Arthur Tudor Edwards

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 character. 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 mediastinal 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 indeed 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 procedures 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. It is interesting that the name of the surgeon is never given at this time and even though there is a column for the name of the physician none is given until January 1909 and then only for eight weeks. In 1910 the physician's name is given spasmodically for a few months, but it is not until March 1913 that the physician is named regularly; the surgeon continues anonymous. In 1918 and 1919 the great influenza epidemic is 198 THORACIC SURGERY represented by the more frequent drainage of empyema, otherwise the operation cases remain much the same. In 1919 J. E. H. Roberts was appointed together with Richard Warren, who continued until 1921 only. In 1919 still only 71 patients were operated on, 41 non-thoracic, 30 for thoracic conditions, mostly acute and chronic empyemata. In 1920 the number was almost the same, 78 with 36 thoracic. In 1921 there were 69 operations, 34 non-thoracic, 33

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thoracic and these included three for division of the phrenic nerve; the thoracic operations were just 50 per cent of the total cases. In 1922 Arthur Tudor Edwards was appointed visiting surgeon and it is clear immediately from the book that a new era had begun. Some un- known genius, touched with the flame of prophecy, has drawn a line in red ink across the page at the end of 1921 and below has written " 1922 " in red ink (Fig. 2). As before, the names in the first months continue in blue ink and then on 9th June they begin to appear in red ink, the first one having in the margin against it "(T.E.)" (Fig. 3). Thenceforward the surgeons are distinguished by the use of red ink or blue ink, but it is not 199 SIR RUSSELL BROCK until 1931 that the name of the surgeon is given! In the year 1922 only 24 operations were performed in the first five months before Tudor Edwards began work and only 10 ofthese were thoracic. In the remainder of the year 56 operations were done, 46 by Tudor Edwards, of which all but 18 were for thoracic conditions. These at once include a variety of procedures not seen earlier, including staged thoracoplasty. On 23rd November 1922 it is recorded that Professor Jacobeas cauterized some

