I have chosen surgery

 

(A surgeon’s memoir)

 

Dov Weissberg

 

 

 

 

 

 

 

 

 

 

 

 

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Rehovot, Israel 2009

 

 

 

 

 

 

 

 

I have chosen surgery

Dov Weissberg

 

Title of the Hebrew original:בחרתי בכירורגיה

ISBN  965-294-139-5     דב ויסברג                        

 

 

 

 

 

 

 

3rd edition (***)

Copyright Dov Weissberg  © 2009

 

All rights reserved. No parts of this publication may be reproduced, stored

in a retrieval system or transmitted in any form or by any means, without permission in writing from the copyright holder.

 

Dov Weissberg, M.D.

11 Be’eri Street

Rehovot 76352, ISRAEL

Telephone 972-8-946-6194

Fax 972-8-946-8065

e-mail dovw@post.tau.ac.il

www.dovweissberg.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Dedicated to my uncle Dr. Józef Klinger

- the first surgeon in the family,

and to my daughter Dorit, who continues

in the tradition of medicine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 


Contents

 

 

Preface

 

 

   9

Chapter 1.

The first steps

 15

Chapter 2.

From Rambam to America

 34

Chapter 3.

Training program with a curriculum

 45

Chapter 4.

Mississippi

 68

Chapter 5.

The interim period: Toronto and New York

 98

Chapter 6.

Shmuel Harofe Hospital

121

Chapter 7.

Struggle at the Wolfson Hospital

141

Chapter 8.

Widening of horizons

159

Epilogue

 

186

 

 

 

 

 

 



 


Preface

 

 

This is a book of memoirs. Its building elements are stories from my life, my experiences. Some touched my very soul and influenced the most important decisions in my life; others carry a simple message or a moral.

Many people contributed to my professional career: teachers, pupils, colleagues, patients under my care and my family. I owe all of them a debt of gratitude and would like to express my feelings of appreciation and thanks for their contribution. Among these, my wife Milka and my children Yifat, Dorit, Limor and Avishai occupy the most prominent place. They gave me all their love and support, and accepted with patience and understanding the harsh reality that kept me busy and usually away from home. They encouraged me to write this book and helped me to edit the material.

Throughout the entire text I tried not to offend anyone. For the most part, I believe, I succeeded; although criticism could not always be avoided. If, in spite of my efforts, some individuals will take offense, I ask for their understanding and forgiveness.

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I do not remember whether I ever consciously “decided” to become a doctor. This decision must have been inborn, although there were at least two factors that helped strengthen it. One was my mother. She was a strong-willed woman, with a legendary power of persistence. It was clear to her, even before we were born, that both her sons (my younger brother and I) must and will be physicians. Any other turn of events was out of question. Any thought that we may, perhaps, choose some other profession or occupation, simply did not cross her mind.

In pre-war Poland it was difficult for Jews to be admitted to universities, particularly to medicine. Many were rejected because of “numerus clausus” – limitation on the number of Jews that were permitted to study at universities. Friends asked my mother: “What if they will not be permitted to study in Poland?” To this my mother had a ready answer: “Then I will send them to England or to Switzerland. Here or there, they will study medicine”. Such were her dreams. But life refused to cooperate. Instead of studies in Switzerland, came World War II and the Holocaust (Fig. 1).

 

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Fig. 1. It was clear to my mother that her sons will be physicians.

 

The second factor was my uncle Joseph (Józek), my mother’s younger brother. He was not accepted for studies in Poland and studied medicine in Italy. Józek was a charming person, friendly and full of joy. He played the guitar and the violin, painted (some of his paintings decorated our walls), sang beautiful Italian songs, and in a most entertaining way, explained secrets of the human anatomy or of the Italian language. Everybody loved him. I was attracted by his company and, as a matter of fact, saw in him a prime example of an ideal human being. Whenever he came to Poland for vacation, I had a real holiday.

I believe that somewhere in the depth of my subconscious, this self-identification with Józek, my love and admiration for him were of crucial influence in my decision to become a doctor.

During the war and the German occupation, in his assumed new identity as a Polish-Christian, Józek became a member of the Polish underground movement Armia Krajowa. He participated in the Warsaw Uprising and, regrettably, was killed in September 1944. He was awarded the Polish Cross of Valor (Krzyż Walecznych) posthumously. To him I dedicate this book (Fig. 2).

 

During my studies in high school, my mind was already made-up. I wanted to study medicine. Nothing else would do. For the time being, the general term “medicine” sufficed, without further analysis. However, at that time I read several books about famous physicians and their discoveries. A particularly fascinating one was Paul de Kruif’s “The Microbe Hunters”. Dramatic descriptions of tropical diseases and the excitement surrounding the discovery of microbes and parasites, all these brought me dreams about a career of science and exploration. Why shouldn’t I become part of the wonderful worlds of discovery? Why couldn’t I be one of those who uncover these worlds and thus save thousands of lives? Later, during bacteriology studies at the University, I saw this exciting field in an entirely different perspective. Bacteriology appeared to me a boring routine of inoculating colonies of microorganisms on agar plates and growing cultures; plenty of dull routine and very little drama. I enjoyed studying anatomy, histology and pathology and at some time even considered making them my career. But bacteriology and parasitology, as seen closely, did not attract me. I studied enough to pass the examinations, but a career of preparing culture media for microorganisms had no appeal to me.

 

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Fig. 2. My uncle Józek (Dr. Józef Klinger) and his Cross of Valor.

 

A dramatic change took place at the outset of my clinical studies. Contact with patients, listening to their histories and examining them, and finally, clinical analysis and treatment spoke directly to my soul. All remnants of my dreams about research and discoveries vanished without a trace. It is impossible not to relate this change to my teacher, Professor Moshe Rachmilevitz, chief of the Department of Medicine in Hadassah. He engraved his unmistakable mark on students’ minds: the understanding that there is need for clear thought and simple logic (“clinical logic” – his favorite expression). In particular, he taught his pupils how to distinguish between the clinically important and the insignificant. “Retain the important and dispose of the rubbish”. Moshe Rachmilevitz taught me to love clinical medicine. During my studies under him, there was almost no doubt in my mind that in the future I will be an internist.

Surgery was different. I was not nearly as attracted to it as to internal medicine. As a surgeon, it is now embarrassing for me to confess, but after the period spent in the Department of Medicine, my rotation through Surgery was rather dull. This was not due to the nature of surgery itself, but rather because of the way we were taught. On Medicine, every student was in charge of a number of patients, had to participate in their diagnostic workup, try to diagnose the case and suggest treatment. On Surgery, the students were supposed to admit patients, obtain their clinical history, do complete physical examination, and then present them at the bedside rounds. During presentation we were asked questions supposed to arouse interest and to help in our studies. But in contrast to Medicine, the clinical workup was limited, and entirely in the hands of physicians. Students could ask questions and received instructions. But the feeling of being part of the team was missing. Our role was passive. My function as a student in the Department of Surgery did not stimulate a desire to become a surgeon.

This changed completely upon my return to the Department of Surgery two years later, as an intern. All patients on the service were now under my care, and I had to suggest their diagnostic workup and treatment. Participation of interns in operations was very limited, and usually not beyond holding retractors, sometimes for long hours. However, if I prepared myself beforehand by reading relevant material, I understood what was going on and the procedure itself was interesting.

Moreover, in Surgery I could immediately see the results of treatment, and they were much more definitive. On the medical service a patient discharged after treatment for a congestive heart failure can return two weeks later with the same problem. Feeling of disappointment is then unavoidable. But a patient, who undergoes resection of a gallbladder full of gallstones, does not return with the same stones and the same pain. Surgery is much more dramatic and decisive, features that befitted my taste and temperament. My rotation as intern in the Department of Surgery was therefore crucial in choosing the field of medicine appropriate for me.


1

The first steps

 

 

 During my internship at Hadassah, an accident occurred that critically influenced my entire professional future. Friday morning, 18 January 1957, on my way to the Hospital, I slipped in the rain and fell. I felt instant pain in my left hip and could not get back on my feet. People on the street helped me, and I continued slowly, limping all the way to the Hospital. I started my routine work - drawing blood samples, preparing patients’ charts for rounds with the Professor, and similar chores. While doing all this, my limping became more obvious and arose general attention. Dr. Shlomo Rogel, at that time a medical resident and later professor and well-known cardiologist in Jerusalem, insisted that I get a radiogram. Finally, against my wishes, he sent me to the radiology department. The radiogram showed fracture of the femoral neck. I was not permitted to get up from the table. I was immediately transferred to the Emergency Room and was operated on that same day. Dr. Makin, chief of the orthopedic division, fixed my broken bone using a Smith-Petersen nail that remained in my body until the hip replacement 46 years later. During the operation a number of complications occurred. As a result, I remained in the hospital for a whole month, and in a convalescent home for another month. For four months I was not permitted to use my left leg, and had to walk on crutches. The curriculum of my internship was modified, to enable me to be in “easier” departments during this difficult period.

Just at that time several resident positions became available in the Department of Surgery and a tender was announced. The candidates were interviewed in the Lecture Room of the Department of Surgery – the famous “shack” in the yard of the Ziv Building. Not doubting that my chances were excellent, I applied for the job. Judging from my student record and my performance as intern, there was no doubt in my mind that my residency position was assured.

When the judges’ decision was announced, the results amazed me. I was not accepted. The shock was beyond description. I felt that a great injustice had been done to me. I did not understand what had happened and could not accept the verdict. True, all the candidates were good, and the number of positions was limited, but still, the fact that of several available openings not one was offered to me, did not make sense. To me it seemed a terrible distortion of impartiality. For the next 29 years, long after recovering from the shock, the puzzle did not stop mystifying me. In 1986, when I had already been Chief of the Department of Surgery for 15 years, I happened to visit Professor Theodor Wiznitzer in Tel Aviv. We were drinking coffee and telling stories. In 1957, when the candidates for the position of resident were interviewed in Hadassah, Wiznitzer served there as a senior surgical resident. During the interviews, he entered the shack several times with some information for the senior surgeons and stayed for a while in the room. In this way he had an occasion to overhear some of the reasoning in favor and against the various candidates. When the candidate – Dov Weissberg – entered the room limping and supported by crutches, all the favorable impression from his good work as intern was forgotten in an instant. The judges saw only the limping intern supported by crutches, and nothing beyond. “Can this disabled young physician be a surgeon?” was their only thought. My fate was decided once and for all. From this moment on I had no chance to be accepted for a residency in Hadassah.

Had I been accepted in Hadassah, my career would probably have developed differently than in fact happened. Had I been... But whatever happened, had happened and it was irreversible. The senior surgeons remained my friends and through letters of recommendation and phone conversations helped me obtain a residency position. But not in Hadassah. This was the way that led me to the Rambam Hospital in Haifa, Department of Surgery B. Chief of the department, Dr. David Erlik (later Professor Erlik, founder of the Abba Khushi School of Medicine in Haifa) himself went through surgical training in Hadassah and all the senior surgeons there were his friends. Their recommendation was enough to ensure being accepted to his department. Indeed, this time there were no difficulties, and the tender was a simple formality. Because of my recent fracture, my military service was postponed for one year, and I could start the surgical residency immediately after my internship (Fig. 3).

 

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Fig. 3. The Graduation; the author first from right.

 

One day in January 1958, just before the end of my internship, I went to Haifa for an interview with Dr. Erlik. He showed me the hospital and invited me to see some operations. The schedule for that day included a porta-caval shunt, a major and new operation at the time. Dr. Erlik was the first surgeon in Israel to have performed this kind of operation successfully, and it was interesting to see him do it. I stood behind him and observed. One of the side-lamps obscured part of the operative field, so I shifted it slightly to the side. While I did this, the lamp hit the main headlight suspended from the ceiling, covered with a special opaque pane. The pane broke with great noise and shreds of glass fell in all directions. It was pure luck that no glass fell into the open belly. I wanted to bury myself on the spot. But Dr. Erlik tolerated the accident with patience and humor. Wasn’t this accident a sign from heaven, an omen forecasting the upcoming developments in Rambam?

 

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I completed my internship in Hadassah on 31 January  1958 and on 1 February started the residency in Surgery. The Rambam Hospital had two Departments of Surgery: A and B. Department A took care of general surgery only. Department B (that of Dr. Erlik) handled, in addition to general surgery, also urology and vascular surgery. The background of this state of affairs should be explained, because it sheds light on Dr. Erlik’s distinctive personality.

In 1948, after the creation of the State of Israel, the British Hospital in Haifa became the Israeli Rambam Government Hospital. At that time the hospital did not yet have a separate urology service. Patients with urologic problems were treated, as in many other hospitals, in the Department of Surgery. To aid in the development of the hospital, a decision was made in the Ministry of Health, to open a separate urology service. Dr. Erlik from Hadassah became the chief of this new service. Due to his past experience in Hadassah, Erlik was equally proficient both in surgery and in urology, liked both, and had not the slightest intention of cutting himself off from either one of these branches. From the beginning, as the new chief, he admitted to his unit patients with both kinds of problems – general surgical, and urologic. The new unit became not just a urology service, but a full-fledged Department of Surgery, with urology as part of it. In retrospect, the Ministry of Health recognized the fact that two Departments of Surgery are better for the Rambam Hospital than one, and acceded to the new reality. But Dr. Erlik did not stop there. At that time a new branch of surgery started developing - vascular surgery - a novelty that appealed to Dr. Erlik very much. Within a short time this branch also became part of Dr. Erlik’s department, which by now had changed its name from Urology to Department of Surgery B. In later years, Erlik performed the first successful kidney transplantation in Israel. Accordingly, his residents had an opportunity to learn and gain experience not only in general surgery, but much beyond. And not just an opportunity; there was simply no other way. The program required more effort, but provided greater experience.

Surgery flowed in Dr. Erlik’s veins and his grasp of it was all-inclusive. He never hesitated to perform important, life-saving operations in any anatomic region outside of his domain. Chest surgery was not out of bounds, although he never studied it. I remember a soldier brought in as an emergency. He was wounded in the chest. Blood was flowing freely through the tube drain placed in his chest. The young man, with blood pressure near zero, was close to death. Without a moment’s hesitation Dr. Erlik opened his chest. The lung and pulmonary vessels were torn, and there was no way to stop the bleeding, short of resection of the entire lung. Erlik caught the pulmonary hilum (root of the lung) with his hand, pressed on it firmly and placed several heavy sutures on the entire mass of tissue, without trying to separate between the pulmonary artery, veins and bronchus. The bleeding stopped. He placed some more sutures to make sure that the bleeding would not restart. When the patient’s blood pressure began to rise, Erlik cut off the lung beyond the sutures and removed it from the chest. Then, in a voice expressing great satisfaction, he said: “This is the way to do a pneumonectomy.” To all present it was obvious that he had never before performed this kind of operation. He probably never even saw one being done. Indeed, this was not the way to do a pneumonectomy. But the bleeding did stop, and the soldier recovered and was discharged from the hospital. Many surgeons, among them chiefs of departments who had never learned how to do a pneumonectomy, would have stood there helpless, while the patient exsanguinated. But not Dr. Erlik. Erlik judged surgeons according to their performance in the operating room. He classified them either as “surgical stuff” or “non-surgical stuff.” If there ever was a physician made of “surgical stuff”, it was Erlik.

Dr. Erlik demanded absolute discipline and promptness. I remember the appendectomy of Dr. Fliegelman, Chief of the Department of Psychiatry in our hospital. Dr. Erlik made the diagnosis while examining him at home. The operation had to be done immediately. It was afternoon. Dr. Erlik was busy with some other business, which influenced his mood unfavorably. I was in the hospital on first call for emergencies. Dr. Erlik called me and demanded that the patient be on the operating table at 5 o’clock. Exactly at 5. I did all I could to complete the examination and bring the patient to the operating room on time, but an unexpected obstacle prevented me from achieving it: Dr. David Barzilai, a senior physician (later, chief of the Department of Medicine), decided to obtain an electrocardiogram before the operation. Due to some technical problem, it was impossible to make the EKG machine work, and Barzilai stubbornly refused to transfer Dr. Fliegelman from the Emergency Room to the operating suite without an EKG record. I told him that Dr. Erlik wishes to have the patient on the table at 5 o’clock, wants to start the operation exactly on time and is in bad mood. “Do you want the Chief of Department to undergo an operation without an EKG record?” asked Barzilai with derision. To my answer, “Yes, this is what Dr. Erlik ordered,” Barzilai did not even bother to answer. At 5 p.m. exactly Dr. Erlik entered the operating room, but the patient was not there: he was still waiting for the EKG in the Emergency Room. With shouts of rage Dr. Erlik ran to the Emergency Room and Dr. Fliegelman was immediately sent to the operating theater. Without an EKG. The operation started after 6 p.m. and throughout its entire course I felt Dr. Erlik’s anger.

 

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When I came to the Rambam Hospital, all the work on the service, including emergencies on our days on call was done by three physicians: Dr. Singer - deputy chief of the department, Dr. Schramek - senior surgeon and Dr. Levin - second year resident, one year ahead of me. I was the fourth to join the team. Occasionally we had an intern for a month, but unlike Hadassah, most of the time there was no such luxury in Rambam. Just then Dr. Singer left for a sabbatical year in the United States, and all the work in the 45 bed department, plus emergency calls, was carried on by the reduced team. To make the picture complete, it should be clarified that in those years, the Emergency Room of the Rothschild Hospital in Haifa was open for emergencies only one day a week, and the Carmel Hospital did not have an emergency department and did not accept emergencies at all. In 1958, the Emergency Room of Rambam Hospital was the busiest and carried the greatest burden of all the hospitals in Israel. There were, as I mentioned, two Departments of Surgery in the hospital, each with two residents. The nights on call were divided equally between the two departments. As senior surgeon, Dr. Schramek did not take emergency calls in the hospital (he was on second call at home). Each one of the four residents was, therefore, on emergency call every fourth night. When one of the residents was called to the Armed Forces for reserve duty (which accumulated to several months per year), we were on call every third night. No one thought that the Emergency Room should have a team of its own, or, at least one surgical resident just for itself. Nights on call were hard. The single surgical resident set into a perpetual motion was cruising between the Emergency Room, the operating room (emergency operations) and both surgical services, taking care of IVs and other urgent matters there. Today it is difficult to imagine the war-like situation that prevailed in the Rambam Hospital in those days. Many times, the work in the operating room went on uninterruptedly until morning hours, and through the windows one could see the rising sun, while no one attended to the Emergency Room, where patients were waiting...

I remember one early morning following a 24-hour period of uninterrupted work, I was assisting Dr. Schramek on a lengthy operation. In the midst of it, I fell asleep. I woke up from a roaring shout of Schramek in Yiddish: “Weissberg, shluf nisht (don’t sleep)!” It was a rare occasion that a surgical resident actually slept while on a night duty; usually my bed remained untouched. On the day following the night duty, came the usual routine of morning rounds, drawing blood samples, operations, admitting new patients, and so on, until late afternoon or evening hours. In view of this intolerable situation, we went to Dr. Erlik to complain. We asked for a solution, which would make our work a little easier. His response was short and typical: “You don’t know how lucky you are, that you have something to do.” That was it. At the time we found it difficult to understand the great wisdom in Dr. Erlik’s words. Yes, I really mean it. Please, try to imagine for a moment people who have nothing to do. There are many. I know them and pity them much more than those young surgeons (including myself) who have no time to be bored. On our free evenings we found time for recreation, company, studies and hobbies. Indeed, I did have girlfriends, saw plays, read books and scientific journals, and more. Anyone who cannot bear this load, perhaps should not be a surgeon...  Is this the way it should be? No, certainly not. But this is the way surgery was taught in the past; the way generations of surgeons have grown. And one can live with it. However, if good results are to be expected from such exertion and stress, two prerequisites must be fulfilled: friendly atmosphere and feeling of progress.

The senior surgeon in our department, Dr. Alfred Schramek worked hard and demanded a lot, not only from others, but from himself as well. He was broadly educated, had a fine sense of humor, spoke several languages fluently, loved music and understood literature and art. One could converse with him on any subject. In short, an intelligent person. But he was hard to work with, did not excel in politeness and in gentleness, and I, the most junior member of the team, felt it well. Dr. Dan Levin, although only one year ahead of me, let me feel his seniority at every opportunity. The atmosphere in our department and in the entire hospital was unpleasant and gave me the feeling of deprivation. Dr. Yaakov Singer, deputy chief of the department, was patient and friendly, but this did not help me when he was studying in America while I was trying to adapt to the uninviting environment. I recall many incidents that exemplify the Rambam atmosphere at that time. A patient with multiple injuries was hospitalized on our service. His broken leg was in a cast. Dr. Steiner, chief of the Department of Orthopedics was supposed to decide when to take the cast off. When the time came, Dr. Erlik ordered me to remind Dr. Steiner, which I did. Dr. Steiner gave me a scorning look and quietly said “good”. Then he waited patiently. On the day when Dr. Erlik made bedside rounds (“Grand Rounds” – twice a week), and when the entire retinue was in the 20-bed ward, a deafening noise of an electric saw burst suddenly in the room. It was Dr. Steiner, removing the cast. This was his way to demonstrate displeasure. Dr. Erlik stopped the rounds, approached Dr. Steiner and asked him what happened. To this Dr. Steiner answered: “Your junior resident gave me an order to take the cast off. That’s all.” Apparently the way I addressed him was not sufficiently polite, or, perhaps he preferred to be invited for a consultation, so that he would decide what to do, rather than being reminded what had to be done. But instead of pointing this out to me, he preferred to make this theatrical demonstration. Dr. Steiner had his own peculiar sense of humor, not always pleasant to his victims.

The Department of Orthopedics did not always have a resident on night call. Minor orthopedic emergencies were taken care of by the surgical resident, who called a senior orthopedist when needed. One evening I was called to see a patient whose leg was in a cast; his toes had become blue and swollen. The cast was apparently too tight and the foot was in danger. I opened the lower part of the cast with an electric saw, to relieve the pressure. I had seen this many times done by experienced orthopedists. The patient’s foot improved immediately. The next day, Dr. Steiner, short of staff, needed assistance on an operation, and I was sent to help him. After the operation he turned to me and said: “I would like to thank you for your help...” Certain that Dr. Steiner was talking about my help in the operation that we had just completed, I answered: “Not at all, I will gladly help, whenever you need”. But Dr. Steiner kept talking: “... for your ‘wonderful’ help in opening the cast last night,” and continued criticizing my way of releasing the pressure, which apparently was not done in the best possible way.

With regard to the feeling of progress, the situation in Rambam surprised me greatly and gave me much to think about. Basic teaching methods, such as clinical sessions, bedside rounds with instruction, and preparation of subjects for seminars and lectures, in Hadassah were taken for granted. In Rambam of 1958 they simply did not exist. The active method of teaching introduced in Hadassah by Dr. Nathan Saltz, based on the North American residency training program, had been initiated by William Halsted at the end of the nineteenth century. It put emphasis on active teaching and gradually increasing the responsibility of the surgeon-in-training (resident). There was an explanation for the lack of similar training program in Rambam: “You see how busy we are; there is simply no time for lectures and discussions. Treating patients comes before anything else.” This was certainly true: hospitals do exist first of all for the purpose of treating patients. However, even simple clinical or technical questions asked during an operation or at bedside rounds, were left unanswered, with a curt “I don’t have time now, let’s move on.” In short, I came to the Rambam Hospital to learn surgery, and after a short while, I had the feeling of marching in one spot. One typical incident clearly illustrates the prevailing situation and the reasons for my frustration.

I had worked already for several months in the department and assisted in many inguinal hernia operations. On the day of the incident the operating schedule included, among others, two boys, 6-year-old twins, both with an inguinal hernia. Dr. Erlik was supposed to operate on both of them, and he chose me to assist him. While we were scrubbing for the first operation, I asked him whether I might operate on one of the boys. Dr. Erlik was visibly shocked by my question. His wet hands, one holding a scrubbing brush, stopped in midair. His eyes, greatly surprised, fixed on me while he asked: “Weissberg, are you crazy?! You want to operate on a hernia? A hernia is a serious operation! You have to learn first how to do it.” If Dr. Erlik was shocked by my question, I was not less shocked by his answer. During my internship in Hadassah I had already operated on a hernia. It was customary that a hard-working, good intern who was interested in surgery, was rewarded toward the end of his rotation either with an appendectomy or a herniorrhaphy. Of course, this operation was done under the supervision of a senior surgeon, but it was the intern who performed the operation with his own hands, and thus learned. Due to the close supervision, the patient was not endangered in any way. The supervising surgeon (in my case Theodor Wiznitzer) was at the head. Had there been any difficulty, he would have taken over and completed the operation by himself. There were no such fancy games in Rambam.

 

*      *      *

Dr. Erlik had a number of principles with regard to surgical technique. One was the need for a sufficiently long incision at every operation. He insisted that a surgeon should have plenty of space available with a comfortable approach to all structures and a possibility to accomplish the purpose of the operation without compromising the patient’s safety. He pointed out jokingly that an incision heals from side to side, not from end to end. This principle is worth remembering now, in the days of minimally invasive surgery, when the tiniest possible incision is pursued above all other considerations. Without denying the advantages of minimally invasive surgery that did not exist in the 1950s, I often see surgeons, some with considerable experience and knowledge, who struggle helplessly with abdominal or thoracic organs because of their difficulty to reach some remote corner of the belly, sometimes causing great damage to tissues. All this, in order to avoid an incision of adequate length. The size of the scar seems more important.

