“Paroperative” Pantheon

HISTORY

“Paroperative” Pantheon Seymour I Schwartz, MD, FACS Surgery is a profession that demands constant intellectual and technical updating on the part of its practitioners. The activities of preparation and performance require focused attention for extended periods. Time and energy are constantly being consumed. Leisure is a relatively infrequent luxury. Given these constraints, special recognition is in order for a unique quartet of surgeons, who contributed to the profession of surgery in an extraordinary and monumental fashion and also added to the arts, be it music or literature, in an equivalently meaningful manner. The four selected individuals, who achieved distinction in surgery and also in a totally disparate field, merit not only consideration but also admiration. For those of us mere mortal members of the surgical profession who worship heroes, they constitute a roster for reverence, a pantheon to which the devised adjective “paroperative” is attached. “Paroperative,” referring to “par” meaning “equal” and “opera” meaning “work” in different unrelated arenas, can be added to the surgical lexicon, preoperative, perioperative, and postoperative, as we describe these four men who should be held in awe.

CHRISTIAN ALBERT THEODOR BILLROTH “It is one of the superficialities of our time to see in science and in art two opposites . . . Imagination is the mother of both.” 1 The statement refutes the concept that science and art are poles apart, and suggests that performance in one does not preclude successful activity in the other. A prime example of a significant physician/scientist, who also excelled in the art of music, is Alexsandr Borodin. The notable Russian composer of Prince Igor and the Polyvetsian Dances was the same man, who as professor of biochemistry at the Medico-surgical Academy, defined the biochemical entity known as the aldole condensation reaction and the measurement of urinary urea. The quotation that introduced this section was written by Christian Albert Theodor Billroth (Fig. 1), the first member of the Paroperative Pantheon to be considered.

Figure 1. Christian Albert Theodor Billroth.

This statement pertains to his own accomplishments because he was the western world’s greatest surgeon of the second half of the 19th century and, at the same time, an accomplished musician, a musical critic, and musicologist of note. Music was the first field to attract the attention of Billroth, who was born on April 26, 1829 in Bergen on the largest German island of Rügen in the Baltic Sea. The city of his birth honored him by naming a street Billrothstrasse in 1896. He gained his basic education at Griefswald’s Gymnasium, an institution that had been founded on that island in 1456. At the gymnasium, he was a below average student and required tutoring, in part due to his preoccupation with music. He would have preferred to pursue a career in music, but his mother (his father had died when Billroth was 5 years old) insisted that he study medicine.

Disclosure Information: Nothing to disclose. Received March 29, 2011; Revised May 13, 2011; Accepted May 13, 2011. From the Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY. Correspondence address: Seymour I Schwartz, MD, FACS, Department of Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642. email: seymour_schwartz@urmc. rochester.edu

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This selection was enforced by a paternal grandfather physician and also, an uncle/godfather physician. Billroth enrolled as a medical student at the University of Griefswald in 1848, and in the spring semester, he followed the school’s professor of surgery, Wilhelm Baum, to Göttingen, where Billroth transformed from an indifferent and marginal student, to one who was energetic, consumed, and highly regarded by the faculty. Music, however, continued to be an integral part of young Billroth’s life, and the level of his capability was evidenced by his selection, in 1850, as piano accompanist for Jenny Lind, “The Swedish Nightingale,” when she performed in Göttingen.2 While at the University of Göttingen, Billroth formed a life-long friendship with the anatomist/histologist Georg Meissner, whose name is attached to “sensory corpuscles” in the skin and neurologic structures in the mesentery. Their friendship was cemented by a shared love of music. In 1851, under the direction of one of their mentors, the physiologist Rudolph Wagner, they investigated the histology of the nerve fibers of the sting ray. Later that same year, Billroth moved to the University of Berlin, where he received his doctorate in 1852. After a brief unsuccessful attempt at general practice in that city, he became 1 of 3 assistants to Professor Bernhard von Langenbeck at the surgical clinic of the University of Berlin. In the ensuing 6 years, Billroth’s indefatigable energy was manifest by the publication of an average of 6.7 papers or books per year.3 Most works focused on pathologic histology, a newly evolving science. His first monograph, published in 1855, concerned intestinal polyps.4 Subsequent monographs considered the development of blood vessels and the histology, pathology, and comparative anatomy of the spleen. The extent of his productivity allowed Billroth to vie with Rudolph Virchow for the professorship of pathologic anatomy at the University of Berlin.5 Billroth’s failure to achieve that position contributed to his decision to alter his ultimate goal and pursue a career in clinical surgery rather than pathology. His last monograph on pathology and histology appeared in 1858. His next monograph, which appeared in 1859, was an historical study of the evolution of the assessment and handling of gunshot wounds from 1500 to the time of publication.6 The review was in keeping with Billroth’s belief that “Only he who masters the art and science of the past and present is competent to promote its progress.”7 In April 1860, Billroth assumed the professorship of surgery at the University of Zurich. The 7 years spent as director of the surgical clinic and hospital in that city were extremely productive. After Karl Wunderlich of Leipzig introduced thermometry to medicine in 1868, Billroth was the first to apply the measurement to determine the body’s

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temperature response to surgical or accidental trauma.8 This formed an integral part of his papers and his book on wound infection and wound fever. In a time before the identification of bacterial causes, Billroth believed that wound fever was caused by a chemical poison formed by some living organism. While in Zurich, Billroth published the first edition of his classic surgical textbook, Die Allgemeine Chirurgische Pathologie und Chirurgie in Fünfzig Vorlesungen (All Types of Surgical Pathology and Surgery in Fifty Lectures) based on his lecture course. The text underwent 16 editions, the 9th and succeeding ones edited by Alexander Winiwarter. It was translated into all of the modern western languages and Japanese. Surprisingly, there was no mention of visceral cancer until the 10th edition appeared in 1882. Billroth also collaborated with Prague surgeon Franz Pitha in the production of Handbuch der Allgemeinen und Speciellen Chirugie during his time at Zurich. It consisted of 8,825 pages in 12 volumes and hundreds of illustrations. Billroth published 26 articles, monographs, or books during his tenure at Zurich. Many of his articles appeared in Archiv für klinische Chirurgie, the editorship of which he had shared with Ernst Gurlt since its foundation in 1860 by Bernhard von Langenbeck. While at Zurich he declined professorships at Rostock and Heidelberg, and, from 1865 to 1866, he served as Dean of the Faculty. During his time in Zurich, his musical interest continued, and it was in Zurich that Billroth first met Johannes Brahms, with whom he would develop a long-term musical association. Billroth defined music as “a mighty instrument which made humans ethical and noble, a pedagogic element of importance, a requirement of a nation’s cultural life.”9 During Billroth’s years at Zurich, he continued to play the piano, and a string quartet, in which he played violin or viola, met regularly at his home. He also wrote musical criticisms for the Neue Zürische Zeitung, using the byline “t” or “th.” Billroth assessed his own attempts at composition as being unsatisfactory and burned all of his manuscripts. In 1867, Billroth followed Franz Shuh in assuming the esteemed position of professor of surgery of the Second Surgical Clinic of the Allgemeine Krankheit in Vienna. Billroth’s selection was based on his recognition as a scientist and pedagogue. In Vienna, where he would spend the remainder of his career, he would evolve to become the leader of operative surgery throughout Europe, advancing boundaries in the removal of cancerous organs. He would gain eponymous fame in the lexicon of surgical procedures. But perhaps his greatest legacy was the development of a generation of surgical leaders who would further extend the field.