Fig. 3. adhesions; his name is written in red ink and presumably he did so at the invitation of Tudor Edwards, who had visited the continental thoracic surgical centres, for two months later, on 23rd January 1923, a " thoraco- scopy and cauterisation of adhesions" is recorded as done by Tudor Edwards. In the previous year he had carried out two simple thoraco- scopies without cauterizations of adhesions. From now onwards the growth of thoracic operations is steady: in 1923 106 cases, 62 thoracic; by 1927 the total was 234 and in 1928 252 of which 200 THORACIC SURGERY 204 were done by Tudor Edwards. The proportion of thoracic operations had now risen to about 75 per cent (Table I). TABLE I OPERATIONS AT THE BROMPTON HOSPITAL FROM 1908 TO 1928 Year Total Thoracic 1908 49 13 1920 78 36 1921 69 33 1922 80 38 1923 106 62 1928 252 184 By 1926 the two surgeons had persuaded their colleagues that it was necessary for them to have direct charge of patients in surgical wards instead of operating solely on patients from beds under the care of a physician. In this year also a new operating theatre was built. By the time of the National Health Service in 1948 more than half the patients admitted to hospital underwent an operation, such was the development of thoracic surgery that followed. On 5th December 1928 appears the first record of lung resection: "lobectomy for growth " by Tudor Edwards on a patient of Dr. Burrell. This was a dissection lobectomy for what was described as a " vascular endothelioma " when reported in the British Journal ofSurgery in 1938 by Edwards and Brian Taylor. It will be noted that, characteristically, Tudor Edwards waited 10 years before recording this case which was, in fact, of great importance seeing that it was the first successful case of dissection lobectomy. The patient was a woman aged 48, with a well-defined large circular opacity in the right lower lobe. At thoracotomy the lower lobe was found to be almost filled with a large tumour. The lobe was removed by ligation of the lobar vessels and suture of the lower lobe bronchus. Recovery was uneventful and the patient was still in perfect health eight-and-a-half years later. I have looked up the later history of this patient and I find that she died on 21st May 1957, nearly 29 years later, with a massive growth in the right lung. The article by Edwards and Taylor contains a report of three similar cases, one treated by left lower lobectomy in May 1934, another by upper lobectomy in July 1934 and the fourth in May 1935. All patients did well. Although lobectomy was established as a routine procedure by 1934 these four cases still make a noteworthy series. Tudor Edwards nearly succeeded in achieving a successful lobectomy as early as March 1926; the account of the case appeared in an article in the British Journal of Surgery in 1927. The patient, a man aged 60, had a sarcoma of the right 201 SIR RUSSELL BROCK lower lobe and the lobe was removed by a series of ligatures and trans- fixion sutures after crushing the larger bronchi. This patient unfortunately died 20 hours after operation from a haemothorax, thought to be caused by haemorrhage from an intercostal artery wounded by a pericostal suture. So far as I can tell the lobectomy of May 1928 was the first successful one-stage lobectomy performed in the world. It is strange how little this achievement is known and what small credit Tudor Edwards has been accorded. The story does not finish even with this case because in 1939, writing in the British Medical Journal of his experience in 199 cases of lung resection for bronchiectasis, he states, "The first successful lobectomy for bronchiectasis in this country was carried out by me in April 1929, by separate ligature of the vessels and the lobar bronchus at the hilum in a boy of 16 years. The patient was later demonstrated at the Medical Society of London by Dr. McDowell in 1930." The patient had then gained 10 lb. in weight and had lost all sputum. It is somewhat astonishing to find this triumph also recorded in this almost casual way 10 years after it had been achieved and one year before Blades and Kent (1940) published their classical article on " Individual ligation technique for lower lobe lobectomy ". This article has resulted in Blades and Kent being almost universally accorded priority in individual ligation technique and yet we find these two successful cases done in 1928 and 1929. They even precede Churchill's brilliant case of dissection lobectomy for an adenoma of the bronchus done in August 1931 (Churchill, 1933). Tudor Edwards's prior claim has been almost entirely ignored or rather has passed unnoticed. There is little doubt that this is chiefly due to his reluctance or failure to record his work promptly and plainly. His publications never reflected the volume and quality of the great amount of pioneer work he did. In 1927 Tudor Edwards successfully resected the upper two-thirds of the left upper lobe containing a secondary deposit from a myeloma of the fibula for which amputation had become necessary in 1921. The patient, a woman aged 57, was alive and well when he reported the case three years later in 1931. This is another example of his boldness and clear surgical vision. By 1932 the total number of operations recorded in the book had risen to 726, nearly 15 times as many as in 1908 and over 10 times the number in 1909. Of these 471 were done by or for Tudor Edwards; only 45 of the grand total were for non-thoracic disease, 681 were for thoracic procedures. Up to now the names of occasional junior operators had been mentioned, but on 5th February a new name appears, that of Clement Price Thomas, who performed an appendicectomy on Nurse Smith; three days later, on 202 THORACIC SURGERY 8th February, he performed an evulsion of the phrenic nerve. It was then customary to note the length of the specimen obtained by the surgeon; on this occasion 2i inches is recorded! On 22nd February this operator is again recorded as extracting 23 inches, but on the same day he caught a bigger fish, 141 inches in length. Unhappily in the afternoon of the same day he slipped from grace by securing only 12 inches! Clement Price Thomas was then clinical assistant to Tudor Edwards and was appointed Assistant Surgeon to him in 1933. In the same year H. P. Nelson was appointed Assistant Surgeon to Mr. Roberts. It is impossible to let this opportunity pass without recalling the brilliance and great promise of H. P. Nelson so tragically and suddenly cut short by his death in 1936 from sepsis acquired from a case of lung abscess. This calamity occurred only just before the introduction of chemotherapy; had his life been spared who knows what great contributions he would have made. It was largely due to Nelson that in 1932 our book records the first lobectomy for bronchiectasis at the Brompton Hospital done on 26th May by Roberts assisted by Nelson. This case is recorded in the article by Roberts and Nelson in their report of 10 cases published in the British Journal ofSurgery in 1933; it was their second case, their first having been done on the previous day, 25th May, at St. Bartholomew's Hospital. It is not