Another of Dr. Erlik’s principles was related to the resection of the thyroid gland. A common complication of this operation is damage to the recurrent laryngeal nerve, the nerve that controls the muscles of the larynx. Injury to this nerve causes speech impairment and must be avoided. While operating on the thyroid gland, some surgeons separate this nerve to protect it against damage. Dr. Erlik claimed that looking for the nerve and dissecting it may be harmful; it is preferable to avoid injury by staying away from it. His results with thyroid operations were excellent, and I do not recall a single case of injury to the laryngeal nerve in our department. One day a well known surgeon from Boston visited Israel. Dr. Berlin was world-famous in the field of thyroid surgery. He insisted that it is essential to dissect the entire length of the recurrent laryngeal nerve, to see it clearly and thus protect it. Dr. Erlik invited Berlin to operate on one of our patients. Dr. Berlin demonstrated his technique clearly, and skillfully separated the nerve from the surrounding tissues. Everything seemed in best order. However, after the operation, the patient’s voice was hoarse, and a laryngoscopy[1] demonstrated paralysis of one of his vocal cords...  This was the first time that I have seen both, how to separate and protect the recurrent laryngeal nerve, and this kind of complication. For many months we joked at the expense of the famous visitor. Apparently Dr. Erlik’s principle was worth more than the elegant demonstration of the nerve.      

 

*      *      *

There was a general frustration among the residents. Our progress was far too slow, and we all felt immense starvation for operating. Itzhak Horowitz, a resident in the Department of Surgery A and later chief of surgery in the Rothschild Hospital, was two years ahead of me in training. Toward the end of his third year in surgery, he was still not permitted to do a cholecystectomy, and Itzik was “hot” to perform it. During one of his nights on call, a patient entered the Emergency Room. She complained of abdominal pain, vomited, and her abdomen was tender in the proximity of the gallbladder. The diagnosis of acute cholecystitis due to gallstones was clear. Horowitz had waited a long time for such a case, and his course of action was planned well ahead of time. He declared that the patient had acute appendicitis, wrote this diagnosis on the admission chart and, according to routine, took the patient to the operating room. Dr. Schramek was on second call at home, but Horowitz decided not to inform him about the case, at least for a while. He asked me to help him on an ”appendectomy”. At that time all abdominal operations in Dr. Erlik’s department were done through vertical incisions. Contrary to many surgeons, Dr. Erlik preferred this incision to all others. This fit exactly Horowitz’s plan. While realizing that the correct diagnosis was acute cholecystitis, he made the incision in the lower abdomen on the right side, as for an appendectomy. As soon as the belly was open, the appendix was found to be normal, as expected. Horowitz resected it, then said “let’s see what’s in the gallbladder”, and extended the incision upward. He found the gallbladder inflamed and full of stones, and started the resection. When this was nearly completed, he asked one of the nurses to call Dr. Schramek and to inform him that during a routine appendectomy an inflamed gallbladder was found and had to be resected. “Perhaps he wants to come, although it is not necessary. I can manage it by myself.” By the time Schramek arrived, the gallbladder was already out and the abdomen almost closed. Horowitz said: “Schramek, there is no need for you to scrub in, the gallbladder is already out.” Schramek was flabbergasted. He barely managed to utter the words: “Horowitz, what have you done?!” “A cholecystectomy”, answered Horowitz, calm and relaxed. He did not show any signs of emotion. Eventually, this entire incident passed without further turbulence. I was too timid and too new in the trade for such tricks, but even much later, I have never reached this level of abusing the regulations.

During the first year of my surgical residency (not an internship anymore!) I was permitted to do appendectomies, but never a case of an inguinal hernia, hemorrhoids, varicose veins etc. Obviously, a cholecystectomy was beyond discussion. I worked in the Rambam Hospital, with an interruption, for a total of nearly two years. During the second year, likewise, I have not done any of these operations, that in the spectrum of general surgery are not considered “major,” except for three operations of inguinal hernia. These were awarded to me through the kindness of Dr. Singer who consented to help and instruct me. Appendectomies and three inguinal herniorrhaphies – this was the total surgical experience that I managed to accumulate during two years of such hard labor in the department of surgery. I felt I was walking in one place and wasting time.

I had enough of the Rambam Hospital and did not want to stay. But what could I do? I went to meet some of my former teachers, chiefs of various surgical services in Hadassah (general, thoracic and others). Conversations with them clarified to me ultimately that my way to Hadassah was blocked. If I was unhappy in Rambam, whose fault was it? Perhaps I was not good enough. And if I failed in Rambam, why should they risk it and take me on? But I believe that there was one other, major reason for their reluctance to specifically accept me as resident in Hadassah: it was their concern not to offend Dr. Erlik. There were plenty of other candidates whose acceptance would not offend anybody. Eventually I realized that my efforts in Hadassah were wasted; there was no point trying there. Should I start looking for a residency position in other hospitals in Israel? As a matter of fact I worried that a position in some other hospital might not necessarily be better than my present position in Rambam, but still, I tried. Several department chiefs in Tel Hashomer and in Beilinson answered my inquiries: “You have an excellent residency position in Rambam. Why are you looking for a job?” Again, the same suspicions and the same reasons for not accepting me, as in Hadassah. There remained two options: to resign myself to the state of affairs in Rambam, or, to give up surgery and specialize in a different branch of medicine.

Or..., there were before me physicians who went to specialize in the land of unlimited possibilities - the United States of America. The most striking example was Dr. Saltz from Hadassah. He did not really “go” to the United States, as he was born in New York, but he took his surgical residency there. I personally saw the truly impressive results of his training. I started inquiring among my friends who have spent various periods of study in North America, and I obtained a lot of valuable information and some good advice.

In order to work in the United States as a physician, a foreign medical graduate must first pass examinations both in medicine and in English, to satisfy the requirements of the American authorities – the ECFMG.

To expedite matters, I decided not to take the full advantage of my one-year postponement, but to leave the Rambam Hospital as soon as possible and get over with my military service. I contacted the military authorities and informed the Surgeon’s General Office that my disability is over. I feel well, I function well, and am ready to serve. Within days I was notified that the next Medical Officers’ Course is expected to open in October (a couple of months ahead), and received an order to return to service. I parted from my colleagues at Rambam with good feelings, we maintained contact and remained friends.

The Officers’ Course started on 8 October 1958. It was enjoyable and, unexpectedly, quite interesting. Part of it was military training, but a considerable portion was spent in the various departments of Tel Hashomer Hospital (later renamed Sheba Medical Center). From time to time I participated in operations and learned. For the first time I saw that clinical and surgical problems can be approached in different ways in various departments, and that these differences are discussed freely, rather than dogmatically dismissed. I learned to set broken bones and to immobilize fractures in a cast. I particularly enjoyed seeing lung operations elegantly executed by Dr. Yehuda Pauzner (Fig. 4).

After graduating from the course, I spent a short holiday in Eilat – my first visit there. Following that, I served in various units of the Air Force and took a course in Aviation Medicine. In parallel, I took emergency calls on weekends and nights in the Rambam Hospital, for a fee. In addition to the income, these calls helped me stay in touch with surgery and with the hospital.

In the beginning of 1960, due to some obligation on the part of the Israel Defense Force (IDF), the Medical Corps was supposed to provide a military physician who would work for one  year  in the Rambam Hospital as part of his military service.         

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Fig. 4. At the Officers’ Course: in the center Prof. Spira and the author holding a bottle of brandy.

 

Dr. Erlik realized that after having spent eight months in his department, I had experience in taking emergency calls, could assist in operations, and could no doubt work more efficiently than some newcomer who had never worked in surgery before. Therefore, he requested from Col. Dr. Baruch Pade, the IDF Surgeon General, to send to Rambam not just any military physician, but me. Dr. Pade objected. According to the administrative routine in the Medical Corps, I was supposed to serve in a field unit and was not entitled to the “treat” of spending one year in a hospital, without committing myself to an additional period of service. But, when Erlik wanted something, he knew how to insist. No one could refuse him. To fulfill his wishes, I was sent to serve in Rambam for one whole year.

The first six months were to be spent on the neurosurgical service. This was new to me. During the years in the Medical School and in my internship I never spent any time on neurosurgery, and this was my first opportunity to learn something in this field. The sole resident that worked there, had just left in rage after a fight with the chief, and Dr. Eli Peyser remained alone. I came to fill the vacuum. Besides the chief, I was the only doctor on this 14-bed service, always full, all its patients seriously ill.

Dr. Peyser was a difficult person, short on patience, exploding easily. However, he was a very good surgeon and an excellent teacher. He taught me how to perform a thorough neurologic examination, management of trauma to the central nervous system, and more. He instructed me in reading articles relevant to our patients’ problems and invested great effort in my education. As his only resident, I participated in every single neurosurgical operation done in Rambam during the 6 months I spent on his service. However, as the only junior member of the team, I was on call every day and night, seven days a week. On days without operations, I could leave the hospital, but had to be within reach by phone, and not too far from the hospital. I found out to what ridiculous situations this can lead, when I was called from a movie theater in the middle of a movie. In the hospital they knew my seat number and called the theater. My girlfriend went home (she did not want to stay and watch the movie alone), while I went to the hospital for an emergency operation. A rather unpleasant experience.

For the remaining 6 months I returned to the Department of Surgery B. During my absence, Dr. Singer returned from the United States, and the general atmosphere became more tolerable. Also, the surgical team had expanded by a couple of new residents and I, as an old-timer among them, felt certain superiority.

There were rumors that Dr. Singer may accept a position of a department chief in the Rothschild Hospital. During a coffee break, this possibility was a subject of conversation. When I uttered a few words, Dr. Yaakov Assa, a new resident, asked me with some derision: “Are you also interested in applying for the position?” I felt embarrassed, and did not know what to say. Instead of me, Dr. Erlik answered in Russian: “Nie tot soldat, kotoriy nie khochet byt’ generalom” (One is no soldier, if he does not desire to become a general). Suddenly, I felt like a victor, because even at that early time, there was a glimmer of hope in the depth of my heart to become one day chief of my own department. Erlik understood this.

While working in Rambam, I learned to keep Dr. Erlik in the highest esteem. Today I understand that he was one of the greatest surgeons I ever met. In my memory he remains engraved as a man of great wisdom and integrity, made of the most distinguished “surgical stuff.” He was a man of impeccable character, utterly devoted to his patients and always ready to support his pupils. All those who managed to endure his residency program, have reached important positions in surgery; several became professors and department chiefs. Also, one should remember that Dr. Erlik was the decisive factor in founding the Medical School in Haifa, and its first dean. Without him, establishment of this important institution would have been delayed for many years. A great man (Fig. 5).

  

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Fig. 5. Dr. David Erlik, 1960.


2

From Rambam to America

 

 

Upon my return to the Rambam Hospital in 1960, I met Jack Abouav. Jack completed his medical studies in Hadassah in 1952, four classes ahead of me. After the internship, he went to the United States to learn surgery. He stayed there for six years: four, as a resident in surgery at the Mount Zion Hospital in San Francisco, and two, as a resident in thoracic surgery at the Albert Einstein College of Medicine - Bronx Municipal Hospital Center in New York. Close to the end of his residency he met Dr. Erlik.

Dr. Erlik was a man of wide horizons, concerned not only with the future of his own department, but also with the expansion and progress of the entire Rambam Hospital. He wanted to establish a first rate medical center in Haifa, with its own medical school, based on Rambam and serving the entire north of Israel. Within several years this dream became a reality due to his initiative and persistent efforts. The nearing return of Abouav to Israel presented Dr. Erlik with an opportunity to bring to Rambam a young, capable, and well-trained thoracic surgeon. For Abouav it was an opportunity to return to Israel and obtain a senior position in a large and growing medical center, with prospects to become the future chief of a new department. At their meeting in New York, they agreed that Jack will start working in Rambam, in Dr. Erlik’s department, and will be in charge of all thoracic patients. With time, the number of patients and the volume of work will grow, creating appropriate conditions for opening a separate thoracic surgical unit or department. Obviously, when the time comes to open such a unit, Abouav will be appointed as chief.

In 1959 Jack graduated from the residency program, passed the American Board examinations, and returned to Israel, to the Rambam Hospital. He entered his new job with eagerness and zeal, was involved in general, vascular, as well as thoracic surgery, and in parallel was active outside of the hospital, not sparing efforts to attract to Rambam patients in need of thoracic operations. The number of those patients grew steadily. Jack also enjoyed teaching. At the bedside, in the operating room and in clinical discussions, he explained everything with enthusiasm (strangely, he managed to find time for those activities). When asked, Abouav either gave the correct answer, or responded with questions that stimulated thought. When the answer did not satisfy him, he recommended appropriate reading material (Fig. 6). A spirit of learning was felt in the department. Also, the way he spoke to everybody was noted. Whether it was the most junior member of the staff or a nurse, he spoke politely, quietly, without rage; an unusual way of communicating in Rambam prior to his arrival. Jack was an asset, which everybody recognized and respected. Obviously, those features were acquired while he went through residency training in the United States. I reflected on it and asked myself: “If this is how they learn surgery in America, then what the hell am I doing here?!”

At that time I had already been studying for the ECFMG examinations, and started correspondence with several institutions, the best and most prestigious ones in the United States and Canada. I thought it pointless to take a position in a mediocre hospital, just because it was in America. I chose the hospitals on advice of several physicians who had spent time in America and had some idea, where and how to look for a residency. My list included Johns Hopkins, Mayo Clinic, Peter Bent Brigham, McGill, and several other medical centers of the highest caliber. I showed my list to Abouav. He looked at it, listened patiently to what I had to say, and finally suggested that I write to Dr. David State, Chairman of the Department of Surgery at the Albert Einstein College of Medicine, the institution at which he himself took residency training in thoracic surgery. He recommended State warmly as a teacher and as a person, and said: “Mayo Clinic, Johns Hopkins and the others on your list, will remain a dream. With State you have a chance to be accepted. Write to him. I was trained by him and I do not regret it.” So I wrote.

 

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Fig. 6. Dr. Jack Abouav, Rambam Hospital, 1960.

 

On 21 September 1960 I passed the ECFMG examinations and the following December received a letter from Dr. State, informing me that I had been accepted for residency at the Albert Einstein (Fig. 7). Toward the move, I turned to some of my Medical School teachers for letters of recommendation. They wrote good letters. I never used them, but the wonderful collection remains in my possession until this day.

Fig. 7. The letter from Dr. State.

 

Only two of my teachers refused my request: Dr. Moshe Prywes and Prof. Moshe Rachmilevitz. Dr. Prywes, at that time Deputy Dean of the Faculty of Medicine and in later days President of the Ben Gurion University and Dean of the Faculty of Medicine at that University, claimed that it is not good for me to go to the United States at this early stage of training. Physicians who go to specialize there, reach such high levels of professional expertise, that there is no place in Israel to which they can return. Every job offer in Israel seems too small to them, and eventually they stay in America. Thus most Israelis who go to the United States prematurely, at their own initiative, do not return. My explanations about my great disappointment in Rambam did not convince him. Dr. Prywes suggested that I look for another place in Israel. It will be better for me to go to America later, for a more advanced specialization. The hospital that will send me there, will be obliged to keep a position reserved for me until I return.

Professor Rachmilevitz saw my plans for residency training in the United States as a preparation for settling there permanently. The idea of abandoning Israel was preposterous to him. He told me that bluntly. He did not want to listen to my explanations about Rambam and assurances that I do intend to return to Israel.

The intentions of both teachers were good and motivated by genuine concern. Both tried to prevent emigration of their pupils, graduates of Israel’s only Medical School. Much effort and expense was invested in our education, and we were expected to stay and serve our people.

While the arguments of Dr. Prywes did not impress me, the words of Professor Rachmilevitz “so you decided to emigrate” touched my very soul. I have no other land and the thought of emigration never occurred to me, but I felt that I caused pain and did great injustice to the dearest, most important and most respected of all my teachers. He invested so much in my medical education, and I had offended him. The memory of our conversation did not leave me during all the years I spent in America and did not let my conscience rest. Eventually, when I returned with my family to Israel, I went to see Professor Rachmilevitz and reminded him of our sad and unfortunate conversation. I told him where I had been, what I had done, and what I am now doing in Israel. He smiled. It made him feel well. So it did to me. And I am sorry that he cannot read this book and accept it as my apology (Fig. 8).

 

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Fig. 8. My venerable teacher, Professor Moshe Rachmilevitz.

 

I was discharged from the military service at the end of February 1961. During the month of March I made preparations for the trip, and on 3 April was on my way. After paying for the trip to America (flight from Tel Aviv to Rome and travel by ship from Marseilles to New York), I had $200 left, which I decided to spend on a 2-month excursion in Europe. A 2-month excursion in Europe on $200? Yes, if one sleeps in youth hostels, travels by hitchhiking, enters museums with a student discount or on days when the entrance is free, and eats only bread with margarine; in 1961 this was possible. Indeed, I managed to survive. I was not really hungry, and hitchhiking was more interesting than travel by train or by bus, and much cheaper. I managed to visit every museum I wanted, climb any tower and see any opera I desired, including the Opera of Rome and La Scala in Milano. The performance of Madame Butterfly with Antonietta Stella and Fernando Corena in La Scala was unforgettable. I saw Italy, Austria, Switzerland, Holland and France, and on 22 May boarded in Marseilles the S. S. Zion. We reached New York on 2 June, and in my pocket I still had $10 for “small expenses”. During the month of June I stayed with my mother’s cousin, Edith Abner, and “studied” New York.

On 1 July I started my new job at the Bronx Municipal Hospital Center, the main teaching hospital of the Albert Einstein College of Medicine. I was given a room in the Staff House, and the hospital took care of the residents’ laundry and supplied us with three free meals a day. And no wonder - the salary of first year resident was $2580 per year ($215 per month), well below the poverty line by the U.S. standards of 1961 (Fig. 9).

After I received my first salary, I entered a branch of the Chase-Manhattan Bank located in the vicinity of the hospital, opened an account and deposited my check. Then, in the hospital, I asked one of the doctors whether Chase-Manhattan is a good bank. “For your $200 it is good enough,” answered Dr. Henry Friedman.

Fig. 9. Certificate of Eligibility for Exchange Visitor Status, specifying the conditions of work and fee.

 

 

For this salary the physician worked full time and was on emergency calls every other day. Thus we worked a whole day, night and another day, before having a free night. This was the system during all the years of my residency. Fifteen or 16 nights on call every month. In my first letter to Dr. Erlik I described the situation, adding that it is not customary here to complain. My colleagues in Rambam wrote to me that Dr. Erlik underlined those words, and on bedside rounds attached the letter with a safety pin to his coat. All could read and appreciate how good they have it in Rambam.

*      *      *

My residency started with a rotation on the Urology Service. During my second week there, they already let me operate. There was a patient with carcinoma of the prostate and metastatic spread. In addition to chemotherapy and hormones, the treatment included orchiectomy (amputation of the testicles). This operation is quite simple and it was decided that I will do it. In order to be prepared, I studied all stages of this procedure in an Atlas of Urology. A resident in a more advanced stage of training assisted me. Several minutes after I started, Dr. Leo Charendoff, the almighty Chief Resident entered the operating room. “Doctor Weissberg,” I heard his voice. “I am here.” “You are here? And what are you doing?” “This is Mr. Posner”, I responded. I told him the name of the patient, so he would know who I am operating on. “I know that this is Mr. Posner, but what are you doing?” The intonation of Dr. Charendoff’s voice sounded rather severe. “I am doing a bilateral orchiectomy.” “And why are you doing it?” asked Charendoff. “Because Mr. Posner has cancer of the prostate.” “So why do you do an orchiectomy, not a prostatectomy?!” Only then did it occur to me, that Charendoff did not ask because he did not know what I am doing. He knew this very well, since he himself decided and wrote the operating schedule. He wanted to know whether I understand why an orchiectomy is necessary in a patient with prostate cancer. I prepared myself by studying the technical stages of the operation, but it did not cross my mind to review the physiology and pathology of the prostate and to learn about the changes that occur in the prostate as a result of orchiectomy. Charendoff did not relax, and continued his investigation mercilessly. At the end of the operation I was covered with sweat. This was the first time that I was taught during the operation as it always should have been, and the last time that I came to operate unprepared. A lesson of exceptional value. It sufficed for the rest of my life.

I had one more undesirable incident with Dr. Charendoff. He knew that I had worked in the surgical-urologic department of Dr. Erlik, before coming to the United States. I also told him that I have done a cystoscopy in the past, which was true. When I asked Dr. Erlik to let me do cystoscopies, he said: “You will be allowed to do, when you know how to take care of the complications.” But Dr. Singer was more liberal, and let me do one, while he supervised. The procedure passed uneventfully and seemed easy. However, the cystoscopy that I did under Dr. Charendoff’s supervision, was not so uneventful. I perforated the urethra. However, by this time, I knew how to treat this complication. I removed the cystoscope and Charendoff inserted a catheter into the bladder. The perforation healed within a few days.

 Would it have been more appropriate not to let me do the procedure and so prevent the complication? He who does not operate has no operative complications, but how does one learn surgery? How did Doctor Erlik learn? Was it by not operating? As my training progressed, I caused many more complications. What surgeon did not? But with the passage of time and growing experience, my work improved, and I learned not only how to treat complications, but also how to avoid them.

 

*       *       *

Jack Abouav did not stay long at Rambam. In 1960 a thoracic surgeon from South Africa immigrated and settled in Israel. After a job could not be found for him in Hadassah and in Tel Hashomer, someone in the Ministry of Health thought up the idea that a position could be created in Rambam - a separate Department of Thoracic Surgery. Therefore, arrangements were made, and the new Department was opened, upon the foundations laid during the previous year by Abouav. It was widely known that Abouav was a capable and successful thoracic surgeon. Everybody valued and highly appreciated his clinical and organizing work, but the new thoracic surgeon was older, and therefore, supposedly, more experienced. He became chief of the department. Abouav found himself in the position of the new director’s deputy (his assistant, as a matter of fact). He became deeply offended. Assurances had been given to him that he would be the chief, once the department is established. His boss’s manners did not make things easier. He treated Abouav with ostentatious criticism and disrespect.

According to the American immigration laws, a foreign physician who comes for postgraduate education, is granted a visa (Exchange Visitor, Visa J) that enables him to stay in the United States until the completion of training. Following this, the physician has to leave the United States, and must not return for at least 24 months. This regulation was enacted in order to encourage physicians to return to their countries of origin and improve the standard of medical care there, while using the knowledge and experience gained in America. Because of this regulation, Jack had no choice, and remained under the new chief’s heavy hand until the end of the two-year period. He did not stay in Israel a day longer, and left greatly disappointed and embittered. His old teacher in San Francisco, Dr. Rosenman accepted him with open arms to the Mt. Zion Hospital, where he settled permanently and spent the remainder of his professional life. He did not try to return to Israel. The Mt. Zion Hospital gained a capable surgeon, full of energy and enthusiasm. The main loser of the affair was the Rambam Hospital in Haifa. And I learned from this story an important lesson, to which I will return later in the book.

 


  3

Training program with a curriculum

 

 

In the United States, the training program in surgery is determined by the American Board of Surgery. Chiefs of surgery in accredited hospitals are responsible for carrying out the requirements of the Board, while strict control is maintained over the quality of the training and the volume of operative experience of every resident. The minimum period of training is four years. However, every department chairman can extend it by a year or more, according to his own judgment and the needs of the hospital’s particular residency program. Toward the end of his training, the resident submits a detailed list of operations that he had performed by himself, and those in which he participated as the first assistant. A minimum number of each kind of operation is required and strictly adhered to. After approval by the Board, the resident is permitted to take the examinations that will qualify him as a specialist in his particular field.[2]

Dr. David State, Chairman of the Department of Surgery at the Albert Einstein College of Medicine, had been trained by Owen Wangensteen at the University of Minnesota, was involved in scientific research and desired to transfer this tradition to his pupils. According to this concept, he added one year to the four required by the Board. During this extra year, every resident worked in surgical research (laboratory or clinical). The first two years of the residency were spent on rotation between the various surgical services and the resident gained clinical and operative experience. The third year was devoted to research, but the resident still spent nights on duty in the Emergency Room. This was to assure that he would not lose contact with clinical medicine. During the fourth year, as senior resident, he was again on the clinical services, and now his work included more advanced operations and greater clinical responsibility. During the fifth and last year, as chief resident, he had the ultimate responsibility for patients in his charge. He decided which operations to perform by himself, and which to let others do. The operating room schedule was checked and usually confirmed by the department chairman. In the most extensive operations, particularly those that he had not done before, one of the senior surgeons, qualified as a specialist, supervised and assisted him. The rule of chief resident was almost absolute. He divided the work between the other residents on the service, and devoted to their training as much or as little time as he desired, all according to his own judgment and sometimes caprice. He also evaluated the work and progress of the trainees under his control and reported this to the department chairman. These reports became part of the resident’s permanent record and influenced the chief’s decision – whose training to extend and whom to fire. In this connection I must mention Dr. Ronald Dee, the best chief resident I met during all the years of my training. He spent many hours introducing me to “practical” surgery and taught me many “secrets of the trade”, both in clinical approaches and in surgical techniques – this particular aspect of teaching that I had longed for at Rambam Hospital. We remain friends until this very day. There were also chief residents of a different kind, who took advantage of their position and coerced all kinds of personal services from their subordinates.

