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The seventh John Homans lecture: Heroes in vascular surgery

1992; Elsevier BV; Volume: 15; Issue: 2 Linguagem: Inglês

10.1016/0741-5214(92)90264-9

1097-6809

E. Stanley Crawford,

Diversity and Career in Medicine

“From time to time, when deemed advisable by the Council, eminent investigators in the field of vascular surgery or allied sciences may be invited to present a John Homans Lecture during the annual meeting.” In this statement, taken from the bylaws of the Society for Vascular Surgery, it is important to recognize that the key word is eminent, which epitomizes Dr. E. Stanley Crawford. The Homans Lectureship is a distinguished accolade that the Society for Vascular Surgery bestows very rarely, and only on those who have made major contributions to the discipline. For example, in the 45 years of the existence of the Society, only six individuals have been so honored. This year the man honored has done more than anyone in the world to advance the science and art of managing complex aortic disease. Many people are alive today, living happy and productive lives, as a result of Dr. E. Stanley Crawford's pioneering and seminal contributions to vascular surgery. With the exception of his residency training at the Massachusetts General Hospital, Dr. Crawford has spent his entire professional life at Baylor University in Houston, Texas, where he holds the rank of Professor of Surgery. To say that his academic career has been productive is an understatement. He has published more than 300 peer-reviewed papers and book chapters and belongs to every major society in the United States and several abroad. He served as president of the Society for Vascular Surgery in 1987. Dr. Crawford is totally devoted to his family, friends, patients, institution, and profession. As many know, Dr. Crawford is courageously fighting a recent illness, which precluded his presenting the Homans Lecture himself; instead, his son Dr. John Crawford spoke for him. However, with a resolute commitment to the Society for Vascular Surgery, which typifies the man, he was present during the lecture. What follows is the Seventh Homans Lecture by Dr. E. Stanley Crawford. Calvin B. Ernst, MD James C. Stanley, MD Dr. Ernst, Dr. Hertzer, Dr. Porter, members and guests. As many of you know, my father, Dr. Stanley Crawford, suffered a severe stroke in late January. Despite 4 months of grueling therapy he has been left with several severe disabilities. My father, my family, and I are very grateful to Dr. Ernst and the Society for allowing me to present my father's thoughts to you today, the seventh John Homans lecture. Mr. President, Mr. Secretary, members and guests, it is both a great honor and pleasure for me to give the seventh John Homans lecture today for I had the great luck to make Dr. Homans' acquaintance during my medical student years in Boston (Fig. 1).Dr. Homans was my first professor of surgery at the Peter Bent Brigham Hospital, and he quickly became one of my heroes in vascular surgery. A graduate of Harvard Medical School in 1903, Dr. Homans had his surgical training at the Massachusetts General Hospital (MGH) plus 2 years with Halsted and Cushing at the Johns Hopkins Hospital. At Johns Hopkins he fell under Cushing's spell and returned with Cushing to Peter Bent Brigham in 1913. Dr. Homans' major interests centered around the treatment of arterial and venous disorders, and his 1939 Textbook of Surgery was one of the earliest works published dealing with vascular surgery. Dr. Homans was a colorful man and an inspiring teacher and lecturer with a striking sense of humor. His description of one approach to the treatment of claudication found in his textbook is quite unique. He wrote: “A stiff drink of whiskey or any strong liquor is, except for the corruption of the individual, an admirable, simple treatment for an intermittent limp—some even walk twice as far!” When asked by his students how much of this remedy one should take, he replied: “Well, any damn fool knows what a stiff drink is!”1The Massachusetts General Hospital 1955–1980, first edition. Brown and Company, Little1983: 251Google Scholar Dr. Homans made major contributions to the understanding, diagnosis, and treatment of venous thrombosis and “the Homans' Sign” remains a useful clinical tool today. Dr. Homans died in 1954 during my chief residency year at the MGH. Because of his influence and the many new developments in surgery occurring around me at that time, I became hooked on vascular surgery. My next hero in vascular surgery was an individual who had a profound influence on me for the rest of my professional life. Edward Delos Churchill (Fig. 2) was the chief of the Surgical Services at the MGH during my years there as a surgical resident and chief resident.Dr. Churchill, or “EDC” as he was called, was for 30 years John Homans' professor of surgery and chief, first of the West and later in 1948 of both general surgical services at MGH. He went to college at Northwestern University and graduated cum laude from Harvard Medical School in 1920. Dr. Churchill completed his surgical training at MGH after serving as the first West surgical resident. After several traveling fellowships he returned to the MGH in 1927 to join the full-time staff under Dr. E. P. Richardson. His research