until 27th July 1932 that Tudor Edwards's first case oflobectomy for bronchiectasis at the Brompton Hospital is recorded; Clement Price Thomas assisted him and in 1934 they were able to report, also in the British Journal of Surgery, 48 cases with only seven deaths. Lobectomy at this time was done by the tourniquet technique pioneered by Brun in 1929 and improved and established by Shenstone and Janes in 1931. I have already described how in 1939 Tudor Edwards was able to report in the British Medical Journal his experience in 199 cases of lobectomy or pneumonectomy for bronchiectasis and that in this article he records that the first successful lobectomy for bronchiectasis in this country was carried out by him in April 1929 by separate ligation of the vessels and the lobar bronchus. It is idle to conceal at this distance of time that he and J. E. H. Roberts were severely estranged. It is certain that Roberts was irritated by and resentful of Tudor Edwards; perhaps he was inspired by jealousy or envy. I witnessed many occasions when Roberts was violently, even virulently, provocative and rude, but never on any occasion, even when he must have been severely provoked, did I ever see Tudor Edwards act without dignity and restraint. If he had ever been the direct cause of strife or friction it was never on any occasion in my presence over a term of nearly 15 years. I have always felt that this enmity between the two surgeons may have contributed to the fact that neither of them wrote as much as they should have done and caused some distraction of their thoughts from that 203 SIR RUSSELL BROCK forward thinking in thoracic surgery that they should have shown. When one thinks of the vast experience both had, of the unusually large numbers of patients passing through their hands and their great opportunities, it is surprising and disappointing that they left it to others to make certain fundamental contributions. This was especially so in the case of the evolution of thoracoplasty for pulmonary tuberculosis. With both Edwards and Roberts it long stayed in the rib-cutting stage; others pon- dered and produced the basic additions of apicolysis in its various forms. Thoracoplasty with apicolysis should surely have come from the Brompton Hospital in the 1930s, that decade in which thoracic surgery was so active there. As it is we do not see the Semb thoracoplasty as such recorded as being done before November 1936, first by Roberts then in January 1937 by Edwards, in February 1937 by Price Thomas and thereafter by all the surgeons. The rivalry between the two surgeons is revealed for he who is informed about the entries for early February 1935. Tudor Edwards's operating day was Wednesday; Roberts's was on Friday. On Wednesday, 6th February, Edwards performed a left pneumonectomy for a bronchiectatic abscess; on Friday, 8th February, Roberts also performed a left pneumonectomy for bronchiectasis. These were the first two successful cases in this country of one-stage pneumonectomy and I remember the occasion well. This first case and another later one were shown at the Royal Society of Medi- cine by Gowar (1935-36) on behalf of Tudor Edwards. On the same occasion Roberts presented his case (Roberts, 1935-36). One month after this we read that Price Thomas performed a partial pneumonectomy for growth, and on 22nd July Tudor Edwards performed a right pneumonectomy for a carcinoma, without success. The rarity of pneumonectomy at that time is shown by the fact that only two more cases are recorded for 1935, one for carcinoma by Edwards and one for bronchiectasis by Roberts. In the following year, 1936, a lung was removed on six occasions, three ofthem by Edwards for carcinoma. Thoracotomy more often revealed an inoperable lesion and Edwards frequently used radon implantation. This use of radon is recorded in two articles he wrote (1931 and 1932) on lung growths; in these also he records his method of intrabronchial introduction of the radon seed container devised by him. In 1937 only five lungs were removed for carcinoma, all by Edwards. By this time individual ligation technique allowed removal of the growth more often, but mortality was still high. In 1938 cases were still scanty but the results were more promising and by 1939 a minor breakthrough had been achieved. My memory of this is very clear and, although it may seem strange to-day, I associate our improved results with the introduction of routine blood transfusion being set up from the beginning of the operation. In 1938 this was not the practice and blood was given only when thought necessary 204 THORACIC SURGERY and then as an ad hoc procedure towards the end of operation. Surgeons to-day may not know how hardly won were many of the advances now con- sidered simple routine. For me 1939 was an important year in the operative treatment of bronchial carcinoma because the operating book records my first successful pneumonectomy for bronchial carcinoma done on 4th April; the tumour was an oat-celled growth and I am happy to be able to say that the patient is still alive and free from recurrence, 25 years later. This event leads me naturally and inevitably to the other subject of my address to you, my experiences in the long-term results of the treatment of lung cancer by operation. Before proceeding to this I should tell you that although Tudor Edwards's activities were greatly curtailed by the grave illnesses that beset him and by his war-time duties, his main surgical interest became the operative treatment of bronchial carcinoma and when he was elected first president of the new Association for the Study of Diseases of the Chest in 1945, which he did so much to found, the subject of this address was the surgical treatment of 1,000 cases of bronchial carcinoma. The address was printed in the first issue of the new journal Thorax and was his last publication. I would like to carry the story of the operating book somewhat further. In 1936 the total number of operations done was 985, but in the following year the 1,000 mark was passed with a total of 1,037. The war years, of course, threw everything into confusion and in the post-war years began the remarkable conquest of pulmonary tuberculosis by chemotherapy. The big operating lists of the 1930s, based mainly on tuberculosis, changed their character completely. Bronchiectasis also began to disappear from the lists to be replaced by the increasing number of lung resections for bronchial carcinoma and the new development of cardiac surgery. In 1963, in spite of the recession of pulmonary tuberculosis, the total number of operations was 1,289, and ofthese 1,268 were thoracic in nature (Table II) in contrast to 13 recorded in 1908. TABLE 11 OPERATIONS AT THE BROMPTON HOSPITAL FROM 1908 TO 1963 (The broken line indicates the coming of Tudor Edwards to the hospital) Year Total Thoracic 1908 49 13 1920 78 36 1921 69 33 1922 80 38 1923 106 62 1928 252 184 1932 726 681 1936 985 949 1937 1037 1000 1938 1054 1020 1963 1289 1268 205 SIR RUSSELL BROCK So much of this story ofthe development ofthoracic surgery was directly due to or was inspired by the work of Tudor Edwards between 1922 and 1945.