 

*      *      *

Three or four times a week, one hour was devoted to teaching and to the discussion of problems on the service; this included the mortality and morbidity conference, analysis of recently published journal articles (“Journal Club”), practical instruction in anatomy with dissection of cadavers, etc. We worked hard and did not have time to waste. As in the Rambam Hospital, this caused much fatigue. I remember a young Japanese intern, Dr. Takaro Suzuki, who was so tired that he fell asleep while examining a patient. I remember the strange view of an unconscious female patient stretched out on the examining table and lying on her, across the table, Dr. Suzuki, stethoscope clutched in hand, deeply asleep and snoring loudly. I tried to wake him up, pulled him firmly by the shoulder and yelled directly to his ear “Suzuki, wake up!” but to no avail. The chief resident, Dr. Chinda Suwanraks, who heard me yelling, entered the room, evaluated the situation, and decided that whatever we do, Suzuki would not wake up. We picked him off the patient and gently put him on the floor. Then I, instead of my sleeping intern, examined the patient. This incident reminded me of that night in Rambam, when I fell asleep during an operation, but with one difference: Dr. Schramek had no difficulty waking me up. Suzuki, known for his drinking habits, was probably drunk at the time.

*      *      *

Whether a patient should be told the entire truth about his condition, is a matter of controversy. There are differences between the Israeli-European, and American approaches. What to tell a patient with an incurable disease? This is a humane-psychological matter, with deep roots in medical ethics. Considerable progress has been made in recent years, but the ideal solution has not yet been found. During the years spent in medical school and at the Rambam Hospital, I had been repeatedly told, how important it is to soothe patients and keep them calm. The truth should never be mercilessly thrown into the patient’s face. Hiding it was customary with a variety of diseases. If high blood pressure did not drop in response to treatment, the patient was not told so, for fear that this would cause the blood pressure to rise even more. This “soothing” approach reached various degrees. Among the physicians I met, there were great liars, small liars, and some, who tried to avoid lying as much as possible, but in general, the tendency was to make the patient calm at almost any cost. This was as important as the treatment itself, if not more so. The intention was always good. For what can be more important than protecting patients from the harsh reality of an incurable malignant disease? The thought behind this was that if the cruel truth becomes disclosed, the patient might commit suicide.

I remember a 50-year-old patient, admitted to the Rambam Hospital because of rectal bleeding. She had cancer of the rectum and was supposed to undergo abdomino-perineal resection of the rectum with creation of an artificial opening in the abdominal wall (colostomy) for bowel movements. This is unquestionably a major and traumatic operation. How does one obtain the patient’s consent for it, without disclosing to her the unpleasant diagnosis? The solution seemed relatively simple. The patient was told that she had hemorrhoids and needed an operation. Not a word that this would be an abdominal operation, nothing about its magnitude and about the artificial opening in the abdominal wall that would replace her anus forever. In those times there was no need for an informed consent; as a matter of fact, any signed consent was not considered essential and quite often was omitted. To the innocent suggestion of hemorrhoidectomy the patient consented without hesitation. How great was her surprise after the operation, upon discovering the long abdominal incision, the big open wound between the buttocks packed with gauze, multiple drains in the abdomen, nasogastric tube in her stomach, catheter in her bladder, two intravenous installations, and severe, unbearable pain. Desperate, she asked what happened. “Nothing. You had an operation,” answered one of the doctors. For whatever reason, this ”soothing“ response did not satisfy our patient. “So much suffering because of hemorrhoidectomy?” she asked. “Yes.” “Had I known what to expect, I would not have agreed to undergo this operation,” answered the patient. Such “impertinence” from a thickheaded woman who understands nothing in medicine! The doctor raised his voice: “Are you trying to teach us, how to operate on hemorrhoids?!” This response shocked not only the patient, but me as well.[3] While I did not know what answers to give to a patient who asked those reasonable and fully justified questions, it was obvious to me that the system of white lies and extreme arrogance exhibited by my colleague was a tragic error. It seemed clear that we should not tell the patient that she has cancer. But what should we tell her? How to prepare her for accepting the unbearable trauma, both psychological and physical? How to convince her to agree to undergo a necessary operation, if she does not understand its importance? I devoted much thought to these questions, but at that time did not find suitable answers.

A short time after starting my residency in New York, I came across a patient with cancer of the cecum. He was supposed to undergo resection of part of his large intestine (right hemicolectomy). When the time of operation came close, I approached him in order to obtain his consent - a written, informed consent, properly signed (this was the United States, not the Middle East!). I told the patient that we plan to resect the right half of his colon, gave him the properly filled consent sheet, and asked for his signature. “Operation? For me?” the patient laughed. “I do not agree.” “But you have intestinal bleeding and it might increase. We must resect the bleeding part of your bowel.” “Don’t worry,” answered the patient, “the bleeding has stopped.” “There is almost no doubt that it will recur. It will be more severe and endanger your life.” “Out of question! I will not have an operation.” The conversation lasted several minutes, during which I tried to explain how dangerous it is not to have treatment, while he, with growing impatience, responded that if I don’t stop bothering him, he would leave the hospital immediately, against medical advice. I went to a senior surgeon, Dr. Meyerowitz, and told him that Mr. V. refuses to sign consent for the operation. “Impossible,” answered Dr. Meyerowitz, as if he had never heard this before from a patient. We both went to Mr. V. “Dr. Weissberg tells me that you refuse to sign the consent for the operation,” said Dr. Meyerowitz. “Yes, indeed, I do not need one, my bleeding has ceased.” “But you have cancer of the large bowel and the bleeding will recur. Besides, the tumor will metastasise.” “Cancer?!”, answered the surprised patient and pointed his accusing finger toward me, “He did not tell me that I have cancer!” Following this, Mr. V. signed the consent form without further delay, and I felt like an idiot. Mr. V. did not become depressed. He did not commit suicide. His operation went smoothly and he lived for many more years, free of cancer. And I still enjoy this didactic lesson in surgical psychology.

Nowadays it is much more acceptable, even in Israel, to tell patients the truth about their condition, although not always the whole truth. There are still differences of opinion on this matter, but finally, the patients’ rights to participate in major decisions regarding their own health and life were recognized. It is their right to know the diagnosis and plans for treatment and to decide whether they wish to accept the treatment.

Psychology of the patient should be considered not only when dealing with consent for operation. I remember a patient with chronic illness who stayed in the hospital for a long time. One day, while she slept, a man came to visit her. The visitor preferred not to wake her up and left the ward. When the patient awoke, I told her that her son had visited her while she slept. “My son? I do not have a son.” “Well, the young fellow who comes to visit you every day, I thought he was your son,” was my innocent response. “Do I look so old?” asked the lady in a scared voice. “That is my husband.” I felt awful, and since then became more careful.

The hospital was always full of medical students, and the residents participated in their instruction (Fig. 10). I enjoyed this work and also learned from it myself. With time, my feeling that I learn best while teaching became stronger. It is relevant at all levels: teaching students and physicians, lecturing to nurses and instructing various other groups and individuals. When I assist a less experienced surgeon on an operation and teach him, I learn together with him. I always allowed my residents to operate from the beginning of their training. They never gave me reason to regret it.

 

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Fig. 10. Lesson in tying a surgical knot; the author first from left.

 

*      *      *

Being in America gave me an opportunity to see world-famous surgeons operating. I took advantage of it from the earliest stages of my residency. From time to time I excused myself from work and went to see the “great” ones, usually recommended to me by friends who knew them. I spent one whole day in the Mount Sinai Hospital and saw the legendary “roaring lion” John Garlock perform several operations on the gastrointestinal tract. On another occasion I spent a day in the Beth Israel Hospital and saw Leon Ginzburg at work. In 1932, he, together with Crohn and Oppenheimer, described a new type of granulomatous inflammation of the intestine, known today as Crohn’s disease. Ginzburg expressed interest in the unexpected young visitor who came to see him operating. He asked several questions, invited me to assist him on one of his operations, and we drank coffee together. I may not have learned much from visiting these famous people, but the meetings enriched my memories.

*      *      *

Each year of my residency I was entitled to a two-week vacation. During the first year I decided to spend the holiday in Washington, D.C. and visit some of the historic sites, museums and other interesting places there. Three weeks prior to my planned trip, I bought a used car, Renault-Dauphin, in good condition. I was a new driver. I received my license about six months earlier, but had almost no opportunity to drive, and my driving experience was close to nothing. After several uneventful trips to Manhattan, I came to a hasty conclusion that I have mastered driving and can drive safely. My friends were surprised at my self-confidence and advised me not to get on the New Jersey Turnpike. But I had no doubts in my driving abilities. “After all, it is only a four-hour trip. What could possibly happen?” On the way to Washington, near Baltimore, I was stuck behind a truck, driving way too slow for my liking. I made a quick move to bypass it...

I woke up in the Emergency Room of the Hartford Memorial Hospital in Havre de Grace, a little town in Maryland. Because of a brain concussion, I did not remember the accident itself. I was lying on the treatment table and felt pain in my chin. The skin was lacerated and a doctor was stitching it up. We started talking. After a couple of sentences it became clear that we were both Israelis, and the conversation continued in Hebrew. The physician, Dr. Gunther (Gideon) Hirsch treated me as if I were his old friend. Instead of leaving me in the hospital for observation, as is customary after brain concussion, he took me to his home for “private” observation, where I stayed with his family for several days. On one of those days I went to visit the Johns Hopkins Hospital in nearby Baltimore. There, I had the opportunity to see Dr. Henry Bahnson operate on an aortic aneurysm. Bahnson was one of the first surgeons who performed operations on the aorta with success. I had heard about him earlier from a friend, an operating room nurse, who had worked with him a couple of years before and admired both his fine work and him as a person.

After recovery at Dr. Hirsch’s home, I still had a few days of vacation left. I went to Washington by train, because the remnants of my car could not be rescued. Dr. Hirsch remained in the United States and still lives in Havre de Grace where he served several terms as its mayor. We remain friends, and exchange holiday cards every year.

 

*      *      *

  In January 1963 I spent my annual two-week vacation in Mexico. I visited archeological sites, places of religious importance, villages, markets, museums, the university campus and the new University Hospital in Mexico City. I saw examples of art and architecture like nothing I had seen before, and conversed a lot with people with whom I had no common language. The holiday was great, perhaps the most interesting and enjoyable in my whole life.

Touring the pyramids of San Juan Teotihuacan was particularly impressive. At noon I became hungry and entered the restaurant “La Gruta” located in a mountain cave. I looked at the menu. “Rabbit a la Gruta” attracted my eyes immediately. I recalled an event that occurred in 1950, when I worked in the zoology laboratory of the Hebrew University, together with Paul Yarden, a classmate and my roommate in the students’ dormitory. We studied anatomy of the mammals, and we were doing an anatomic dissection of a rabbit. I worked with diligence and followed the instructions scrupulously. My meticulous dissection arose Paul’s anger. “You are destroying the meat!” he said. “Excuse me, I am following the instructions exactly, not destroying anything.” “Yes, of course, you are following the instructions and destroying the meat,” insisted Paul. It took some time before I understood that Paul intended to take the rabbit home to eat. One could understand this. In 1950 Israel was on a strict austerity regime. The immigration wave was at its peak, and in order to feed everybody, the government imposed rigid austerity measures with rationing of all food. The rationing of meat was particularly rigorous, with 100 grams (3.5 ounces) of meat per week, per person. Everybody was hungry for meat. Assuming that our rabbit was not poisoned, but had been killed by a blow on the head, and that prior to death it was a healthy creature (this we could not verify, but it was a convenient assumption), dissection completed, we took the dead animal home and cooked it. Neither of us knew how to cook a rabbit, and we did not add any spices. We just put the rabbit in a pot full of water and let it boil for several hours. We certainly managed to kill all the germs, but the food... A terrible stench filled our room and the entire dormitory floor, but this is the smell of rabbit, and nothing could be done about it. We tried to eat the “broth”, but its taste was so awful, that we poured it down the drain. But we could not afford to waste the meat. We managed to eat it, despite the bad taste.

And now... the menu! I wanted to taste a rabbit, a properly cooked rabbit, and nothing would stop my spirit of exploration. So this was my lunch for the day. The taste and the smell reminded me very much of that awful dinner in the students’ dormitory. I could not finish the dish. But the lunch added something to the spirit of my wonderful holiday.

 

*      *      *

My third year of residency (research laboratory) started in the summer of 1963. I desperately wanted to work in the vascular laboratory of Dr. Robert Goetz. In order to assure that I would be assigned to his laboratory (for there were several other, less attractive possibilities), I activated all my diplomatic abilities one year ahead of time.

 First, I met Dr. Goetz, told him that I would like to work in his laboratory and asked him about subjects for research that might fit the 12 months allotted to me. Presented with several possibilities, I studied one of the subjects and prepared the project in general outlines. Dr. Goetz read my research plan, expressed reservations and criticized the weak points. This enabled me to introduce changes and to add some points. This went on several times, until the project was ready. At this point I went to Dr. State (Chairman of the Department) and told him that I was interested in spending my research year with Dr. Goetz, and that we were already well advanced in planning a research project on a subject related to blood vessels. My plot worked well. When the time came to allocate third year residents to the various laboratories, I was assigned to work with Dr. Goetz.

Robert Hans Goetz was born in Germany and studied medicine in Frankfurt. He completed his studies in 1933, the year the Nazis came into power. He was not Jewish, but because of his democratic-liberal ideas and his opposition to the Nazi regime, he left Germany in 1934 and worked for several years in research in Switzerland and in England. In 1938 he moved to South Africa, where for the next 20 years he directed the cardiovascular research laboratory at the University of Cape Town. The results of his work became famous among scientists and he won international renown. In 1958 Dr. Goetz moved to the United States and assumed a position at the Albert Einstein College of Medicine in New York, where he became chief of the surgical research laboratory and of the vascular surgical unit. A brilliant man abounding in original ideas and a charming person (Fig. 11).

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Fig. 11. Dr. Robert Goetz in his research laboratory.

 

In surgery, those were the times of excitement with the use of glue in place of sutures for joining tissues. Dr. Goetz’s dream was to create a safe vascular anastomosis[4] in coronary bypass operations.[5] The bypass operation was considered difficult, and Goetz believed that if a sutureless technique could become feasible, it would make the operation easier. Our purpose was, therefore, to create a coronary anastomosis, using surgical glue instead of sutures. The experiments were carried out on dogs, under general anesthesia. Besides me, two other residents worked in the laboratory: Ruben Hoppenstein, a resident in neurosurgery and Mo (Mohammed) Amirana, a Pakistani, resident in thoracic surgery. Each one helped the two others in their experiments, and we published some of our articles together. My project on vascular anastomoses begun with a failure: the dogs survived the operation, but were dead within several days. At autopsies we found that the anastomoses disrupted because of necrosis of the tissue that came in contact with the glue. The adhesive, methyl-2-cyanoacrylate, in short “preparation E-910” was no good. The project was, therefore, changed: from then on, I studied the adhesive itself, and its effect on tissues. I found that application of E-910 to blood vessels and other tissues caused abscesses and necrosis. There was no point in using it. Because the “revolutionary” glue was in widespread use in many laboratories in the United States, we described the various aspects of our findings, presented them at three international conventions and published six articles in surgical journals (Fig. 12).

 

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Fig. 12. One of the research papers published with Dr. Goetz.

 

In spite of the heavy work load in the laboratory, the emergency night calls and the usual teaching sessions in the hospital, I felt considerable relaxation throughout the entire year. The working hours (morning till afternoon) were convenient, and the work was not nearly as strenuous as that on the wards. There was enough time for socializing, seeing plays and excursions - particularly on weekends. I tried my abilities at skiing, with fracture of my leg as a result (Fig. 13).

 

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Fig. 13. My broken leg – result of skiing.

 

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Fig. 14. Dr. Goetz on the fishing boat.

 

The work in Dr. Goetz’s laboratory was an ongoing pleasure. He was a great teacher, and I had a very rewarding year. Toward the end of the year he took the entire laboratory team for a day of fishing (Fig. 14).

My friendship with Dr. Goetz lasted a lifetime. I visited him shortly before his death and found him active, of clear mind and, as always, young in spirit. He died in December 2000, at the age of 90.

*      *      *

During the fourth year, as senior resident, I no longer had to do the boring, routine work. Instead, I operated more, my operations were more extensive, and I also taught more. This greater responsibility had serious implications regarding matters of my judgment.

I was on a rotation in the Lincoln Hospital in southern Bronx – a neighborhood of poverty, crime and violence. This was an important and useful rotation because of the wide exposure to trauma, that were rarely encountered in the more civilized and quieter neighborhood of the Albert Einstein. I remember a black boy, 16-years-old, shot in the abdomen. I operated on him late at night. Abdominal exploration disclosed extensive laceration of the blood vessels supplying the left kidney, with profuse bleeding. The kidney itself was not damaged, but repairing and connecting the blood vessels was out of the question. The patient was close to death. I had to resect his kidney, which was a life-saving procedure. The bleeding stopped, and the boy recovered. At the weekly mortality and morbidity conference, one of the senior surgeons, Dr. Donald Perlman pointed out that I had resected a “healthy” kidney of a 16-year-old boy. To my explanation that otherwise the bleeding could not have been controlled and the boy would have died, Dr. Perlman shouted in anger: “But you did stop the bleeding! How did you accomplish it?” “I put a clamp on the blood vessels proximal to the laceration site.” “And why did you not use the DeBakey clamp?” This is a special clamp for blood vessels that enables a gentle grasp to stop bleeding, without crushing the vessel. Then one can repair the torn vessel by sutures. In our case this solution was not possible, because the vessels were totally destroyed. There were no sufficient stumps to put sutures in. Had I tried to repair the vessels, the bleeding would have restarted, and the boy would have died. But Dr. Perlman’s outburst gave me something to think about. I learned something. Two years later, while serving a thoracic residency at the University of Mississippi, I operated on a patient shot in the left lung. Upon opening his chest, I saw that the bullet had passed through the pulmonary artery[6], which was bleeding profusely. Rather than resecting the lung, I put the DeBakey clamp on the bleeding vessel, as suggested by Dr. Perlman at the Lincoln Hospital. The bleeding stopped. I sutured the torn vessel gently and removed the clamp. The lung was saved and the patient recovered. While a similar approach was not feasible in the boy who lost his kidney, Donald Perlman’s screaming planted a seed of an idea in my head.

Anticipation of a major operation that I had not performed before, may end in a great disappointment, if the operation is cancelled. I remember a patient with cancer of the rectum, on whom I was supposed to perform my first abdomino-perineal resection. I prepared myself well by reading the relevant articles and book chapters. The morning of the operation, I approached the patient for a little chat. He complained of chest pain and shortness of breath. Appropriate tests were performed immediately and disclosed myocardial infarction. The operation was cancelled, and the patient received treatment for his heart attack. Despite all efforts, he died on that same day. I was disappointed to lose this major operation, supposed to be my first of this kind. The senior surgeon in charge of the patient told me “Do you know how lucky you are that the patient died before you operated on him, rather than during, or immediately following your procedure? Imagine what everybody would have thought about you and how it would have effected your further progress”. Small consolation...

Good working relations and cooperation are of utmost importance and influence the conduct of an operation and its results. Among the many surgeons at the Albert Einstein there was one, with whom I did not manage to establish good relations. Dr. R. did not miss an opportunity to make my life difficult. He always managed to find flaws in my work and criticized every aspect of it, both in the course of operations and on the wards. I never found out his reasons for this strange conduct, so different from all the other senior staff members. Naturally, I did not like to work with him and tried to limit as much as possible my contact with him, but this was never easy, and not always possible. My efforts to avoid Dr. R. became particularly important in the case of Mrs. Angelina Occuizzo, a 72-years-old Italian woman who had cancer of the lower end of the esophagus, where it connects to the stomach. An adequate operation for this tumor involves resection of the lower half of the esophagus and two-thirds of the stomach, with translocation of the remnant of the stomach into the chest and its connection by anastomosis to the remaining part of the esophagus. This is a major operation and a challenge for every surgeon, particularly a young one who had not completed his residency yet. Dr. R. was in charge of this patient, and he was supposed to help me with her operation. I had no earlier experience with this kind of operation, and I particularly worried that if Dr. R. will start his “games” with me, the operation might end in a failure, perhaps even result in the patient’s death. For the patient’s benefit it was important to get Dr. R. out of the way and prevent his participation in the operation. For this particular operation I desired the help of Dr. Louis DelGuercio, whom I respected very much as a knowledgeable and experienced surgeon, and as an excellent instructor. My relations with DelGuercio were good, and at operations we always got along very well. But how to neutralize Dr. R.? How does one prevent a senior surgeon who is in charge of a patient, from participating in this attractive and challenging operation? There was no doubt in my mind that Dr. R. would not renounce his right voluntarily. In order to avoid him, I had to use a stratagem.

I decided to act as a naive “boy” and pretend that I was not aware of Dr. R.’s role in the case. While ignoring him, I went to Dr. DelGuercio, told him about the patient and asked when can we operate on her. DelGuercio was not stupid. He knew very well, who was in charge of the case, but decided to cooperate. He chose a day convenient for the operation and gave me detailed instructions on how to prepare the patient. Our cooperation brought good results. The operation was uneventful, without difficulties or surprises. I enjoyed and learned. The postoperative course, likewise, was smooth.

Dr. R. boiled with anger. Dr. State, Chairman of the Department, was on a sabbatical year in Los Angeles, and Dr. R. complained to the acting chairman, Dr. William Metcalf. I had committed a serious transgression, a sophisticated trick, connived in collusion with DelGuercio. Dr Metcalf was an austere man, rarely seen with a smile, and all residents were afraid of him. But he was unbiased. He usually appreciated my work, and always treated me with fairness. Still, I was quite scared when he called me to his office, less than 24 hours after the operation. Luckily, I was not the only offender. Dr. DelGuercio, the senior surgeon on the case, cooperated with me. Dr. Metcalf did not investigate my transgression in depth; he just wanted to know why I asked Dr. DelGuercio, not Dr. R., to assist me. I took advantage of the situation and told him about Dr. R.’s unfairness toward me and about our unhappy working relations – the plain truth. I did not have any remorse about “telling” on Dr. R. After all, I wasn’t the one to initiate the conversation with Dr. Metcalf. He had invited me and I only answered his questions. We conversed in good spirits and I wasn’t even reprimanded. However, Dr. Metcalf made it clear that only the surgeon in charge of patient, and no other, should be called upon to assist the resident with the operation. He also stressed that in the future I must behave in accordance with the department rules and not initiate changes on my own. When I told DelGuercio about the judgement, he laughed. And Dr. R. learned that he should not give me unjustified trouble. Our working relations improved instantly. From then on, when we operated together, he behaved decently. Dr. Metcalf probably pointed out to him his past unfairness toward me.

Angelina Occuizzo was discharged from the hospital after an uneventful recovery and remained a grateful patient. This woman who had never learned to read and write, sent me every year a Christmas-New Year’s card written by her daughter. The daughter added relevant information about her mother’s progress and so enabled me to maintain a follow up. Angelina lived for another 20 years. She died at the age of 92, free of cancer. Her daughter and I continue to exchange Christmas and New Year cards now for more than 35 years. So perhaps it is justified to use a “non-kosher” trick from time to time...?

 

*      *      *

An essential part of a surgical residency is cooperation between a senior surgeon and a resident, in which the resident is obliged to obey. This is part of learning. But on occasion it can lead to mishaps with serious consequences. I operated on a patient with a mass in the cecum (part of the large bowel). The mass was demonstrated on the barium enema study, and the patient was scheduled for a right hemicolectomy. The senior surgeon who assisted me on this operation had worked earlier in a most prestigious oncologic hospital in the New York City and had extensive experience in oncologic surgery. He was aggressive in all that concerned cancer and usually favored radical, extensive resections. During the operation, I wanted to be sure that the mass is, indeed, cancerous, and suggested that we send a small section for an immediate microscopic examination, while we continue to operate. My instructor looked at me with surprise, smiled and asked: “Are you in doubt? What else can it be?” “It could be a periappendicular abscess, a complication of appendicitis in the past.” “Really?” He took the mass in hand, moved it from side to side and asked: “How many times have you seen an abscess that can be grasped by hand and moved from side to side?” “Never”, I answered. “So, what is this mass?” “This is cancer of the cecum.” “And what is the treatment of cancer of the cecum?” “Right hemicolectomy.” “Very well then, do it.” So I did. The postoperative course was uneventful. After several days we received the report of histologic examination: the resected mass was not cancer, but an abscess, the result of perforated appendicitis...

