ORIGINAL SUBMISSIONS

History of Cardiothoracic Surgery at Washington University in Saint Louis Marc R. Moon, MD The Division of Cardiothoracic Surgery at Washington University evolved a century ago to address what many considered to be the last surgical frontier, diseases of the chest. In addition, as one of the first training programs in thoracic surgery, Washington University has been responsible for educating more thoracic surgeons than nearly any other program in the world. Beginning with Evarts A. Graham and continuing through to Ralph J. Damiano Jr., the leaders of the division have had a profound impact on the field of cardiothoracic surgery. Semin Thoracic Surg ]:]]]–]]] I 2016 Elsevier Inc. All rights reserved. Keywords: history, cardiovascular surgery, thoracic surgery, pneumonectomy, Maze procedure Since 2004, when I became the program director of the Thoracic Surgery Residency Program at Washington University in Saint Louis, we have welcomed applicants to our program each interview weekend with a 40-minute presentation on the history of cardiothoracic surgery at our institution. Like every other program, we generally interview a dozen or so applicants for each position that is available. We consider these weekends our opportunity to share not only a current day snapshot of our program but also the historical foundation of how we got to where we are today. In a recent interview, Dr Irving Kron, the 91st President of the American Association for Thoracic Surgery (AATS), referred to Joseph Simone's Maxim: “The Institutions Don't Love You Back” noting that “It's definitely the people” that make an institution great, not the buildings.1,2 As such, I thought I would summarize what I believe to be the most important contributions to our field from each of the 7 chiefs we have had in cardiothoracic surgery at Washington University during the 98 year existence of our program. WASHINGTON UNIVERSITY CHIEF #1: EVARTS A. GRAHAM (1919-1951) Evarts Graham was born on March 19, 1883 in Chicago, IL, the son of a surgeon (Fig. 1). He completed his undergraduate work at Princeton University in 1904, Rush Medical College in 1907, and surgical training at Rush and Presbyterian Hospital at the University of Chicago in an apprentice-type model that he would eventually Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri Address reprint requests to Marc R. Moon, MD, Division of Cardiothoracic Surgery, Washington University School of Medicine, 4566 Scott Ave Campus, Box 8234, St. Louis, MO 63110. E-mail: moonm@wustl. edu

Barnes-Jewish Hospital on the campus of Washington University in Saint Louis.

abdicate himself as the founding chairman of the American Board of Surgery in 1937. Dr Graham served on the Empyema Commission during World War I, the goal of which was to develop treatment regimens for the pleural suppurative diseases afflicting young soldiers overseas. After the war, Dr Graham was appointed the Bixby Professor of Surgery at Washington University. His appointment represented only the second full-time academic Chairman of surgery in the United States, the first being Dr William Halsted at Johns Hopkins. The idea behind the academic appointment was that the professor was not required to establish a private practice to survive and could focus on research and teaching.3 That being said, by the late 1940s, Dr Graham accounted for 22% of the Department of Surgery's clinical funds. After publication of the Flexner Report,4 which outlined the requirements for proper medical training and ultimately closed nearly half of the medical schools in the United States, Dr Graham's department became the prototype for medical school reorganization across the country. In the mid-1920s, Dr Graham initiated the Medical-Surgical Chest Service in conjunction with Dr J.J. Singer who was the medical director of the Koch TB Hospital. In 1929, he started a dedicated Thoracic Surgical Fellowship funded by the Rockefeller Foundation. The fellowship was the second in the United States. The first was introduced a year before at the University of Michigan under Dr John Alexander (17th AATS President). Dr Graham's training program was modeled after Dr Alexander's 2-year fellowship based on his conclusion that, “Two years of intensive study are sufficient to take the examination of a Board.”5 At the time, however, there was no Board. It was not until 1948, under the leadership of Dr Graham and others from the AATS, that the Board of Thoracic Surgery was founded.6 Dr Graham went on to become the president of virtually every major surgical organization and was the first president of the AATS from Washington

