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Mid-century invention recalled
J THORAC
CARDIOVASC SURG
1989;98:814-6
Mid-century invention recalled F. John Lewis, MD, Santa Barbara. Calif.
Because our last names start with the same letter, as medical students some years ago, Walt and I dozed next to one another on the middle benches of Todd amphitheater. On weekends we drank Select beer spiked from the same bottle of laboratory alcohol. Thus we endured common experiences arid acquired similar prejudicesthe bases of an enduring friendship. I remember Dick, his brother, as a nervous boy playing jazz piano at Walt's house just before Walt and I drove off with a friend, in the friend's new Ford coupe, to Carlisle barracks and the army, celebrating with free drinks along the way our new roles as defenders of the nation. When drunk or otherwise deluded, I can still tell stories about the war years and the years thereafter in the dog lab and on the wards, but my stories make poor history. Old men peer through foggy windows at the past. Sometimes we old men may give speeches on which, unfortunately, naive listeners may establish a faulty view of history. Napoleon said that history is a set of lies agreed on. H. L. Mencken described a historian as an unsuccessful novelist. Henry Ford laid it out in three terse words when he said: "History is bunk." Still unless their fantasies too obviously fail to match mine, I enjoy the old speech makers, who, like myself, populate these occasions. Parts of their recalled jumble, or my own, may sustain a meeting or briefly entertainso I will push ahead. For this article I have decided to stick with what little of the past on which I can really count, that is, I will stick with my fantasies. Although I can no longer remember very well, I can still imagine. So I will describe an imagined surgeon rather than a real one. Not Walt, but perhaps someone a little like him and the way we were back then. This imagined or fabulous surgeon wanted to drink more, party more, and stay up all night talking while everyone else listened; thus, he was commonplace, but deeper. He had a spark of ambition and a sense Address for reprints: F. John Lewis, MD, 505 Picacho Lane, Santa Barbara, CA 93108. 12/0/12709
814
of urgency brought on by the lost years of the War. Understandably, he did not comprehend enough to know quite where to start, except as he was told. He learned in time, however, that for some enterprises he had to start almost at the bottom, standing on the ground instead of on the shoulders of his teachers-a platform he had been promised by the old speech makers of that day. He soon understood several principles: asepsis as a barrier to germs, hemostasis as prophylaxis for hemorrhage, and discipline as a way to endure. He came across many tools, which by then were made of stainless steel with replaceable blades, and thick books (that have always handicapped our profession). In time he mastered a general therapeutic pharmacopeia that included anodynes, bowel stimulants, and purgatives, plus too few antibiotics. These techniques and principles served him. However, he ran into serious technical and ethical problems. Because of an uncertain balance at the time between possible achievement and actual need, he did not know how much anatomy he should excise. He should have been warned before he wielded his surgical blade in the swamp lands of total gastrectomy, cerebral hemispherectomy, superradical mastectomy, four-quarter amputation, and hemicorporectomy. For cases of cancer he might, in one fell swoop, have taken out everything between the duodenum and the sigmoid colon-forget the liver for the present, that will come out later. Clients for such surgical gymnastics might have been fed directly by the intravenous route or perhaps by way of the peritoneal cavity. To work out such techniques, he would have to study chemistry and physiology. So he did. Beyond its sound and enduring technical center, surgery was to acquire a scientific patina. There was much to do. However, following his submission to surgery, thus violating a prudent surgeon's general rule never to be operated on, his life changed. For awhile he became sensitive, listened to his patient's complaints, and kept them in bed so long that their deep veins plugged and their bladders became distended. He took out less vital tissue and called in psychiatric consultation and respiratory therapy. He even thought about the nature of man.
