'Surgical' Spirit of St. Louis
|Evarts A. Graham
In the "Preface" to Evarts A. Graham: The
Life, Lives, and Times of the Surgical Spirit of St. Louis (BC
Decker Inc., 2002), author C. Barber Mueller, M.D. '42, states:
"Evarts Graham was American surgery's 'Man for All Seasons,' and
his accomplishments are of such importance that he deserves more
than a cluster of obituaries as a final record. His high ideals
and many achievements placed him alongside [William] Halsted and
[Harvey] Cushing as one of the three most eminent American surgeons
of the day. He was so highly regarded that, without an interview,
the governing bodies of Johns Hopkins and Harvard agreed to appoint
him to the vacant chairs of Halsted and Cushing before they asked
if he were willing to consider the positions. Graham was sufficiently
astute to refuse both offers, for Washington University had given
him all he needed, permitting him to be a leader in the development
of clinical research, clinical surgical techniques, and residency
surgical education. A half century later, abandoned by the historians
of our day, he has become a forgotten hero."
Throughout the book, Mueller, who was Graham's
last chief resident, pays tribute to Graham's historical significance.
Among his many accomplishments, Graham (1883-1957), the Bixby Professor
of Surgery and head of the Department of Surgery, performed the
first successful pneumonectomythe removal of a lungfor
the treatment of lung cancer. The following passages are taken from
the chapter on the successful surgery, Chapter 7:
(the surgical removal of a lung)
The Arrival of Gilmore
On February 27, 1933, Dr. James Lee Gilmore,
a 49-year-old obstetrician from Pittsburgh, Pennsylvania, was admitted
to the Medical and Surgical Chest Service (the chest clinic) of
Barnes Hospital, accompanied by his referring physician Dr. W.T.
Mitchell. Little did anyone realize his registration that day would
initiate a series of events that would make him the central figure
in a surgical melodrama that would last for years. His operation,
recovery, and survival marked a new epoch in the development of
Dr. Gilmore underwent four hospitalizations at
Barnes; the first lasted for 6 days; the second, on March 9, was
for 1 day; the third, on March 13, lasted for 11 days; and his final
admission, on April 4 for an operation on April 5, ended with his
discharge on June 18, 10 weeks later.
In January 1929, Dr. Gilmore had had pneumonia
of the right lower lobe that required several weeks before full
recovery. He was then well until July 1932, when he experienced
general discomfort, chills, fever, and an elevated white blood cell
count. One month later a chest radiograph revealed a "fan-shaped
shadow in the region of the left axilla" (the upper lobe of his
left lung) that regressed over the next few days; this condition
recurred in October and, once again, soon subsided. An attempted
aspiration of a suspected lung abscess in December 1932 resulted
in a pneumothorax that persisted until his February 1933 admission
to Barnes Hospital. His December symptoms had abated somewhat, but,
10 days before admission, fever and chest discomfort recurred, and
he arrived with a tentative diagnosis of lung abscess.
Gilmore, who was of medium build, had restricted
movement of the left chest. A chest radiograph showed collapse of
the upper lobe of his left lung. A biopsy taken during bronchoscopy
by Dr. M.F. Arbuckle failed to establish the presence of carcinoma.
An iodized oil (Lipiodol) bronchogram showed an obstruction in the
left upper lobe bronchus, with satisfactory visualization of the
left lower lobe bronchus.
There is no record of the events that occurred
during Gilmore's 1-day admission of March 9. A visit to the chest
clinic with some procedure seems likely, although it may have been
merely an opportunity to be seen and have his case reviewed. His
third admission, on March 13, was for further work-up. Dr. Arbuckle
bronchoscoped him again and, after visualizing the left upper lobe
bronchus, stated that its lumen was larger than it had been at the
prior examination. He saw walls lined with a dark red membrane that
bled easily, but was unable to distinguish whether these were chronic
inflammatory changes or malignant growths. In the main stem bronchus,
just at the opening of the upper lobe bronchus, a mass the size
of a pea with similar dark red characteristics was noted, and, after
attempting to biopsy both the mass in the main stem and that in
the upper lobe bronchus, Arbuckle felt that the biopsy material
was not sufficient for diagnosis. Nonetheless, Dr. W. Dean, Jr.,
pathologist for the Ear, Nose, and Throat Service, reported the
condition to be squamous cell carcinoma of the left upper lobe.