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Shortly after settling in his post, Billroth published a complete analysis of the surgical experience of his clinic in Zurich.10 This represented the first systematic application of statistical methods to clinical data concerning operative procedures and their results. Subsequently, he would continue with his publication of analysis of surgical results at his clinic in Vienna.11 After participating in the Franco-Prussian War of 1870 as a civilian volunteer and inspector-general of volunteer hospitals, Billroth returned to concentrate his activities in Vienna. He did, however, publish a monograph, coauthored by Jaromir Mundy, on the improvement of care of injured and sick patients in the field.12 His first advance in surgical technique was reported in 1872, when Billroth published the results of his experimental studies on resection of the cervical esophagus in dogs; his first successful anastomosis had been performed in 1870.13 A 6-cm segment of the esophagus was removed. The two ends were brought out through the skin and feeding was accomplished via the distal stoma. In 1877, Czerny would report the first successful excision of an annular carcinoma of the cervical esophagus.14 Billroth and Czerny would team up to perform the first successful total laryngectomy for carcinoma in 1873.15 This was preceded by a total laryngectomy for syphilis by Watson of Edinburgh in 1866. Billroth modified the procedure of removal of the tongue for extensive malignancies. Of 45 patients operated on by Billroth, 10 were apparently cured.16 Billroth’s first successful small bowel resection and anastomosis was performed in November 1878.17 Billroth’s most famous contribution to the surgical armamentarium and the one that perpetuates his name followed the theme of previous procedures in that it was directed at removal of a visceral malignancy. Also, in keeping with Billroth’s approach to the introduction of a new operation, it was preceded by statistical assessments, pathologic studies, and animal experimentation before it was applied to a human. On January 29, 1881, Billroth resected a pyloric cancer from Therese Heller and re-established continuity between the proximal stomach and the duodenum. The operation is still referred to as a Billroth I procedure. This represents the first successful gastric resection; previous attempts by Jules Péan for cancer in Paris in 1879 and Ludwig Rydygier, for peptic ulcer, in Chelmno, Poland in 1880, resulted in death. Six days after his success, Billroth described the procedure in an “open letter” to the Viennnese physician Leopold Wittelshöfer that appeared in Wiener MedizinischeWochenschrift.18 The patient died 4 months later with peritoneal and liver metastases. Billroth’s name also remains attached to the procedure of gastrectomy, in which

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the duodenum is oversewn and gastrointestinal continuity is established by a gastrojejunostomy. This so-called Billroth II procedure was first reported by Billroth’s assistant, Viktor Hacker, in 1885.19 By 1892, 45 gastric resections for cancer had been performed, with a mortality rate of 45%. There was a single 5-year survivor. From 1867 through 1892, 949 laparotomies had been carried out at Billroth’s clinic, with a 39% mortality rate.20 Another clinical interest of Billroth was cancer of the breast. He was the first to apply statistical analysis to treatment of the disorder, and in the 1889 edition of Allgemeine Pathologie und Chirurgie, he reported on the cure rate of 200 mastectomies performed at his clinic 3 or more years previously. Billroth wrote 3 books on the subject, the most complete of which, Die Krankheiten der Brustdrüsen, was published in 1880. During his early years in Vienna, Billroth continued his interest in pathology and histology. After Joseph Lister’s introduction, in 1867, of his theory and practice of antisepsis, for which Billroth maintained skepticism, Billroth conducted investigations related to germs and “wound disease.” In the process, he discovered cocci in chains and clumps, which he presented, in 1874, in a monograph, Untersuchungen über die Vegetationsformen von Coccobacteria Septica.21 Billroth regarded bacteria and organisms as carriers of disease rather than as causes of the disease themselves. In 1878, when Robert Koch published his evidence that bacteria were the etiologic agents of wound infection, he wrote Billroth, “As I started my first researches, I was totally affected by your studies about Coccobacteria septica.”22 In his monograph, Billroth reported on the inhibitory influence of the Penicillium class of fungi on bacterial growth in urine, preceding Alexander Fleming’s discovery of antibiosis.23 Billroth’s reputation as an operating surgeon, which led to visits by Samuel D Gross, William Stewart Halsted, and George Crile, was embellished by his reputation as an educator. He championed freedom in teaching and learning, and correlation between the basic and clinical sciences. His ¨ ber das Lehren und Lernen der medicinischen WissenU schaften an den Universitäten det Deutschen Nation, nebst allgemeinen Bemerkungen über Universitäten was published in 1876. Its significance is attested to by its translation into English by Abraham Flexner with an introduction by William Welch 50 years after its original publication. A measurement of a great teacher is his pedagogic progeny. No surgeon, with the possible exception of Halsted, could match Billroth’s legacy. The surgical sons of Billroth include Alexander Winiwarter, professor of surgery at

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Liege, who introduced compression therapy for lymphedema; Vincenz Czerny, professor of surgery at Freiberg and Heidelberg, who extended Billroth’s work on visceral cancers; Albert Narath, successor to Czerny as professor of surgery at Heidelberg; Carl Gusssenbauer, professor of surgery at Prague and successor to Billroth at Vienna; Anton Eiselberg, professor of surgery at Utrecht, Kömigsberg, and Vienna, who was one the first to notice tetany after thyroidectomy and produced it experimentally; Robert Gersuny, who succeeded Billroth as director of the Rudolfinerhaus, the hospital for the training of nurses that Billroth developed in 1881; Johannes Mickulicz-Radecki, professor of surgery at Krackow, Königsberg, and Breslau, who described the salivary glandular disease that bears his name and introduced the mask and cotton gloves into the operating room; Viktor Hacker, professor of surgery at Innsbuck and Graz; Anton Wölfler, professor of surgery at Graz and Prague, who introduced gastroenterostomy in 1881; and Theodor Kocher, professor of surgery at Bern, whose work on the thyroid made him the first surgeon to win the Nobel Prize for Physiology or Medicine. In 1887, Billroth declined the offer of the rectorship (presidency) of the University of Vienna. Two years later he became the editor of Wiener Klinische Wochenschrift. In 1888, Billroth was elected president of Vienna’s most prestigious medical society, Gesellschraft der ärzte, and held the position until he died. Billroth honored American medicine by accepting honorary membership in the American Surgical Association, the Philadelphia Academy of Surgery, and the St Louis Pathological Society. Billroth’s life in Vienna immediately became and continuously remained intimately intertwined with his passion for music. Johannes Brahms, who had preceded Billroth in establishing Vienna as his home, and Edward Hanslick, Austrian music critic and founder of professional music criticism, joined Billroth in a long-term friendship. Billroth’s Vienna home on Alserstrasse and his summer house in St Gilgen on the Wolfgang See was the venue for many musical sessions. Billroth would play 4-handed piano with Brahms or would be joined by Brahms, Hanslick, and a fourth to perform chamber music as a quartet in which Billroth would play violin or more frequently, viola. Many of Brahms’ pieces were played for the first time by the foursome. Brahms dedicated his first two string quartets, the C-minor and A-minor quartets, Opus 51, to Billroth. Billroth encouraged Brahms, a native German, to make Vienna his permanent home and remained a champion of Brahms’ music. Robert Schumann’s, Giuseppe Verdi’s, and Antonin Dvorak’s works were also admired by Billroth, who maintained a life-long musical antipathy toward Richard Wagner and Franz Liszt.

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Billroth and Brahms conducted a correspondence lasting more than 2 decades that was compiled by Billroth’s son-in–law, Otto Gottliieb-Billroth, who adopted his father-in-law’s name.24 The first 23 years reflected a deep and binding friendship. From 1888, there was increasing tension that was amplified when Brahms noted that Billroth had cut the autograph portion of the manuscript of Opus 51, which Brahms had dedicated to Billroth, and affixed the signature to a photograph of Brahms. The purpose of Brahms’ relatively brief letters was to communicate; Billroth’s correspondence, on the other hand, was literary and substantive. Billroth philosophized with Brahms in his letters. Billroth turned down an appointment in Berlin because of the musical satisfaction provided by Brahms and Hanslick in Vienna. In 1888 Billroth wrote a book, Wer is musikallisch? (Who is Musical?), which was published posthumously. In it, Billroth points out that some have a talent for rhythm while others better perceive melody. Edward Hanslick arranged for publication of the book 1 year after Billroth’s death because he thought it was original in that it was the first treatise on the psychology of music. Six subsequent editions attest to its popularity. Billroth’s book on the anatomy and psychophysiology of musicality emphasized that the essential element of rhythm derived from the periodicity of physiologic functions, citing the heart beat as a prime example. He also addressed tonality, relating it to organic function, and compared it to language. Billroth’s work was regarded as “an admirable attempt and largely a successful one, to blend and harmonize the esthetic aspects of music on the one hand, with the physiologic and physical aspect on the other.”25 Billroth was elected to the German parliament in 1891. He died in February 1894. His funeral drew large crowds; his body lay in state for a day, attended by thousands. Vienna assigned a grave of honor to his remains. His teaching and medical writings reflected his motto, “Wahrheit und Klarheit” (Truth and Clarity). His musical equivalence persisted throughout his life. He embodied the sentiment of a contemporary philosopher, Herbert Spencer, who wrote, “Music must take rank as the highest of the fine arts-as the one which, more than any other, ministers to human welfare.”26

SIR FREDERICK TREVES “The Extra-ordinary Edwardian” is the subtitle of the one biography27 that captures the life of an individual who contributed significantly to surgery and literature during a 50-year period that spanned the last 3 decades of the 19th century and the first 2 decades of the 20th century. His life can be divided into 2 distinct periods. During the first 50

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Figure 2. Frederick Treves.