The same bold and aggressive senior surgeon was embroiled with another case, similar, but with more grave implications. This time, fortunately, I was not involved. The “honor” was bestowed upon another resident. The patient was admitted because of rectal bleeding. Examination disclosed an ulcerated nodule in the rectum. The finding was strongly suggestive of cancer. The appropriate treatment for cancer was abdomino-perineal resection of the rectum with creation of colostomy for bowel movements. The resident who examined the patient suggested biopsy of the nodule in order to confirm the diagnosis, but the senior surgeon was amused: “What else can it be? It is a clear-cut case of cancer.” The operation was technically a “success”, but histologic examination disclosed an inflammatory lesion in the rectum, with no evidence of cancer. The patient recovered uneventfully, but remained without the anus and with a permanent colostomy...

 

*      *      *

The ultimate responsibility for all the patients on the service rests with the chief resident. This brings certain rigidity and inconvenience to the routine of his work: he has no nights off. The chief resident is on call at all times, day and night.

There were three surgical services in the Department of Surgery at the Albert Einstein College of Medicine, with a chief resident on each service. Every night one of the three remained on active duty in the hospital. The other two left hospital at the end of the day, but remained in contact by telephone with their respective services. While during the earlier years I had enough time to see plays and occasionally a movie, this became impossible during my final year as chief resident. However, I did not grasp this new reality from the beginning. I learned it from experience.

On Broadway they were showing the musical “Oklahoma!” I invited a nice medical student who was on a rotation on my service and bought two tickets. I had great hopes for an interesting and pleasant evening. Toward the end of the day I made bedside rounds and discovered a complication in one of my patients: bleeding after a stomach operation. I had to operate on him again, immediately, to stop the bleeding. My hopes for the pleasant evening evaporated in a moment. I apologized to the student (this was the end of our friendship), gave the theater tickets to a junior resident who was free that evening, and stayed in the hospital to operate. The next morning the young physician told me that he and his wife had enjoyed the show immensely...

The bleeding that prevented me from seeing the show had three consequences. First, I never saw the musical “Oklahoma!” Too bad. Second, for the rest of the year as chief resident I never bought tickets for another play. For the whole year I did not see a theater performance. Never mind, one can live without it. But the most important result of that bleeding was the third one: three years later, when I met Milka, I was still a bachelor. Pure gain. Since then I believe in luck.

 

*      *      *

Lung operations caught my interest long before the beginning of my surgical residency. As early as my internship in Hadassah, chest surgery appealed to me. The thought remained hidden in some corner of my brain and started developing while I made my first steps in surgery. The idea matured during my annual rotations on the thoracic surgery service at the Albert Einstein. During the year in the research laboratory it was already clearly established in my mind. I decided to specialize in thoracic surgery. I immediately started searching for an attractive residency position. At this time I met my old friend from Hadassah, Yona Fruman. She used to be an operating room nurse, but at that time worked as a flight attendant in El Al and visited New York frequently. In the spring of 1964 she told me that Dr. Morris Levy from Tel Hashomer has been appointed as chief of the Department of Thoracic Surgery in the Beilinson Hospital in Petah Tikvah. He was expected to return shortly to Israel from the University of Minnesota. I remembered Dr. Morris Levy well from the time I spent in the department of Dr. Pauzner in Tel Hashomer, and had seen him operating on a number of occasions. In 1960 he left Tel Hashomer to work at the University of Minnesota Medical Center in Minneapolis. The news about his imminent return to Israel electrified me. The moment I heard it, I decided to go to Minneapolis to meet Levy and discuss with him the possibility of working with him in the future. Yona suggested that I hurry, because Levy was planning to return to Israel within the next couple of weeks.

Several days later I was on the plane to Minneapolis. Levy remembered me from Tel Hashomer and met me in a good, agreeable mood. Toward his return as department chief, he would need a new team of surgeons. He suggested that I stop my surgical residency, return with him to Israel and join his staff. “Why waste your time here? Come to my department and you will learn something.” His offer was kind and friendly, but I had different plans. Ahead of me were the best two years of my residency: senior and chief. To discontinue at this point, after I invested so much time and effort and became well settled at Albert Einstein – did not make sense. Also, I was planning to continue my surgical education – residency in thoracic surgery – in the United States. My purpose of meeting Dr. Levy was to establish contact toward a more remote future, rather than an immediate, drastic change that would involve interruption of my residency. Thus our meeting did not end in a matrimonial union. But we decided to maintain contact, with eyes on the future.

After the meeting, Dr. Levy showed me the research laboratories of the University of Minnesota. From there I took a short trip to Rochester, to see the Mayo Clinic. I spent a whole day there and became immensely impressed by this legendary institution. I believe that every physician in the world should strive to visit it at least once in a lifetime, to see and learn from its rich history and wonderful organization. Medicine at its best.                

 

  

 


4

Mississippi

 

 

In applying for residency in thoracic surgery I took into account several considerations. I felt certain that I could get an appointment at the Albert Einstein. But this was not what I wanted. During each year of my residency I spent a month or two on rotation on the thoracic surgery service and I had already learned well the routine of the department. Now I was looking for a change: I wanted to meet different surgeons and learn different methods and approaches from them. I wanted to work in a department with a predominance of pulmonary rather than cardiac surgery. Furthermore, I thought that after five years in New York, it might be better to move elsewhere and spend time in a different part of the United States. Above all, I was interested in a department with a good training program, and a leader in surgical progress. With Dr. State’s recommendation I could apply to the best and most prestigious institutions, with a good chance of being accepted in one. Friends advised me to visit the hospitals where I applied and to get a personal impression of the places of my choice, before committing myself anywhere. I took that advice seriously and traveled to several medical centers for exploratory conversations with surgical residents. To my surprise, I discovered that the most prestigious hospitals were not necessarily the best ones for learning. After much hesitation, I applied to eight medical centers and was accepted in four. The hospital that suited my needs best was the University of Mississippi Medical Center in Jackson. It was not the most prestigious hospital on my list, but the Chairman of the Department, Dr. James Hardy was a known pioneer in surgery. Among his many accomplishments were the world’s first human lung transplantation (1963) and the first ape-to-man heart transplantation  (1964).  Dr. Hardy’s  response  to  my  letter was

Fig. 15. The response letter from Dr. Hardy.

encouraging (Fig. 15). In  March  1965 I met him during his visit in New York, in September 1965 my acceptance was formalized (Fig. 16) and in the last week of June 1966 I crammed all my possessions into my old battered Volkswagen beetle, and went on a one-way trip to Mississippi. On the way I took time to visit places of interest, among them the Shenandoah Valley, the Luray and the Skyline stalactite caverns in Virginia, the battlefields of Gettysburg and other historic sites from the Civil War. On the evening of 29 June I arrived in Jackson and stayed in a hotel. The next morning I went to the Medical Center and in one day of fervent activity, managed to meet all the secretaries of Dr. Hardy, register in the hospital offices and obtain a bachelor apartment in the Medical Center. Already on my first day in Jackson I encountered difficulties in understanding the English spoken in the South. It took me some time to get used to it, but today I hear and understand the southern drawl without difficulty.

 

*      *      *

Each year Dr. Hardy accepted one resident for two years of training in thoracic surgery. During the first year the resident occupied a junior position in relation to the second year thoracic resident, but he was senior in relation to the general surgical residents. This particular state of affairs existed because there was no administrative division between the thoracic and the general surgical services. All surgical patients in the University Hospital – general, thoracic and vascular – were hospitalized together, and were taken care of by one “house staff” – the team of surgical residents. This arrangement, which also existed in the Veterans Administration Hospital in Jackson, enabled the general surgical residents to become involved and gain experience in thoracic and in vascular surgery throughout their training. However, this arrangement also created tension between the general surgical and the thoracic residents, because we, the thoracic residents, were “taking” all the thoracic and some of the vascular cases, considered “best”, from the generalists.

 

Fig. 16. Confirmation of acceptance for residency at the University of Mississippi Medical Center.

 

The entire Medical Center included both these hospitals, as well as the School of Medicine and, in addition, the Mississippi State Sanatorium – a hospital for tuberculosis located in Magee, 75 km (45 miles) from Jackson. The head of this whole surgical empire was Dr. James Daniel Hardy.

In addition to routine clinical work, each resident participated in some kind of laboratory research project, and the further one advanced in clinical surgery, the stronger was the research obligation. I was involved in lung and heart transplantations in dogs. This work was done in the laboratory for experimental surgery, three to four hours a week, usually in the afternoon (Fig. 17).

 

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Fig. 17. With Dr. Hardy and our exhibit at the Convention of the American College of Surgeons, 1967.

 

The entire period of my stay in Mississippi was characterized by loneliness, especially if one considers the plentiful social life (within the possibilities of a surgeon-in-training) that I had in New York. The thoracic resident one year ahead of me was Dr. Suheil Saleh, an Arab born in Palestine. In 1948 his family moved to Jordan, and he studied medicine in Beirut. We never worked together: when I was at the University Hospital, he worked at the Sanatorium; due to rotation between the three hospitals we were separated most of the time. This way political frictions were avoided, except for a short-lasting increase in tension during the Six-Day-War.

There were about 150 Jewish families in Jackson and around 100 families in the remainder of the State of Mississippi. But the main problem was not just the small number of Jews in the area. In the past, in my youth in Poland and later in New York, I had quite a few non-Jewish friends, and I felt well in their company. But I did not find a common language with the Mississippi gentiles. Their way of life was utterly different from mine. They never understood my background and my past, and I never showed any interest in hunting, fishing or football (American or European). I like photography, opera, history books... There is no doubt in my mind that there were people like me in the southern states, but I did not have an opportunity to meet them. Many of my gentile acquaintances in Mississippi tried hard to be friendly with me, but usually the conversation centered on their attempts to educate me about Jesus and to point out (for my benefit, of course) my erroneous ways without him. Still, for whatever reasons, I was not in want of Jesus. In spite of many invitations, I had no desire to attend religious ceremonies in churches and listen to sermons, interesting and eye-opening as they may have been. So I remained lonely.

Nevertheless, I found a way to the Jewish community. Before I left New York, my old friend, Dr. Ronald Dee (the chief resident in the beginning of my training), provided me with the telephone number of his relatives in Jackson. They invited me to their home, and later to the temple on Friday night. All the Jews, even those from distant towns where only one Jewish family lived (there were several such towns) used to attend services on the Sabbath. They, like me, missed the company of other Jews, and every Friday night, the only temple in Jackson (reform) was full to capacity. This way I became acquainted with the entire Jewish community in the State of Mississippi. It was the first time in my life that I have been to a reform temple. The rabbi and the majority of congregation prayed with their heads uncovered, although there was no penalty for wearing a skullcap. Some people covered their heads. Men and women sat together. In general, this institution called the Jewish Temple reminded me more of a Christian (Protestant) church than a synagogue. Is this important? I do not know. But the entire show, when seen for the first time, seemed strange. Still, I believe that it was better to attend this “unusual” synagogue, than to remain completely separated from the Jewish community. They welcomed me with friendliness and hospitality. A lonely Israeli, the only one in their town and in the entire state, stimulated the interest and curiosity of many. There was a local chapter of Hadassah Organization, and here, at their court, was a young physician, a graduate of Hadassah, “made in Israel.” Several families invited me to their homes, usually for dinner, but also for a lecture: they wanted me to tell them about Hadassah. I had plenty of relevant slides, and used them in Jackson as best I could.

The approach to work was most serious. Dr. Hardy insisted on it and gave a good example. He made bedside rounds every day, including Sundays. All physicians, from the most senior ones to the most junior interns, and all medical students had to participate. On Sundays the rounds had to be over by 11 a.m., so that people could go to church, therefore it started early in the morning. Dr. Hardy burst with energy and was short on patience. He never waited for an elevator. After completing the rounds on the first floor (adult service), the entire retinue leaped upstairs to the pediatric surgical service on the seventh floor. No one would wait for the elevator, while the boss practically ran up the stairs.

Heart operations were scheduled two days a week. After a heart operation, the resident who participated in the procedure (in essence, always myself), stayed with the patient without a break until the next morning. I used to sit next to the patient’s bed in the Intensive Care Unit all through the night, and if there was anything to do for him, I did it. In the free time I memorized all available current information on the patient, including the results of the most recent laboratory tests (tension of blood gases etc), in order to have instant answers ready for the chief’s visit. He usually came late at night or just before dawn, asked questions and gave example of devotion to the patient and profound knowledge of his problems. However, despite the efforts, the results of our heart operations were not satisfactory, and I did not find much interest in them. I studied cardiac surgery, because this was part of the material I needed to know toward the board examinations, but at this time I was already determined not to continue with it after the completion of my residency. In contrast, the pulmonary and vascular surgery results were exemplary. The team of surgeons included several who accumulated extensive experience in this field and were excellent teachers.

I learned, made progress, and the day was approaching when I would perform my first pulmonary lobectomy. The operation was planned for September 24th that coincided with Yom Kippur. I asked Dr. Gus Neely, the senior thoracic surgeon on the case, to postpone the operation for a day or two. I tried to explain to him what Yom Kippur was and why it was important for me not to operate on that day. But Dr. Neely was not agreeable, and my reasoning did not impress him. He thought that because of my laziness I simply did not want to work on a holiday. He issued a verdict that the operation will be performed as scheduled, with or without my participation. He knew that not performing the lobectomy would be a punishment for me, and was fully satisfied with it. Other residents did not understand my problem. Some asked: “Why can’t you just operate and then go on to celebrate?” For non-Jews in Mississippi it was totally impossible to grasp the meaning of Yom Kippur. Holidays are for celebrating, not for mourning and fasting. I stopped explaining, and on Yom Kippur did not come to work at all. Instead, I went to temple and stayed there – for the first time in my life – the whole day. The operation was performed by another surgeon. Dr. Hardy knew about the incident, but did not interfere. And I was left with the feeling that I did the right thing. It gave me more satisfaction than the lobectomy would have.

The best part of my work was the rotation at the Sanatorium in Magee. This 250-bed hospital was for patients with advanced tuberculosis, coming from the entire State of Mississippi. The work was done by a team of pulmonary physicians. The only surgeon in the house was the thoracic resident from the University Hospital – myself during the six months of my rotation. Three times a week one of the senior thoracic surgeons from the Medical Center in Jackson used to come to the Sanatorium to teach and help me with the operations. The majority of operations were in patients with pulmonary tuberculosis, but there were also many with lung cancer, infectious diseases of the lung and chest cavity, lung cysts, emphysematous bullae and other problems. I also did all the surgical work outside of the chest. For operations on gallbladder, uterus or prostate I contacted the appropriate expert at the University Hospital and made an appointment for the operation date. I performed all the operations, with the experts’ help.

Three senior surgeons instructed me on lung operations. The most prominent character was Dr. Gus Neely – the one who refused to yield on that famous “Yom Kippur lobectomy”. In the much smaller community of the Sanatorium, without disturbances from the “audience”, Dr. Neely learned to appreciate my work, and the relations between us improved greatly. We remained friends until my last day in Mississippi. I know that his reports to Dr. Hardy on my performance as resident were excellent. The second surgeon, Dr. Jesse Wofford, could be best characterized by his extreme religiousness. He served as a part-time Methodist preacher. On every occasion (suitable and unsuitable) he used to bring up the subject of Christian faith and ask me what I think about Jesus. My usual response that I do not think about Jesus did not satisfy him. Apparently he saw the opportunity to convert me to Christianity as his most important human obligation. It seemed obvious to me that his efforts would not stop as long I remain in Mississippi. In fact, he did not stop even for years after I left. I happened to meet Dr. Wofford several times at various surgical conventions in the United States. He never forgot to ask me whether I had learned meanwhile about Jesus and what I think about him now. Both Dr. Neely and Dr. Wofford had been Dr. Hardy’s residents some years earlier. Both were excellent surgeons and teachers and I learned a lot from them. The third surgeon, Dr. Hans Karl Stauss, a German, was born in Dresden in eastern Germany and spent a major part of his life in Romania. He arrived in the United States after World War II and settled in Mississippi. He was friendly toward me and showed great interest in my past in Europe. Dr. Stauss was a good teacher, but as a surgeon, did not equal his two friends. During my six-month rotation at the Sanatorium, I performed under the guidance of these three surgeons 77 thoracic operations. This included pneumonectomies, lobectomies, thoracoplasties of every possible kind and others. As far as operative and clinical experience is concerned, my work at this hospital for tuberculosis was for me the richest and most rewarding period ever.

Wednesdays at the Sanatorium were devoted to bronchoscopies[7] and bronchographies.[8] These procedures were performed on the conveyor belt principle: nurses placed the first patient on the table and started applying local anesthetic to the larynx. I continued with the anesthesia (always local), performed bronchoscopy, and concluded the procedure by injecting contrast medium through a fine catheter into the bronchi. While I was recording the bronchoscopy findings, the nurses took the patient to the Radiology Department for a series of roentgenograms taken at various angles. Meanwhile, I started working on the next patient. At the end of the day’s work, I saw and interpreted all the roentgenograms and compared them with the bronchoscopy findings, as recorded earlier. On an average day there were between 10 and 20 bronchoscopies and bronchographies. All this was done without the help of an anesthesiologist or a radiologist, as such specialists were not on the Sanatorium staff. The work was completed by midday. Then I collected all the roentgenograms and drove to the University Hospital in Jackson – a trip of over one hour – for a conference with my three instructors. They praised my work and decided on further treatment of the patients. The majority were operated on during the following week. In the middle of the conference there was a coffee break (actually, this was my Wednesday lunch). We discussed the white patients before the break and the black ones after (Fig. 18). An  important  detail  should be  pointed out: this

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Fig. 18. Roentgenogram of a black patient. “Colored Infirmary” is clearly indicated on the film.

 

separation by race was exercised only with regard to patients from the Sanatorium. At the University Hospital and the Veterans Administration Hospital the conferences were integrated with no regard to skin color. Racial separation was abolished in the mid-1960s in all hospitals and other institutions that received financial support from the federal government. This change occurred in all Veterans Administration hospitals in the United States, and also in “our” University Hospital, but not in the Mississippi State Sanatorium, which was financed entirely by the government of the State of Mississippi. Accordingly, the segregation at the Sanatorium remained in power, and was not limited to conferences. The institution was based in two buildings: the “Sanatorium”, where white patients were hospitalized (Fig. 19), and the “Colored Infirmary” for blacks (Fig. 18). Each of the buildings had separate teams of nurses and other employees (it was inconceivable that a white nurse would serve black patients), although there was only one team of physicians – all white.

 

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Fig. 19. The Mississippi State Sanatorium.

 

A typical characteristic of Southerners is considerable politeness and notable formality. Except for relatives and close friends, one never addresses people by the first name, only as Mr. or Ms. with the surname following. In my “ignorance”, I used this formal approach with regard to everybody, including my black patients. This resulted occasionally in a misunderstanding, because the blacks did not understand that I was talking to them, and did not respond. However, a corrective remark by one of the nurses was not late to come: “Doctor, we do not call them Mr. or Ms. Her name is Jessie.”

The struggle of blacks for equality in the Southern States reached its peak while I was there. In the summer of 1966 I happened to witness a demonstration in Jackson. Two competing groups of demonstrators arrived in town. One was headed by Martin Luther King, Jr., the other by one of the more violent activists; if my memory does not fail me, it was Stokely Carmichael. Both groups met in one of the town’s main squares. The two groups stood opposite each other. The Carmichael group shouted in unison “power!”, and the group led by King, responded “freedom!”, and so alternating: “power - freedom - power – freedom.” Blood was not spilled. I may have felt lonely in Mississippi, but there was no boredom.

While working at the Sanatorium, I lived in a comfortable house, sufficient for a whole family. Many of the employees lived on the hospital grounds, in similar houses. During a tornado that struck Mississippi (the only one that I have experienced in reality, not on television), I locked myself in the house and worried that the wind might blow it away along with me, as happened to quite a few uprooted trees and some cars. But my house was strong enough and remained firmly on the ground. My Volkswagen, likewise, did not suffer any damage (Fig. 20).

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Fig. 20. My house on the Sanatorium grounds.

 

I had good and friendly neighbors who made every attempt to help me, according to their best understanding. For example, my secretary, Mrs. Mary Polk – like Dr. Wofford, religious to the extreme – overwhelmed me with invitations to visit her church and meet her pastor. Later she implored that I tell them about “the land where Jesus walked.” After several such requests, I accepted the invitation and took my slides and projector to their church. My slide show must have disappointed them, at least to some extent, because presumably they expected to hear about the primitive life in the Holy Land: shepherds and sheep – as in the days of Jesus; also, they probably expected me to tell them more about the Christian holy places and about Jesus himself. Views of contemporary Jerusalem and Tel Aviv, the Hadassah Medical Center (less impressive than the buildings of the University Hospital in Jackson), and sunbathing beauties at the seashore in Haifa were not of particular interest to them. Despite that, Mrs. Polk continued with invitations to visit her church, but I became more resistant and did not come again. Mrs. Polk remained a good and faithful secretary, and her husband, the best barber in Magee, cut my hair every month with great expertise.

*      *      *

The news about the Six-Day-War reached me in the most peculiar way. For a long time before the war started, television and radio programs abounded in threats by Arab leaders who predicted prompt destruction and elimination of the State of Israel. They were arrogant and brazenly self-confident. The economic stagnation in Israel reached new depths. It seemed, that in a well coordinated war effort against Israel, the Arab armies might overcome Israel and materialize their threat. The situation was very grave and there was a general feeling of an approaching war.

On June 5th 1967, while I was on the rotation at the Sanatorium, I woke up later than usual and, contrary to my routine, did not have time to listen to the radio newscast. Without knowledge of the last 24-hour developments in Israel, I went to the operating room. I had just completed a bronchoscopy, when one of the nurses called me to the telephone. It was from the Israeli consulate in New York. They told me that the war had just begun, there is an urgent need for Doctors, and asked me to fly to Israel as soon as I can.

I left the operating room, drove to Jackson, entered Dr. Hardy’s office and told him that I must leave for Israel immediately (Fig. 21). At the Kennedy Airport in New York, an immense crowd of Israelis was waiting for flights to Israel. But the number of planes and flights was limited, and the chances to fly “immediately” were slim. Everybody had good reasons to get to Israel, and my argument that I am a surgeon, did not impress the El Al clerks very much. I waited in the airport on a stand-by basis for a couple of days, with minimal hope and no result. In the meantime, the political and military situation in Israel changed completely. Israel prevailed on all fronts and won the war. I returned to Mississippi to continue my work.

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Fig. 21. The Six-Day-War letter from Dr. Hardy, June 5th 1967.

 

*      *      *

I heard about mediastinoscopy for the first time at the congress of the American Association for Thoracic Surgery in Montreal, in the spring of 1964. Dr. State, always utterly concerned about the education of his residents, used to send us to scientific conventions. He knew about my interest in thoracic surgery and decided that I should go to Montreal. One presentation at the convention arose my particular interest: it was a report on mediastinoscopy with experience in 74 patients. The material was presented by a young surgeon from Toronto, Dr. Frederick Griffith Pearson.

Mediastinoscopy, a method of exploration of the mediastinum,[9] is indicated in patients with enlarged lymph nodes or other masses in this anatomic area. The procedure consists of a direct inspection of the mediastinal contents and obtaining tissue sections for microscopic examination. It is particularly important in patients with lung cancer. The spread of cancerous cells from the primary lung tumor to the mediastinum is a contraindication to major lung surgery, and a documentation of such metastatic spread has important therapeutic implications. I was greatly impressed by the usefulness of this procedure and easiness of its performance. The clarity of the presentation enhanced my interest in the subject. I became obsessed with the idea of mediastinoscopy, and upon my return to New York, suggested to the chief of the thoracic surgery service, Dr. Robert Frater, that we introduce it to our clinical practice. However, Dr. Frater thought that the procedure was hazardous and expressed objections. He also thought that any new method, such as mediastinoscopy, should be concentrated initially in the hands of only one person, who would first learn it well and then teach others. At that time I was the only one in the hospital with an interest in mediastinoscopy and spent only short rotations on the thoracic service. It was not possible for me to take charge of this new operation. Thus my pleas to Dr. Frater did not lead to any results. But the idea remained in my head.