Long-term results of the treatment of lung cancer by operation Many articles have been written on the surgical treatment of lung cancer and indeed Sir Clement Price Thomas devoted his Memorial Lecture to conservative and extensive resection for carcinoma of the lung. The study of my own cases, extending now for a quarter of a century, allows me to present some features that you may think interesting and important. The analysis is confined to patients I have operated on myself; operations by assistants and others have been excluded. First of all the type of operation to be done for carcinoma of the lung. A number of surgeons still advocate lobectomy as the procedure to be aimed at. Of course there is much to be said for a conservative type of operation when this is feasible. Cancer of the lung occurs in different forms, with differing grades of malignancy, and often the less severe forms are related to greater age and frailty. I use my knowledge and intelligence to perform a lesser operation when this seems indicated. I offer confirma- tion of this in the fact that of my total of 264 cases treated by resection, lobectomy was performed in 67 (approximately one-quarter). In common with other surgeons I welcome and support any procedure that combines removal of the growth with conservation of functioning lung tissue. It is repellent to me to have to excise a quantity of healthy lung that could with advantage have been left with the patient. I strongly support any rational conservative operation. It seems, however, that surgeons can lose their judgement in this matter and by making a fetish ofconservatism endanger the chance of their patient obtaining lasting relief or cure. For example, I have seen a case recorded on an operating list as " lower lobectomy for carcinoma of the lung ". This clearly showed the surgeon had prejudged the issue; knowing that it is an advantage functionally to a patient to retain an upper lobe he was setting out to do a lobectomy come what may. From the radiographs the lesion seemed of doubtful operability even by pneumonectomy. The chest was opened and the lower lobe was attacked; eventually removal was abandoned and the chest was closed. This illustrates how totally wrong we can get in our thoughts. The first task with this dreadful disease should be to aim at curing the patient, and this can best be done by removing the growth as radically as possible. When a surgeon sets out to apply a weak policy of conservatism routinely it is surely not in the best interest of the patient. Cancer of the lung is not a standard disease and we should decide what type of operation to do when we survey each individual problem. 206 THORACIC SURGERY For example an elderly patient with a well localized tumour within a lobe can be treated by lobectomy. When respiratory function is impaired it becomes important to conserve lung tissue at any age. But for a man below say 55 years of age, the chance of lasting cure, of longevity, is of paramount importance and in general this cannot be achieved by a conservative operation. A radical removal is needed. A wider clearance of potentially involved tissues gives a greater chance of cure. This would seem to be self-evident and is in keeping with all our knowledge of cancer anywhere in the body; it is not peculiar to cancer of the lung. Pneumonectomy as ordinarily practised might well be thought a radical procedure in itself, seeing that a whole lung is removed. Indeed it may be a fully radical procedure, but it cannot be so in all cases. The classical cancer operations demand removal of the affected viscus together with its fascial connections and as much of the associated lymphatic field as possible. As applied to the lung this includes removal of the anterior and posterior mediastinal fatty tissue and lymph nodes, clearance of the right or the left tracheobronchial group of nodes and also most of the inferior tracheobronchial group. In addition it is very important to avoid disturbing the hilar structures by routinely securing the vessels within the pericardium and excising an area of pericardium. This is not the time or place to describe the operation fully, but details are available in the original description of the operation of radical pneumonectomy (Brock and Whytehead, 1955). An objection has been made that the radical operation carries a higher mortality. That this is just not true can be seen from the actual mortality figures. A radical procedure permits removal of the lung in a higher proportion of cases and thus the range of operability is increased. Al- though this inevitably embraces more poor risk subjects the mortality is still not adversely affected. Whether the best operation for lung cancer is a radical or a conservative one may not yet be decided. It is a good thing for surgery that different surgeons use different types of operation, for only by comparing our separate results can we hope to learn.