years of Sir Frederick Treves’ life, he rose to a level of leadership in British surgery and capped that segment of his career with a successful operation, which attracted unparalleled attention around the world. Shortly thereafter, complete retirement from surgery allowed him to devote his inexhaustible energy to travel and the publication of books that chronicled his exotic itineraries. To these critically acclaimed writings he added other diverse literary contributions that were embellished by his final and most memorable work, which recently attracted worldwide attention more than a half century after its initial appearance. Considering the focus and energy requirement that resulted in Treves’ surgical eminence, it is not surprising that his more literary contributions occurred after he consciously closed the door to medicine and opened a door that exposed him to new and broader vistas. Frederick Treves (Fig. 2) was born in 1853 at Dorchester in Dorset, a region associated with the famous novelist Thomas Hardy, with whom Treves maintained a life-long friendship. Treves’ father, a carpenter and upholsterer, built

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for Hardy his first writing desk, which was used by the author throughout his long life. In 1867, Treves’ father died and the family moved to the London suburb of Kennington. Treves was determined to embark on a medical career at a time when the profession in England was distinctly stratified. Superiority was assigned to physicians who were members of the Royal College of Physicians, which had been founded in 1518 and admitted only graduates of Oxford or Cambridge to fellowship. The next level was occupied by the Royal College of Surgeons of England, which was established in 1843 in spite of the fact that the Royal College of Surgeons of London had been recognized in 1800 by Henry VIII. At the bottom of medicine’s professional ladder was the Society of Apothecaries, which was first allowed to grant a license to practice medicine in 1815. When Treves began his studies, surgery still was regarded as a craft rather than a scientific discipline, and preparation for a surgical career had only recently required a formal university-based education. In 1871, Treves began his training at University College London, which was established in 1827 to educate those who were not allowed to attend Oxford or Cambridge because of class or religion. University College specialized in science and medicine and the London Hospital, under the aegis of the university, was noted for the largest surgical ward in the country and a staff of excellent teachers. Treves published his first scientific paper while he was still a second year student, and he qualified for the Society of Apothecaries 2 years later. In 1875, he passed the membership examinations for the Royal College of Surgeons on the first try, an unusual circumstance. After a 4-month service as house surgeon at a London hospital, Frederick joined his older brother, William, who was consultant surgeon at the Royal National Hospital for Scrofula in Margate. As early evidence of his energy and resolve, Frederick immediately began his research on scrofula, an enlargement of the lymph nodes, mainly in the neck. The disorder had been romanticized during the Middle Ages, when it was referred to as the “King’s evil” because, allegedly, it could be cured by the monarch’s touch. Treves’ investigations were published in his first book, Scrofula and Its Gland Diseases, in 1882, the same year that Robert Koch discovered the etiologic agent, the tubercle bacillus. Treves’ path as a “wunderkind” proceeded by passage of the examination for fellowship in the Royal College of Surgeons on the first try at the astonishing age of 25. He returned to London and joined the London Hospital as a surgical registrar. Within a year he was promoted to assistant surgeon and, shortly thereafter in 1880, became a

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demonstrator in anatomy and a lecturer in practical anatomy. His contribution to anatomy is evidenced by assignment of his name to 2 folds between the ileum and appendix. The ileocecal fold of Treves is a bloodless sheet of peritoneum that is located between the antimesenteric border of the terminal ileum and the base of the appendix and adjacent ileum. The ileocolic or ileocecal fold of Treves is present between the ventral surface of the mesentery of the terminal ileum, in front of the ileocolic junction, and the anterior surface of the ascending colon near the cecum. Within a year of his appointment, Treves published 20 articles, an impressive productivity that led to his being honored with the 1-year designation as Erasmus Wilson Professor of Pathology. In 1883, at age 30, and in keeping with the standard of Henry Gray, who published his classic anatomy textbook when he was only 31, Treves’ first edition of Surgical Applied Anatomy appeared on bookshelves. Treves shepherded the popular work through 6 editions, and 5 subsequent editions were revised by other surgical anatomists after Treves retired from surgery. The last edition appeared in 1962. The work is generally considered to be Treves’ most important contribution to the surgical literature.28 After the textbook was published, Treves was appointed head of the school of anatomy and full surgeon to the London Hospital. His prolific literary production continued with the publication of Intestinal Obstruction: Its Varieties, with their Pathology, Diagnosis, and Treatment in 1884, The Anatomy of the Intestinal Canal and Peritoneum in Man in 1885, and the 3-volume Manual of Surgery in 1886. Treves’ name is intimately intertwined with the history of appendicitis and appendectomy. In a landmark paper published in an 1886 volume of the American Journal of Medical Sciences, Reginald Fitz, professor of pathology at the Harvard Medical School, introduced the concept that the disorder that had been attributed to inflammation of the cecum and named “typhlitis” or “perityphlyitis,” was actually an inflammation of the appendix. He introduced the term “appendicitis.” In addition, Fitz specifically stressed that early removal of the diseased appendix was indicated.29 The recommendation was enthusiastically endorsed and carried out by two of America’s most prominent surgeons, Charles McBurney, of New York City, whose name defines the diagnostic point of maximal tenderness in patients with appendicitis, and John B Murphy, of Chicago, who performed more than 2,000 appendectomies.30 Treves vehemently discredited the importance of McBurney’s eponymous physical finding and initiated a pathologic review to strengthen

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his own conclusion regarding the location of abdominal pain related to the disorder.31 Toward the end of the 19th century, the pattern of surgical progress usually took a westerly course from Europe and Great Britain to the United States. Appreciation of appendicitis and the case for appendectomy represent an anomaly in that Europe and Great Britain followed the initiative of American medicine. On February 16, 1887, Treves operated on a patient with alleged “relapsing typhlitis” and “cured the symptoms” by straightening the appendix.32 This had been considered the earliest elective operation on the appendix in England. In a historical review,33 however, Shepherd credits Lawson Tait as the first English surgeon to diagnose acute appendicitis and successfully remove the appendix. The evidence offered appeared in Tait’s 1890 report, which includes 2 such patients, the first operated on in 1880 and the second in 1886.34 Treves’ stance related to the disease remained counter to the American posture. His attitude was in keeping with the same “crusty arrogance and stubborn conservatism”35 that characterized his opposition to Listerism and its focus on asepsis. Treves continued to use the terms “typhlitis” and “perityphlitis,” and, in an 1897 monograph on the subject, referred to “appendicitis” as an “uncouth name.”36 He believed that acute cases should be treated medically and that removal of the appendix should be delayed until the acute symptoms became quiescent. In 1902, he reported that he had performed more than1,000 appendectomies during the quiescent period with only 2 deaths.37 In his Hunterian Lectures, Treves erroneously suggested that the appendix might have a physiologic function. He wrongly stated that most cases of appendicitis subsided spontaneously. Ten years after Fitz’s article, Treves wrote in his A System of Surgery: “. . . peritonitis is started by mischief in the caecum itself, the appendix is sound.” And, in discussing management of the acute episode wrote; “ [for] perityphlitis the application of a half-a-dozen leeches often acts with magical effect.” His anachronistic misconception concerning appendicitis resulted in a personal tragedy for Treves. In 1900, he failed to diagnosis appendicitis in his 18-year-old daughter, Hetty, until peritonitis ensued. At that point, Treves operated on his daughter, who died postoperatively. Ironically, it was Treves’ notably successful management of a patient with appendicitis that permanently etched Treves’ name in the annals of English history. Only 18 months after Treves’ unsuccessful operation on his daughter, Great Britain was preparing for the coronation of Edward VII and Queen Alexandra. On June 13, 1902, 14 days before the crown was to be placed on the head of the Prince of Wales, Queen Victoria’s son, he developed the

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first manifestations of appendicitis—abdominal pain, fever, and right lower quadrant tenderness. Three days later, with his pain blunted by opiates, the King moved from London to Windsor Castle, where he worsened. On the June 18, when the royal patient’s status had progressed to be deemed critical, Frederick Treves was summoned. The findings of an elevated temperature and a readily palpable tender right lower quadrant abdominal mass strongly suggested the diagnosis of appendicitis, which Treves adamantly referred to as “perityphlitis.” The patient improved and on June 23, was moved to Buckingham Palace, set on proceeding with the coronation on the designated date. The King’s situation suddenly became worse and it was agreed by all medical consultants in attendance that an operation was necessary. This was performed in the palace slightly after noon the next day. Treves made an incision in the right lower quadrant of the abdomen, evacuated pus from an abscess, and inserted 2 drains into the cavity. The appendix was not removed. The King rapidly recovered and the coronation took place on August 9. One year later, Treves was made a baronet and took the title of Sir Frederick Treves of Dorchester. Edward VII reigned for less than 8 years, during which he added to Treves’ honors with recognition as a Knight Grand Cross of the Victorian Order. Edward VII died on May 6, 1910 of causes unrelated to the episode of appendicitis and Treves was once again called upon, this time to sign the death certificate. Treves, who had served 2 monarchs—Queen Victoria as surgeon-extraordinary, and sergeant-surgeon to King Edward VII— had the distinction of adding a third when King George V, the successor to Edward VII, designated Treves as his sergeant-surgeon. Before Treves’ encounters with his daughter’s and his King’s appendices, he was an energetic medical participant in the Boer War in South Africa. One month after war was declared on October 11, 1899, Treves created his own civilian surgical team, and he was appointed consultant surgeon with the Field Force. Treves and his staff were sponsored by the Duchess of Bedford, and for 6 months, although he was officially independent of the Royal Army Medical Corp (RAMC), he was in charge of Number 4 Field Hospital following troops led by Sir Redvers Buller during several battles that led to the relief of the garrison at Ladysmith in Natal. Treves captured his war experience in a book, The Tale of a Field Hospital, which was published in 1900 and contained photographs he had taken. On his return, he received his first royal appointment from Queen Victoria as surgeon-extra ordinary and a year later was made Companion of the Order of Bath (CB) and created Knight Commander of the Royal Victorian Order