Dr. Arbuckle's third bronchoscopy, on March 21, showed abnormalities
in both the upper lobe and the main stem bronchi, and satisfactory
biopsies taken from these areas showed squamous cell carcinoma.
Following discharge, Gilmore returned to Pittsburgh
taking the biopsy slides with him for review. He had plans to re-enter
Barnes on April 4 for a left upper lobectomy the following day.
There is no record that Graham and Gilmore discussed the possibility
that a lobectomy might be inadequate. In a 1948 restatement of these
events written for the Texas Cancer Bulletin, Graham noted:
"The patient had an unusually stoical disposition. He insisted on
knowing exactly our diagnosis. ... He stated that he would like
to go to his home to get some things in order and would like to
borrow our biopsy slides to show them to some pathologist friends.
... I recommended the removal of the left upper lobe. It is of interest
that he demonstrated himself to be not only a stoic but also an
optimist, because while at home he had some cavities filled." Years
later, Gilmore confided to Dr. Graham that he had not only visited
his dentist but that he had purchased a cemetery plot. ...
Accompanied by his lifelong friend Dr. Sidney
A. Chalfont, also of Pittsburgh, James Gilmore was admitted to Barnes
Hospital on April 4, in preparation for a left upper lobe lobectomy
the following day. He was assigned room 3117 on the third floor
of the east (medical) wing of the hospital, where medical or surgical
semiprivate and private patients received care. The operative permit
obtained that evening read: "I herewith request the performance
of the required operation and such additional work as may be found
necessary or advisable at the time. /s/ James L. Gilmore/Witness:
s/ W. Erlich, M.D."
On that evening, one of the house officers visited
Gilmore and told him that, if he were in Gilmore's shoes, he would
get out of the hospital right then and there because the mortality
rate had been extremely high. He suggested that Gilmore sign out
against medical advice; Gilmore did not report the incident to Graham,
for he was sure that Graham would make life uncomfortable for the
house officer. Dr. Kenneth Bell's preoperative orders were as follows:
Routine prep for lobectomy "L."
Morphine 0.15 gm @ 9 A.M.
Atropine .0004 gm @ 9 A.M.
To OR when called in bed.
Bedrest with bathroom privileges.
On April 5, 1933, shortly after 9:00 am, Gilmore
arrived in Operating Room No. 1. His blood pressure was 100/60;
his pulse, 84 bpm; and his respiration rate, 20 breaths per minute.
Anesthesia was begun at 9:35, and an endotracheal tube (probably
a Magill tube) was introduced 10 minutes later. Graham made the
initial incision at 10:00 am and entered the chest with the removal
of ribs no. 6 and no. 7. After cutting adhesions between the upper
lobe and chest wall, he felt several hard nodules in the upper lobe,
and he focused attention upon the hilum. Confirming that the main
stem bronchus was involved and that there was no uninvolved area
in the upper lobe bronchus, Graham turned to Dr. Chalfont, Gilmore's
physician friend (who was accompanied by Gilmore's brother-in-law,
Dr. Archibald Campbell of Montreal, Quebec) and said that it would
be useless to perform a lobectomy. He strongly advised the removal
of the entire lung and asked for Chalfont's opinion. Chalfont asked
if such an operation had ever been done before. Graham replied that
it had been performed successfully in animals, in fact, he had even
done it himself, but he knew of no case of a successful one-stage
removal of the lung in a human being. After a little more discussion,
and particularly because Graham felt that Gilmore would want to
take any chances that might effect a cure, Graham decided to perform
the total pneumonectomy. A rubber catheter was placed around the
hilum to constrict the arterial and venous flow for 2 or 3 minutes.
No cardiovascular collapse occurred. Graham then applied two clamps,
cut between them, removed the lung with one clamp, and placed three
sutures around the hilar stump before removing the second clamp.
The stump was cauterized with heat and silver nitrate, radon seeds
were implanted, and, aghast at the size of the cavity, Graham removed
seven more ribs (nos. 3 to 5 and nos. 8 to 11) to let the chest
wall collapse onto the mediastinum and bronchial stump. The entire
procedure took 1 hour 45 minutes. Gilmore's blood pressure was recorded
as 120/80 upon leaving the operating room, and he received a transfusion
of 500 mL of whole blood. Dr. Kenneth Bell, chief resident, was
Graham's first assistant, and Dr. William Adams was his second.
Listed also as members of the operative team were Drs. Hall and
Erlich; Miss Moore, the surgical nurse; and Miss Lamb, the anesthetist.
