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
* * *
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
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.
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
In addition to his prominent place in surgery, Dr. Robicsek is also an
accomplished amateur archeologist and wrote several books on South
Fig. 58. An asymmetric pectus carinatum.
Fig. 59. Normal appearing chest wall following operative correction of pectus excavatum.
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
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
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. 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
Fig. 62. F.G.Pearson’s book Thoracic Surgery.
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
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 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).
* * *
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
visit was followed by another invitation two years later, when I spent
another four days in Rochester, lecturing and teaching (Fig. 65
Fig. 64. The visit was concluded with my lecture on chest injuries during the Yom Kippur War.
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
Fig. 66. Certificate of Visiting Professor.
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
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. With my interpreters, Miss Cai Wen-jing and Dr. Mu Jin at Confucius’ tomb.
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
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. 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
Fig 71. Drying contrivance: straw spread over highway.
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. On the Great Wall of China.
Direct observation of the esophagus through a special instrument, with biopsies from areas suspected as abnormal.
Pericardioscopy: direct look inside the pericardium (the membranous sac enclosing the heart).