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(KCVO). His popularity was evidenced by the appearance of his portrait by Spy in Vanity Fair that year. In 1900, during the hearings of a royal commission investigating the performance of the RAMC in the Boer War, Treves maintained a patriotic posture throughout his testimony that countered the criticism of William BurdettCoutts, a member of Parliament from Westminster. Three years later, in the face of continued concern, a Royal Commission on the War in South Africa was conducted. On that occasion, Treves completely reversed his position and gave poignant evidence against the performance of the RAMC during warfare. He proposed a series of reforms, most of which were adopted. At the age of 50, Treves abruptly retired from surgery while at the pinnacle of his career. His eminence in surgery was, in large part, a product of his contributions to the medical literature. In addition to the previously mentioned books, Treves published A German-English Dictionary of Medical Terms (with Hugo Lang) and The Surgical Treatment of Typhlitis in 1890; A Manual of Operative Surgery, 2 volumes in 1891; the Student’s Handbook of Surgical Operations in 1892; A System of Surgery, 2 volumes (ed.); Their Pathology, Manifestations and Treatment in 1895; and Perityphlitis and Its Varietie in 1897. These coupled with 222 medical articles that appeared in peer-reviewed journals were unrivaled during the period in which Treves devoted his energies to surgery. He was awarded honorary degrees from the University of Pennsylvania, the University of St Petersburg, and the University of Aberdeen, where, in 1903, he was appointed rector for 5 years. Treves’ departure from his position of professional prominence allowed him to focus on new and distant horizons. The same analytic vision and fluid flow of words that had been applied to his anatomic descriptions would delineate and describe the geography, flora, fauna, and ethnography of the exotic destinations he reached. In 1904, his first voyage took him to India, Malaysia, China, and Japan. The impressions formed during that trip found expression in The Other Side of the Lantern: An Account of a Commonplace Tour Round the World, which was published in 1905. The first printing sold out in a week and it remained in print for 28 years. His second geographic descriptive work focused on the towns and villages of his home county of Dorset. Highways and Byways in Dorset was commissioned by Macmillan as part of a series and appeared in 1907. Treves’ return to the literary genre of travel books was marked by the 1908 publication of Cradle of the Deep, which stemmed from his voyage to the West Indies. His third work describing a distant land was Uganda for a Holiday, published in 1910,

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in which he praised the natives and derided the big game hunters and capitalists aiming to change the landscape. The Land That is Desolate: An Account of a Tour in Palestine, which was published in 1912, was one of Treves’ better literary works. Critics deemed it irreverent in that it confronted organized religion and biblical dogma. Iconic sites and locales, such as the Via Dolorosa, were presented as fraudulent works of fiction foisted on the public by the Church in order to enhance and cement their belief. Treves shifted his geographic attention to Rome, the Riviera, and Lake Geneva. While in Rome, he began working on an unusual detailed reconstruction of the Italian sites of action in Robert Browning’s long poem, “The Ring and the Book.” The result of Treves’ effort was the 1913 publication of The Country of the Ring and the Book, which incorporated Treves’ own interpretation of the tale and his photographs of the pertinent locations. The last 4 years of Treves’ life were spent with his wife in the favorable climate of the European Mediterranean coast and Lake Geneva. The more leisurely life style failed to decrease the intensity of his work ethic or the flow of ink from his prolific pen. The two regions were captured in The Riviera of the Corniche Road, published in 1921, and Lake of Geneva, which appeared a year later. One month before he died, Frederick Treves’ greatest and most lasting literary contribution was delivered to his publisher. The Elephant Man and Other Reminiscences recounts Treves’ 6-year relationship with Joseph Merrick, who was billed as “The Elephant Man,” when Treves first encountered him at a London freak show in 1884. Treves arranged for Merrick to be examined at the London Hospital. The examination took place and, contrary to what Treves had assumed, Merrick was “highly intelligent.” The medical assessment failed to make the correct diagnosis of neurofibromatosis, a genetic disorder that initially had been described by Armand Trousseau in 1865, and was referred to as von Recklinghausen disease, based on an 1882 monograph published by Friedrich Daniel von Recklingausen summarizing the literature. After a hiatus of 2 years, Treves’ association with Merrick was reactivated and arrangement was made to house Merrick in 2 infrequently used rooms on the ground floor of the London Hospital. Merrick became the object of attention by the press and society ladies, who visited periodically. Most notable among them was the Princess of Wales, later to become Queen Alexandra. Joseph Merrick died in his sleep at the age of 27 in 1890. In 1979 David Pomerantz’s play appeared on Broadway and, a year later, David Lynch directed the film that was nominated for several Academy Awards.

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Figure 3. Harvey Cushing.

Sir Frederick Treves died at Montreux, France on December 7, 1923, the victim of peritonitis, a disorder on which he had been regarded to be the expert. In the absence of an autopsy, the cause was not determined, but the Wangensteens, in their 1978 The Rise of Surgery, provide an ironic speculation. They suggest that Treves may have had congenital incomplete decent of the cecum; that the appendix was located in the right upper quadrant and accounted for the peritonitis rather than the earlier suggestion of a biliary origin.38 In 1924, Treves’ ashes arrived at Dorchester and the service was arranged by Thomas Hardy, the famous Dorset literary figure, who had been a life-long friend of Treves and was 84 years old at the time. Leadership in anatomy and surgery followed in time by a highly acclaimed corpus of literature distinct from medicine and surgery that characterize Sir Frederick Treves as a Victorian and Edwardian surgeon of distinguished duality.

HARVEY WILLIAMS CUSHING The third member of the exclusive quartet of surgeons who contributed significantly to surgery and a disparate field is the most recognizable by the current readership. His talents are encapsulated in a letter, which he received from Lewis Weed, a former student and a contemporary dean of the Johns Hopkins Medical School: “When I read one of your papers and addresses, I think you should do nothing else but write; when I see you operate I think that you should do nothing else but operate; and when I see you experiment I think you should do nothing else but experiment.”39 Harvey Cushing (Fig. 3) was born on April 8, 1869 in Cleveland, OH bearing the paternal genes of 3 generations of physicians. Harvey Cushing was educated in Cleveland until he entered Yale in 1887. His academic performance during his 4 years at Yale was creditable, but was outshined by his athletic distinction. Cushing’s athleticism and mem-

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bership on the highly regarded baseball team were strikingly similar to the collegiate characteristics at Yale of his future surgical mentor, William Stewart Halsted. In 1891, Cushing followed his brother, Edward Fitch Cushing, “Ned,” who had graduated, to Harvard Medical School. Cushing’s first significant contribution to surgery occurred in early 1893 while he was still a medical student. In Cushing’s daily diary, he reported that on January 10 a woman whom he had etherized died on the operating table at the Massachusetts General Hospital before the class.40 Cushing’s classmate, Amory Codman, who had a similar depressing experience, began monitoring the patient’s pulse and respiration during an operation in 1895. Cushing refined the “ether chart,” and 15 years later would add blood pressure measurements using a modification of the Riva-Rocci inflatable cuff, to which he was exposed during his European tour of 1900 and1901. Codman became an orthopaedic surgeon in Boston and a crusader for measuring outcomes of surgical interventions. Cushing graduated Harvard Medical School, cum laude, in June 1895, but had begun his formal appointment as a house pupil at the Massachusetts General Hospital in April. His internship began in August. During his internship, Cushing began working with x-rays, within months of Wilhelm Conrad Röntgen’s announcement of his discovery. Cushing moved to Baltimore in 1896 to become an assistant resident in surgery at the Johns Hopkins Hospital, exposing himself to the tutelage of the most highly acclaimed American surgeon, William Stewart Halsted. Cushing’s maiden clinical study used x-rays, which he personally performed. A woman with a gunshot wound in her neck and sensory disturbance and paralysis consequent to a spinal cord injury underwent x-ray localization of the bullet. The one case led to an exhaustive study of the literature on spinal cord injury and Cushing’s first publication in a national journal.41 In 1898, Cushing reintroduced block anesthesia with cocaine, which had been initiated by Halsted but abandoned at Johns Hopkins. It was used liberally in the repair of hernias to obviate operative death from anesthesia.42 Relief of pain provided Cushing with his entrée into neurosurgery. In 1899, he modified Gasserian ganglionectomy to erase the excruciating pain of trigeminal neuralgia.43 The operation was hailed in the press as “probably the most daring operative procedure ever attempted by a surgeon.” 44 This introduction into the realm of neurosurgery provided a focal point for Cushing as he embarked on a 14month period of travel abroad. He would visit Victor Horsely of London, who had pioneered a variety of neurosurgical procedures including Gasserian ganglionectomy,

