FEATURE — Fall 2003
   

  The '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 pneumonectomy—the removal of a lung—for the treatment of lung cancer. The following passages are taken from the chapter on the successful surgery, Chapter 7:

 


The Pneumonectomy
(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 thoracic surgery.

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. ...

Gilmore's Operation

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.
TPR q4h.
Bedrest with bathroom privileges.
Tub bath.
Light diet.

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 fairly sparse:

Regular diet as tolerated.
CO2 routine.
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 the pneumonectomy.

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 Carlson's article.

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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