activities involved cardiovascular physiology and shock, and his clinical interests quickly turned with great vigor to the development of thoracic surgery. Over the ensuing years his contributions to surgery were heroic—he performed the first pericardiectomy for constrictive pericarditis in this country, the first mediastinal parathyroidectomy, and he pioneered the surgical treatment of bronchiectasis, tuberculosis, lung cancer, and pulmonary embolism. The premature disability of Dr. Richardson profoundly changed the course of events. On April 21, 1931, at the astonishing young age of 36 years, Edward D. Churchill was appointed chief of the West Surgical Service at the MGH. Over the next 30 years he dramatically changed the face of the surgical department. Under his leadership the research laboratories flourished, traveling fellowships for the faculty and the resident staff were created, and his concepts of residency training, involving a 5-year longitudinal tract with two resident-run ward services was to change the precepts of Halsted and win nationwide acceptance. His creation of a hospitalwide disaster plan saved many lives after the famous Coconut Grove fire in Boston on Nov. 28, 1942. In January 1943 during World War II Dr. Churchill was appointed chief surgical consultant to the North African and Mediterranean theatre of operations. He enjoyed the challenge of the war years and later chronicled his experiences in a wonderful book entitled Surgeon to Soldiers. To Dr. Churchill (in his words): “Military surgery was not to be regarded as a crude departure from accepted surgical standards, an awful business, but as a development of the science of surgery to carry out a specialized and highly significant mission—the surgery of trauma encountered in epidemic proportions.”2Churchill ED. The scope and nature of military surgery. Christopher's textbook of surgery. WB Saunders Co, Philadelphia1949Google Scholar During the late 1940s and 1950s clinical surgery flourished at the MGH under Dr. Churchill's leadership (Fig. 3).The men in his department were to become giants of American surgery in their own right and included Grantley Taylor, Leland McKittrick, Richard Sweet, Robert Linton, Claude Welch, Marshall Bartlett, and Oliver O. Cope. Dr. Churchill retired from MGH in 1962. He was an intellectually formidable and complex man who, despite his many immense responsibilities, always remained sensitive to the needs of his patients and his residents. He had a way with words, and he made people think. The following excerpt from his presidential address at the American Surgical Association in 1947 entitled “Science and Humanism in Surgery” is appropriate today: “In times of change there is need for wisdom both in the external social order and within the profession. Spokesmen who loudly proclaim measures based on self-interest will not be tolerated. A hold-fast on science is essential, but this represents only a part of the strength of surgery. By maintaining the ancient bond with humanity itself through charity—the desire to relieve suffering for its own sake—surgery need not fear change if civilization itself survives.”3Churchill ED. Science and humanism in surgery.Ann Surg. 1947; 126: 381-396Crossref Scopus (12) Google Scholar My third hero in surgery is Richard Harwood Sweet (Fig. 4).Dr. Sweet, affectionately and respectfully known as “Sir Richard” to his colleagues and residents, was to become a legendary figure at the MGH as a master technician. He graduated from Columbia and Harvard Medical School in 1926, and after completing his surgical training at MGH, he served an apprenticeship under Daniel Fiske-Jones, the preeminent Boston surgeon of his day. It is said that thoracic surgery at the MGH was pioneered by E. D. Churchill and advanced, perfected, and standardized by Richard H. Sweet. He carried out the first American esophagectomy with supraaortic anastomosis, the first splenorenal shunt at MGH, he divided the first tracheoesophageal vascular ring, and he introduced, with Edward Bland, the azygous vein-pulmonary artery shunt for patients incapacitated by mitral stenosis. His technique of secure esophageal anastomosis became a surgical standard that I faithfully used throughout my career. His many surgical techniques and his fastidious devotion to detail in the operating room are well described in his two published volumes: Diseases of the Esophagus and Thoracic Surgery. Dr. Sweet was a generalist; he always believed that thoracic surgery must be grounded on skills acquired as a general surgeon. He enjoyed exhibiting his mastery of anatomy and technique during general surgical procedures, constantly reminding the awestruck resident staff that — “The battle of thoracic surgery is won on the playing fields of the pelvis.”4The Massachusetts General Hospital 1955–1980, first edition. Brown and Company, Little1983: 220Google Scholar Dr. Sweet was a dashing, elegant figure, and I was always inspired by the plaque devoted to his memory at the MGH, which reads: Dr. Richard H. Sweet “Those attributes of a great surgeon—maturity of judgement, dexterity of hand, devotion in teaching, and serenity in crisis.” Dr. Sweet died of a myocardial infarction on Jan. 11, 1962. In E. D. Churchill's words he was “a master among masters.” My fourth hero in surgery was one of the major pioneers of