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and Theodor Kocher of Berne, who had published on lesions of the spinal cord. While in Berne, Cushing divided his time between observing Theodor and his son, Albert Kocher, operate and performing experiments in the laboratory of the distinguished professor of physiology, Hugo Kronecker. There, Cushing demonstrated that an increase in intracranial pressure results in a rise in systemic blood pressure to a level slightly above the pressure exerted against the medulla. This work was completed by Cushing in the Turin laboratory of Angelo Mosso and published in the Johns Hopkins Hospital Bulletin.45 Cushing completed the medical aspect of his tour with a visit in Liverpool to the future Nobel Laureate neurophysiologist, Charles S Sherrington. During the visit, Cushing trephined the skulls of an orangutan and a gorilla, and observed Sherrington’s techniques of localization by electrical stimulation of the brain. Cushing returned to Johns Hopkins, and was given the title of “associate” in surgery. One day a week would be allotted for neurosurgery, and he would teach a course to third-year medical students in surgical anatomy and another course in operative technique. So, the Hunterian Laboratory was established and would be replicated by several American medical schools. Modern neurosurgery was fathered by Harvey Cushing during the first decade of the 20th century. At the same time, his appreciation of the need for surgeons to keep up with all aspects of surgery and have the opportunity to observe new operations led to his endorsement of George Crile’s idea of forming a new traveling club, which met for the first time in 1903 as the Society of Clinical Surgery. By 1908, Cushing had performed more than 300 neurosurgical operations, mainly for decompression, and detailed his technique in a chapter, “Surgery of the Head” that appeared in 1908 in WW Keen’s Surgery. The same year, he began his focus on the pituitary body. In March 1909, Cushing removed a tumor from the anterior lobe of a man with acromegaly—the first successful case performed in the United States. Shortly thereafter, in a presentation before the Section on Surgery of the American Medical Association, he introduced the terms hyperpituitarism and hypopituitarism.46 During the period of Cushing’s concentration on the pituitary gland, he modified a transphenoidal approach, which had been introduced in Europe. Cushing’s 1912 book, The Pituitary Body and Disorders47 detailed the histories of 48 patients whom he had managed. In that book, he introduced the concept that the pituitary’s secretions controlled growth. At the same time, Cushing continued to perform ganglionectomies for trigeminal neuralgia and remove brain

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tumors. His acclaim was enhanced in 1910 when he successfully removed a meningioma from Major General Leonard Wood, Chief of Staff of the Army and later Governor of the Philippines. A year later, his seminal paper on the use of silver clips to control cerebral bleeding during an operation appeared.48 Cushing’s reputation was firmly established during his 16 years at Johns Hopkins. He was offered and declined professorships of surgery at the University of Maryland, Jefferson Medical College, University of Virginia, New York Hospital, New York University, Yale University, and Washington University at St Louis. In 1910, as part of the planning for the construction of the Peter Bent Brigham Hospital, Harvard University opened negotiations with Cushing that culminated in his appointment as surgeon-in-chief. In June, Cushing received formal notification of his appointment as Moseley Professor of Surgery as of September 1, 1912. Cushing moved to Boston in the fall of 1912; the first operation at the Brigham, excision of varicose veins, took place at the end of the following January; the hospital formally opened in 1914. In March 1915, Cushing began a 2-month period as head of a Harvard unit at a French military hospital in Paris. After 2 years back in Boston, Cushing returned to the war in May 1917 as a member of a base hospital initially with the British Expeditionary Force and subsequently with the American Expeditionary Force until the end of hostilities. Cushing adapted the precision and compulsive behavior that characterized him as a surgeon to that of a war diarist. He also used his own artistic and photographic capabilities in assembling material that was bound into 9 volumes in his library. A distillate that received broad critical acclaim was published in 1936.49 In the interval between the 2 military tours, Cushing published his second monograph, in which he presented his experience with 29 cases of acoustic neuroma.50 On December 29, 1919, Sir William Osler, arguably the most highly regarded physician of the last 2 decades of the 19th century and the first 2 decades of the 20th century, died. It was logical that Lady Osler would call upon Cushing, for whom Osler played the extended roles of surrogate medical father and stimulus for bibliophilia, to produce a biography. During the years that Cushing worked on the project, he also continued his consuming clinical activities and exercised the role of president of the Society of Neurological Surgeons (1920 and 1921), Association for the Study of Internal Secretions, later to become the Endocrine Society (1921), Society of Clinical Surgery (1921), American College of Surgeons (1922), and American Neurological Association (1923). In 1927, he would serve as president of the American Surgical Association.

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The Life of Sir William Osler was published by the Oxford University Press in 1925; 1,371 pages bound as 2 volumes provide evidence of the extent of the undertaking. Most reviews were positive and Cushing was awarded the Pulitzer Prize in biography in 1926. As the only surgeon to be the recipient of that distinction, Cushing must be vaulted into the “pantheon.” The year of the Pulitzer Prize also witnessed Cushing’s exposure to an electrosurgical device, which combined cutting and coagulation, and was developed by WT Bovie. Cushing was responsible for introducing and popularizing the apparatus, which has become a staple of brain surgery. Also in that year, 2 new books by Cushing were published. One, coauthored by Percival Bailey, was a classification of gliomas.51 The other book was a compilation of the 3 lectures that Cushing presented in Edinburgh when he received the Cameron Prize.52 In 1928, a volume of Cushing’s essays were published as Consecratio medici and Other Papers. The review in the Boston Globe stated: “-once again he wields the pen that commemorated Osler—in Consecratio medici and Other Papers he takes lay readers on an enchanting stroll through the humanism of a noble profession-essays and addresses which are a mosaic of medical history, reminiscence, humor and serene philosophy . . . The hand which can wield both the scalpel and pen, can make the reader forget the doctor in the man of letters.”53 On April 15, 1931 Cushing removed the 2000th brain tumor in his career. The patient had acromegaly due to a pituitary tumor. Two months before his retirement, a group of young neurologists and neurosurgeons, who lacked the seniority for the Society of Neurological Surgeons, formed the Harvey Cushing Society. In 1965, it changed its name to the American Association for Neurological Surgeons and has become the leading professional organization of neurosurgeons in the United States. In 1932, Cushing permanently etched his name in the lexicon of medical disorders when he described the manifestations of the hypersecretions of pituitary basophilic adenomas (Cushing’s disease).54 Cushing’s Moseley Professorship and appointment at Peter Bent Brigham came to an end on September 1, 1932. A year later the family moved to New Haven, where he assumed the title of Sterling Professor of Neurology at Yale University. In his final role in academia, he never operated and did no research or formal teaching. He initially occupied his time with the editing of his war journal. Once it was completed and sent to press he dedicated his efforts to working with Louise Eisenhardt on a monograph concerning meningiomas. The book was published in 1938.55 It was immediately considered to be a “masterpiece, a classic, an epic of neurosurgery . . . it con-

