic surgery at Robert Koch Hospital, a 700 bed municipal tuberculosis hospital in St. Louis, when the previous chief resident, Dr Thomas Burford, left for the war. Doctor Wu and his colleague Dr Mario Pianetto, a surgical fellow from Argentina, were soon sharing almost all the cases. This proved to be a great opportunity for them. They set a record for not having a single wound infection in 150 consecutive stages of thoracoplasty [8,10], which was an outstanding improvement compared to an infection rate of 12% only 10 months earlier [10]. In March 1943, Dr Wu decided to return to China to fight in the war against the Japanese. This was certainly not an easy decision. Many may have chosen to stay in the United States where the standard of living was much higher and research facilities far superior than in China. However, as a patriot, Dr Wu did not hesitate before returning home. This decision, in fact, had a major impact on the development of thoracic and cardiovascular surgery in China for the next 50 years.
More than 100 patients at Robert Koch Hospital presented Dr Wu with a wristwatch as a farewell souvenir (Fig 2). Doctor Wu has been wearing that watch ever since [8].
1943 to 1980: Unique Achievements in a Unique Time Doctor Wu Ying-Kai left Philadelphia in August 1943. It took him 6 weeks to arrive in India by a British ordnance ship, and another 2 weeks to catch a plane for China. Despite the poor working conditions during wartime, Dr Wu struggled and made his contribution to thoracic surgery in his own country. In 1944, soon after he became the head of the Department of Surgery at Central Hospital in Chongqing, Dr Wu performed the first ligation of
Fig 2. Wristwatch presented to Dr Wu by the patients of Robert Koch Hospital on March 23, 1943. On the back of the watch was the following inscription: “3-23-43, Y.K. Wu, from patients of Koch Hospital” (Reprinted from Wu YK. Reminiscence of personal association with American thoracic and cardiovascular surgery. Am J Surg 1980:139;765–70 with permission from Excerpta Medica Inc.)
1192
HERITAGE WAN AND YIM A CHINESE THORACIC SURGEON
Fig 3. Doctor Wu Ying-Kai at Fu Wai Hospital in 1962. (Reprinted from Wu YK. Seventy years in medicine (1927–1997): learning, practicing, and teaching. Beijing, China Science & Technology Press, 1997 (in Chinese) with permission from the China Science & Technology Press.)
patent ductus arteriosus in China [12]. In 1947, Dr Wu and colleagues performed the first successful pericardectomy in China for chronic constrictive pericarditis [13]. Doctor Wu returned to PUMC in May 1948, as an associate professor of surgery. Doctor Loucks left China two years later and Dr Wu was soon appointed Chief of Surgery. Major political and economic changes took place after the founding of the People’s Republic of China in 1949. This was followed by the Korean War and the so-called Cultural Revolution. Communications between China and the United States essentially ceased during the next two decades. In 1974, Dr Lyman Brewer III, a former fellow under Dr Graham and the 54th president of the American Association for Thoracic Surgery (AATS), invited Dr Wu to join the Association’s annual meeting. The trip was, unfortunately, not possible for Dr Wu due to political circumstances. Few who know the modern history of China would deny that the Cultural Revolution of 1966 to 1976 was a disaster for many. Dr Wu was not an exception. His clinical practice was totally stopped during this period. He was even forced to do some labor work unrelated to medicine for 4 years, despite being the founding president of the Military Thoracic Hospital and the Cardiovascular Institute of Chinese Academy of Medical Sciences. The latter institution is also known as Fu Wai Hospital, the biggest cardiovascular medical center in China where Dr Wu (Fig 3) and his associates had carried out some pioneering cardiac and thoracic projects some years earlier. Open heart surgery with the use of hypothermia and extracorporeal circulation started early in 1960 at this institution [14,15], but was almost discontinued for ten years afterwards. Despite the setback, the work initiated by Dr Wu on carcinoma of the esophagus has gained momentum. Doctor Wu once said, “The only systematic scientific research I have done is the study on carcinoma of the esophagus.” It indeed represents a long journey in his
Ann Thorac Surg 1999;67:1190 –3
professional life, step by step, since 1940. In fact, Dr Wu and his colleagues had performed close to 1,000 operations for patients with esophageal cancer between 1948 and 1958. Doctor Wu noticed that many patients came from the Taihang Mountain Range in North China. From April 1959 to August 1961, a survey of the prevalence and mortality of esophageal cancer was conducted in Beijing and four provinces of North China. Populations totalling 17 million were studied. The incidence and mortality in some regions were found to be exceptionally high. For example, in Linxian of Henan Province, a county with a population of a half million, more than 500 cases of this malignant disease were diagnosed each year and fourfifths of those patients died. This means that more than one patient died each day from esophageal cancer in that small county. Based on epidemiologic, pathologic, and clinical investigations, Dr Wu and colleagues, including Drs Huang Guo-Jun, Shao Ling-Fang, and Zhang Yu-De, proposed that the natural history of esophageal cancer consists of initial, developing, overt, and terminal phases. They concluded that emphasis should be directed to the first two phases: prevention