THORACIC SURGERY: AND THE LONG-TERM RESULTS OF OPERATION FOR BRONCHIAL CARCINOMA The Tudor Edwards Memorial Lecture delivered at the Royal College of Surgeons of England on 20th May 1964 by Sir Russell Brock, M.S., F.R.C.S., Hon. F.R.A.C.S., Hon. F.A.C.S. President of the Royal College of Surgeons of England; Surgeon to Guy's Hospital and to the Brompton Hospital Fig. 1. Arthur Tudor Edwards. ARTHUR TUDOR EDWARDS (Fig. 1) was born in 1890 and died in 1946 at the early age of 56. In honour of his memory and of his great surgical achievements his friends, colleagues and admirers subscribed to a Memorial Fund that was used in 1948 to endow a named lecture. It is my privilege to deliver the lecture on this occasion and I have to thank the President of the Royal College of Physicians and the members of the committee representing the two Royal Colleges who administer the Fund for doing me the honour of appointing me. This is the fifth lecture. The first was given in 1949 by Dr. Shenstone, the next in 1955 by Sir Geoffrey Marshall, the third in 1958 by Sir Clement Price Thomas and the last one in 1961 by Dr. Comroe. Both Sir Geoffrey Marshall and Sir Clement Price Thomas were closely associated with Tudor Edwards over many years. I was fortunate in 195 SIR RUSSELL BROCK being associated with him from 1934 until his death, although not so intimately as these two previous lecturers. Alas, few of his direct associ- ates are still with us. Sir Thomas Holmes Sellors shared with me the advantages of working with him in the London County Council Thoracic Surgical Unit at St. Mary Abbot's Hospital and Mr. Norman Barrett was for a time his clinical assistant at the Brompton Hospital. Tudor Edwards was born in Swansea in 1890; he was educated at Mill Hill School and St. John's College, Cambridge, before completing his medical training at the Middlesex Hospital, where he was dresser and house- surgeon to Sir Gordon Gordon-Taylor. He was serving as surgical registrar when he was commissioned in the R.A.M.C. at the outbreak of war in 1914, ultimately working in a casualty clearing station and attaining the rank of major. After the war he applied for but failed to secure a post at Cardiff and served as Resident Assistant Surgeon at St. George's Hospital until, in 1919, he was appointed Assistant Surgeon to the Westminster Hospital. In 1922 he was appointed Surgeon to the Brompton Hospital and thus began the work in thoracic surgery that was to bring him an international reputation. Before speaking of his work at the Brompton Hospital it seems appro- priate to say something of his character and personality. Price Thomas dealt with this quite fully and out of his greater knowledge of Tudor Edwards and I can only add certain of my own impressions. You will observe from his photograph that he was of a handsome, even of a debonair appearance. His general demeanour was one of aloofness that gave the impression that he could be disagreeable, unfriendly and even arrogant. Price Thomas, who knew him better than anyone else did, states that he was essentially shy and very much of an introvert. I think this is a correct assessment, but he was also vain and had an important streak of jealousy; perhaps understandably human features in his char- acter. I was much junior to him so could not necessarily expect a warm friendliness but it was rare to see him warm and friendly although he could be so. He hid, or rather was able to control, his emotions and this was especially striking when he was personally attacked, as I shall mention later. This control of emotions showed at its very best when he was con- fronted with difficulties while operating. He was then completely cool and efficient. He could be a superb technician and was unquestionably a bold, courageous, intelligent and safe operator. I remember an occasion when I was assisting him at an operation on a huge deeply placed media- stinal tumour, thought possibly to be an aneurysm. As he approached it fearlessly and efficiently I commented that no-one could say that he was not a bold surgeon; his reply was, "Not, I hope, at the expense of my 196 THORACIC SURGERY patient". The tumour turned out to be a tubular dermoid cyst and was removed. Although he was a fine technical operator his interests in surgery did not extend to the basic principles and he made no contributions to the basic anatomy, physiology or pathology of his subject. In addition to his fine qualities and courage as an operator he was an excellent cliniciani and diagnostician. Gordon-Taylor, his former chief and teacher in general surgery, wrote in