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tained a whole philosophy of surgery and of the doctorpatient relationship.”56 In 1943, four years after his death, Cushing’s A Bio-bibliography of Andreas Vesalius was published posthumously. Cushing’s “paraoperativity,” that merits his inclusion in a pantheon, is based, in part, on his expertise in the history of science, which was a consequence of his bibliophilia. Cushing’s avidity for collecting rare books stems from his association with Osler. Their first meeting, although probably of little consequence, took place at Dr Weir’s clinic in Boston in April 1893.57 When Cushing arrived at Johns Hopkins in 1896, he was 27 years of age and Osler was 47. Little is mentioned of Osler in Cushing’s letters and journals during Cushing’s first 2 years in Baltimore, but obviously an early bond occurred because when Cushing went abroad in 1900, Osler, who was spending the summer in England, warmly entertained him. The extent of Cushing’s extraordinary collection is evidenced by the first publication of the Historical Library of the Yale Medical Library, The Harvey Cushing Collection of Books and Manuscripts. Within the publication, 5 pages of manuscripts, 5 pages of incunabula, and 188 pages are used to catalogue the collection.58 Cushing credited Osler with promoting his scholarship concerning the works of Andreas Vesalius. On May 31, 1903, 40 years before Cushing’s posthumous publication, he wrote, “Dr. Osler started me on a Vesalius essay,” which was presented in December at a meeting of the Osler Book and Journal Club.59 Cushing began his focus on the biobibliography of Vesalius in 1939. Cushing, the father of modern neurosurgery, directed his vigor, indefatigability, and his meticulous nature to the project. Cushing, with his long-term dedication to medical history, planned to publish A Bio-bibliography of Andreas Vesalius, the father of modern anatomy in 1943, on the 400th anniversary of Vesalius’ monumental work, De humani corporis fabrica. The book was published posthumously in 1943. To commemorate Cushing’s 70th birthday, the Charles C Thomas Co, which began with the publication of an illustrated monograph on blood vessel tumors of the brain by Cushing and Bailey, published a 108-page octavo that listed Cushing’s writings. Cushing died on October 7, 1939. In 1941, the redesigned Yale Medical History Library opened as the Harvey Cushing/John Hay Whitney Library. It houses Harvey Cushing’s collection of rare books, his desk, and other memorabilia. In 1988, a 45-cent commemorative stamp was issued by the US Postal Service bearing Cushing’s portrait, the most recent of a total of 7 surgeons so honored.

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Cushing’s literary equivalence to his surgical productivity is defined by the sum of his war journal, his classic work on Vesalius, and his Consecratio medici, which was placed on a par with Osler’s famous addresses Aequinimitas,60 coupled to the fact that he was the only surgeon to receive a Pulitzer Prize. In his primary role as the father of effective neurosurgery, the esteem in which he was held was unparalleled. His presidency of America’s 3 most distinguished surgical societies (American Surgical Association, Society of Clinical Surgery, and American College of Surgeons) has been matched by others, but never enhanced by the presidency of 2 nonsurgical national groups (American Neurological Association and the Endocrine Society). A review of the 4 printed pages of small font that constitute an appendix in Fulton’s biography lead to the conclusion that Harvey Cushing was the most honored surgeon in the 20th century and perhaps in all of history.

SIR GEOFFREY KEYNES Esteem is in the eye of the beholder. The assignment of pre-eminence to an accomplished individual is a personal choice. In structuring a personal pantheon, which is identified by the neologism, “par-operativity,” one such individual is uniquely unrivaled and yet underappreciated. Over the past half century, his accomplishments have sunk into oblivion and his name has been perpetuated only by its association with that of his notable brother, John Maynard, who achieved eponymous status when Keynesian economics was so designated. The life of the English surgeon Geoffrey Keynes (Fig. 4), the younger brother of John Maynard, is detailed in The Gates of Memory, an autobiography by Sir Geoffrey Keynes that was published when the author was 94. His family itself was remarkable. His father was a lecturer in moral science and also served in the university registry at Cambridge. Geoffrey’s mother, Florence Ada Brown, was a successful author and a social reformer. In addition to his famous older brother, John Maynard, Geoffrey’s older sister was notable as the wife of the Nobel Prize winning physiologist, Archibald Vivian (AV) Hill. Geoffrey married Margaret Darwin, the daughter of the eminent astronomer and mathematician, Sir George Howard Darwin, who was the second son of Charles and Emma Darwin. Geoffrey and Margaret’s oldest son, Richard Darwin Keynes, became a professor of physiology at Cambridge and edited accounts of his grandfather’s voyage aboard the HMS Beagle. The second son, Quentin, became a leader of African safaris and maker of highly regarded films of Africa. The third son, William Milo Keynes, was a Doctor of Medicine and a Fellow of the Royal College of Surgeons, who was best known for his books on the history of science and

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Figure 4. Geoffrey Keynes. (From: Gates of Memory by Geoffrey Keynes, with permission from Clarendon Press, Oxford, UK.)

genetics. The youngest and only surviving son, Stephen John Keynes, is currently the chairman of the Charles Darwin trust. The earliest of Geoffrey Keynes’ contributions in the realm of medicine occurred in 1913 while he was still a house surgeon at St. Bartholomew’s Hospital. At the time, he lodged at the same house on Brunswick Square in Bloomsbury as Virginia Stephen, later to become famous as Virginia Woolf. She had been found comatose in her room after her first suicide attempt. Keynes and Leonard Woolf, who would become Virginia’s husband, rushed her to the hospital, where Keynes and Virginia’s physician, Sir Henry Head, inserted a tube into her stomach and washed out the remaining ingested narcotic. Virginia Woolf survived to enrich English literature until she eventually succeeded in taking her own life.61 The first major contribution of Geoffrey Keynes in medicine took place during World War I, when he popularized blood transfusion among British military hospitals and developed an apparatus that was named the “Keynes Flask.” After the war, Keynes authored several scientific articles on the subject. In 1922, he published the first textbook on transfusion printed in Great Britain.62 A second edition of Blood Transfusion appeared in 1949. It included a section

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defining the 4 blood groups (A, B, AB, and O) in 50 individuals of 4 generations of Darwins and Keyneses, demonstrating the Mendelian inheritance. Keynes’ most significant medical contribution concerned the treatment of cancer of the breast. He was a visionary who ventured against the contemporaneously accepted surgical dicta of luminaries in the field. His approach would not be proved correct until after he died. In 1898, William Stewart Halsted, the most distinguished American surgeon and chief of surgery at the Johns Hopkins Hospital in Baltimore, and prominent New York City surgeon Herbert Willy-Meyer almost simultaneously had introduced an operation for the eradication of breast cancer that came to be known as a “radical mastectomy.” The name was appropriate in that it was an allencompassing operation, which widely removed all the breast tissue, the underlying pectoralis major and minor muscles, and the draining axillary lymphatic nodes and channels on the involved side. It was a mutilating procedure, fraught with complications, and was advocated for even the earliest forms of the disease. Recommendation of routine use of the procedure for breast cancer rapidly spread across the Atlantic Ocean and was accepted by the British and European surgical establishments. In 1922, Geoffrey Keynes initiated a clinical trial that evaluated the treatment of advanced, unresectable cancer of the breast with the insertion of radium-filled needles. In 1927, he began to report encouraging results with a number of patients whose local disease was either arrested or disappeared after treatment.63 At that time, he completely abandoned the radical mastectomy and actively championed conservative surgery. For a small tumor, only a small segment of the breast was removed; for a large tumor, a simple removal of the entire breast was performed, and was unaccompanied by removal of the underlying muscles or axillary lymphatics. Keynes also emphasized that the main hope for improved survival was early diagnosis.64 In 1937, Keynes was invited to present his early work with radium treatment of breast cancer at the American Surgical Association, from which he received an honorary degree. In general, his advocacy of conservative breast surgery for cancer was ignored or it incurred criticism and scorn. But, in 1967, when the American surgeon and founder of the Cleveland Clinic, George Crile, Jr, published his book, A Biological Consideration of Treatment of Breast Cancer (Charles C Thomas, Springfield, Illinois, 1967), Keynes’ pioneering work was recognized in the dedication. It states: “To Sir Geoffrey Keynes, whose wisdom and foresight made him the first to resist the trend towards ever more radical treatment of breast cancer.”

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Geoffrey Keynes died in 1982 at the age of 95. Four years later, Bernard Fisher and associates reported the results of the National Cancer Institute’s definitive National Surgical Adjuvant Breast Project (NSABP)-04 study, which demonstrated that breast conservation with local radiation achieved the same survival results as radical mastectomy for women with cancer.65 The radical operation would be relegated to the status of a surgical dinosaur and the results of Keynes’ pioneering efforts would reduce the trauma of an operation for the 1 in 8 women in western civilization who developed breast cancer. Keynes’ other significant surgical contribution affected a much smaller patient population, those who were afflicted with myasthenia gravis in which there is a failure of passage of nerve impulses to the recipient muscles. In 1939, Alfred Blalock, professor and chair of surgery at Johns Hopkins, had removed a thymus gland containing a tumor and noted that the patient, who coincidentally had myasthenia gravis, experienced symptomatic improvement of his neuromuscular disorder. He followed up with 5 subsequent removals of the substernal thymic gland in patients suffering from myasthenia, some of whom had no tumor within the gland. Amelioration of the neuromuscular symptoms was achieved. The Johns Hopkins group failed to pursue the issue, and it remained for Keynes to conduct the first extensive clinical study to convincingly demonstrate the salutary effects of removal of the thymus on the symptoms of myasthenia gravis. Keynes perfected the operation and identified the importance of securing the great innonimate vein that drained the gland.66 His initial report concerning 51 patients who underwent the operation demonstrated that 80% were either cured or improved, requiring less medication.67 Adverse opinion was initially expressed by members of the staff of the Mayo Clinic, but 30 years after Keynes’ report, the Mayo Clinic physicians recanted and affirmed that the removal of the thymus had a distinct role in the treatment of myasthenia gravis.68 During his career, Keynes removed the thymus from 281 myasthenic patients.69 The operation remains an integral component in the treatment of that disease. Keynes, as an active surgeon, admittedly planned his life to allow for simultaneous satisfaction of his literary passions. The reasons behind his deliberate selection of a modus vivendi that is counterintuitive for a pioneering surgeon is found in his autobiography. My beloved Chief, George Gask, I believe had formerly hoped that I would wish to follow him in an academic career, but I had decided not to attempt this, the main consideration being that that the practice of surgery was the central passion of my life. I was