in the initial phase and early detection/surgery in the developing phase. The first part includes the avoidance of carcinogenic substances such as nitrosamine, changing harmful habits such as eating food that is too coarse, hard, or hot, and swallowing hastily [16]. The use of a cytologic screening technique, which was developed by the pathologist Dr Shen Qiong, has been the most effective method for early detection of esophageal cancer in the high incidence region and contributed to the improved long-term survival of Stage I patients. In the hands of an experienced team in Linxian of Henan Province, headed by Dr Shao, the 5-year survival rate had reached 90% in more than 200 Stage I patients by 1977 [16,17]. The political situation in China had improved by the late 1970s. Doctor Wu was now able to accept the invitation of another president of AATS, Dr Thomas B. Ferguson, to deliver an honored lecture at the association’s Sixty-Second Annual Meeting in Phoenix, Arizona, on May 4, 1982. The topic, naturally, was the 40-year Chinese experience on surgical treatment of esophageal cancer [16].
1980: The Second Decision As the president of the Cardiovascular Institute of the Chinese Academy of Medical Sciences and Fu Wai Hospital, Dr Wu spared no effort to promote open heart surgical projects in the late 1970s, inasmuch as the development of cardiac surgery was severely baffled during the years of the Cultural Revolution. However, he was forced to retire in 1980 when he approached his 7th decade. Many might have been happy to do so having worked all their lives, but not Dr Wu. “I was not prepared,” Dr Wu recalled, “I was still full of energy and, most importantly, I wanted to make good for the loss of more than 10 years” [8]. Despite being forced to retire at Fu Wai Hospital, he decided to start all over again and found a new center of cardiovascular medicine, which would provide not only clinical services, teaching, and
Ann Thorac Surg 1999;67:1190 –3
scientific research, but also community health care and preventive care, as well as international exchange. The Beijing Heart Lung Blood Vessel Medical Center was inaugurated in September 1981 at Chao Yang Hospital. Two years later, the center moved to its current location and became the Anzhen Hospital. Aiming at high standards from the very beginning, Dr Wu organized an international symposium on cardiothoracic surgery in October 1981. Supported by the Chinese Medical Association and the Lyman A. Brewer International Surgical Society, it was the first dedicated meeting in China for exchanging knowledge on cardiothoracic surgery among more than one hundred experts from all over the world. Moreover, the meeting became a foundation of continued collaboration. Four years later, the second international symposium on cardiothoracic surgery was held at Anzhen Hospital to celebrate the publication of a 111 chapter textbook entitled “International practice in cardiothoracic surgery” [18]. Edited by Drs Wu and Richard Peters, with contributions from 157 distinguished authors in 12 countries, this book immediately became, and has remained, a classic reference for many Chinese cardiothoracic surgeons. With the importance of teamwork in mind, Dr Wu sent some of his assistants, including cardiac surgeons, anesthesiologists, intensivists, and perfusionists, for training abroad. The first open heart operation by this young team was done on December 27, 1982, and marked the launching of the cardiac program at Beijing Heart Lung Blood Vessel Medical Center. This program grew rapidly thereafter at Anzhen Hospital: 528 open heart operations were performed in 1986, and the annual pump cases has exceeded one thousand since 1994. Doctor Wu was also instrumental in developing a national cardiovascular community control program [19], which he called “my second specialty.” A collaborating study, as part of the multinational monitoring of trends and determinants in cardiovascular disease, the MONICA project of the World Health Organization (WHO) has been carried out in 16 provinces in China since 1982, with a total population over 5.5 million being monitored. The data collected from this study are of particular importance since few other Asian countries were involved in this kind of epidemiologic study. Although the trend in cardiovascular disease is increasing in this part of the world, the patterns of coronary heart disease and stroke in China are quite different from many western countries and these are probably related to the different ways of life [20]. Such a timely investigation also provided a reliable database for future internal evaluation as well as international comparison. The quality control of this project was ranked No. 1 by WHO in 1987, among 39 collaborative centers from 27 countries. A comprehensive program in the prevention of hypertension, stroke, and coronary heart disease for a population of more than 50,000 was established in 1987 in Beijing. Doctor Wu and his associates have also vigorously fought for an anti-
HERITAGE WAN AND YIM A CHINESE THORACIC SURGEON
1193
smoking campaign since 1984. “Where there is a will, there is a way” remarked the septuagenarian. A 1-week exhibition was held at the Chinese Revolution Museum in Beijing in June 1996, in honor of Dr Wu Ying-Kai’s 70-year dedication to medicine. Doctor Wu was asked, regarding his two decisions in 1943 and 1980, whether he would do it all again if given the choice. The answer was a predictable yes. Irrespective of being 34 or 70, his prime concerns in life have been for his patients and his country, and not for himself.