After several months in Mississippi I suggested to Dr. Hardy, as to Frater before him, that we start doing mediastinoscopies. Dr. Hardy, likewise, did not become excited with the idea. He pointed out the dangers. Mediastinum contains large blood vessels, heart and other organs. The method of inspecting mediastinum is performed through a 25 mm incision in the neck. Through this incision the operator inserts the scope – a metal tube illuminated at the end. The area of inspection is limited by the 15-mm internal diameter of the scope. During the procedure blood vessels might be injured, with possible life-threatening bleeding. Still, I was not ready to give up, and waited for a suitable case. A short time later, a patient with lung cancer was admitted to our service. Roentgenograms showed enlarged lymph nodes in the mediastinum, and metastatic spread was suspected. When Dr. Hardy repeated his warnings about the possibility of complications, I said: “Dr. Hardy, you were the first surgeon to perform human lung and heart transplantations; you are doing kidney transplantations and open heart operations; are these not dangerous procedures? What about medical progress?” Hardy thought for a moment and said: “Well, try, but be careful!” The next day I performed the first mediastinoscopy in Mississippi. I had no previous experience with it, and felt a burden of great responsibility and fear of complications. I knew that I must not fail, and worked with extreme caution. Thus my first exploration of the mediastinum was very limited; as a matter of fact, it was incomplete. Yet, I was very lucky, and this limited procedure sufficed: next to the windpipe I felt a firm nodule – an abnormal finding in any mediastinum. I took a small section of the nodule for biopsy and did not look for more. Histologic examination of the tissue disclosed a metastasis of lung cancer. The importance of this finding could not be overrated. It prevented a major operation: an unnecessary thoracotomy. Dr. Hardy felt that progress has been made. He smiled and summarized the subject in one sentence: “Dov, you have my permission to do mediastinoscopies.” So I did. The results were not always as clear-cut as on the first case, but I always managed to avoid complications. The feeling of great satisfaction that I was the first surgeon to perform mediastinoscopy in Mississippi (and later in Israel as well) has not left me until this very day. For historical honesty, I must admit that I learned the proper technique of mediastinoscopy later, while working on the service of Dr. Pearson in Toronto, the same surgeon who summarized his experience with mediastinoscopy at the convention in Montreal.

 

*      *      *

To complete the process of obtaining a specialist certificate, one must pass the examination of the American Board of Surgery. The examination is composed of two parts. Part I is a written examination and includes, in addition to surgery, also basic sciences. Only the candidates who pass this part, can apply for Part II – the oral examination. After having completed my residency in surgery in June, the earliest date of the written examination was 7 December 1966. On this day the examination was held in several cities; the nearest to Mississippi was Galveston, Texas (Fig. 22). I used part of my annual vacation, and after the examination stayed in Galveston a day longer, to see this historically interesting city. From there I went to the National Aeronautics and Space Administration (NASA) and to the Baylor University Medical Center in Houston. I managed to have a look at the superstars of cardiovascular surgery in America – Drs. DeBakey, Cooley and others of worldwide fame.

The oral examination took place in Houston on 31 January 1967 (Fig. 23). The atmosphere was relaxed. Dr. DeBakey, usually feared by those he examined, was among my examiners, but was simply charming (Fig. 24). After the examination I stayed in Houston for ten days, again to see the “superstars” operating. The volume of their work, their organization and efficiency were exemplary and exceeded all that I had expected or could have imagined. Between operations, Dr. Denton Cooley invited me for a short conversation over a cup of coffee.

I received my specialist certificate after several weeks (Fig. 25).

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Fig. 22. Letter of admission for the written part of the examination.

 

 

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Fig. 23. Letter of admission for Part II (oral) examination.

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Fig. 24. Schedule for Part II examination.

 


 

 

Fig. 25. Specialist certificate in surgery.

 

As in general surgery, the examination in thoracic surgery could also be taken only after completing the residency. However, my visit in the United States as a trainee in surgery was initially limited to five years. For the purpose of residency in thoracic surgery my stay was extended for an additional two-year period, but this extension was final, with no possibility of appeal. I could not stay in the United States beyond June 30th 1968.

In order to enable me to take the examination and obtain specialist certificate, Dr. Hardy used his influence with the American Board of Surgery, and I was given permission to be examined while still in training. The examination dates given to me were 20 and 21 April 1968. The examination took place in Pittsburgh, during the days preceding a convention of thoracic surgeons in that city (Figs. 26 and 27). This examination, likewise, was successful (Figs. 28-30).

 

 

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Fig. 26. Admission letter for examination in thoracic surgery.

 

 

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Fig. 27. Examination card of candidate No. 75.

 

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Fig. 28. Letter informing me of examination results.

 

 

Fig. 29. Specialist certificate in thoracic surgery.

Fig. 30. Congratulatory letter from Dr. David State.

 


*      *      *

Equipped with specialist certificates in general and in thoracic surgery, I was ready to return to Israel, and I hoped that this would become possible as soon as my residency was completed. But that was not a simple matter. Before I left Israel, Dr. Prywes from the medical school told me that every physician who succeeds in training in America, returns to Israel with demands that the Israeli hospitals, as a rule, cannot accept. The return to Israel is thus delayed, and, eventually, the successful graduate stays in America permanently. Professor Rachmilevitz, likewise, was let down by my decision to seek training abroad, and accused me of abandoning Israel. At that time I did not believe that this could happen to me, but now his prophesy threatened me.

As early as during my work in the Rambam Hospital, I felt the heavy hand of my seniors. I dreamed that some time in the future, I would become chief of my own service. During the two years spent in Dr. Hardy’s department, this feeling consolidated. Hardy was a great teacher and represented the best in medical education and in surgical progress, but during all the time spent under him, I felt like a slave. More than anything, I wanted to obtain a position of department chief. No more serving another master. Assuming that I would start working in Israel in someone else’s department, it was very unlikely that the chief would be to my taste. Much more likely he would be similar to Jack Abouav’s boss at the Rambam Hospital. This possibility was unacceptable to me. I felt that my knowledge and experience were sufficient for heading a department of my own. During my visit in Israel in 1965 I met several high-ranking personalities in the Ministry of Health, the central offices of Kupath Holim (health services of the Labor Federation) and other institutions. I told them about my plans to return to Israel, and about my expectations. They were ready to offer me a job in almost every hospital, but no one offered me a service of my own. As a matter of fact, I was not surprised. They did not know me and had not seen me working. The risk of accepting a “stranger” for a position of chief was too great.

 Following my visit in Israel, I continued to correspond with people who could offer me a job, but I received only hints and implications as to the future. These did not satisfy me.

Because I had to leave the United States by 30 June, it seemed that the best solution for me would be accepting a temporary job in Canada. I had no desire to stay in Canada permanently, but while working in Canada, I would continue maintaining contacts with medical institutions in Israel.

I initiated contacts with several medical centers in Canada. The most attractive response came from Dr. William Drucker, Chairman of the Department of Surgery at the University of Toronto. Dr. Drucker informed me about his plans to establish a general thoracic surgical division, separate from heart surgery. In view of my qualifications, he was willing to consider accepting me to the staff of the new division. He invited me for an interview.

In Toronto, in addition to Dr. Drucker, I met the appointed chief of the soon-to-be-opened new division – Dr. F.G. Pearson, who interviewed me, showed me the hospital and invited me to the operating suite to see some of the operations scheduled for that day. The first procedure on the schedule was mediastinoscopy. At this point I suddenly realized that Dr. Pearson is the same one who lectured on mediastinoscopy in Montreal in 1964. At the end of the interview I was accepted to the new division as a senior fellow in thoracic surgery for one year, with a possibility of an extension for another year.                 

        

 


 

5

The interim period: Toronto and NewYork

 

 

At the end of June 1968 I parted from my friends in Mississippi and on 1 July started my new work in the Toronto General Hospital, the University of Toronto main teaching center. The activity of the new Division of Thoracic Surgery involved surgery of the lungs, trachea, esophagus, thymus, diaphragm  all the chest contents, excluding heart and major blood vessels. These confines of work were very much to my liking. The service was temporarily situated in the hospital’s oldest building. It was erected in 1913 and situated at the corner of College Street and University Avenue. Four certified surgeons formed the team. Chief of the division was Dr. F.G. Pearson.[10] Another member of the team was Dr. Norman C. Delarue, an older generation thoracic surgeon, with extensive experience in pulmonary surgery. The third surgeon was Robert (Rob) Henderson, who concentrated his activity mostly around the esophagus – study of esophageal physiology and disease, and surgery of the esophagus. I was accepted as a senior fellow (the highest rank of postgraduate training), although at that time I had been already certified in thoracic surgery. In addition, there were residents and interns on rotation.

My work included participation in operations, teaching students in seminars and clinical discussions, clinical research, and consultations in other Toronto hospitals, mainly the Princess Margaret Hospital. This was a hospital for oncology from which I brought many patients to be operated on our service. I shared a secretary with another physician, and had an office of my own, with a telephone. The office was only 2x2 meters (7x7 feet), but the privacy was of inestimable value – I never had such a luxury in New York or in Mississippi.

Dr. Pearson was among the world’s first surgeons to operate on the trachea[11] (resections, plastic repairs) and by the time I worked on his service, had already been widely recognized as one of the leaders in this new and exciting field. My involvement in the clinical workup of his patients and participation as an assistant in his operations, provided me with much valued experience and enabled me to learn a lot about the problems associated with surgery of the trachea. In parallel, I studied records of all the patients with tumors of the trachea treated in the hospital in the past and prepared an article on this subject for publication  (Fig. 31). Similarly, I prepared and wrote up neoplasms of the thymus[12] and another group of interesting tumors – the bronchial carcinoid. This material was presented at several congresses of the most prestigious surgical societies and was published in leading medical journals. Through Pearson I became acquainted with other pioneers of tracheal surgery, among them Hermes Grillo from Boston and Mikhail Perelman from Moscow. Griff Pearson was an excellent teacher and a charming person. He treated members of his team as equals, and never gave anyone the feeling of being his subordinate (Fig. 32).

 

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Fig. 31. The article on tumors of the trachea, with Pearson and others, Annals of Thoracic Surgery, 1974.

 

Every one of us, the senior staff members, as well as interns and nurses, visited his home in Toronto and his farm in the country, a 2-hour drive from the city. He had a house there with a creek behind it, widening to a fish pond, all surrounded by woods – part of his farmstead, with cows and other animals. Canada is a big country… (Figs. 33 and 34). I spent many weekends on that farm, befriended the Pearson family – Griff’s wife and their three little children, swam in the pond, skied and even tried to hunt – unsuccessfully. I spent Christmas Eve of 1968 there, and in 1969 watched on the television the first man landing on the moon. Griff Pearson and I remain lifelong friends.

 

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Fig. 32. F.G. Pearson at the end of a hard day’s work.

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Fig. 33. F.G. Pearson with his family.

 

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Fig. 34. At the Pearson farmstead.

 

Pearson knew that I wanted to return to Israel and that I was looking for a job. However, for the time being, my connections with the institutions in Israel were limited to the exchange of meaningless letters. There was no progress. In order to revive the subject, I had to go to Israel, meet people personally and remind them that I existed and was looking for an opportunity to return to Israel. It was embarrassing to ask for a vacation only three months after I started working, but there was no choice. Pearson did not object that I take my annual holiday in the beginning of the year rather than at the end. So, in October, three months after starting my new job, I went to Israel.

I had meetings with senior officials in the Ministry of Health, city hospitals, central offices of Kupat Holim (health services of the Labor Federation) and the deans of both medical schools – Tel Aviv University and Hadassah. The possibility to find a position in Kupat Holim seemed reasonable for a while. A meeting was arranged for me with Dr. Eger, chief of the Department of Surgery in the Kupat Holim Hospital in Be’er-Sheva (today the Soroka Medical Center). Dr. Eger described to me the situation on his service and stressed that he needed a good deputy. Also, he told me that the hospital was in desperate need of a thoracic surgeon, and that there were plans to open a thoracic surgery service. If I start working there as his deputy, I would be able, besides my work as a senior surgeon, to take care of all the thoracic patients. When the time comes to open the thoracic surgery service, it would be only natural that I would be its chief.

I was very much impressed with Dr. Eger. “This is an example of a department chief, not to be afraid of” I thought. “With a man like him, it would be possible for me to cooperate and, in parallel, built foundations for a unit of my own.” The day’s activity was over and I was in good mood. I went to visit an old friend who served as a senior physician in one of the hospital departments. I told him about my conversation with Dr. Eger and about my plans and dreams for the future. My friend was skeptical. He agreed that Dr. Eger was a nice person and an excellent surgeon, but was surprised at my naiveté. “Of course, you could work and get along well with Dr. Eger, but your hopes for a thoracic surgical service of your own will remain a dream.” He told me that during the Six-Day-War, a thoracic surgeon, Dr. Joseph Borman from Hadassah, was brought to the hospital in Be’er-Sheva to fill the void. He was my age, a senior surgeon on the thoracic surgery service headed by Professor Milwidsky. He worked well and had a good reputation. He was the candidate of Kupat Holim to become chief of the thoracic surgery service, once it will be established. My friend was greatly surprised that I did not know about this, as apparently everybody else did. Meanwhile Dr. Borman worked under the greenhouse conditions of Hadassah, and was not in a particular hurry to come to Be’er-Sheva and start organizing the new service from scratch. He preferred to wait for the department to open, and then come as its chief. He had been assured of this position by the hospital administration and by the Kupat Holim executives.

I had witnessed a similar scenario before. An exact reconstruction of the Jack Abouav affair in Rambam was now unfolding in Be’er-Sheva. By accepting the Kupat Holim’s offer, I would actually be building the foundations of thoracic surgery service for Joe Borman. Should I prefer to stay in thoracic surgery, I could possibly work on Dr. Borman’s service, perhaps as his deputy. In the Kupat Holim offices no one told me this, nor did Dr. Eger mentioned it to me, although it stands to reason that he must have known about it.

I returned to Kupat Holim with a counter-offer: I would start working in Dr. Eger’s department as his deputy, if the tender for the position of chief of thoracic surgery takes place now, and I win it. Once the thoracic surgery service opens, no matter when, there will be no need for another tender. “This is not logical” was the officials’ response. “The tender will be announced when the service is ready to open; at the moment it is not of immediate interest.” They added that if I start working now and organize the service from the foundations, there would be almost no doubt that I would succeed in the tender. However, they were not ready to commit themselves. During those conversations no one mentioned Joe Borman. The people who conversed with me did not suspect that I knew anything about him, and I preferred not to disclose all the information I had, bringing about an open confrontation. In the final outcome I did not accept the job offer in Be’er-Sheva, but the correspondence with the Kupat Holim and other institutions in Israel was rejuvenated and strengthened.

Although at this stage I did not obtain a desired job in Israel as I had hoped, my visit in Israel had one other important result. Until that visit, I have never seen the Western Wall in Jerusalem. Now, that Jerusalem was liberated and united, I went to see it. In the Old City I met an old medical school friend, and right there she introduced me to her relative Milka. I will not elaborate on the details of courting that lasted two weeks, but at the end I proposed to Milka and brought her to Canada, where we married. Now we have four children and nine grandchildren. One could say that my trip was not wasted…

Dr. Joseph Borman did not come to Be’er-Seva to run the thoracic surgery service. On 21 February 1970, a Swissair aircraft exploded in the air, fifteen minutes after its takeoff from Zurich, on the way to Tel Aviv. “The Popular Front for the Liberation of Palestine” took proud responsibility for the explosion. Among the 47 victims of this heinous act of  “liberation” was Professor Hanoch Milwidsky, Chief of the Department of Thoracic Surgery in Hadassah. Joseph Borman was appointed as the new chief and was no longer interested to move to Be’er-Sheva.

 

In order to work in the Province of Ontario (Toronto is the capital of Ontario) I needed an Ontario medical license. I passed the necessary examinations in 1969 (Fig. 35). I also sought recognition of my title of Specialist (Board Diplomate) that I had obtained in the United States. However, during the late 1960s, the institution in charge of qualifying specialists in Canada (The Royal College of Physicians and Surgeons of Canada) was not yet ready to approve titles that were obtained “south of the border”. My Specialist Certificate, valid in the United States, was meaningless in Canada. I had to study for examinations once again. At that time, the Royal College examinations were conducted on two levels. The lower level was to obtain the title of a specialist (Fig. 36). The higher level was to become Fellow of that prestigious and highly respected College. All examinations were written and oral.

 

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Fig. 35. Certificate of the Medical Council of Canada.

 

 

Fig. 36. Specialist Certificate of the Royal College of Surgeons of Canada.

 

For physicians who read this book, I copied some of the questions from the written part of the fellowship examinations (Figs. 37 and 38). Those were the most difficult examinations in my entire life. But I passed them too, and in 1970, at three different ceremonies, I was accepted to three prestigious societies: the Royal College of Physicians and Surgeons of Canada (Fig. 39), the American College of Surgeons (Fig. 40) and the American College of Chest Physicians (Fig. 41). All paths of professional progress in North America were now open for me, on both sides of the border.

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Fig. 37. Questions in pathology and bacteriology at the examination in surgery.

 

 

 

 

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Fig. 38. Questions in basic sciences at the examination in surgery.

 

Fig. 39. Fellowship Certificate in the Royal College of Physicians and Surgeons of Canada.

Fig. 40. Fellowship Certificate in the American College of Surgeons.

Fig. 41. Fellowship Certificate in the American College of Chest Physicians.

 

My daughter Dorit (named in the memory of my late mother) was born in March 1970 (Fig. 42), and in the summer I completed my second year of fellowship at the University of Toronto. I wanted to obtain a permanent position in Israel and to return home. The search for a job by correspondence reached a new peak, but there was no real progress. I reached a dead end, exactly as predicted by Dr. Prywes, when I had asked him for a recommendation letter before setting on my American adventure. Therefore, in parallel to the search in Israel, I started looking for work in the United States. The most attractive job offer came from the Montefiore Medical Center in New York. This hospital had been requested to upgrade the professional level of an old city hospital – the Morrisania City Hospital in the Bronx, a few city   blocks   from   Montefiore.   The   administration    of    the

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Fig. 42. Dorit, six days old, with Milka and Yifat.

Montefiore Hospital was supposed to fill the vacancies in Morrisania with physicians who were on the Montefiore staff and served on the faculty of the Albert Einstein College of Medicine. The position offered to me was a full time appointment in the Department of Surgery at the Morrisania. I would instruct residents in general surgery and, as the only thoracic surgeon in the hospital, would be in charge of thoracic surgery. In parallel, I was offered the academic appointment as Assistant Professor of Surgery at the Albert Einstein College of Medicine. The salary, to be paid by Montefiore, was quite good. I accepted this offer, and in July 1970 my family and I moved to New York. During the four years of my absence, some changes had occurred at the Albert Einstein: Dr. State moved to Los Angeles and the new Chairman of the Department of Surgery was Dr. Marvin (Marv the Marvelous) Gliedman from the Montefiore.

The Morrisania Hospital was located in an area of poverty, riddled by crime. Most of the work in surgery was related to trauma. Until I came, no chest operations were performed there; all thoracic patients were transferred to the Montefiore Hospital. My initial work concentrated on organizing the groundwork for thoracic surgery. The necessary instruments were purchased and operations on lungs and esophagus were performed for the first time in Morrisania. The thoracic surgeons in Montefiore were relieved when the volume of chest trauma in their hospital dropped significantly. Groups of students from Albert Einstein – Montefiore came to the Morrisania for short periods of study. My relations with the surgical staff and with the department chairman – Dr. Gliedman, were excellent. I enjoyed my work and was happy.

*      *      *

I had been at the Morrisania for about two months, when a letter came from the Ministry of Health in Jerusalem: a position of chief of surgery became vacant at the Shmuel Harofe Hospital in Be’er-Yaakov, and a tender was announced. Forms were enclosed, to be filled, in case I was interested in applying for the position. Before receiving that letter I had never heard of the Shmuel Harofe Hospital and had not been aware of its existence. Its obscurity notwithstanding, Milka and I, both viewed this tender with great hope: an opportunity to return home. In case I won the tender, I would have an assured job and could return to Israel immediately. There was no room for hesitation. Without knowing a thing about the Shmuel Harofe Hospital, I filled the forms and mailed them to the Civil Service Commission in Jerusalem. The authorities in charge of the tender agreed to my unusual request to conduct the tender without my personal appearance and were satisfied with my documents, submitted by mail. From the day of application until the results of the contest became available, we lived under indescribable stress. I could barely function. The tender took place in November. At the end of that month I received a telegram (why not a phone call?) stating that I had won the contest (Fig. 43). Here I must point out an extremely important detail: the tender was for the position of Chief of the Department of Surgery (Thoracic and General). At the time I did not realize the importance of this particular phrasing. Its significance became clear only ten years later, when Shmuel Harofe was converted to a geriatric hospital and my department was transferred to the Wolfson Medical Center. I will return to this subject in a later chapter.

 

From that moment on, our lives had changed greatly. After ten years in America we became used to certain way of life. We had to liquidate our home, make purchases toward our return to Israel and organize the trip. But most important, I had to see the hospital  in  which  I  expected  to  spend  the   following   years,

perhaps the remainder of my professional life. With this in mind, in December 1970 I went on a trip of acquaintanceship.

 

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Fig. 43. The telegram (in Hebrew): “We are happy to inform you that you were appointed for the position of Chief of the Department of Surgery at the Shmuel Harofe Hospital. Please let us know the time of your arrival.”

 

The hospital in Be’er Yaakov was built in the days of the British Mandate in Palestine as part of a big military camp. It consisted of barracks built of ”mud and rags”, according to the description of the hospital director, Dr. Walter Davidson. During World War II they started using this particular part of the camp as a British military hospital, and the barracks served as hospital wards. After the establishment of the State of Israel, the hospital was converted into a rehabilitation center for new immigrants with chronic disabilities (“MALBEN”). Most patients were hospitalized for long periods of time, sometimes for several years. Many had lung diseases, usually tuberculosis. After several years, the center was transferred to the government ownership and served as a hospital for tuberculosis. During the Six-Day-War it was temporarily converted to a hospital for wounded prisoners of war. Later it became a general hospital, with a heavy predominance of chest medicine: there were four pulmonary services, but only one general medical service. The Department of Surgery consisted of one 50-bed surgical ward. It filled the function of a general surgical service, but again, there was great predominance of pulmonary surgery. The chief of the Department, Dr. Süsskind Herman, was a thoracic surgeon with extensive experience in surgery of the lungs. In 1970 he died after a prolonged illness and the position of department chief became vacant. Dr. Herman’s staff consisted of two surgeons, both in their fifties. The hospital was not affiliated with any medical school and had no teaching tradition. Patients were admitted to the surgical service for operations only. Dr. Herman performed all lung operations by himself. The two members of his team performed operations of hernia, hemorrhoids and the like. “Major” operations in the realm of general surgery were rare. The physicians in the department of medicine preferred to refer patients who needed surgery, to other hospitals. However, the four pulmonary services supplied Dr. Herman with sufficient volume of work.        

When I came for my acquaintance visit in Be’er Yaakov, I met the hospital director, Dr. Davidson, who also served as chief of one of the pulmonary services. I was not given the opportunity to meet the staff of the Department of Surgery. In retrospect, I believe that this omission was intentional, planned ahead of time by Dr. Davidson, who had good reasons to hide my future team from me.

The hospital barracks were spread over a wide area (Fig. 44). Among the hospitals in Israel it was a peripheral institution, not widely known. Of course, there were no medical students. Only the Department of Medicine was approved for residency training and in 1970 it had only one medical resident. All the other services, including surgery, were not approved for training and had no residents. Thus I was condemned to work with two surgeons whom I had never met. I only knew that both were much older than I. That was it, at least for the immediate future.

 

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Fig. 44. Department of Surgery (barrack no. 7) in Shmuel Harofe Hospital.

 

I could not have been encouraged by this visit. But what was the alternative? To stay in the United States and wait for another opportunity? Others before me have done that. Their “temporary” stay in America lasted their lifetime. It was obvious that the chances for another “lucky strike” with a possibility of returning to Israel were close to nothing. This was my first and probably the only opportunity to become chief of a department of surgery in an Israeli hospital, miserable as it may be. I expected years of tough struggle, but also a challenge. In spite of the disheartening impact of my visit, I did not hesitate. My final conversation with Dr. Amos Arnan, the executive officer in the Ministry of Health in charge of Hospitalization Services, concentrated only on the date of my arrival. Dr. Arnan tried to convince me to return to Israel and start working immediately. Without a chief, the surgical services in Shmuel Harofe were close to collapsing. However, my contract with the Montefiore Hospital obliged me to work for a whole year at the Morrisania, and I was not ready to violate it. In addition, after ten years in America, I needed time to get organized. I promised Dr. Arnan to try to shorten the “arrangements” as much as possible, but could not commit myself to return before July – six months ahead.

In New York I had a concluding conversation with Dr. Gliedman, Chairman of the Department of Surgery at the Albert Einstein-Montefiore – the surgical empire of the Bronx. Dr. Gliedman considered me an asset, important to the further progress and development of the Morrisania Hospital and did not want me to leave. He offered me a considerable raise in salary, tried to tempt me with promises of additional modern equipment, such as a flexible bronchoscope (a novelty in 1970), and more. But all this did not attract me. My decision was unshakable. I had spent ten years in America. It was now time to part from this wonderful country. Further postponement would turn into a permanent abandonment of Israel.

Milka supported my decision without hesitation. During the following six months we concentrated all our efforts on preparations for the return home and in July we set on a trip. We were happy.

On 1 August 1971 I entered my new position as chief of my own surgical department.      