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a craftsman by instinct, not a teacher, an administrator, a committee man, or a medical politician, as I noticed a professor had to be. I did not dislike teaching and enjoyed the company of students but I had many outside interests, among them a strong desire to acquire as many works by Blake as possible and to form a library of original edition of English literature, science and medical history. In addition I had a growing family of sons who had to be educated. All of these required a larger income than was awarded to a professor; and could only be provided by private practice; the having the additional advantage of fulfilling my desire to have human relations with a proportion of my patients, which one loses if they are all confined in hospital beds as ‘cases.’70 In achieving the distinction of “par-operativity,” Geoffrey Keynes’ concomitant contributions to the literary field were prolific and extraordinary. So much so that Wikipedia refers to him as “a biographer, surgeon, physician, scholar and bibliophile, the brother of the economist John Maynard Keynes.” The remainder of his profile concentrates on his literary achievements and makes no mention of his medical accomplishments. Keynes’ entrance into the world of literature began with his matriculation in 1902 at the old English public school, Rugby, where he “fell under the spell”71 of Rupert Brooke, a fellow student and son of his housemaster. Keynes’ bibliographic pursuits began with the collection of everything that this close friend Brooke, an evolving poet, produced. Both Keynes and Brooke proceeded, in 1906, from Rugby to Cambridge, where Brooke introduced Keynes to the poetry of Dr John Donne, the subject of Keynes’ first published bibliography. Keynes’ Bibliography of Dr. John Donne (1572–1631), the metaphysical poet, lawyer, and Anglican priest, who was appointed royal chaplain and dean of St Paul’s Cathedral, first appeared in 1914, and went through 4 editions. Among the famous Donne quotations are, “No man is an island of itself . . . And therefore never send to know for whom the bell tolls, it tolls for thee.”; “Death be not proud, though some have called thee Mighty and dreadful, thou are not so.” Rupert Brooke, who was a member of the Bloomsbury literary group, died in 1915 of sepsis after receiving a mosquito bite on the way to the battle of Gallipoli, and was buried on the island of Skyros in the Aegean Sea. Prophetically, he had written “If I should die, think this only of me; that there is some corner of a foreign land that is forever England.” Keynes published The Poetical Works of Rupert Brooke in 1946, a bibliography of his close friend’s writings in 1954, and the Letters of Rupert Brooke in 1968.

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Continuing his bibliographic pursuits, Keynes published Jane Austen: a Bibliography in 1929, and, the following year, Selected Essays of William Hazlitt. In 1939, his John Evelyn: A Study in Bibliophily and a Bibliography of His Writings, incorporating the works of the famous English diarist who lived from 1620 to 1706, was published conjointly by the Grolier Club of New York and the Cambridge University Press. Keynes, while a student at Cambridge, also developed an interest in Sir Thomas Browne (1605–1682), the English physician whose poignant prose addressed diverse issues, including religion and science. This led Keynes into a close relationship with Sir William Osler, Oxford’s Regius Professor of Medicine, who had previously established his reputation while serving as the founding professor of medicine at the Johns Hopkins Hospital. Osler was noted for his frequent use of quotations from Sir Thomas Browne’s Religio Medici. Examples of Browne’s writings are, “As reason is as a rebel to faith, so passion is a rebel to reason.” and “Man is a noble animal, splendid in ashes, and pompous in the grave.” Keynes delivered the initial Oslerian oration at the Royal College of Physicians in 1968. In that address, Keynes detailed his friendship and shared bibliophilia with Osler. Keynes’ The Works of Thomas Browne was published in 1931. Medicine and bibliography came together for Keynes in his consideration of 2 famous English physicians, William Harvey (1578–1657) and Timothie Bright (1550–1615). Keynes first produced a bibliography of the works of Harvey, who had worked at the same St Bartholomew’s Hospital where Keynes trained and worked, that was published in 1928 and a second edition appeared in 1953. Keynes’ first edition of the Life of William Harvey, detailing the life of the man who demonstrated the circulation of blood in De Motu Cordis, was published in 1966. Doubtless, the fact that Timothie Bright was the third physician appointed to the staff of St Bartholomew’s Hospital after its refounding by Henry VIII in 1546 created a point of interest for Keynes. Although Bright did not distinguish himself in that role, his book, Treatise of Melancholie (1586) provided the source for several passages in Shakespeare’s Hamlet. Bright is also credited with inventing a system of shorthand that was regarded as particularly suitable for recording sermons. Keynes’ Timothie Bright 1550–1616. A Survey of his Life with a Bibliography of his Writings was published in 1962. The bibliographic efforts and talents of Geoffrey Keynes were directed at a broad diversity of literature that included medicine, fiction, essay, diary, philosophy, religion, prose, and poetry. But over the years of his activities in the arts, one persistent if not consummate interest was clearly

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dominant. Looming above all others within Keynes’ corpus is the mystical poet and artist, William Blake, whom Keynes discovered in 1907 while a second year student at Cambridge. Blake (1757–1827) presents a complex subject for biography and bibliography far beyond his recognition as author of a school child’s memorized 4 lines” Tiger Tiger, burning bright In the forest of the night; What immortal hand or eye Could frame thy fearful symmetry?” Blake was a mystic poet, a painter, and printmaker, and is regarded by some devotees as England’s greatest poet. Keynes’ pioneer work about Blake, A Bibliography of William Blake, was published by the Grolier Club in 1921. Keynes’ Poetry and Prose of William Blake was published in 1948 and the following year his Blake Studies appeared. In 1950, Keynes edited and introduced William Blake’s Engravings and, a year later, Keynes edited The Tempera Paintings of William Blake. Sequentially there followed: A Study of the Illuminated Books of William Blake Poet, Printer, Prophet (1964); On Editing Blake (1964); Blake: Complete Writings with Variant Readings (1966); William Blake: Songs of Innocence and of Experience. Introduction & Commentary by Sir Geoffrey Keynes (1967); William Blake Engraver (1969); Drawings of William Blake (1970); and William Blake’s Water-Colours Illustrating the Poems of Thomas Gray (1972). A sense of Keynes’ literary productivity is evidenced by the fact that the University of Rochester Library lists 83 publications in their collection. Keynes’ affinity for William Blake was extended when he produced a ballet with music by Ralph Vaughan Williams and choreographed by Ninette de Valois. The work, entitled “Job: A Masque for Dancing,” premiered in July 1931, and has enjoyed continued success with several dozen performances over the years. In May 1955, after retiring from the active practice of surgery, Geoffrey Keynes was knighted by Queen Elizabeth in recognition of his service and contributions to medicine. Keynes’ literary accomplishments were recognized by honorary Doctorates of Literature by Oxford and Cambridge in 1965— a most unusual circumstance— and identical degrees from Edinburgh, Birmingham, Sheffield, and Reading. But almost a half century has taken its toll and has relegated Keynes to the realm of the underappreciated.

REFERENCES 1. Prof. Dr. Th. Billroth’s Anrwort aud die Adresse des Lesevereines der deutschen Student-en Wien’s. Vienna: C Gerold Verlag; 1875. 2. Absolon KB. The Surgeon’s Surgeon Theodor Billroth, Vol. 1, Lawrence, KS: Coronado Press;1979:15–25. 3. ibid., p.183.