his obituary in the British Journal of Surgery: "His chest surgery was learned from no other pioneer, but was carved out of the hard rock of personal experience." I suppose that in this statement lies one of the shrewdest assessments of Tudor Edwards's achievement. His success rested in great part on his own efforts and his own inspiration and tenacity of purpose. But no man can succeed alone and it is certain that he also owed much to the confidence shown in him by the physician colleagues who asked him to treat their patients. Their confidence, of course, sprang from his proven ability and achievements. Chief amongst these colleagues one must mention Sir Robert Young, Sir Geoffrey Marshall and Dr. Burrell, although there were many more who regularly sent patients to him. Gordon-Taylor writes: " . he was also blessed in the co-operation of wise physician colleagues, particularly at the Brompton Hospital, who were possessed of vision and who reposed complete confidence in him." And again, " He served Westminster, London, Queen Mary's Roehamp- ton, Midhurst, Millbank and others; doubtless his heart lay in Brompton but he served each institution with fidelity and brought lustre and distinc- tion wherever he was attached ". In addition to serving as his assistant at the Brompton Hospital I also acted for him at Queen Mary's, Roehampton, when he fell ill, and sub- sequently succeeded him there when he retired from the arduous operating it provided. He did this with great reluctance because of the many years of invaluable and interesting surgery he had done there. It should be known that in addition to being a brilliant thoracic surgeon he was also a general surgeon of the first water and this was especially well shown at Roehampton in the complex abdominal problems encountered in those pensioners from the first World War who had often already undergone many complex abdominal operations. I would say that his experience and his success in cases of gastrojejunal ulceration and of gastrojejunocolic fistula was at least equal to and probably superior to that of any surgeon in Europe. He also had much experience in dealing with those very difficult cases of arteriovenous fistulae that follow gunshot wounds, many of which were seen at Roehampton. 197 SIR RUSSELL BROCK Tudor Edwards was a tiger for work, seemingly untiring and unaware that he might be tiring others. At the Brompton on Wednesday afternoon he would begin by seeing out-patients, follow this with a complete round of his many patients and then go to the operating theatre where he would begin a list of perhaps 6-8 cases continuing until 8 or 9 p.m. The list would include major thoracic procedures of every type. There is no doubt that it was his work at the Brompton that pleased him most. Countless visitors came from every part of Great Britain and in- deed from every part of the world to see him working there, assisted by Clement Price Thomas and that prince of anaesthetists, Ivan Magill. The old operating book of the Brompton Hospital I wish to expand upon his work at the Brompton Hospital because it was there he did so much of his best work, and it is with the Brompton that his name is most firmly associated. The place that he holds in the establishment and the development of thoracic surgery is also admirably demonstrated by the entries in the old operating book of the Brompton Hospital and it is with this that I now wish to deal. The record of operations begins on 20th January 1908 and continues until 22nd July 1941; the book is a vivid record of the evolution of thoracic surgery in this country and reveals Tudor Edwards as the leading figure. The staff of the hospital from its foundation included a consulting surgeon, but it was not until 1884 that a visiting surgeon was appointed. The consulting surgeons were four and all were very distinguished: Robert Liston (1842-1847), Sir William Fergusson (1849-1876), John Marshall (1878-1891) and Lord Lister (1891-1912). Fergusson and Marshall were both Presidents of the Royal College of Surgeons as also was Sir Rickman Godlee, the first visiting surgeon, who served from 1884 to 1900. He was followed by Stanley Boyd, who served from 1900 to 1916, over the time of the first operations recorded in our book. Most of the operations the visiting surgeon was called upon to perform were the routine pro- cedures liable to occur in any hospital together with a few specially related to tuberculosis. In 1908 49 operations were done, 36 were for non- thoracic conditions, only 13 on the chest, all for empyema, including four Estlander procedures.