 

 


6

Shmuel Harofe Hospital

 

 

Upon our return to Israel we needed, first of all, a place to live. The hospital administration took care of this problem ahead of time and, on the day we arrived, we received keys to one of the houses kept by the administration for hospital employees. It was a modest two-bedroom wooden house (“Swedish barrack”), adequate as temporary living quarters for an unassuming family trying to take root in a new place. We could catch our breaths and start looking for permanent housing. We soon found and purchased one “on paper”: at the time of signing the contract, an old house stood on that site, ready for demolition. However, the contractor assured us that the construction of the new building would take no longer than two years. Indeed, in September 1973, just prior to the outbreak of the Yom Kippur War, we entered our own new apartment in Rehovot.

The immediate proximity of our temporary house to the hospital was very convenient, particularly during the first two years of my work, when I used to spend whole days in the hospital, from the early morning hours (before 7 o’clock) until after the evening bedside rounds, weekends included, and quite frequently nights as well. This exhausting schedule was the result of my early relationship with the two surgeons on my team. They viewed the appointment of an outsider as chief of the department, as an encroachment upon their ”rights”, sanctified by their longer presence on the service and their age. For them, I was an intruder without seniority, who had seized the position on the top of the pyramid and pushed them down.

As chief, I wanted to be in full control of the department. This was not only my right, but indeed, my obligation. In order to achieve this, I had to be present on the ward at all times. I had to write and personally sign every order; without it, none would be carried out. My work would be sabotaged – I knew this for sure. [13]

The only person on the surgical service I could rely upon, was the head nurse, Nurit Firt. Nurit was a charming and hard-working woman, full of enthusiasm and initiative. She did not spare time and effort to save the service from collapsing. During the following years, my relations with my deputy, Dr. Shmuel Winter, improved markedly. We learned to work together, with respect for each other. Dr. Winter told me, repeatedly, that only since I came to Shmuel Harofe Hospital, did he start performing lung operations by himself. Under Dr. Herman, his participation in the operations was limited to opening and closing the chest. Dr. Winter remained my deputy until his retirement in 1980.

The second surgeon was quite a different matter. I despised him, and for obvious reasons, do not wish to reveal his name. Of course, my opinion might not be considered objective, but save for my own impression, I have no other sources to draw upon. In my appraisal, he was extremely lazy, incredibly stubborn and dishonest. On many occasions I discovered complications – the result of his negligent work that he had tried to hide from me.

The following incident may serve as an example of his dishonesty. A patient who had undergone resection of the pilonidal sinus (abscess over the tail bone) came to me and complained that his operative wound failed to heal. Upon investigation, I found that this surgeon had operated on him, and at the end of the operation, had left a drain in the wound. At the time of closing the wound, the drain had been unintentionally caught in one of the sutures. When the time came to remove it, the surgeon pulled it forcefully, tearing the drain, so that part of it remained in the wound. The surgeon knew well that the wound would never heal as long as the foreign body remains inside, but he told the patient that the treatment has been successfully completed, and discharged him. The wound continued to discharge pus for many weeks, and the patient returned to the hospital. Upon opening the wound, I found the torn drain inside. I showed this to the surgeon. He smiled and said “I thought that it would heal.” I barely restrained myself from slapping his face.

His stubbornness and laziness are well exemplified by his refusal to take emergency night calls because of… his age. He was 51 at the time, and many physicians, his age and older, took night calls according to the needs of their respective services. Following his refusal, he simply ignored the rules and did not stay in the hospital while on a night duty. What could I do? I had no means to impose the law upon him, because of his tenure – a sacred and untouchable right in the Israeli labor relations. I could not fire him. In order not to leave the service overnight without a surgeon on duty, I had to stay in the hospital myself, or to look for surgeons from other departments (urology, orthopedics), or even from outside the hospital. Those surgeons would be strangers, who did not know the patients on the service at all. But nothing else could be done about it. I could only hope, pray, and wait for a miracle to happen. I do not usually believe in miracles, but perhaps this case should provide an opportunity to reassess my beliefs, because a miracle did, indeed, happen.

One day this surgeon told me that he needed two or three months leave of absence. A relative of his had died and he must go to France to receive a great inheritance. In view of the extreme shortage of doctors on my team, it was very inconvenient for me to let him go. But together with the hospital director, we came to a conclusion that we had no choice. The surgeon had accumulated a sufficient number of unused vacation days, and had a good reason to take them now. I had to consent to his request.

The leave of absence declared to last two months, started in February 1974. In May 1974 I received a letter from the surgeon. The return address was that of an attorney’s office in France. The Doctor asked for an extension of his leave for an additional three months, in order to “complete his business.” After another consultation with the hospital director, I granted him this extension too, but added that this one was final. If he does not return by the end of the additional three months, we would replace him. Following this, I did not hear from him for over a year. I wrote him several letters, mailed them all to the attorney’s office in France, but they remained unanswered. During that time, people who knew him well told me that the story about the inheritance in France was a pure fiction; the surgeon was in Germany, where he tried to obtain a medical license and find a job. The chances of his return to Israel were nil.

In November 1974, a doctor with a Russian accent asked for an appointment with me. Dr. Moritz Kaufman, a new immigrant from the Soviet Union, one year in Israel, was a general surgeon with 20 years of professional experience. During the past year he had worked in the Ichilov Hospital in Tel Aviv on a temporary job, but at the end of the year, no position could be found for him, and he was looking for work. I accepted him for a trial period. He came full of energy. It was the first time since I came to Shmuel Harofe, that I had in my department a surgeon with a positive approach, willing to work. He had experience, common sense and good clinical judgement, and always worked hard. He was a general surgeon, but while working with me, learned thoracic surgery as well. We became good friends. When Dr. Winter retired, he became my deputy. On several occasions he told me: “In 1974, when you set our appointment for 6 a.m., I thought that it was an isolated incident.” But he became used to the unusual working hours on my service. Until this day I do not understand why they had not kept him on at the Ichilov Hospital. It was, undoubtedly, their mistake, from which I benefited for the next 21 years. At the end of this period we both retired.[14]

 

Fig 45. Twenty-one years of cooperation and friendship.

 

The surgeon who tried to settle in Germany, returned to Israel in 1975 and appeared before me without any announcement. He entered my room and, with the usual smile on his face said “I am back”. To this I answered “I am very happy to see you, but I wrote you several times that if you do not return by the specified date, we will be forced to look for a replacement. We found one. The position, previously yours, is now occupied by Dr. Kaufman.” “This position belongs to me. I have tenure. Kaufman can look for a job elsewhere,” answered the surgeon, this time without a smile, and left the room. Since then I have not seen him. Not seen, but I heard a lot. The struggle for the position in question lasted a whole year. It involved the Israel Medical Association and the Organization of Government Physicians, both of which supported the surgeon’s claim of his “rights”, but it also involved the executive director of the Ministry of Health, whose primary concern was the benefit of the very problematic Shmuel Harofe Hospital. The hospital had to be upgraded. It was a war in which I invested great efforts, letters, and innumerable hours of emotional argumentation at discussions devoted to this problem. Tenure is holy and untouchable… but at the end I won. Does anyone still doubt that miracles do happen?

When I started my job in Shmuel Harofe, I found there one more surgeon, who was not there during my “acquaintance” visit in December. Because of the severe shortage of staff, the hospital director looked desperately for a surgeon, and found an unemployed one. He appointed him to the surgical staff, in spite of the fact that during the preceding two years the new surgeon had been appointed on a trial basis in 12 different departments of surgery in virtually every hospital in Israel and was fired from each one promptly. It did not take me much time to discover that he was a difficult psychopath and an incurable liar. Fortunately, he did not have the “holy” tenure, so I promptly initiated the proceedings for dismissing him. He reacted to the letter of dismissal by beating up the hospital director and wrote to the Ministry of Health  malicious letters of accusation against me, the hospital director and the hospital.

Getting rid of these two surgeons was a very important and decisive step in improving the status of my department. In parallel, I applied to the Scientific Council of the Israel Medical Association (the equivalent of the American Board of Medical Specialties) for accreditation to provide residency training to surgeons. A commission was appointed and the term for its investigation was set for April 1972. The moment I saw the three surgeons, members of the commission, entering my office, I knew that my chances of passing the test were nil. The Commission Chairman was that thoracic surgeon from the Rambam Hospital, involved in the old “Abouav affair”. He knew me, knew that I was Jack Abouav’s friend, and there was strong feeling of aversion between us. The second member of the commission was Dr. Joseph Borman from Hadassah – a former student and friend of the chairman. That was enough. The third member was Dr. Dintsman from the Beilinson Hospital. He did not know me and had no incentive to struggle in my favor.

The “investigation” by the Chairman of the Commission was particularly traumatic. In striking contrast to the custom of such investigations (in later years I participated in them many times), he did not concentrate on the number of operations done on my service, nor on their variety; not on the function of the supporting services in the hospital, such as the Institute of Pathology, the Emergency Department and others, nor on the availability of other services (e.g. urology, orthopedics) on which the residents would spend part of their training (“rotation”). Instead, he chose to concentrate on the number of patients who died on my service after prolonged illnesses, digging from under the earth “complications” that supposedly could have been prevented, had we tried hard enough, and other similar allegations. The investigation was intentionally antagonistic and ended with the unavoidable and expected result: the accreditation was not granted.

In the beginning of 1973, less than a year since my failure with the first commission, I was granted a second chance. This time the composition of the committee was different and the investigation was conducted in an objective, unbiased spirit. In spite of the fact that no great changes could have occurred in the hospital and in the function of my department in such a short time, the members of the committee did not have any reservations and my department was granted full accreditation for training of surgeons. Many came; some were from other hospitals, interested to spend rotation on my service. The work became more interesting and academically oriented.

The residents were happy with their training and some asked for extension of their rotation period, which was usually granted. A rather striking example of such turn of events was Dr. David (Dudu) Schneider, a resident in gynecology and obstetrics at the Assaf Harofe Hospital. The curriculum of his residency included a six-months rotation period on a surgical service, and he chose to do it in my department. Close to the end of his rotation he asked Prof. E. Caspi, his chief in Assaf Harofe, to let him stay on my service for an additional period of six months. Professor Caspi consented. After that came another request for a six-months extension, and another one. Altogether, Dudu Schneider spent a full two years on my service. He was satisfied with the experience gained and won the highest appraisal of the entire staff. He was a charming fellow and an intelligent and industrious physician. During his rotation, besides the routine work, he managed to write two clinical papers, which we published together. Eventually, he became chief of the Department of Obstetrics and Gynecology at the Assaf Harofe Medical Center, and a leading gynecologic-oncologic surgeon in Israel.

Medical students also came to my department, initially for their elective period of study – one or two months at a time. The first student who came was Richard Reznick from Canada. My friends, surgeons in Toronto told him about me, and he decided to spend his elective month on my service. We were “on the map”. Today Dick Reznick serves as Professor and Chairman of the Department of Surgery at the University of Toronto Faculty of Medicine. Training residents and teaching students demanded great efforts, in which the help of Dr. Kaufman was of inestimable value.

 

In the early 1970s only four hospitals in Israel had departments of thoracic surgery: Hadassah in Jerusalem, Rambam in Haifa, and two hospitals in the Tel Aviv area – Beilinson and Tel Hashomer. In addition, there was my department – thoracic mixed with general surgery. Because other hospitals did not have services of a thoracic surgeon, I was frequently called for consultations, and the patients were transferred to my department for operations. Particularly good relations evolved with three hospitals: Hadassah-Rokach in Tel Aviv (today part of the Sourasky Medical Center), Assaf Harofe and Kaplan. However, I was also frequently called to other hospitals. On several occasions I operated in the Meir Hospital in Kfar Saba.

Soon after entering my job in Shmuel Harofe, I started performing operations that were not done in Israel before. The first one was, quite naturally, mediastinoscopy – that exploration of the mediastinum, which I did in Mississippi in 1967. I was the first surgeon to perform it in Mississippi, and now, the first one in Israel. Since 1971, this procedure became routine in my department, before every resection of lung cancer, as part of the preoperative workup. Many patients were referred to me from other hospitals for this operation, before it became common.

Another operation, that according to my knowledge, no one performed in Israel before me, was the resection of the trachea, because of a tumor, or a scar with an obstruction. During the 1970s I performed more than 20 such operations in Shmuel Harofe, and several others on visits in Meir and Assaf Harofe Hospitals. It should be pointed out that all tracheal resections at Shmuel Harofe, were performed on patients referred from other hospitals.

Pleuroscopy[15] had been in clinical use in the first half of the twentieth century, mainly in the evaluation and treatment of tuberculosis. With the discovery of drugs against tuberculosis and the development of techniques of pulmonary resection, the importance of pleuroscopy declined markedly, and gradually its use was discontinued. The early 1970s brought renewal of this method, not in the management of tuberculosis, but for diagnostic purposes, mainly in patients with pathological changes in the chest cavity, such as masses or collections of liquid. In 1974, my department was the first one in Israel to reintroduce it into clinical use, and in 1980, at the convention devoted to pleuroscopy in Marseilles, France, I presented our early experience with this method in three lectures.

In general surgery, likewise, an invigoration occurred in my department. Patients with major problems in need of surgery, who until recently were referred from the Department of Medicine to other hospitals, started coming to our service. In 1971 and 1972 we did our first porta-caval shunts[16] the     operation that Dr. Erlik was doing in the 1950s as a pioneer, and which I observed him perform when I came for my interview; radical neck dissections for cancer of the neck; resections for cancer of the esophagus with transposition of the stomach into the chest; fundoplication[17] at that time a new operation in Israel; and others. Most of these operations were done in Israel before, but never in Shmuel Harofe Hospital.

At that time I was still interested in surgery of blood vessels, and I performed such operations from time to time. However, for good practice of this branch of surgery, one needs special instruments and a unique installation for angiography.[18] We did not have all these, not even the special needle needed to inject the contrast medium. I received one such needle, a used one, from Prof. Pajewski, chief of the Radiology Institute at Assaf Harofe Hospital. I used it several times successfully, but this was not enough. I talked about it with my former chief, Prof. Erlik, and with Prof. Mark Mozes from Tel Hashomer, both pioneers and leading vascular surgeons in Israel. They managed to convince me that one cannot practice vascular surgery in the 1970s, using methods and equipment of the 1950s. Complications are likely to occur. Furthermore, Prof. Erlik told me: “You cannot be a successful specialist in all three branches: thoracic surgery, general surgery and vascular surgery. Each one demands time for itself. Leave something to others…” Rather than waiting for complications, I decided to follow his good advice and gave up on vascular surgery.

I continued doing only one kind of operation classified as “vascular”, but in which no procedure is performed directly on the blood vessels. There is a condition of excessive palm sweating (hyperhidrosis), caused by a disproportionate function of the autonomous (sympathetic) nervous system. Excision of a short segment of the sympathetic nerve (the segment that affects the palm sweating) brings sweating back to its normal level. This operation is not new. It was conceived and carried out for the first time in 1949 by my old teacher in New York, Dr. Robert Goetz, while he was working in South Africa, before moving to the United States.[19] This operation is not difficult, trauma to the patient is minimal (a 5 cm. incision in the armpit) and the results are excellent. There is no need for any special instruments or radiograms, and every surgeon acquainted with anatomy of the chest and with the physiologic basis of the operation, can perform it. I learned it from Dr. Goetz, while working in his laboratory in New York. In Shmuel Harofe, I introduced this procedure into routine use, and patients started arriving in impressive numbers. Nowadays, this operation is performed in many hospitals in Israel, and the technique for its execution has changed somewhat.

*      *      *

The building of our apartment house lasted two years, and in mid-September 1973 we moved to Rehovot. Of course, we had no telephone. In the 1970s, waiting for a telephone line in Israel (for someone without connections) could last up to 10 years and more (yes, ten years, no mistake), and cellular phones were not yet invented. I hoped, that due to my function as chief of surgery in a government hospital, my waiting period would be shortened, but at the moment we did not have a phone connection.

On Yom Kippur day, 6 October, we were all at home. As usual on that day, there were no radio broadcasts; in fact, we were effectively isolated from the world. Should I suddenly be needed in the hospital for any reason, they would send an ambulance to bring me. There was quiet and tranquility and I was reading a book. A knock on the door interrupted my rest. Our neighbor, a military reserve paramedic was suddenly called to service. Military maneuvers on Yom Kippur? We turned the radio on and the broadcast was on. This was the way we found out that the war had started.

I went to the hospital. The hospital director and his deputy were already there, as well as a group of military officers from the Medical Corps. Within a short time, most of the physicians and the other senior employees were in the hospital. Dr. Davidson explained the situation. All wounded prisoners of war would be concentrated in one hospital, and Shmuel Harofe was selected to be the one. We had to quickly organize to be ready for an influx of wounded prisoners. The plan included:

1.     Maximizing the number of available beds. This would be achieved by discharging nearly all of our current patients. Those who could not be discharged, would be transferred to other hospitals.

2.     Converting as many barracks as possible into “surgical” units.

3.     Organizing the work of all physicians in the hospital, and adjusting it to the conditions of war.

4.     Preparing a daily working schedule with detailed hours, and a list of emergency calls.

5.     Organizing the Emergency Department.

6.     Organizing the Operating Rooms.

7.     Preparing a helicopter landing pad.

 

With regard to Point 1, discharging patients and freeing beds – most of our patients could be discharged either immediately or within a couple of days. Transferring patients to other hospitals was impractical, as all the other hospitals were also preparing for the war and needed free beds. None would accept civilians from Shmuel Harofe. Thus the patients who could not be discharged, were concentrated in one barrack, and were taken care of by their respective physicians.

Point 2 did not present any special problems – the necessary equipment for wound care and change of dressings was brought from the storerooms.

Point 3, organizing work of the physicians, meant concentrating the greatest efforts on treatment of the wounded. Teams were formed, composed of doctors with different expertise (internists, pulmonologists, etc), with one surgeon (from any surgical subspecialty) for every team.

The new daily working schedule was identical for all the medical and surgical staff: 36 hours of work, followed by 12 hours of rest. The 36-hour working period started in the morning and ended in the evening of the following day, when the physician would leave the hospital for the night. This way, we were all in the hospital during the day, every day, while half of us stayed in the hospital for the night. This was not entirely my own original idea. I followed the example of my residency at the Albert Einstein – Bronx Municipal Hospital Center.

The Emergency Department and the Operating Rooms were staffed by surgeons, urologists and orthopedists, who used maximum flexibility and adaptation according to the volume of work.

Point 7 was, of course, not my concern. The helipad was prepared by an Army team.

 

The wounded were brought by ambulances or by helicopters, usually in groups (Fig. 46). There were hours of relative quiet, but when a wave of 20 or 30 casualties hit the emergency room, all changed in a moment, and the team worked under pressure. In every group of wounded there were some severely injured and some who needed operations. The shortage of working hands was overcome by an excellent cooperation between the Emergency and the Operating Room teams. In addition, when needed, groups of “internists” were temporarily transferred from the “wards” (barracks) to the Emergency Department. Classifying the wounded and making early decisions demanded particularly great responsibility, often more than that required by the operations, therefore, the senior surgeons, those with the greatest experience, spent most of their time in the Emergency Department.

 

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Fig. 46. The helicopter landing pad in Shmuel Harofe Hospital.

 

The small staff of Shmuel Harofe Hospital could not handle all these demands by itself. We needed enforcements. Many Jewish physicians, among them experienced surgeons from various countries, felt a need to contribute to the war effort. They interrupted their usual occupations and volunteered to work in Israel. Upon their arrival, they were distributed to various hospitals; some were sent to Shmuel Harofe. Their work was of inestimable value, and I will never forget them. Dr. Ashkenazy, an Israeli, interrupted his surgical residency in Buffalo, U.S.A., and worked in Shmuel Harofe. Professor Gurevitch arrived from Britain and contributed from his extensive experience. Dr. Alan Gross arrived from Canada. I had met him several years earlier, during my fellowship at the University of Toronto, while he was a resident in orthopedics. He came to Israel full of enthusiasm and worked hard until the end of the war. Later, he was promoted to the rank of Professor and Chief of the Department of Orthopedics at the University of Toronto. Dr. Alan Padwell, a young physician, just beginning his training in surgery, arrived from Britain. After the war ended, he stayed in Israel and continued his surgical residency in my department. Eventually he married a charming English young lady and returned to Britain.

I developed a particularly warm relationship with a volunteer from Boston, Dr. Theodore (Ted) Waltuch. This young surgeon was certified both in general and in thoracic surgery. He worked with amazing industriousness beyond the “official” hours, under hard and primitive conditions, so utterly different from those he was used to in Boston. His enthusiastic approach to work and to helping the wounded was exemplary. After the war we remained friends and kept close contact. He returned to Israel for a visit, and during several of my trips to the United States, I visited his home, met his family and lectured at the staff meeting in his hospital. Last year Ted died from heart disease. Blessed be his memory.

To complete the picture, I cannot avoid mentioning another, less exemplary case. About a week into the war, a vascular surgeon from the United States came to Israel. Because of his expertise in vascular surgery, he was referred to Shmuel Harofe, as we did not have a good vascular surgeon.  He did not hide his unhappiness with being referred to treat prisoners of war, and said: “I came to help Jews, not Arabs”. I replied that helping in our war effort certainly helps Jews, and a conscientious physician cannot abstain from treating wounded enemy soldiers. He seemingly agreed with me. Then I showed him our working schedule, pointed to his working hours and nights on call, and we agreed that he would enter his schedule the next morning. However, he did not come. Neither the next morning, nor evening. And not the following day. He did arrive at my office ten years later, with his new wife, before whom he praised himself and his heroic deeds as a war “volunteer”. I did not want to embarrass him in front of his wife, therefore I did not correct his chivalrous stories, but also I did not praise him for what he had not done ten years earlier.

During the war we admitted to the hospital 779 wounded soldiers. Of these, 284 (a little over one-third) were operated on. Ten prisoners died from their injuries. Seventy-seven wounded had penetrating chest injuries (10% of all). There were no deaths in this group. One particular point is worth stressing: although all chest wounds were contaminated and 70 of the 77 were grossly dirty, full of sand, clods of earth and torn clothes, only in one patient (1.3%) did an empyema (purulent infection in the chest) occur. Review of data from the Vietnam War disclosed a 6% empyema rate among the American soldiers with chest injuries. This big difference can probably be explained by the different background of the casualties. The majority of the Egyptian and Syrian combatants were from rural areas. In contrast to the urban Israeli population or to the U.S. combatants in Vietnam, they had rarely received antibiotic treatment in the past. Thus their microorganisms were not resistant to antibiotics, and the first antibiotic treatment gave immediate good results. This phenomenon was particularly striking among soldiers with chest injuries and those with burns.[20]     

The wounded remained in the hospital for a long time beyond that justified by their medical condition, because it was impossible to discharge them “home” or to a convalescent home. They had to stay, until they could be sent to a camp for prisoners of war, which usually meant some time after their complete recovery. Thus they continued to occupy valuable beds, keeping the hospital full to capacity, until the end of the war. A surplus of casualties, for whom no place was available (to the best of my memory, over 30 combatants) were hospitalized in the Assaf Harofe Hospital. Those in need of neurosurgical treatment, were hospitalized at the Sheba Medical Center in Tel Hashomer.

We developed good personal relations with some of the Egyptians, and from time to time we heard a few words of thanks. I remember a young military physician injured in the chest and with fractures in three of his limbs, all in a cast. We conversed almost every day and, as an expression of our special relations, gave him a separate room. In contrast to the Egyptians, we never heard a word of thanks from the Syrians; their eyes and conduct expressed only deep-rooted hatred, and they did not engage in any private conversations with us.

The cease-fire agreement with Egypt was signed in December 1973. Soon thereafter, most of the Egyptian prisoners were freed, and we returned to “civilian” surgery. The progress with Syria was slower and their prisoners remained with us until January 1974 (Fig. 47).

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Fig. 47. The deliberations preceding discharge of prisoners; the hospital director, Dr. Davidson, first from right, in white coat.

 

On 17 November 1973, Nurit, the head nurse, left the service for maternity leave and the same day gave birth to a daughter. Another nurse took her place on the surgical service. At that time I thought that the replacement was temporary, but it was an illusion. As I later found out, the substitute nurse agreed to replace Nurit under the condition of permanency on the service. When Nurit returned from her leave, it was to a different service, not to surgery.

 

During the 1970s the Shmuel Harofe Hospital made great progress. Much had been achieved. However, at the same time there were serious considerations in the Ministry of Health, to convert the hospital into a geriatric institution. Finally, in 1979, it was announced that at the end of the fiscal year, Shmuel Harofe would be converted from a general to a geriatric hospital. No one knew what would happen to the acute services, such as surgery, that do not belong in a geriatric institution. Various ideas were discussed. One possibility was to merge Shmuel Harofe with the Assaf Harofe Hospital, located in close proximity, and transfer our acute services to Assaf Harofe. At the same time, the construction of another hospital had just been completed. This was the Wolfson Hospital in Holon, supposed to replace the old and obsolete Donolo Hospital in Jaffa. Toward the end of the year, stormy deliberations were repeatedly conducted in the Ministry of Health with regard to the future of the various departments at Shmuel Harofe and their personnel. I did not participate in these meetings and do not know many of the details. Some may have been left intentionally undisclosed. The entire affair was characterized by immense tension between the teams of the various departments. A strong feeling of deprivation developed among those supposed to remain at Shmuel Harofe. The final decision was that the departments of orthopedics, urology and medicine (Second Department), would be transferred to Assaf Harofe, while the first medical department, surgery and one of the pulmonary services with its respiratory intensive care unit – to Wolfson.