Volume 98 Number 5, Part 2 November 1989
It could have been a rum time for our surgeon. During his personal trial, he had looked over the edge of the cliff, but perhaps he had seen, in the distance, new paths on the sand. Soon he had helped train enough surgeons to perform about twice as many cholecystectomies, polypectomies, hysterectomies, hemorrhoidectomies, discectomies, viserectomies, and four-quarter amputations as were actually needed. Perhaps too he had seen that cancer was destined to someday slip away to the likes of Krebozin, Laetrile, and oncology. In mournful droves potential clients would someday look for advice to strange new practitioners rather than to their biologically natural authority, the surgeon. Brain surgery was a bust; some of its principal diseases lost out to electric shock, faith healers, humanistic psychologists, and Valium. Although the male genitalia still received respect and intense surgical attention, few cleancut, American boy-type surgeons could imagine themselvesever inserting plastic balloons in the penis anymore than they could imagine themselves deceitfully blowing up a breast with Styrofoam. Finally, relatively unexplored was the heart. Although it was not prone to cancer, a disease about which he now knew something, it sometimes started out wrong, became plugged up, or thinned out often enough to employ a great cohort of pill-dosing physicians and then, in time, a few risk-taking, East-coast surgeons. Something more might be done. With his local colleagues and acolytes, our surgeon and similar intrepid or rash bands of surgeons here and there about the country turned to the heart. You could not, at least at first, cut it out altogether, but you might, they believed, tweak it a little and still get the client off the operating room table alive-maybe in time for the evenmg news. . Of course, it was not as easy then as it sounds now. Administrators and internists controlled hospital admissions; anesthesiologists, who were almost nonexistent before the War, grabbed the breathing orifice and intravenous tube and hung on. They draped the ether screen a few notches higher than nurse-anesthetists had dared to. Pump-oxygenators appeared in the laboratories but in the hands of physiology engineering scientific types who were very careful about pushing ahead. The regular, good-old-boy surgeon we love stood restlessly around or was forced to attend conferences, seminars, and workshops. Had the "Golden Age of Surgery" passed? Of course not. Do not fret. Do not think about writing history, studying statistics, or getting a job with the Public Health Service. He kept the faith.
Mid-century invention recalled
8 15
Because of an inspired captain who navigated our surgeon's vessel, you could rock the boat, so there was a pitch and toss, but the ship had momentum and held an uneasy course. Our surgeon successfully procured what the administrators called "monies" and learned that universities are built of bricks and machines as well as ideas. Did the end he now worked for justify the means? A type of ambiguous ethics was built into his work, but the medical ethicist who was to build an edifice to these soft, plastic, philosophic bricks came much later. Do not get nervous, friend; only a creative spirit drives technique and action. He worked because he loved the work; it became a career. If it were a good career, his work would simultaneously improve his world. Focus-specialize. After all human beings are not general purpose machines. When opportunities appeared, he had a way of being in the right place with people whose motives he could understand. His purposes fit the general mood ofthe times. Those times required teams and inventive energy. No time for a Thoreau sitting alone in his $28.00 cabin grumbling eloquently in ways that would finally change the world. Our surgeon had to work with a team: nurses, cardiologists, and anesthesiologists---even the deans had to be brought along-as well as an unseen chain of shadowy figures who stretched all the way to Washington, DC, from whence came the money. And at the center, please remember and credit the patients, who finally went where they intended to go, and who, often not quite fully knowing, accepted the danger, the life risk. (I have no record of a surgeon losing his life attempting new surgery.) Editors too had to go along, and program committee chairmen, and God knows who else, all spouting off at conference and seminars. Was this really a team? It was more like a mob that sometimes, strangely, as a flock of resting gulls on the shore, faced the sun together. As spoken by Willie Lohman in "Death of a Salesman," it helped to be "well liked," to fit in. Just as it takes a penguin to hatch an egg on the Antarctic plateau, here in Minnesota maybe it took a Swede or a Norwegian to hatch a project; they fitted in, they knew how to hunker down for those long Arctic months. Our surgeon attracted students, who, discontent with the pervasive medical culture of pills, talk, physiotherapy, and doctor-patient relationships, decided to take up surgery. Acolytes began to clutter our surgeon's laboratory. He never thought of kicking them out. If he did, they might end up in pediatrics, pathology, proctology, or holistic medicine. Preventive medicine confused them,
The Journal of
8I6
Lewis
and they knew that internal medicine might encumber them with a band of obedient neurotics who really do come back for regular checkups. So he kept his students around for awhile, and many of them actually did the work. Here in this north country during the bad weather, one hangs on to an inside job, even if it is in the dog lab or on Station Twenty-one. Good things came of all this. It worked both ways with our surgeon and his students. The suckled breast swells with pride as the nipple provides milk. Over the years, our imagined surgeon became confident and felt needed. He was credited with many inventions. His enduring creative energy paid off. He
Thoracic and Cardiovascular Surgery
had many victories. People were helped. His work changed his students, his colleagues, and his profession. Some believe he has made the culminating transition from delight to wisdom. So in time his friends and former students decided to meet here, now, to celebrate his continued existence, and remember, each by way of his own fantasies, how it was back then, some years ago. Though old eyes may see the past reflected in wavy, funhouse mirrors the best of their remembered visions can push the present beyond its mundaneexpectation.