RESULTS Lobectomy I have already mentioned that lobectomy was used in one-quarter of my 264 cases. Table III shows the figures. TABLE III LOBECTOMY FOR BRONCHIAL CARCINOMA Total ...... 67 Died from operation .. 3 (5%) Died since .. 49 Still alive .. 15 207 SIR RUSSELL BROCK Table IV shows the long-term results in those who survived operation. It will be seen that three patients lived some 20 years. TABLE IV LONG-TERM SURVIVAL AFTER LOBECTOMY Survival ...... 64 5 years and over .. 24 (36%) 10 years and over .. 8 (12 %) 13 years and over .. 6 16 years and over .. 4 19 years and over .. 2 21 years .. 1

Simple pneumonectomy Table V shows the figures for this operation. TABLE V RESULTS OF SIMPLE PNEUMONECTOMY Total ...... 85 Died from operation .. 18 (21 %) Died later .. 59 Still alive .. 8

Table VI shows the long-term results. TABLE VI LONG-TERM SURVIVAL AFTER SIMPLE PNEUMONECTOMY Survival ...... 67 5 years or more .. 21 (25 °/) 10 years or more .. 17 (20%) 12 years or more .. 15 15 years or more . . 11 18 years or more .. 8 20 years or more .. 6 21 years or more .. 4 24 years or more .. 3 25 years .. I