I remained in Shmuel Harofe until the end of the fiscal year – 31 March 1980, when the operating rooms and the Emergency Department were closed, and the acute departments were transferred, each one to its respective new place.

 

The 9-year period at Shmuel Harofe was very important for me. During that time two of my children were born: Limor Tal, in January 1974, while we were still under the shadow of the Yom Kippur War; and Avishai Moshe, in September 1975. Avishai was named in memory of our fathers: Milka’s and mine.[21] I learned to be independent and to direct a hospital department. I did commit some errors, but also had successes. And I played a significant part in putting Shmuel Harofe “on the map.”. In my judgment, the conversion of Shmuel Harofe into a geriatric institution was a success. Today it is a magnificent geriatric hospital, in my opinion the best in Israel. We did have part in making it such by building the foundations. In spite of all the difficulties, it was a beautiful era.               

             


7

Struggle at the Wolfson Hospital

 

 

The construction of a new medical center in the area of Jaffa – Holon – Bat-Yam was planned because of the deterioration of the Donolo Hospital in Jaffa. The old Donolo Hospital, dispersed in several barracks, was rapidly becoming obsolete. As there was no other general hospital nearby, a replacement was urgently needed. In 1963, construction of the new hospital was started in the Tel Giborim section of Holon. However, the “disappearance” of huge sums of money designated for continuation of work, halted the construction. According to the official version, the funds were diverted from the Ministry of Health to the coffers of one of the political parties, an event known as the “Itzhak Rafael affair”. Due to shortage of capital, the construction was delayed for many years and, quite likely, would never have been renewed, were it not for the generous help of the British-Jewish philanthropist, Sir Isaac Wolfson, whose magnanimous contributions enabled the work to continue. The building was completed in the beginning of 1980, and the Edith Wolfson Hospital named in honor of Lady Wolfson opened in Holon at a solemn ceremony on 4 March 1980 (Fig. 48). On 1 April my department was transferred to the new establishment. Because the operating rooms were not quite ready, I used to spend most of the time in my office, reading or writing. On several occasions I operated at the Assaf Harofe Hospital, and in May, I managed to arrange a trip to Marseilles, France, to participate in a convention on pleuroscopy. The orderly work started only in July, with opening of the operating rooms.

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Fig. 48. The Edith Wolfson Medical Center in Holon.

 

Initially, the Wolfson Hospital was planned to replace Donolo and was intended to have two surgical services – the two that functioned in Donolo. Because of the last moment’s decision to convert Shmuel Harofe into a geriatric hospital and the long-lasting deliberations regarding the future of the “acute” services at Shmuel Harofe, my department was not taken into account and, in a way, became superfluous: a third surgical service in the hospital where only two were planned. The hospital administration came to Wolfson from Donolo and did not want us. For them, we were not a transfusion of fresh blood that would rejuvenate and invigorate their aging institution, but invaders who came to rob them of all that by the force of habit became “theirs”. They approached the team of Shmuel Harofe with undisguised hostility. From the first moment we were treated as unwanted “stepchildren”, and we felt it acutely. The 73 beds appropriated to surgery were divided according to the scheme that only the hospital administration could understand. The first surgical service was assigned 30 beds, the second service, 25, and the third (my service), 18. This, despite the fact that in the Donolo Hospital each of the two surgical services commanded only between 25 and 30 beds and performed only general surgery, while my department in Shmuel Harofe had 45 beds, and served both general and thoracic surgery. Also, the first service, since the death of its chief, Dr. Haim Izak, did not have a permanent chief, only an acting chief. This was with complete disregard of the requirements of the Scientific Council concerning accreditation for training residents in surgery. In Israel, for full accreditation, a surgical service must have a minimum of 30 beds, and for partial accreditation (in collaboration with other services) a minimum of 25 beds. The first surgical service that did not have a permanent chief until March 1982 and therefore could not become accredited, was assigned 30 beds, as required for full accreditation. The second service, with its 25 beds, could barely become partially accredited. My service would not qualify even for partial accreditation. My appeals and petitions to the administration fell on deaf ears. I conducted a number of conversations with senior officials in the Ministry of Health, individuals who were personally involved in the transfer of my department and its integration within the Wolfson Hospital, but they ignored my arguments. In case I desired further conversations in the Ministry of Health, they advised me to apply for an audience through my hospital administration, according to the rules. A “useful” suggestion, indeed. I was completely helpless. Throughout all my professional life, I do not remember a period of greater anguish than the first four years at Wolfson. Only in 1985 did the hospital director make the fortunate decision to retire at the age of 62, and in his place came Dr. Amnon Shahar from the Sheba Medical Center. He had not been involved in the Donolo Hospital politics and was not prejudiced against the Shmuel Harofe “invaders”.

Among the surprises that the administration had in store for me, was its unshakable desire to get general surgery out of my department and to limit its activity to thoracic and vascular (!) surgery, this branch that I had stopped practicing several years earlier. I was not sufficiently skilled in it, and I had good reasons to believe that the administration intended to make me fail by imposing it on me, and by forcing on me a “deputy” who would “help me” with vascular surgery and in parallel sabotage my work. An appropriate candidate did, indeed, work in the hospital at that time, and the administration tried to force him into my department against my manifest opposition. The struggle over the character of my department reached the Ministry of Health, but I had a strong legal base to lean on: that famous letter of appointment from 1970, when I won the tender for the position of Chief of the Department of Surgery (Thoracic and General).[22] The law of tenders was on my side and the hospital administration had to retreat.

In parallel, several changes occurred in the hospital. Dr. Alex Dinbar, chief of the second surgical service, also became disenchanted with the Wolfson Hospital atmosphere. He applied for a position of chief of surgery in the Meir Hospital in Kfar Saba, and won. In his place came Dr. Arie Merhav from the Ichilov Hospital. After a year of trial, he returned to Ichilov. Following him, there was one year of interregnum, when Dr. Dona served as acting chief, and in September 1983 Dr. Yehuda Adam arrived from the United States. After three months, in December of the same year, he too decided to leave, and returned to the United States.

This rapid rotation of chiefs paralyzed the work of the second surgical service completely. In 1984 it was decided to “freeze” it, and its beds were divided between the first and the third services. Now I could apply to the Scientific Council. Accreditation of my department for training of residents followed promptly.

Likewise, the hospital directors changed from time to time. Dr. Shahar remained in Wolfson until 1989 and then returned to the Sheba Medical Center. Dr. Waysbort served as acting director from 1989 to 1993, and in 1993 Dr. Moshe Mashiah came, bringing with him stability and progress.

 

*      *      *

The affiliation of my department with a medical school was delayed for a number of years. My petitions to the successive deans of the Faculty of Medicine of the Tel Aviv University remained without response for a long time. In 1986 I was invited to Prof. Theodor Wiznitzer’s home. At that time he was not the dean anymore – Prof. Haim Boichis had replaced him. While we drank coffee, Wiznitzer told me some details connected with that tender in 1957, when my candidacy for residency in Hadassah had been rejected. Also, in contrast to his earlier indifference, he promised to take an interest and to find out the reasons the medical school was not responding to my repeated petitions for affiliation. His “interest” appeared to be quite effective, because in the beginning of the new academic year, in October 1986, I was appointed to the Faculty of the Tel Aviv University Sackler School of Medicine. I did not have to pass through all the ranks of academic promotion, such as instructor, lecturer and senior lecturer, but was appointed directly as Associate Clinical Professor of Surgery (Fig. 49). Together with the appointment, came a variety of functions, such as lecturing in the Medical School, instructing groups of students in the hospital, and others. During the years that preceded my appointment, I missed students greatly, and now I received them with enthusiasm.

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Fig. 49. Letter of appointment as Associate Clinical Professor.

 

*      *      *

The job of instructing physicians and turning them into expert surgeons brings both joy and obligations, and sometimes disappointments. During the years, many physicians started their training in my department. Some were good, others very good or excellent. But there were also individuals who did not complete their tour of education. I remember a resident who, while admitting a patient, wrote that normal breath sounds were heard over both lungs. In the past that patient had undergone a left pneumonectomy (total resection of the left lung). Was the resident unable to recognize the absence of breath sounds over the left lung? Did he not see the large operative scar? No. It was a simple case of laziness and cheating. The doctor admitted that he did not examine the patient: “Everybody’s breath sounds are the same anyway, so why bother with examination?” This resident did not stay long in my department. There were also cases of gross meanness. I remember two residents who started working on my service, and without telling me, tried to get residency positions in another hospital. When those positions became available, they left my service without a moment’s notice. I could have tried to hold their paychecks, but what good would that do? They foiled me and failed me, but I learned something from this experience.

It is, therefore, gratifying to recollect those residents who excelled in intelligence and in performance. Their achievements are the true measure of my work as an educator.

I mentioned Dudu Schneider in the preceding chapter. Another striking example was Manoucher Robenpour, a young physician, just out of medical school. He managed to escape from Iran, arrived in Israel and came to me looking for a job. As a newcomer to Israel, he did not know Hebrew. My first impression of this graduate of the Teheran University was not particularly favorable (what can one learn in Teheran?). But he came to me in 1985, several years before the onset of the great immigration wave from the Soviet Union, when we were very short on staff. Discussing his application with Dr. Kaufman, we arrived at a conclusion that the newcomer could not be any good. However, he could assist on operations and participate in emergency night calls. At that time, even construction of the “on call” list was difficult. I had no choice, but to accept him.

Dr. Robenpour had some surprises in store for me. He worked with exceptional diligence. He came to see patients with difficult clinical problems every night, even when not on call, 4read scientific journals and books pertaining to those problems and stimulated discussions. In addition, he found time to write a number of articles for publication. I learned from Manoucher that it is not important what university one graduates from, but the personality of the graduate. In 1987 I recommended him for citation as an outstanding resident. He stayed in my department for three years, but eventually went into plastic surgery, of which he had always dreamed. At present he is in private practice – a well-known plastic surgeon in Israel.

   There was another bright star among my residents. One day in 1993, a young female doctor entered my office, told me of her desire to become a surgeon and asked whether I would accept her for residency training. “Little girl”, I though skeptically, “how will she fit into surgery?” Eventually, I accepted her for a trial period. This graduate of the Ben Gurion University School of Medicine, Dr. Yael Refaely, worked hard, had a brilliant mind, excellent clinical judgment and manners, and the skillful hands of a born surgeon. During her work on my service we wrote and published together seven clinical papers. Her most important features were honesty, integrity and courage to carry a responsibility. I remember well an operative complication in which Yael was involved – a bleeding that could have been easily avoided. In other, similar cases, I saw how the physician who caused the complication, tried to shift the responsibility onto others who participated in the operation (“he told me to do so…”). Instead of trying to evade responsibility, Yael entered my office, told me about the case, accepted full responsibility for the complication and asked me whether this was not the time for her to leave surgery and find a different branch of medicine that would fit her better. I took that idea out of her head. From complications such as hers, one should learn, not run away. Only someone who does not operate, has no operative complications.

Among the doctors who worked on my service (both, residents and certified specialists), Dr. Refaely was the only one, the head nurse never yelled at. She was like a flower on the service. Years later I found out that before visiting me, Yael conducted a search among residents on surgical services in several hospitals, including my own, before she decided to ask for a position in my department. Following two years of fellowship at leading medical centers in Baltimore and in Boston, she became chief of Thoracic Surgery Unit at Soroka Medical Center – Ben Gurion University in Be’er Sheva (Fig. 50).

    

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Fig. 50. “The girl who wanted to be a surgeon” –

Dr. Yael Refaely at the time of her work on my service.

*      *      *

In April 1976 a 53-year-old patient was referred to me because of coughing and raising sputum mixed with blood. He smoked two packs of cigarettes a day for most of his life. His chest roentgenogram disclosed a tumor in the left lung. At the operation I found cancer (squamous cell carcinoma) at the base of the lung. The tumor invaded the diaphragm and the spleen. I resected the lower lobe of the lung along with part of the diaphragm and the spleen, and closed the rent in the diaphragm with a patch of plastic mesh (marlex). The postoperative course was uneventful. The remaining upper lobe of the lung expanded well and filled the chest cavity, and the patient recovered promptly. In spite of my repetitive advice and his wife’s assertive demands, he did not stop smoking and refused to accept any further treatment – either by radiotherapy or by chemotherapy. But the operation apparently had been adequate, the cancer did not recur, and the patient enjoyed another 17 years of good life. He died at the age of 70, from a different kind of cancer (sarcoma) in his other lung. We remained friends until the day of his death, and during those 17 years that he won, I shared many of his joys, such as the weddings of his daughters and the births of his grandchildren. The course of cancer is sometimes a matter of luck, more than anything else.

 

*      *      *

Another victory, with a romantic background, occurred when a 24-year-old woman was attacked by her former boyfriend. He grasped her hair with his one hand, and with a knife held in the other, stabbed her eight times in the belly and on both sides of the chest. This event occurred very close to our hospital. There was no time for the usual routine evaluation. Without roentgenograms or any other tests she was brought into the operating room. She had no palpable pulse and her blood pressure was zero, but her heart sounds and breath sounds were still audible. Her bleeding had to be stopped before anything else. I was ready to begin the incision, when the anesthesiologist said: “Dov, you are wasting your time, she is dead”. I started the operation. Inside the abdomen I found two liters of clotted blood. There were several bleeding stab-wounds in the liver that I sutured, a torn spleen which I resected, and several cuts in the intestines and in the stomach – all treated according to needs. By the time of closing the abdomen, her blood pressure rose to 60. The injuries to the chest were taken care of by inserting tube drains on both sides. Over one liter of blood was drained from the chest, but the bleeding diminished gradually, and there was no need to open the chest. The patient recovered. One year later I attended her wedding. When I danced with her, she seemed alive and very much so. I would point this out to the anesthesiologist, but he was not present at the wedding.

 

*      *      *

Unfortunately, surgery is not composed only of victories and joys. A short time after the operation just described, I treated a 26-year old man, married and father of two daughters, both under 3 years. He had cancer of a rare kind (adenoid cystic carcinoma) extending from the lower end of the trachea (windpipe), along the entire left main bronchus, down to its bifurcation into two lobes. The patient’s family understood the severity of the situation. I remember his mother’s emotional appeal: “Doctor, gouge my eyes out, but save my child”.

The surgical treatment of this kind of neoplasm involves resection of the entire left lung, a procedure that requires opening the chest on the left side. But because of the extension of the tumor to the trachea, the resection must involve the lower end of the trachea as well, and connecting the trachea to the bronchus of the right lung – the only lung left to the patient. This procedure cannot be performed from the left side, because the aorta obstructs the surgeon’s approach to the trachea (Fig. 51). It was necessary, therefore, to open the chest on both sides – a very traumatic operation. I knew of the exceedingly great danger to the patient, but this kind of cancer was not sensitive to radiotherapy and there was no effective chemotherapy. The only hope was in resection as described, with two operating teams working simultaneously on both sides of the patient.

Fig. 51. Schematic drawing of the operative finding and the procedure. A. Criss-crossed area indicates the tumor. Broken lines mark the limits of the resection. B. The left lung had been resected together with the lower part of the trachea and the right bronchial stump. The right bronchus had been sutured to the trachea.

 

The operation was technically successful, but at the end, the patient was unable to breath spontaneously, and it was impossible to detach him from the artificial respirator. He remained in the operating room, ventilated by the machine until the late evening – the time of his death. It is difficult to describe the conversation with his mother and wife – and I will not try. For me, it was an exceptionally traumatic experience.

 

*      *      *

Another tragic case was that of a girl, less than three years old, from a religious agricultural settlement. She played in the yard in front of her house, near her father’s tractor. The father did not notice his daughter, climbed the tractor and went to work. When he heard his daughter’s screams, it was too late. The girl suffered a severe head injury and was hospitalized for a prolonged time. Her breathing ability was temporarily impaired, and she was ventilated artificially for three weeks. The breathing tube inserted into her trachea caused an inflammatory reaction, resulting in a scar with obstruction of the trachea. The obstructed segment had to be resected, and the girl was transferred to my service (Fig. 52). The operation itself and the immediate postoperative course were uneventful, but after several weeks the breathing difficulties recurred. Bronchoscopy disclosed excessive growth of connective tissue (granuloma), with narrowing at the suture line. I removed the granuloma with forceps, and normal breathing was immediately restored. After another three-week period, early symptoms of narrowing recurred. One Friday night the breathing difficulties increased. Because of the onset of the Sabbath, the parents decided to postpone the hospital visit until Sunday. That night at dinner, the girl aspirated a small morsel of food into the trachea and the airway became obstructed. Sabbath notwithstanding, the parents took her to the hospital, but she was dead on arrival. Resuscitative measures were ineffective. According to the parents wish, autopsy was not performed. There was no doubt about the cause of death. The parents – deeply religious – accepted theirs daughter’s death as fate and God’s wish.

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Fig. 52. A strange conjunction: artificial opening into the windpipe and the pacifier...

 

*      *      *

Medical negligence is bad. It may cause patient’s deterioration and death, and must always be avoided. But it is not always the physicians who are at fault. It may be the patient’s own ignorance or plain stupidity that prevents the necessary treatment. An unforgettable case comes to mind, from the times of my surgical residency in New York, 40 years ago. A woman in her early forties visited the outpatient department because of a “wound” in her chest. On examination there was  a shocking view of the woman’s chest. The left breast was missing. In its place there was a deep crater, 15 cm in diameter, muscles and other soft tissues destroyed. At the bottom of the wound one could see uncovered ribs. The entire cave was full of pus, dissipating offensive stench. It was an obvious case of an extremely neglected breast cancer. It must have taken years to reach this level of breakdown. To my questioning about presence of a mass in her breast at some earlier time, the patient answered “yes, there had been a mass and it grew over several years. Afterwards the skin ulcerated, and that wound too kept growing.” She added, that she avoided an examination by a physician, because of her worry that it might be cancer, and the doctor would suggest an operation. During all those years she even managed to conceal the horror from her husband. “So why did you come now to the hospital?” “Because last week my husband discovered the wound and forced me to come.” At that time, the management of breast cancer, this advanced, involved resection of both ovaries (oophorectomy) because of their hormonal influence on this neoplasm. This was the first case of oophorectomy in my career.

 

*      *      *

The following story illustrates the importance of experience in clinical practice – a feature that does not depend on a high level of education. I remember an incident from my internship in Hadassah, during my rotation on the pediatric service. One night I was called to see an infant. One of the older nurses did not “like” the baby’s breathing. I examined the infant and found nothing wrong, but because I did not have previous experience with little babies, I decided to alert the pediatrician on call. He came, examined the infant, and also did not find anything exceptional. He calmed the nurse, and we both went to sleep. Before dawn the infant died. What happened? We never found out. But it is clear to me that the nurse had extensive clinical experience and knew something about newborn babies. She was right in her impression that something was wrong. The infant was not saved, but my decision to alert the pediatrician was correct. Perhaps he should have alerted a more experienced, senior pediatrician?

*      *      *

Following is an example of a “medical miracle”. This is a story about an 11-year-old boy with a huge mass inside his chest on the left side (Fig. 53). He was sent to me in 1976 for a possible resection. The tumor was malignant; it invaded the mediastinum and the chest wall (Fig. 54). Resection was impossible. I took a biopsy and closed the chest. Histological examination disclosed neuroblastoma, a malignant tumor of the nervous system in children, with a very bad prognosis. The child was referred to the oncological service for treatment, but his parents procrastinated, and he was not treated. He also never came for a follow-up examination. Several years later, when I reviewed the experience of my department with similar tumors in the lung, I was unable to trace this patient and to find out what had happened to him. I assumed that he must have died. However, 23 years after the operation, a physician from another hospital called me, requesting detailed information about this patient. It turned out that he was hospitalized for a condition not related to his childhood tumor. He did not keep his hospital discharge summary from 1976 and did not know much about his disease, but he remembered my name, which helped his physician to find me. The tumor had vanished without a trace.[23]

What is a medical miracle? I use this term to describe a clinical course that is contrary to all expectations and cannot be explained. This phenomenon does exist.

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Fig. 53. Chest roentgenogram shows a huge mass filling the chest cavity on the left side.

 

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Fig. 54. The patient on the operating table, just before start of the operation. There is a considerable bulge on the left side of the chest, due to tumor invading from within.

*      *      *

I will conclude this bunch of clinical cases with a story about a patient with Bürger’s disease (occlusion of blood vessels in limbs), a chain-smoker, incurable and without hope. All his limbs were amputated, but his wounds still would not heal because of lack of blood supply. I was involved in his treatment in the Rambam Hospital in 1958. Every week or two we had to amputate a further part of one of his extremities in order to reach a healthier level of tissue, with a chance to heal. His suffering was beyond description. His pain did not react to drugs, including morphine that he received without restriction. His wife was sitting at his bedside, holding a cigarette in his mouth – the cause of his disease, but also his last and only pleasure. No one would stop her from doing it. He told me: “This is not life; I prefer to die, I want to die”. He meant it. It was clear to all that his death was close and no treatment could save or prolong his life; we could only prolong his suffering.

Such patients are not a rarity, today as then. We have no right, legal or moral, to shorten their lives. But do we have the right to prolong their agony?      


8

Widening of horizons

 

 

There are limits to the knowledge and experience that a young surgeon can acquire in a surgical department throughout the period of his training. The knowledge conveyed to the trainee by the department chief and his group of associates is inevitably limited by the volume of their experience and by their own personal prejudices.

Departments differ in their experience and in their approaches to various problems. When I first saw these differences, they seemed to me disorderly and I doubted their value. In one of our conversations, Dr. Erlik pointed out my mistake. There are no absolute rules of surgical wisdom. One has to learn from experience of others, become acquainted with methods different from our own and widen horizons. Policy differences between various departments are thus justified and exchange of ideas should be encouraged. Hence the importance of visiting other medical centers, both in Israel and abroad.

The custom to send young physicians abroad became routine in some hospitals in Israel, mainly in the largest and most developed ones; less so in others, with limited possibilities. In those poor hospitals, traveling arrangements are often a matter of personal initiative of every physician and each one has to care for himself. And so did I.

William J. Mayo wrote in 1910: “Take frequent vacation from active work, to attend clinics and walk hospital wards. See things for yourself; reading alone is not enough.” Following his advice, I used some of my free time, while in the United States and Canada, to visit the most prestigious medical centers and to observe surgeons of great fame, about whom I had read or heard before. I visited the Lahey Clinic and the Peter Bent Brigham Hospital in Boston, Johns Hopkins in Baltimore, the Mayo Clinic, the University of Minnesota, the Mount Sinai and Beth Israel hospitals in New York, and several medical centers in Houston. At the beginning of each visit I usually introduced myself in the public relations office and told them the purpose of my visit. I was always welcomed. They toured the hospital with me and let me observe the surgeons of my choice operate. Among those were some who today are part of medical history. I saw Henry Bahnson, Michael Ellis DeBakey and Denton Cooley operate on blood vessels and the heart, John Garlock and Leon Ginzburg on the gastrointestinal tract, and many others. Initially, my visits were not focused on specific kinds of operations. I just wanted to see the “great“ ones at work. I learned a little and I was left with formidable impressions. In later years I organized these visits in a more orderly way, directing them at specific subjects.

*      *      *

Thoracic outlet syndrome is the result of an anatomic abnormality in the area where blood vessels and nerves pass from the chest to the arm. This narrow passage is surrounded by the clavicle (the collarbone), the first rib, ligaments of tough fibrous tissue and muscles (Fig. 55).

Various local anatomic derangements, such as fractures and posttraumatic scars, congenital anomalies and other deviations from normal, may cause an additional narrowing of this passageway, exerting pressure on the enclosed structures. This excessive pressure causes pain, sensory disturbances, and limitations of movements in the arm and hand. For effective treatment of this condition, the entire first rib has to be resected. A wider passage between the clavicle and the second rib is thus created, and the pressure is relieved. This operation was devised and first performed by Dr. David Roos of Denver. However, the surgical approach to the first rib is difficult, and the resection of the entire rib, hazardous. Because of its immediate proximity to the vessels and nerves, manipulation around the rib may cause injury to these structures. I felt that the best way to learn this operation would be to visit Dr. Roos and learn his method directly from him.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Fig. 55. Anatomic preparation of the thoracic outlet dissected by Dr. Ze’ev Zurkowski, resident in my department in the 1970s.

A. The first rib, B. The clavicle, C. The tunnel for nerves and vessels.

 

I made an appointment, and in January 1978, I flew to Denver. For economic reasons I decided to stay at the YMCA. My choice of hotel caused Dr. Roos some embarrassment. He could not tolerate a guest of his staying at the YMCA. After a short forewarning by telephone, he arrived at the hotel, took me out nearly by force and brought me to his home, where I stayed for the remainder of my visit. During all this time I remained in his company, participated in his operations, visited his clinic and laboratory and learned all aspects of his work. I met and befriended the Roos family, and before leaving Denver, I addressed staff meetings in the two hospitals in which he used to operate (Fig. 56). Soon afterwards I introduced the first rib resection as routine in our treatment of patients with the thoracic outlet syndrome. A year later I visited Dr. Roos again and learned the most recent developments in his methods of diagnosis and operation. From Denver I went to Dallas, to see the work of Dr. Harold Urschel – another expert on thoracic outlet syndrome.