CARDIOVASC SURG
1989;98:814-6
Mid-century invention recalled F. John Lewis, MD, Santa Barbara. Calif.
Because our last names start with the same letter, as medical students some years ago, Walt and I dozed next to one another on the middle benches of Todd amphitheater. On weekends we drank Select beer spiked from the same bottle of laboratory alcohol. Thus we endured common experiences arid acquired similar prejudicesthe bases of an enduring friendship. I remember Dick, his brother, as a nervous boy playing jazz piano at Walt's house just before Walt and I drove off with a friend, in the friend's new Ford coupe, to Carlisle barracks and the army, celebrating with free drinks along the way our new roles as defenders of the nation. When drunk or otherwise deluded, I can still tell stories about the war years and the years thereafter in the dog lab and on the wards, but my stories make poor history. Old men peer through foggy windows at the past. Sometimes we old men may give speeches on which, unfortunately, naive listeners may establish a faulty view of history. Napoleon said that history is a set of lies agreed on. H. L. Mencken described a historian as an unsuccessful novelist. Henry Ford laid it out in three terse words when he said: "History is bunk." Still unless their fantasies too obviously fail to match mine, I enjoy the old speech makers, who, like myself, populate these occasions. Parts of their recalled jumble, or my own, may sustain a meeting or briefly entertainso I will push ahead. For this article I have decided to stick with what little of the past on which I can really count, that is, I will stick with my fantasies. Although I can no longer remember very well, I can still imagine. So I will describe an imagined surgeon rather than a real one. Not Walt, but perhaps someone a little like him and the way we were back then. This imagined or fabulous surgeon wanted to drink more, party more, and stay up all night talking while everyone else listened; thus, he was commonplace, but deeper. He had a spark of ambition and a sense Address for reprints: F. John Lewis, MD, 505 Picacho Lane, Santa Barbara, CA 93108. 12/0/12709
814
of urgency brought on by the lost years of the War. Understandably, he did not comprehend enough to know quite where to start, except as he was told. He learned in time, however, that for some enterprises he had to start almost at the bottom, standing on the ground instead of on the shoulders of his teachers-a platform he had been promised by the old speech makers of that day. He soon understood several principles: asepsis as a barrier to germs, hemostasis as prophylaxis for hemorrhage, and discipline as a way to endure. He came across many tools, which by then were made of stainless steel with replaceable blades, and thick books (that have always handicapped our profession). In time he mastered a general therapeutic pharmacopeia that included anodynes, bowel stimulants, and purgatives, plus too few antibiotics. These techniques and principles served him. However, he ran into serious technical and ethical problems. Because of an uncertain balance at the time between possible achievement and actual need, he did not know how much anatomy he should excise. He should have been warned before he wielded his surgical blade in the swamp lands of total gastrectomy, cerebral hemispherectomy, superradical mastectomy, four-quarter amputation, and hemicorporectomy. For cases of cancer he might, in one fell swoop, have taken out everything between the duodenum and the sigmoid colon-forget the liver for the present, that will come out later. Clients for such surgical gymnastics might have been fed directly by the intravenous route or perhaps by way of the peritoneal cavity. To work out such techniques, he would have to study chemistry and physiology. So he did. Beyond its sound and enduring technical center, surgery was to acquire a scientific patina. There was much to do. However, following his submission to surgery, thus violating a prudent surgeon's general rule never to be operated on, his life changed. For awhile he became sensitive, listened to his patient's complaints, and kept them in bed so long that their deep veins plugged and their bladders became distended. He took out less vital tissue and called in psychiatric consultation and respiratory therapy. He even thought about the nature of man.