his day in pediatric and vascular surgery and was responsible for some of the most important surgical advances of this century. Dr. Robert E. Gross (Fig. 5) graduated AOA from Harvard Medical School in 1931 and received his surgical training at the Peter Bent Brigham Hospital and Boston Children's Hospital.On Aug. 26, 1938, at the age of 33 years, while still a resident, he performed the first successful operation for correction of patent ductus arteriosus. His other accomplishments in the field of cardiac and vascular surgery were of heroic proportions—he performed the first successful resection of coarctation of the aorta in the United States in 1945. He experimented with hypothermia to guard against spinal cord ischemia, he developed an atrial well technique for closure of atrial septal defects, and his further research led to the use of aortic homografts for correction of long-segment aortic coarctation in 1948. His many accomplishments in pediatric surgery are published in his classic textbook, The Surgery of Infancy and Childhood, published in 1953. His operation for oophalocele proved highly successful and salvaged many desperately ill infants. In 1947 Dr. Gross became the Ladd professor of children's surgery and Surgeon in Chief at the Boston Children's Hospital where he served tirelessly until his retirement in 1972. He was the only physician to win the Lasker Award twice, and he was a member of the founding group of the Society for Vascular Surgery. After I left the MGH in the summer of 1954, I moved to Houston, Texas, where I went to work for Dr. Michael DeBakey, a tireless surgeon whose monumental contributions to cardiovascular surgery were to profoundly influence the profession for many years to come (Fig. 6).Dr. DeBakey trained under Dr. Alton Ochsner in New Orleans, served under Dr. Churchill during the war years, and moved to Houston from Tulane in 1948 to head the Department of Surgery for the newly created Baylor College of Medicine. For the next 37 years, Dr. DeBakey remained my mentor, a constant inspiration, and a warm friend. Dr. DeBakey's contributions to vascular surgery are legendary. He was the first to replace an abdominal aortic aneurysm in this county. He and his team performed the first carotid endarterectomy in 1953, the first resection of a descending thoracic aortic aneurysm that same year, and the first graft replacement of the aortic arch with yours truly in 1957. He pioneered the understanding, classification, and treatment of dissecting aortic aneurysms and along with Dr. Ed Garrett performed the first saphenous vein coronary artery bypass procedure in 1967. His development of the roller pump for the bubble oxygenator was a major advance in extracorporeal circulatory technology. Under his leadership, the Baylor College of Medicine and the Texas Medical Center blossomed and gained international prominence in the fields of cardiovascular medicine and surgery … these were indeed exciting times in Houston and in my life. It was quite fitting that Dr. DeBakey was to become the founding editor of the Journal of Vascular Surgery in January 1984. My final hero exemplifies the incorporation of science and humanism in a distinguished career in surgery. Dr. Frank C. Spencer (Fig. 7) was born in Haskell, Texas, a small town just north of Abilene, and he received his medical degree from Vanderbilt in 1947.After serving 2 years in the U.S. Navy medical corps during the Korean War, he completed his surgical training at Johns Hopkins in 1955 under Dr. Alfred Blalock. His career took him initially to Lexington, Ky., and in 1966 he was appointed the George David Stewart professor and chairman of the Department of Surgery at New York University Medical Center. As a young resident in Korea in 1952, Lt. (jg) Spencer demonstrated the feasibility of direct repair of arterial injuries in battle casualties, and launched a successful, though unauthorized vascular repair program, in direct violation of written orders developed during World War II. For this work he was awarded the Navy's Legion of Merit Award. Dr. Spencer always has been a “shaker and a mover.” He is a busy clinical surgeon, and his research interests included the use of the internal mammary artery for coronary artery bypass, closed chest cardiac massage, and the surgery of aortic aneurysms. Dr. Spencer is currently the seventy-first president of the American College of Surgeons. His eternal optimism, his dedication to and love of teaching, his concern for young surgeons, and his high regard for human dignity have been an inspiration to all of us. These six distinguished surgeons, then, are my surgical heroes. Just what is a hero and why are heroes so important today? In Greek mythology a hero was a man of great strength and courage favored by the gods and often regarded as half-god. Webster ascribes additional characteristics to a hero—“any person admired for his qualities or achievements and regarded as an ideal or model.”5Webster N. Webster's new universal unabridged dictionary.in: second ed. Simon and Schuster, New York1979: 852Google Scholar To be heroic and perform heroic deeds is to be bold, intrepid, daring and courageous. A hero ascends to his lofty status by his style of achievement as well as his nobility and his eloquence. A hero is one who challenges the insurmountable with singularity