 

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Fig. 56. Letter from Dr. Roos, following my visit in Denver.

 

*      *      *

Congenital deformities of the chest are infrequent. The most commonly encountered ones are pectus excavatum (a congenital depression of the breastbone) and pectus carinatum (a protrusion, usually asymmetric). The cause of these deformities is uneven development of the ribs. Due to a genetic defect, some ribs grow excessively, becoming longer than normal. While growing, the ribs push the sternum (breastbone) out of its normal place. If the defective ribs push the sternum inside (backwards), a depression is formed (Fig. 57); if the sternum is pushed forward, a bulge forms (Fig. 58). There are several operations to correct these defects. The most common one consists of excising excessive lengths of ribs and restoring the breastbone to its proper location, sometimes aided by plastic correction of the deformed bone.

 

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Fig. 57. A pair of twins with pectus excavatum.

 

For a long time I considered going to see this operation performed by one of the renowned masters. After corresponding with several authorities, I decided to visit Dr. Francis Robicsek in Charlotte, North Carolina. After seeing him operate, I used his method routinely on our patients (Figs 59 and 60). In addition to his prominent place in surgery, Dr. Robicsek is also an accomplished amateur archeologist and wrote several books on South American archeology.

 

 

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Fig. 58. An asymmetric pectus carinatum.

 

 

 

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Fig. 59. Normal appearing chest wall following operative correction of pectus excavatum.

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Fig. 60. The same teenager as in Fig. 58, after operative correction of the carinatum defect.

 

*      *      *

Surgery of the trachea is a relatively new field that requires special expertise. I learned operations on the trachea from F.G. Pearson in Canada, during the two years of my fellowship, and started doing them myself soon after my return to Israel in 1971. To the best of my knowledge, no such operations were done in Israel prior to my return. In fact, nearly all the patients on whom I operated, were referred to me from other hospitals.

The actual “father” of operations on the trachea is Hermes C. Grillo from the Massachusetts General Hospital and the Harvard University in Boston. Grillo is an old friend of F.G. Pearson’s, and I met him while still working in Toronto. In order to see him operate, I contacted him, and in February 1978, after visiting David Roos in Denver, I went to Boston. There, I participated with Grillo in an unforgettable 9-hour operation. We were three surgeons on the case: Dr. Grillo who actually performed the operation, his chief resident Dr. Lowe and I. The patient had an extensive stricture of the trachea and of both main bronchi – the result of long lasting tuberculosis. In order to enable her to breathe normally, the major part of her trachea and segments of both bronchi had to be resected, with secondary, nearly impossible connections. An exceptionally difficult and trying operation. But there was no limit to Grillo’s patience and his technical abilities. He worked slowly and with great precision. The operation started at 8 a.m. and came to a successful conclusion at 5 p.m.

Heavy snow started falling in the morning and kept falling for the whole day; I saw it through the operating room window. In the evening Grillo took me out to a restaurant for dinner, and after that to my hotel (Suisse Chalet Motor Lodge). All this time the heavy snowing did not stop.    

We were supposed to meet the next morning and operate again, but the snowstorm continued, all roads and highways were blocked by heaps of snow, and there was no possibility to leave the hotel. Dr. Grillo also stayed at home and we communicated only by telephone. This famous “snowstorm of the century” continued uninterruptedly for six days. The snow accumulated to the height of several meters (Fig. 61). Only ambulances, fire engines and police vehicles were permitted the use of the roads. Meanwhile, the day of my return home was approaching. I was supposed to fly to Israel from New York, but I could not reach New York by plane, because the Boston airport was closed. Grillo obtained a special police permit to drive me in his car to the railway station. I went to New York by train and caught my flight to Israel literally at the last moment. I was home on time.

 

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Fig. 61. Boston covered with snow after the “storm of the century”.

 

*      *      *

Besides travels for learning specific operations or diagnostic methods, I participated in international surgical conventions twice every year. One trip was to North America, to attend the Annual Congress of the American College of Surgeons or the meeting of the Society of Thoracic Surgeons. Participation in these conventions was mostly for the purpose of learning. The other trip, usually to a congress in Europe, was to present something from my own experience.

To some of these conventions I traveled as an invited speaker. The first such invitation came from the American College of Surgeons. In 1975 their annual congress took place in San Francisco. A postgraduate course in thoracic surgery was organized as part of the convention. I was invited to talk on the subject of tumors of the bronchial glands. This invitation to lecture at one of the world’s most prestigious conventions gave me great satisfaction, and I made a considerable effort to be well prepared and to not disappoint the organizers. Following this lecture, I received many more invitations for addresses at conventions and also requests for writing book chapters on this and related subjects. One of these chapters was for Pearson’s textbook Thoracic Surgery (Figs. 62 and 63).

 

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Fig. 62. F.G.Pearson’s book Thoracic Surgery.

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Fig. 63. The first page of my chapter.

 


*      *      *

In 1988 Dr. John Odell of Cape Town invited me to the Biennial Convention of Thoracic Surgeons and Cardiologists of South Africa. Odell asked me to lecture and lead a discussion on lung abscess and empyema. These are my favorite subjects on which I had written several articles. When I arrived with Milka in Cape Town, I was surprised to discover that my presentation was scheduled as the opening lecture of the congress. At dinner I asked Dr. Odell why he chose me. There are many thoracic surgeons of great fame, worldwide, who have extensive experience in pulmonary and pleural infections. Odell answered that the members of his team had read and discussed my articles and wanted to hear more.

During the convention I visited the University of Cape Town Medical Center and Groote Schoor Hospital. This was the institution at which my teacher, Dr. Robert Goetz, conducted his most important experimental work, before coming to the United States. It was here that Christian Barnard performed the world’s first successful human heart transplantation. This hospital is considered a historic site and has a fascinating museum. After the convention we participated in a sightseeing tour of South Africa, specially organized for invited speakers. The tour lasted a whole week and included the Kruger National Park, the entire southern seashore of South Africa, major cities, and more. We were left with unforgettable memories.

 

*      *      *

Particularly important for me was the Centenary Congress of the Polish Surgical Association. It took place in Kraków (Cracow) in September 1989, on the 100th anniversary of the Association, the 200th anniversary of University Surgery in Poland and 50 years after outbreak of World War II.

This international meeting was bilingual – one could present the submissions either in Polish or in English. After 39 years of absence from Poland and without knowledge of Polish medical terminology, I hesitated a lot what language to use. I could get mixed up with the Polish terminology and thus fail in my presentations. As a matter of fact, all physicians who left Poland just a few years earlier, chose to deliver their presentations in English, sometimes after a short apology for using a foreign language. However, I thought that it would be unbecoming to lecture at a Polish convention in English, while Polish was my native tongue. I submitted seven subjects for presentation at the meeting, all in Polish. The result was a standing ovation after each one of my presentations, and close friendly relations with surgeons who appreciated my effort and my flawless Polish. As a result of my new relations with the leaders of surgery in Poland, this trip to Poland, initially intended to be one-of-a-kind, turned to a nearly annual event. During the 12 years since the congress in Kraków, I have been to Poland eight more times, in most instances to participate in various surgical conventions. On four occasions (Warsaw, Lublin and twice in Wrocław) I came as an invited speaker. In 1993, in Lublin, I was elected Member of the Editorial Board of the Polski Przegląd Chirurgiczny (Polish Journal of Surgery), and my cooperation with people on the top of surgery in Poland continues to blossom.

My trip to Poland in 1989 had another important implication. It helped me to renew relations with old friends. In 1999, on the fiftieth anniversary of matriculation, I participated in an emotional reunion of my high school class. I took advantage of those trips to visit sites to which I had been emotionally attached, such as places of my hiding during the war, and more.

Under similar circumstances I visited the city of my birth Lwów (today Lviv in the Ukraine) on two occasions: the first time on the fiftieth anniversary of the extermination of the Lwów Ghetto, and two years later, as an invited speaker at a surgical convention.

During the following years, the trips to the congresses as an invited speaker became more common, and included conventions in Belgrade (Yugoslavia), Moscow, āeşme (Turkey), Genoa (Italy) and Dresden (Germany).

 

*      *      *

Besides the conventions, I received invitations from various medical centers to come as a visiting professor. In 1979 Dr. William Drucker invited me to the University of Rochester. Dr. Drucker, who had served as Chairman of the Department of Surgery at the University of Toronto at the time when I worked there, prepared for me a tight four-day schedule of lectures, seminars and clinical conferences with the surgical staff and students. At the conclusion of my work, I addressed the staff meeting, lecturing on the subject “Chest injuries during the Yom Kippur War” (Fig. 64). That visit was followed by another invitation two years later, when I spent another four days in Rochester, lecturing and teaching (Fig. 65).

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Fig. 64. The visit was concluded with my lecture on chest injuries during the Yom Kippur War.

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Fig. 65. The concluding lecture, 1981.

In 1982 Dr. James Hardy invited me for a similar working visit at the University of Mississippi – the place of my residency in thoracic surgery 15 years earlier. This invitation was for me a symbol of Dr. Hardy’s pride in the progress and success of his former resident.

Among all my visits to various medical centers, I had particular pleasure visiting Toronto many times. I always feel at home among my friends in that city and at the Toronto General Hospital.

In October 1989, at the initiative of Dr. Clifford Straehley, a thoracic surgeon and professor at the University of Hawaii, I went to Honolulu, where I spent two weeks, lecturing in six university-affiliated hospitals. I was quite busy, but still found time for sightseeing, and Milka defined our trip as “two weeks in Paradise.” We have wonderful memories from that trip, and many friends in Hawaii (Figs. 66 and 67).

 

Fig. 66. Certificate of Visiting Professor.

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Fig. 67. Letter from the Chairman of the Department of Surgery, Dr. Whelan.

 

*      *      *

I will conclude this chapter with the description of my mission in China.

During the past decade there has been a considerable growth of cooperation between Israel and China in the areas of agriculture, industry and medicine. Experts from Israel are traveling to China, usually for several weeks, where they work together with their Chinese counterparts, teaching and updating them on recent progress in the field of their expertise. Individuals involved in this activity introduced me to Mr. Yossi Marek, President of the “Matat – Knowledge from Israel”, and through him, to the Shandong-Jining Association for International Exchange of Personnel. During several meetings, appropriate topics were selected and a working plan was formulated. Eventually, in June 2000, I went to Qufu, a city of 600,000 in the Province of Shandong, China. I was scheduled to work in the Department of Thoracic Surgery of the Qufu People’s Hospital.    

My functions in the hospital included participation in operations, clinical consultations, bedside rounds, outpatient clinic and lectures. To make my work possible, I was assigned two interpreters who accompanied me at all times, not only during my professional activity, but also on sightseeing tours, receptions, all meals (in restaurants and hotels), and even on my shopping excursions in stores, where their help was not really needed. One of my interpreters was a physician, a cardiologist from the same hospital, Dr. Mu Jin. He spoke reasonably good English, but we had problems with medical terms, because no international terminology (English or Latin) is taught in the medical schools in China. All instruction is conducted in Chinese (Mandarin), including textbooks – with Chinese terminology. However, using dictionaries, explanations and plenty of patience and good will on both sides, we managed to understand each other and worked together. Before every lecture, I had to thoroughly prepare Dr. Mu Jin. Later, during the “real” lecture, we stood together on the podium, or sat together at a table with the audience around us. Each one of my sentences in English was followed by Dr. Mu Jin’s translation into Chinese. This, in my opinion, kills the spirit of a lecture and is the most certain method to convert it from interesting to dull, but there was no other way. The Chinese audience listened patiently, and in their extraordinary politeness, seemed happy. This exceeding politeness exists only in China.

My second interpreter was a postgraduate student and teacher of English. Her English, while quite rich, was heavily Chinese-accented, which made it difficult for me to understand. But she was beautiful, elegant and very nice (Fig. 68). Another person who helped me in every possible way, was Dr. Gao Xian-cheng, an expert in pulmonary medicine and the hospital director. One of his hobbies was Chinese calligraphy. He gave me a lesson in Chinese script and made a poster for me with my name and a citation from Confucius (Fig. 69).

My most important activity was, of course, the clinical work. This is well illustrated by the following example. A female patient, a candidate for resection of esophageal cancer, was presented to me at bedside rounds. She had not undergone esophagoscopy,[24] no biopsy of the tumor and no roentgenograms of the entire gastrointestinal tract, as required in patients with suspected cancer of the esophagus. There was only one single roentgenogram of the esophagus, taken with a swallow of the contrast medium, which showed a filling defect in the esophagus. While such filling defect does arise suspicion, it does not prove cancer. Moreover, the patient had palpable masses over both collarbones – undoubtedly metastases – a clear-cut contraindication to the operation. I recommended postponing the operation and, instead, obtaining biopsies from the esophageal lesion and from both masses in the neck. But her physicians would not consider such an option. “The patient had already paid for the operation and there is no possibility to cancel it. She would be very disappointed. Besides, it is impossible to refund her money.” Despite my objections, the operation was carried out the next day. The patient did have cancer of the esophagus with metastatic spread. The operation was extensive by any definition and included resection of the entire esophagus, transposition of the stomach into the chest, and reconstitution of continuity of the digestive tract in the neck. It lasted only three hours  and was performed with  great skill and elegance, without

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Fig. 68. With my interpreters, Miss Cai Wen-jing
and Dr. Mu Jin at Confucius’ tomb.

 

 

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Fig. 69. A lesson in Chinese calligraphy.

 

 

significant blood loss and with minimal trauma to tissues. I admired the excellent operative technique of Dr. Lian Shi-fa, but not his clinical judgment (Fig. 70). In the West, a patient with such widespread metastases as this one, would have been treated by other oncologic means, not by operation. Because the purpose of my visit was to teach, I discussed this case widely with the team, pointing at modern diagnostic methods and concentrating on indications and contraindications to operative procedures on cancer.

I encountered similar problems in patients with lung cancer. Again, as with resection of the esophagus, I was greatly impressed by the skillful surgical technique of my hosts and by their extensive operative experience, but the level of diagnostic evaluation and the disregard for indications and contraindications – all the medical aspects of the case, were unacceptable.

 Diagnostic procedures, such as mediastinoscopy, pleuroscopy and pericardioscopy[25] were unknown to physicians in Qufu. I taught them these procedures, using a set of instruments brought with me, and recommended that they purchase a similar inexpensive set.

One morning I was supposed to demonstrate to Dr. Lian Shi-fa pericardioscopy on a patient with accumulation of liquid in the pericardium. Dr. Lian arrived in the hospital with severe pain in his knee, unable to bend it or to step on his leg and, obviously, unable to operate. The pericardioscopy was cancelled and we went to the Acupuncture Clinic for treatment. Dr. Lian joined the group of patients lying on a row of ten treatment tables, acupuncture needles protruding from various parts of their bodies. I observed the steps of Dr. Lian’s treatment: insertion of needles, illuminating the painful knee with a special lamp  (ultraviolet? infrared?), mild  electric shocks to the leg for

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Fig. 70. Dr. Lian Shi-fa and the author operate on the esophagus.

 

10 minutes, and massages.  At the end  of  the treatment he  rose from the table – able to function. The change was dramatic and most impressive. It is difficult to ascribe this to psychological effect only, although this factor must have played a major role. Another occasion to observe ancestral Chinese medicine came, when I visited the China Academy of Traditional Chinese Medicine in Beijing. At the hosts’ invitation, I volunteered to undergo “pulse and tongue examination” conducted by an accomplished expert in this field. The examination consisted of observing my tongue and palpating my pulse in both hands, for 10 minutes. At the end, the expert delivered a list of diagnoses and recommended treatment. I was diagnosed with infertility, kidney weakness, mental tiredness, dizziness, and disinclination to speak. For treatment of these disorders, as well as for “nourishing the spleen, tranquilizing the mind and strengthening the legs”, I was offered several kinds of quite expensive pills of the expert’s own production and composed of undisclosed ingredients. According to the booklet distributed to people seeking treatment, the ingredients are “based on a secret recipe from a famous expert” (quoted literally). Medical witchcraft at its best.

 

While visiting a ward in the Qufu Hospital, I had an opportunity to see an important aspect of human relations in the Chinese society. I was shown a VIP room – it was spacious, clean, luxuriously furnished and richly decorated. It contrasted sharply with the neglected rooms for ordinary people. It was an impressive example of “equality” in the communist society.      

 My hosts pampered me throughout my stay. My free time was filled with excursions to places of historic or cultural interest, such as Confucius’ birthplace and tomb, a selection of temples, the Qufu University, the City High School and others. A stage show – program of Chinese ethnic music and dance was arranged especially for me: only I and my usual entourage were present. At the meals there was always great selection of Chinese dishes, among them rarities prepared especially for me.

In my excursions to places of interest in the Province of Shandong, we often passed through the countryside. I saw long stretches of highway covered with thick layers of straw, alternating with yellowish granular material, which appeared to me to be sand. My interpreters explained that it was actually grain of wheat and straw, spread out for drying. During threshing, the grain is still moist. If it is stored humid, it might sprout or rot. In the absence of a better drying contrivance, the peasants spread the grain and straw on the highways, where it remains during the daytime. Before nightfall they collect it into sacs. This is a backbreaking labor, and the highway traffic causes incredible waste, but at least a major part of the grain and straw is saved (Figs. 71 and 72).

 

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Fig 71. Drying contrivance: straw spread over highway.

 

 

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Fig 72. Peasant laborers in Shandong.

 

My mission in Qufu completed, I still had two days for sightseeing, which I spent in Beijing. Of all the places visited, the most impressive one  was the Great Wall of China (Fig. 73).   

 

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Fig. 73. On the Great Wall of China.

    

Epilogue

 

 

I have devoted 43 years of my life to surgery. This experience brought me to several basic conclusions.

The first one involves the choice of profession. My choice seems to have been correct. It is no exaggeration to state, that in all my professional life I did not have one single day of boredom. There were times of satisfaction and joy, and others, of sad, even tragic events. But never boredom. Surgery was always attractive and always interested me. Have I chosen the world’s most interesting occupation? Yes, for me surgery was just that. Of course, it is not for everybody. The interest in vocation depends on every individual’s character. Not everybody likes to see blood, to cut human flesh or to examine a sick human being.

I remember well a conversation with my friend, more than 50 years ago. We were close to graduation from high school, and we were discussing choice of our future occupations. I always wanted to be a doctor and never had any doubts about my choice. My friend wanted to study Chinese culture. I told him that one has to make a living from one’s occupation. Can one do that from studying Chinese culture? My friend did not take this argument seriously, and said: “I can repair shoes. If necessary, I will make a living from that. But I will study what interests me.” He was consistent, studied Chinese culture and became a great expert on China and professor at a famous university. Of course, he did make a living from his vocation. In retrospect, it is obvious that he was right.

None of my four children has chosen surgery, although I have one physician-daughter. But like me, they all have chosen whatever interested them. My son studies Japanese culture. I believe that he, as my old friend, will make a living from his profession, because this is the one thing that interests him most. My conclusion is, that whoever chooses an occupation based on genuine interest, assures himself of success. My work was interesting, and I enjoyed it. Those who chose an occupation because of ill-founded considerations, such as prospective wealth, prestige or any other concern not based on true curiosity, condemn themselves to a life of boredom, disappointment and failure.

 

The second point concerns the choice of the branch of medicine. This consideration stretches beyond mere interest, because any person with interest in medicine should be able to adjust himself to one or another branch. However, the choice involves the psychological background and disposition of each person.

As a rule, clinical investigation in internal medicine entails gathering of the greatest possible amount of information, which requires time. In surgery, the time factor is much more limited. Under threat of emergency, the surgeon is forced to restrict his investigation and must make a decision on the basis of data available at the moment. Hence, surgery attracts a different type of person than internal medicine – one who wants to see results quickly. According to William Nolen, the surgeon prefers the quick cure of a scalpel to the slow healing by pills. But what he lacks in patience, he makes up in decisiveness.[26] When in a hurry, one is prone to make mistakes. Later, in retrospect, many volunteering “consultants” are ready to give advice and point to what could have been done better, but at the time they were not present. In the moment of crisis, when there is no time for consultation, the surgeon must decide by himself and immediately.

I like decisiveness, hate hesitations, and usually make my decisions quickly, sometimes perhaps too quickly. These features predispose to surgery and they led me to make my choice.  I believe, that choice was correct.

 

The third point pertains to gaining experience. One cannot learn surgery by just observing others and reading books. One learns from experience, and this comes from practical work. Experience of others is good for others. While working and gaining experience, we make mistakes. Our errors may result in somebody’s death. But can experience be gained without it? Some errors, particularly those resulting from lack of experience cannot always be prevented, but it is important to learn from them and to avoid them in the future.

Progress in surgery is a slow and complicated process, but it creates a mature surgeon, confident of himself. I enjoyed this process all along.        

 


Other books by Dov Weissberg

 

I Remember… (Holocaust memoir),

         Freund Publishing House, Ltd, 1998

 

התעוררתי משריקת הקטר (Holocaust memoir,

         Hebrew edition), Freund Publishing

         House, Ltd, 1998

 

Zbudził mnie gwizd parowozu (Holocaust
memoir,  Polish edition), Freund
Publishing House, Ltd, 1999

 

בחרתי בכירורגיה (A surgeon’s memoir,

Hebrew edition), Freund Publishing

House, Ltd, 2001

 

ועוד סיפורים מהחיים (Some more stories from life)

         Self-published, Rehovot, 2004

 

Idioms, proverbs, thoughts (Book of quotations)

         Self-published, Rehovot, 2004

 

Handbook of Practical Pleuroscopy,

         Futura Publishing Company, Inc,
Mt. Kisko, New York, 1991



[1] Observing inside of the larynx through a specially devised instrument.

[2] Male gender was used in this paragraph, as nearly all surgeons and trainees in surgery (well over 90%) were men. In the 1960s a female surgeon was a rare exception.

[3] I wish to emphasize that this shocking story is not invented. It really happened, exactly as described. 

[4] Vascular anastomosis: connection of blood vessels, allowing blood to flow between them.

[5] Recently an interesting article was published about Dr. Goetz and his scientific work: Igor E. Konstantinov: Robert H. Goetz: The surgeon who performed the first successful clinical coronary artery bypass operation. Ann. Thorac. Surg. 2000; 69: 1966-1972.

[6] The main artery supplying blood to the lung.

[7] Direct observation of the bronchi through the bronchoscope.

[8] Roentgenography of the bronchi with the use of contrast medium.

[9] Mediastinum is the central area of the chest, located between the two lungs.

[10] For historic accuracy I wish to point out, that prior to the establishment of this service, no department or division of general thoracic surgery (separate from heart surgery) existed anywhere. The new division was the first of its kind in the world, and F.G. Pearson was the first person to ever head this kind of service, which makes him the Father of General Thoracic Surgery.

[11] Windpipe.

[12] Thymus: a gland located in the mediastinum, important in immunologic processes.

[13] For a non-Israeli reader I must clarify that in Israel, after one year of uninterrupted work, every government employee is automatically guaranteed tenure and cannot be fired, no matter how inadequate his work may be. Exceptions include major crimes, but never “minor” misdemeanors such as absenteeism, negligence, or any kind of inadequacy at work. My dissatisfaction with the two surgeons on my team could never have served as a reason for discontinuing their employment.   

[14] Dr. Kaufman died in April 2001 of incurable illness. A close friend, an excellent surgeon, and a gentleman.

[15] Pleuroscopy – observation of the inside of the chest cavity through an instrument inserted between the ribs. This procedure enables performance of certain lung operations.

[16] This operation lowers the blood pressure in vessels bringing blood from the intestines to the liver. It is indicated in patients who suffer major bleedings because of cirrhosis (a chronic liver disease). 

[17] Operation for prevention of the flow of gastric contents into the esophagus.

[18] Roentgenography of blood vessels with simultaneous injection of contrast medium.

[19] My work and personal relations with Dr. Goetz are described in Chapter 3.

[20] D. Weissberg. Treatment of thoracic injuries. Annals of Thoracic Surgery 1986; 42: 348.

[21] AVISHAI: Avi – in Hebrew “my father”; Sh – short for Shmuel, Milka’s father; I – short for Israel, my father. Moshe was the name of my late brother.

[22] See Chapter 5.

[23] A similar case with spontaneous complete disappearance of an invasive neuroblastoma has been described by William A. Nolen in his book “The Making of a Surgeon”, Random House, New York, 1968, p. 201.

[24] Direct observation of the esophagus through a special instrument, with biopsies from areas suspected as abnormal.

[25] Pericardioscopy: direct look inside the pericardium (the membranous sac enclosing the heart).

[26] William A. Nolen: The Making of a Surgeon. Random House, New York, 1968.