The anesthetic agent was nitrous oxide and oxygen (ether was never
used when hot cautery was anticipated).
Graham dictated a lengthy operative note to Ada
Hanvey, in which he documented his intraoperative decision to remove
the entire left lung. After the lung was removed, the mucosa of
the bronchus was cauterized with a hot cautery as well as 25 percent
silver nitrate solution before being transfixed with double no.
2 chromic catgut suture around the whole pedicle. A second ligature
was placed distal to the first, and a third was applied before the
tourniquet catheter and the remaining clamp were removed. The open
end of the stump of the main stem bronchus was slightly less than
1 inch from the bifurcation of the trachea. Two enlarged mediastinal
lymph nodes that seemed soft and unlikely to contain cancer were
removed for microscopic examination, and seven radon seeds of 1.5
mCi each were introduced into the severed pedicle. Graham did not
record the radon administration in his dictated operative note,
but he did so in his later report. After the thoracoplasty was completed
and the space obliterated, a small catheter that fitted tightly
through the skin was led into a boric acid solution below the bed
to give underwater sealed drainage. The operation was completed
by closing the chest in layers. ...
The Postoperative Course
Postoperative orders written by Dr. Bell were
Regular diet as tolerated.
Elevate foot of bed.
BP and Pulse q15 minutes.
May be turned.
Tight chest binder.
|After Dr. James Gilmore (right) was released
from Barnes Hospital, he and Dr. Evarts Graham (left) became
friends, frequently corresponding and occasionally visiting
each other. The above image was taken in 1955, 22 years after
By 3:15 the next afternoon, Gilmore was quite
comfortable and had gone 8 hours without an opiate but had not voided.
About 800 cc of fluid had drained through the chest catheter. Gilmore's
temperature remained approximately 37.2°C, his pulse 134 bpm,
and his respirations 32/min, with some respiratory difficulty. He
coughed when he attempted to lie on his right side or upon talking.
He was given Aspirin and codeine to lower his temperature and taken
to the operating room for a thoracostomy and drainage of a pus cavity
in the left upper chest. With Gilmore under nitrous oxide anesthesia,
Graham removed a portion of the second rib and entered a cavity
at the apex of the left chest, where he inserted a small tube. He
planned to permit this drainage tract to seal, and then follow up
with removal of the first and second ribs. From incision to closure,
the procedure took 20 minutes. Once again, Dr. Bell was his assistant.
Nine days later, Gilmore was returned to the
operating room for a two-rib thoracoplasty under nitrous oxide and
oxygen anesthesia. In a 20-minute procedure, the prior incision
was extended upward and the first and second ribs were removed.
Dilaudid, Veronal, and codeine were the postoperative analgesics
used. One week later Gilmore was permitted to get out of bed, and
on June 18 he was discharged to go home.
Gilmore's activity had been increased gradually
during his postoperative hospital period and, at time of discharge,
he had been walking around for about 2 weeks, with moderate dyspnea
on exertion. On admission his vital capacity was 3500 cc; at discharge,
1650 cc. His admission weight of 145 lb had fallen to 122 lb; a
photograph published with the report in the Journal of the American
Medical Association shows an extremely thin man with satisfactory
motion of the left upper extremity. Gilmore had undergone 44 days
of hospitalization and three operative procedures, but he never
needed to return. ...
Publicity and Priority
Evarts Graham must have realized the significance
of his successful procedure, for 7 days later he wrote to H.A. Carlson
with comments about the upcoming publication of an article that
Carlson and Ballon had prepared. Graham's letter was chiefly devoted
to a description of the events in St. Louis, not the substance of
I wish you could have been here. ... I removed
the entire left lung ... for an early carcinoma of the left [main
stem] bronchus just where it bifurcated. ... The operation was performed
a week ago and he has had a surprisingly little post-operative reaction
... he looks like a patient recovering from a simple appendectomy
or hernia ... I feel greatly thrilled about it. ... it looks now
as if he would surely recover from the operation. This is the first
time that a whole lung has been removed for carcinoma. ... I do
not think it would be advisable to put a note about it in the article
by yourself and Ballon on the operability of carcinoma of the lung
because of course there is still the possibility of an embolus or
something of that sort which might carry him off unexpectedly.
||C. Barber Mueller,
M.D. '42, is professor emeritus of surgery at McMaster University
in Hamilton, Ontario, Canada, from which he recently received
an Honorary Doctor of Science.
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