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8. Further progress and widening 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.

During my stay in the United States I used some of my free time 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.

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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
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.

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

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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.

 fig 57
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.
 
fig 58
Fig. 58. An asymmetric pectus carinatum.

fig 59
Fig. 59. Normal appearing chest wall following operative correction of pectus excavatum.
 
fig 60
Fig. 60. The same teenager as in Fig. 58, after operative correction of the carinatum defect.

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

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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).

 fig 62
Fig. 62. F.G.Pearson’s book Thoracic Surgery.
 
fig 63
Fig. 63. The first page of my chapter.

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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.

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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 past five years, the trips to the congresses as an invited speaker became more common, and included conventions in Belgrade (Yugoslavia), Moscow, Çeşme (Turkey) and Genoa (Italy).

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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).
 
fig 64
Fig. 64. The visit was concluded with my lecture on chest injuries during the Yom Kippur War.
 
fig 65
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
Fig. 66. Certificate of Visiting Professor.
 
fig 67
Fig. 67. Letter from the Chairman of the Department of Surgery, Dr. Whelan.

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

 fig 69
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 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.

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

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 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).

 fig 71
Fig 71. Drying contrivance: straw spread over highway.

fig 72 
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).   

 fig 73
Fig. 73. On the Great Wall of China.


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).

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