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¨ ber den Bau der Schleimpolypen. Berlin: G Reimer; 4. Billroth T. U 1855. 5. Absolon KB. The Surgeon’s Surgeon Theodor Billroth, Vol. 1, Lawrence, KS: Coronado Press;1979:132 6. Billroth T. Historische Studien über die Beuerteilung und Behandlun der Schusswunder von xv. Jahrhundert bis auf die neuste Zeit. Berlin: G Reimer; 1859. 7. Absolon KB. The Surgeon’s Surgeon Theodor Billroth, Vol. 1, Lawrence, KS: Coronado Press; 1979:167. 8. Billroth T. “Beobachtungs-Studien über Wundfieber und accidentelle Wundkrankeiten”, Archiv für klinische Chirurgie 1868; 9:52–168. 9. Absolon KB. The Surgeon’s Surgeon Theodor Billroth, Vol. 1, Lawrence, KS: Coronado Press; 1979:262 10. Billroth T. Chirurgische Klinik, Zürich, 1860–1867. Berlin: Hirschwald; 1869. 11. Billroth T. Chirurgische Klinik, Wien, 1871–1876, nebst einem Gesamtberich über chiurgische Kliniken in Zürich und Wien währeend der Jahre 1860–1867. Berlin: Hirschwald; 1879. ¨ ber den Transport der im Felde Verwun12. Billroth T, Mundy J. U deten und Kranken. Vienna: C Gerald’s Sohn; 1874. ¨ ber die Resection des Esophagus. Archiv für klinis13. Billroth T. U che Chirurgie 1872;13:65–68. 14. Czerny V. Neue Operationem: 1. Resection des Esophagus. 2. Extirpation eines retroesophagealen Kropfes. 3. Enterorhaphie wegen einer Kotfistel im Bruschsacke. Zentralblatt für Chiurgie 1877;4:433. 15. Gussenbauer C. Ueber die erste durch Th. Billroth am Menschen Ausgeführte Kellkopf-Exstirpation. Archiv für klinische Chirurgie 1874;17:343–356. 16. Absolon KB. The Surgeon’s Surgeon Theodor Billroth Vol. 2. Lawrence, KS: Coronado Press; 1981:110. 17. ibid., vol.3, 1987:229. 18. Billroth T. Offenes Schreiben an Herren DR. Wittelshöfer. Feuilleton. Wiener mmedizinische Wochenschrift 1881;31: 162–164. 19. Hacker V. Zur Casuistik und Statistik der Magenresectionen und Gastroenterostomien Verhandluingen der Deutscen Gesellschaft für Chirurgie 1885;14:62–71. 20. Absolon KB. The Surgeon’s Surgeon Theodor Billroth Vol. 3. Lawrence, KS: Coronado Press; 1987:231 21. Billroth T. Untersuchungen über die Vegetationsformen von Coccobacteria Septica. Berlin: G Reimer; 1874. 22. Absolon KB. The Surgeon’s Surgeon Theodor Billroth Vol. 2. Lawrence, KS: Coronado Press; 1981: Fig. 63. 23. ibid., Fig. 62. 24. Gottlieb-Billroth O. Billroth und Brahms im Briefwechsel. Berlin and Vienna: Urban und Scwarzenberg; 1935. 25. Hemmeter JG. Theodor Billroth, Musical and Surgical Philosopher. A Biography and a Review of his Work on Psychophysiological Aphorisms on Music. Bull Johns Hopkins Hosp 1900; XI: 297–317. 26. Spencer H. Essays on Education. On the Origin and Function of Music. London: M Dent & Sons; 1928. 27. Trombley S. Sir Frederick Treves: The Extra-Ordinary Edwardian. London: Routledge; 1989. 28. ibid., p.27. 29. Fitz R. Perforating inflammation of the vermiform appendix. Am J Med Sci 1886;92: 321–346. 30. Murphy JB. Two-thousand operations for appendicitis and deductions from his personal experience. Am J Med Sci 1904;128: 187–211.

Schwartz

“Paroperative” Pantheon

333

31. Treves F. The Cavendish Lecture on some phases of inflammation of the appendix. BMJ 1902;1:1589–1594. 32. Treves F. Surgery of the appendix vermiform (letter). Medical News 1892;61: 531. 33. Shepherd JA. Acute appendicitis: a historical survey. Lancet 1954;2:299–302. 34. Shepherd JA. Lawson Tait and acute appendicitis. Lancet 1956; 2:1301–1302. 35. Trombley S. Sir Frederick Treves: The Extra-Ordinary Edwardian. London: Routledge;1989:73. 36. Treves F. Perityphlitis and Its Varieties: Their Pathology, Clinical Manifestations, and Treatment. London: Macmillan & Co; 1897. 37. Treves F. The Cavendish Lecture on some phases of inflammation of the appendix. BMJ 1902;1:1589–1594. 38. Wangensteen O, Wangensteen S. The Rise of Surgery. Minneapolis: University of Minnesota Press; 1978. 39. Lewis H. Weed to Harvey Cushing, Jan. 26, 1925, Harvey Williams Cushing Papers, Yale University (CP), 53/1079, 131/607. 40. Fulton JFF. Harvey Cushing: A Biography. Springfield, IL: Charles C Thomas; 1946:69. 41. Cushing H. “Haematomyelia from gunshot wounds of the spine. A report of two cases, with recovery following symptoms of hemilesion of the cord.” Am J Med Sci 1898;115:654–683. 42. Cushing H. The employment of local anesthesia in the radical cure of certain cases of hernia, with a note upon the nervous anatomy of the inguinal region. Ann Surg 1900;31:1–34. 43. Cushing H. A method of total extirpation of the Gasserian ganglion for trigeminal neuralgia. By a route through the temporal fossa and beneath the middle meningeal artery. JAMA 1900;34: 1035–1041. 44. Bliss M. Harvey Cushing A Life in Surgery. Oxford: Oxford University Press; 2005:130. 45. Cushing H. Concerning a definite regulatory mechanism of the vaso-motor center which controls blood pressure during cerebral compression. JHH Bull 1901;12:290–292. 46. Cushing H. The hypophysis cerebri-clinical aspects of hyperpituitarism and hypopituitarism. JAMA 1909;31:249–255. 47. Cushing H. The Pituitary Body and Its Disorders. Philadelphia: JB Lippincott & Co:1912. 48. Cushing H. The control of bleeding in operations for brain tumors. With the description of silver ‘clips’ for occlusion of vessels inaccessible to the ligature. Ann Surg 1911;54:1–19. 49. Cushing H. From A Surgeon’s Journal 1915–1918. Boston: Little Brown and Company; 1936. 50. Cushing H. Tumors of the Nervous Acusticus and the Syndrome of the Cerebellopontine Angle. Philadelphia and London: WB Saunders Co; 1917. 51. Bailey P, Cushing H. A Classification of the Tumors of the Glioma Group on a Histiogenetic Basis with a Correlated Study of Prognosis. Philadelphia, London and Montreal: J B Lippincott Co; 1926. 52. Cushing H. Studies in Intracranial Physiology and Surgery. The Third Circulation. The Hypophysis. The Gliomas. London: Humphrey Milford, Oxford University Press; 1926. 53. Fulton JFF. Harvey Cushing: A Biography. Springfield, IL: Charles C Thomas; 1946:562. 54. Cushing H. The basophil adenomas of the pituitary body and their clinical manifestations,(pituitary basophilism). JHH Bull 1932;50:137–195. 55. Cushing H, with the collaboration of Eisenhardt L. Meningiomas: Their Classification, Regional Behavior, Life His-

334

56. 57. 58. 59. 60. 61. 62. 63.

Schwartz

“Paroperative” Pantheon

tory, and Surgical End Results. Springfield, IL: Charles C Thomas; 1938. Bliss M. Harvey Cushing A Life in Surgery. Oxford: Oxford University Press; 2005:510 Fulton JFF. Harvey Cushing: A Biography. Springfield, IL: Charles C Thomas; 1946:74. Yale Medical Library. The Harvey Cushing Collection of Books and Manuscripts. New York: Schuman’s; 1943. Fulton JFF. Harvey Cushing: A Biography. Springfield, IL: Charles C Thomas; 1946:230. ibid., p. 562. Keynes G. Gates of Memory. Oxford: Clarendon Press; 1981: 115. Keynes G. Blood Transfusion. London: Henry Frowde; 1922. Keynes G. Radium treatment of primary carcinoma of breast. Lancet 1928;2:108–111.

J Am Coll Surg

64. Keynes G. Radium treatment of primary carcinoma of breast. Brit J Surg 1932;19: 415–478. 65. Fisher B, Redmond C, Fisher ER, et al. Ten year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with and without radiation. N Engl J Med 1985; 312:674–681. 66. Keynes G. Surgery of the thymus gland. (Hunterian Lecture). Brit J Surg 1946;33: 201–214. 67. Keynes G, Collins DH, et al. Symposium on the surgical treatment of myasthenia gravis. Proc Roy Soc Med 1946;39:600– 604. 68. Buckingham JM, Howard FM Jr, Bernatz PE, et al. The value of thymectomy in myasthenia gravis: A computer-assisted matched study. Ann Surg 1976;184:453–458. 69. Keynes G. Gates of Memory. Oxford: Clarendon Press; 1981:281. 70. ibid.,p. 219. 71. ibid., p. 36.