References 1. Wu YK, Miltner LJ. The operative treatment of tuberculosis of the knee joint. Chin Med J 1936;50:253– 8. 2. Wu YK, Miltner LJ. A procedure for stimulation of longitudinal growth of bone: an experimental study. J Bone Joint Surg 1937;19:909–21. 3. Wu YK, Loucks HH. Surgical treatment of carcinoma of the esophagus. Chin Med J 1941;60:1–33. 4. Marshall SF. Carcinoma of the esophagus. Successful resection of lower end of esophagus with reestablishment of esophageal gastric continuity. Surg Clin North Am 1938;18: 643– 8. 5. Adams WE, Phemister DB. Carcinoma of the lower thoracic esophagus. Report of a successful resection and esophagogastrostomy. J Thorac Surg 1938;7:621–32. 6. Ferguson TB. Evarts A. Graham — the man. J Thorac Cardiovasc Surg 1984;88:803–9. 7. Lischer CE. Discussion on: Wu YK, Huang KC. Chinese experience in the surgical treatment of carcinoma of the esophagus. Ann Surg 1979;190:365. 8. Wu YK. Seventy years in medicine (1927–1997): learning, practicing, and teaching. Beijing: China Science & Technology Press, 1997 (in Chinese). 9. Wu YK, Loucks HH. Resection of the esophagus for carcinoma. J Thorac Surg 1942;11:516–28. 10. Wu YK, Pianetto ME. The problem of wound infection in thoracoplasty. J Thorac Surg 1943;12:648–52. 11. Wu YK. Reminiscence of personal association with American thoracic and cardiovascular surgery. Am J Surg 1980;139: 765–70. 12. Wu YK. Ligation of patent ductus arteriosus. Chin Med J 1947;65:71– 6. 13. Wu YK, Huang KC. Surgical treatment of constrictive pericarditis. Chin Med J 1953;71:247– 86. 14. Chang TH, Wang YC, Wu YK. Open heart surgery under selective hypothermia and extracorporeal circulation. Chin Med J 1962;81:207–11. 15. Hou YL, Shang TY, Wu YK. Surgical treatment of aneurysm of thoracic aorta. Chin Med J 1964;83:740–9. 16. Wu YK, Huang GJ, Shao LF, Zhang YD, Lin XS. Progress in the study and surgical treatment of cancer of the esophagus in China, 1940 –1980. J Thorac Cardiovasc Surg 1982;84: 325–33. 17. Wu YK, Huang KC. Chinese experience in the surgical treatment of carcinoma of the esophagus. Ann Surg 1979; 190:361–5. 18. Wu YK, Peters RM, eds. International practice in cardiothoracic surgery. Beijing: Science Press, 1985. 19. Wu YK. Epidemiology and community control of hypertension, stroke and coronary heart disease in China. Chin Med J 1979;92:665–70. 20. Wu ZS, Hong ZG, Yao CH, et al. Sino-MONICA-Beijing study: report of the results between 1983–1985. Chin Med J 1987;100:611–20.