Table VII presents eight patients who are still alive; five for over 20 years and one for 25 years. TABLE VII LENGTH OF SURVIVAL IN EIGHT PATIENTS AFTER SIMPLE PNEUMONECTOMY Still alive ...... 8 4 years .. .. I 10 years .. .. 1 18 years .. .. 1 20 years .. .. 2 24 years .. .. 2 25 years .. .. 1 It should be noted that my longest surviving patient is still alive after removal of an oat-celled carcinoma on 4th April 1939, 25 years ago. 208 THORACIC SURGERY The first patient successfully submitted to pneumonectomy for lung cancer by Dr. Evarts Graham in April 1933 died in March 1963; that is one month short of 30 years' survival. He succumbed to a fractured neck of the femur, and autopsy showed no trace of recurrence of the lung growth. It is noteworthy that he continued smoking 40 cigarettes a day!

Radical pneumonectomy The results of this operation are shown in Table VIII. TABLE VIII RESULTS OF RADICAL PNEUMONECTOMY Total ...... 112 Died from operation .. 16 (14%) Died later *. .. 68 Still alive *. .. 28 The long-term results are shown in Table IX. TABLE IX SURVIVAL AFTER RADICAL PNEUMONECTOMY Total ...... 96 5 years or more .. 39 (35%) 10 years or more .. 19 (17%) 1 years or more .. 18 12 years or more .. 14 13 years or more .. 11 14 years or more . . 11 15 years or more .. 7 16 years or more .. 5 17 years or more .. 3 18 years or more .. 2 20 years or more .. 1

Comparative results These are best presented in table form (Table X). TABLE X COMPARATIVE RESULTS IN ALL 264 CASES Total Mortality Five years Still survival alive Per cent. Per cent. Lobectomy .. .. 67 5 36 15 Simple pneumonectomy 85 21 25 8 Radical pneumonectomy 112 14 35 28 Total figures .. 264 14 32 41

The percentage of long-term survival throughout the tables is based on those originally submitted to operation and not as a percentage of those surviving operation. It should be noted that in the overall figures 32 per cent survived five years or more. This compares with the figures of Gifford and Waddington (1957), in which the five-year survival rate was 209 SIR RUSSELL BROCK 28 per cent, and of Bignall and Moon (1955), in which it was 33 per cent. I know of no pneumonectomy figures in the world literature that show a five-year survival rate over 33 per cent. It is common to find the five- year survival rate after lobectomy to be much higher, e.g. 40 per cent to 50 per cent, but this is essentially in a selected group. In my own figures it is 36 per cent. I suggest that the significant figure from this table is the five-year survival rate for radical pneumonectomy of 35 per cent. This is slightly greater than the world figures and is almost the same as the survival rate for the lobectomy cases. It suggests that radical pneumonectomy does in fact improve the chance of a five-year survival. It certainly shows that the survival rate is not less than that of simple pneumonectomy, neither is the mortality of operation higher. Irrespective of the type of operation, it is noteworthy that of patients in whom removal of the growth is possible there is a one-in-three chance of five-year survival. This can be comforting knowledge to give to a patient or to his relatives. The object of the radical operation is to try and catch in the wider surgical net lymph nodes that have been involved by growth and which would not otherwise be removed. Some indication of what is achieved is given in Table XI. TABLE XI To SHOW SIGNIFICANCE OF NODAL INVOLVEMENT WITH RADICAL PNEUMONECTOMY

Survivors ...... 96 Nodes Invaded Not invaded Total ...... 53 43 Dead ...... 43 26 Alive .. .. 10 26 Lived more than five years .. 10 17