Volume 98 Number 5, Part 2 November 1989
It could have been a rum time for our surgeon. During his personal trial, he had looked over the edge of the cliff, but perhaps he had seen, in the distance, new paths on the sand. Soon he had helped train enough surgeons to perform about twice as many cholecystectomies, polypectomies, hysterectomies, hemorrhoidectomies, discectomies, viserectomies, and four-quarter amputations as were actually needed. Perhaps too he had seen that cancer was destined to someday slip away to the likes of Krebozin, Laetrile, and oncology. In mournful droves potential clients would someday look for advice to strange new practitioners rather than to their biologically natural authority, the surgeon. Brain surgery was a bust; some of its principal diseases lost out to electric shock, faith healers, humanistic psychologists, and Valium. Although the male genitalia still received respect and intense surgical attention, few cleancut, American boy-type surgeons could imagine themselvesever inserting plastic balloons in the penis anymore than they could imagine themselves deceitfully blowing up a breast with Styrofoam. Finally, relatively unexplored was the heart. Although it was not prone to cancer, a disease about which he now knew something, it sometimes started out wrong, became plugged up, or thinned out often enough to employ a great cohort of pill-dosing physicians and then, in time, a few risk-taking, East-coast surgeons. Something more might be done. With his local colleagues and acolytes, our surgeon and similar intrepid or rash bands of surgeons here and there about the country turned to the heart. You could not, at least at first, cut it out altogether, but you might, they believed, tweak it a little and still get the client off the operating room table alive-maybe in time for the evenmg news. . Of course, it was not as easy then as it sounds now. Administrators and internists controlled hospital admissions; anesthesiologists, who were almost nonexistent before the War, grabbed the breathing orifice and intravenous tube and hung on. They draped the ether screen a few notches higher than nurse-anesthetists had dared to. Pump-oxygenators appeared in the laboratories but in the hands of physiology engineering scientific types who were very careful about pushing ahead. The regular, good-old-boy surgeon we love stood restlessly around or was forced to attend conferences, seminars, and workshops. Had the "Golden Age of Surgery" passed? Of course not. Do not fret. Do not think about writing history, studying statistics, or getting a job with the Public Health Service. He kept the faith.
Mid-century invention recalled
8 15
Because of an inspired captain who navigated our surgeon's vessel, you could rock the boat, so there was a pitch and toss, but the ship had momentum and held an uneasy course. Our surgeon successfully procured what the administrators called "monies" and learned that universities are built of bricks and machines as well as ideas. Did the end he now worked for justify the means? A type of ambiguous ethics was built into his work, but the medical ethicist who was to build an edifice to these soft, plastic, philosophic bricks came much later. Do not get nervous, friend; only a creative spirit drives technique and action. He worked because he loved the work; it became a career. If it were a good career, his work would simultaneously improve his world. Focus-specialize. After all human beings are not general purpose machines. When opportunities appeared, he had a way of being in the right place with people whose motives he could understand. His purposes fit the general mood ofthe times. Those times required teams and inventive energy. No time for a Thoreau sitting alone in his $28.00 cabin grumbling eloquently in ways that would finally change the world. Our surgeon had to work with a team: nurses, cardiologists, and anesthesiologists---even the deans had to be brought along-as well as an unseen chain of shadowy figures who stretched all the way to Washington, DC, from whence came the money. And at the center, please remember and credit the patients, who finally went where they intended to go, and who, often not quite fully knowing, accepted the danger, the life risk. (I have no record of a surgeon losing his life attempting new surgery.) Editors too had to go along, and program committee chairmen, and God knows who else, all spouting off at conference and seminars. Was this really a team? It was more like a mob that sometimes, strangely, as a flock of resting gulls on the shore, faced the sun together. As spoken by Willie Lohman in "Death of a Salesman," it helped to be "well liked," to fit in. Just as it takes a penguin to hatch an egg on the Antarctic plateau, here in Minnesota maybe it took a Swede or a Norwegian to hatch a project; they fitted in, they knew how to hunker down for those long Arctic months. Our surgeon attracted students, who, discontent with the pervasive medical culture of pills, talk, physiotherapy, and doctor-patient relationships, decided to take up surgery. Acolytes began to clutter our surgeon's laboratory. He never thought of kicking them out. If he did, they might end up in pediatrics, pathology, proctology, or holistic medicine. Preventive medicine confused them,
The Journal of
8I6
Lewis
and they knew that internal medicine might encumber them with a band of obedient neurotics who really do come back for regular checkups. So he kept his students around for awhile, and many of them actually did the work. Here in this north country during the bad weather, one hangs on to an inside job, even if it is in the dog lab or on Station Twenty-one. Good things came of all this. It worked both ways with our surgeon and his students. The suckled breast swells with pride as the nipple provides milk. Over the years, our imagined surgeon became confident and felt needed. He was credited with many inventions. His enduring creative energy paid off. He
Thoracic and Cardiovascular Surgery
had many victories. People were helped. His work changed his students, his colleagues, and his profession. Some believe he has made the culminating transition from delight to wisdom. So in time his friends and former students decided to meet here, now, to celebrate his continued existence, and remember, each by way of his own fantasies, how it was back then, some years ago. Though old eyes may see the past reflected in wavy, funhouse mirrors the best of their remembered visions can push the present beyond its mundaneexpectation.