of purpose and will and triumphs despite overwhelming odds for the benefit of others. By the magnitude of their deeds, their perseverance, their striving to constantly improve themselves and others about them for the benefit of their patients and their chosen specialty, these six men are truly heroes. I have tried to pattern my life and my surgical career after their example. I think Karen Ravin was writing about heroes in her poem when she wrote: “Only as high as I reach, can I grow,Only as far as I seek, can I go,Only as deep as I look, can I see,Only as much as I dream, can I be.” Vascular surgery has come a long way in the past 50 years, and I consider myself one of the luckiest people alive to have lived through these exciting times. A great many of you in this room can take pride in these heroic accomplishments: the development of durable arterial replacements, the safe management of aortic aneurysmal and occlusive disease, the prevention of devastating neurologic injury by safe, standardized surgery, on the extracranial vasculature, the constantly improving care of civilian and military vascular injuries, noninvasive diagnosis of arterial and venous disease, and the surgical correction of renovascular hypertension. Because of the ingenuity of vascular surgeons we are able to salvage extremities and lives when faced with complicated situations involving failure of prior vascular reconstructions. Lytic therapy, the prevention and management of venous disease, such as by the use of the Greenfield and bird's nest filters, and reconstructive cardiovascular surgery on children and the elderly have become common and safe procedures. The era of “endovascular surgery” is solidly on us and promises exciting new approaches to the treatment of vascular disease. Vascular training programs, research on vascular disease and vascular societies such as this have flourished, and the Journal of Vascular Surgery has become the premier journal of our specialty. Look what our efforts have led to! High-tech intensive care units are staffed in some areas by a whole new “breed of cat”—the “intensivist.” We know more about blood and the dangers of blood transfusions. The fields of organ transplantation and plastic surgery have benefited from refinements in vascular surgical techniques, as have thousands of unfortunate patients on chronic hemodialysis. Despite our accomplishments, many significant challenges remain ahead of us. I spent many years trying to understand and prevent the devastating complication of paraplegia after thoracoabdominal aortic replacement. I am sad to say that we appear no closer to this solution. We need to understand the fundamental pathogenesis of atherosclerosis and intimal hyperplasia, and much needs to be learned about blood clotting in our vascular patients. I am particularly troubled by the multitude of forces currently stifling the enthusiasm, resourcefulness, and creativity, of our younger vascular surgeons. These young men and woman are wrestling with radiologists and cardiologists to preserve their specialty, they face a hostile government that perceives them as basically dishonest and acting only out of self-interest. They face RBRVS, an uncertain financial future, the threat of AIDS, malpractice, and a hostile public who will pay $23 million to and glorify a baseball player who bats 0.350 but will not forgive the vascular surgeon who bats 0.999. Heroic men like the ones I have described today are responsible for the achievements in the field of vascular surgery that we are so rightly proud of. Every specialty of medicine, every, area of human endeavor needs its exalted, daring heroes to make progress, to make new discoveries, and to transcend the insurmountable. In so doing they also provide for the perpetuation of the specialty among its younger colleagues. We need to continually dedicate ourselves by our deeds and our behavior under fire to being heroes to our younger generation and to inspire in them those qualities that will make them want to be heroes in their own right. In this way the baton will be passed and we will “perpetuate the passion” in these exciting young people. I have had a long and wonderful career in vascular surgery that has taken me to many foreign countries and has brought me into contact with many fascinating people. I would not have traded my life with anyone. The past 4 months have been very hard for me for I am no longer able to do what I enjoy doing most in life—I cannot be the hero I want to be. I express my thanks to all of you who sent me letters, cards, baseball hats, cassette tapes, and your pictures to keep me going. In difficult times like these one finds oneself quietly turning to his faith, whatever it may be. Everyday I reread a short passage from Isaiah that one of you recently sent to me: “But those who wait upon the Lord will renew their strength, they will soar on wings like eagles, they will run and not grow weary, they will walk and not faint.”6Holy Bible, King James version. Isaiah 40:31.Google Scholar The Lord is my strength and he has blessed me with a long, exciting life in surgery, a wonderful wife and family, and friends like you. Thank you for this honor. Thank you for being my friends and for inspiring me over the years. You have been the wind beneath my wings. Strive to be heroes. God bless you all.