The diminished survival rate when nodes are invaded is clearly shown and corresponds with all published experiences. It is to be noted, however, that 10 patients in whom invaded nodes were removed lived more than five years after operation. Without a radical operation they could scarcely have survived so long. Not only have 10 patients survived more than five years, but some have survived much longer than this after removal of invaded lymph nodes, as is shown in Table XII. Five have survived more than 10 years and five are still alive, up to 17 years. Deep therapy as an adjuvant to operation The question obviously arises of the part that deep irradiation might play in improving the results of operation for bronchial carcinoma. My experience has been, in common with most other surgeons, that the results are disappointing. 210 THORACIC SURGERY I commonly advise it to supplement an operation when some growth may have been left behind. In general no substantial improvement has been evident except for isolated cases. The patient often finds a full course of radiation so much more disturbing than the operation that it should be recommended only after careful consideration. Usually in a younger patient in whom every effort at cure or prolongation of life is justified. Pre-operative irradiation has also been very disappointing and this is the experience of most other surgeons. Bromley and Szur (1955) wrote an important report on their experiences in 66 cases. My own policy is to advise radiation before operation in patients under the age of 40

TABLE XI1 LENGTH OF SURVIVAL WITH NODAL INVOLVEMENT Years Numbers Still alive 5-6 2 1 6-7 1 0 7-8 2 1 9-10 1 0 11-12 1 1 14-15 1 1 16-17 2 1 TOTAL .. 10 5 years unless the growth is obviously removable, and in older patients when operability is very doubtful. Few of these patients come to thoracotomy, but I have had two outstandingly encouraging cases. Fifteen years ago, in 1949, I saw a young girl, aged 28 years, with a large growth of the right upper lobe. At bronchoscopy it was hopelessly inoperable with a grossly widened carina and compression of both main bronchi. Biopsy showed an undifferentiated celled carcinoma. A full course of deep radiation given by Professor Smithers resulted in great regression of the tumour and bronchoscopically it now appeared removable. That this was indeed so was shown at operation six months later in July 1949, when radical pneumonectomy was done. She remains alive and free from recurrence 15 years later. Some four-and-a-half years ago I was asked to see a man, aged 42, with a carcinoma of the left upper lobe and a mass of malignant glands high in the posterior triangle. He had been adjudged incurable by a surgical col- league. After a full course of radiation the glands receded and 6 months later, in March 1960, I performed a radical pneumonectomy. He remains well and working, now four years after operation. Cases such as these encourage one in an aggressive approach to the treatment of lung cancer. 211 SIR RUSSELL BROCK The development of a new primary bronchial carcinoma I shall conclude by speaking about the remarkable occurrence of the development of a new bronchial carcinoma in patients who have been cured of one cancer of the lung. Clearly this very interesting biological occurrence could not be observed until successful operation had provided the prerequisite of prolonged survival. Biologically it is remarkable that bronchial carcinoma, if caused or activated by an external irritant, does not frequently occur in more than one site. Nature can be prodigal in her gifts and there is Inow quite a large literature on bilateral bronchial carcinoma. Peterson, Pirogov and Surulevich (1963) writing from Moscow have recently described a case of successful simultaneous bilateral resection of a double lung carcinoma, bilateral upper lobectomy being performed. They give a useful survey of the literature and note that 19 cases of bilateral cancer have been recorded, but in only six cases were the lesions in both lungs found before death. Three of these six patients were operated on for primary cancer of one lung and a primary cancer of the other lung developed in 3-10 years after operation. Hughes and Blades (1961) record two cases of a second primary bronchial carcinoma occurring nine years and 10 years after resection of the original primary. Both patients had a left pneumonectomy and in both the new primary was on the right. In one of these cases an apical lower segmental resection was done, but six months later the patient had frank cerebral metastases. According to Peterson et al. (1963) this case was the only recorded example of bilateral surgical treatment of double primary bronchial carcinoma until their own report. LeGal and Bauer (1961) survey the literature and record four cases of a second lung cancer in 63 patients who had survived for 30 months or more after resection of their first growth. My own results are perhaps of some interest. Of the 264 patients in this series seven developed a new primary growth, or what appeared to be one. In one patient who had a right lower lobectomy in 1945, a new growth appeared in the left upper lobe in 1960, i.e. 15 years later, and this was successfully removed with conservation of the lingula and he remains well four years later and 19 years after his first operation. In addition to these seven cases I have recently seen an eighth patient who had a left pneumonectomy done by an assistant in 1953 and who developed a new primary tumour 10 years later, in his right lower lobe. This patient had continued smoking 20 cigarettes a day since his first operation and the patient mentioned above whose new cancer was successfully resected also continued to smoke after his first operation. A smoking history is not obtainable in all the other patients, but at least two had not abandoned smoking. It is clear that a man who has had a cancer of the lung successfully treated must be told that he must NOT smoke again. 212 THORACIC SURGERY Table XIII shows the eight cases of a new lung primary cancer. TABLE XIII EIGHT EXAMPLES OF THE OCCURRENCE OF A NEW PRIMARY LUNG CANCER Operation Year New primary Interval 1. R.L. lobectomy 1945 1960 L.U. 15 years lobectomy 2. R. radical pneumonectomny 1948 1961 Died 16 years 3. L. radical pneumonectomy 1948 1961 Died 16 years 4. L. radical pneumonectomy 1951 1961 Died 10 years 5. L. radical pneumonectomy 1951 1957 Died 6 years 6. L. radical pneumonectomy 1952 1957 Died 5 years 7. L. radical pneumonectomy 1954 1964 Died 10 years 8. L. radical pneumonectomy 1953 1964 Alive 11 years

Memorial lectures such as this serve a dual function. They remind us of the individual commemorated and they serve as an occasion to present an informative subject. I have tried to do both things to-day. I hope that the presentation of the long-term results of operation in the treatment of lung cancer is informative. I am glad to have been able to remind you of the life and work of Tudor Edwards. Memory is fickle, and only a few weeks ago I learned that Tudor Edwards's name meant nothing to a group of recently qualified doctors. I hope that what I have said and the occasion of this Memorial Lecture will serve to inform those who have not heard of his work and will remind us all of a great surgeon.

REFERENCES BIGNALL, J. R., and MOON, A. J. (1955) Thorax, 10, 183. BLADES, B., and KENT, E. M. (1940) J. thorac. Surg. 10, 84. BROCK, R. C., and WHYTEHEAD, L. W. (1955) Brit. J. Surg. 43, 8. BROMLEY, L., and SZUR, L. (1955) Lancet, 2, 937. CHURCHILL, E. D. (1933) J. thorac. Surg. 2, 254. EDWARDS, A. T. (1927) Brit. J. Surg. 14, 607. (1931) Brit. med. J. 1, 129. (1932) Brit. med. J. 1, 827. (1935-36) Proc. R. Soc. Med. 29, 221. (1938) Brit. J. Surg. 26, 166. (1939) Brit. med. J. 1, 809. (1945) Thorax, 1, 1. and TAYLOR, A. B. (1938) Brit. J. Surg. 25,487. and THOMAS, C. P. (1934) Brit. J. Surg. 22, 310. GIFFORD, J. H., and WADDINGTON, J. K. B. (1957) Brit. med. J. 1, 723. GowAR, F. J. S. (1935-36) Proc. R. Soc. Med. 29, 221. HUGHES, R. K., and BLADES, B. (1961) J. thorac. cardiovasc. Surg. 41, 421. LEGAL, Y., and BAUER, W. C. (1961) J. thorac. cardiovasc. Surg. 41, 114. PETERSON, B. E., PIROGOV, A. J., and SURULEVICH, V. B. (1963) J. thorac. cardiovasc. Surg. 45, 705. ROBERTS, J. E. H. (1935-36) Proc. R. Soc. Med. 29,220. THOMAS, C. P. (1959) Ann. Roy. Coll. Surg. Engl. 24, 345.

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