1043-0679/$-see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semtcvs.2016.10.008

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Figure 1. Evarts A. Graham, circa 1925. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

University in 1928 (11th AATS President). Dr Graham was the first editor of the Journal of Thoracic Surgery in 1931, renamed the Journal of Thoracic and Cardiovascular Surgery in 1959, and remained as an Editor until his passing in 1957. Dr Graham received Emeritus status in 1951 at the age of 68 years and stepped down as Chief, although he continued to participate in clinical practice, research, and teaching (Fig. 2).

Figure 2. Dr Graham teaching in the Chest Clinic, 1948. This view box still resides in the Division of Cardiothoracic Surgery offices in memorandum to Dr Graham. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

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In 1933, Dr Graham performed the first successful pneumonectomy for cancer in the world, which some feel was his most important contribution to the field.7 Dr Graham's patient was a 49-year-old obstetrician from Pittsburgh. Dr James Gilmore presented with a left upper lobe mass and after an attempt at aspiration was unsuccessful to make the diagnosis, he came to Saint Louis for a second opinion. Dr Graham first performed a rigid bronchoscopy where he diagnosed squamous cell cancer with inflammation of the left main bronchus. The patient went back to Pittsburgh before surgery to “get some things in order.”8 Showing optimism, he had some cavities filled but in addition to visiting the dentist, he also purchased a cemetery plot! As was the case back in the day for high-profile patients, when Dr Gilmore returned to Saint Louis for surgery, his primary care physician, Dr Sidney Chalfont, accompanied him on the trip. Dr Graham took his patient to the operating room on April 4, 1933 for a planned left upper lobectomy. The procedure was performed in an amphitheater-type setting so the patient's private physician could watch from the bleachers. During the operation, Dr Graham found the distal main stem encased in tumor, making lobectomy impossible. Dr Graham then turned to Dr Chalfont for an intraoperative consult. Graham strongly advised the removal of the entire lung and asked Chalfont for his opinion. Chalfont questioned the history of the procedure to which Graham replied he had performed it successfully in animals. Knowing that Gilmore would have wanted even heroic attempts to cure the disease, Chalfont agreed (Fig. 3).8 On the year after Dr Graham's death, Dr Brian Blades, who was on the Washington University. faculty before World War II, gave as his AATS Presidential Address in 1958, “A Case Report and Miscellaneous Comments,” in which he summarized

Figure 3. Artist's rendition of the intraoperative consult between Dr Graham and Dr Gilmore's primary physician.8

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CT SURGERY AT WASHINGTON UNIVERSITY Graham's first pneumonectomy.7 Graham started with a rubber catheter around the hilum for 2 or 3 minutes to make sure cardiovascular collapse did not occur. He then clamped the hilum, cut out the lung, cauterized the bronchial mucosa, and oversewed the pedicle with no. 2 chronic catgut suture. Reportedly aghast at the size of the empty cavity,3 Graham performed a thoracoplasty with removal of 7 ribs to fill the space. The following month on Wednesday May 10, 1933, Dr Howard Lilienthal (fifth AATS President) from Mount Sinai in New York City was presenting “Pneumonectomy for Sarcoma of Lung in a Tuberculous Patient” during the AATS 16th Annual Meeting at the Willard Hotel in Washington, D.C. (Fig. 4).9 Dr Lilienthal's patient had died in the early postoperative period. During the discussion of the article, Dr Graham rose to say, “Just a short time before I performed a complete pneumectomy and in my case, however, fortunately the result was successful.” The rest of the discussion became one of etymology during which Dr Pol N. Coryllos of New York, an expert in Latin and Greek word roots, definitively proclaimed that removal of the entire lung was a pneumonectomy, not a pneumectomy as Graham had originally stated. Dr Graham's case report was published in the October 28 issue of the Journal of the American Medical Association just 4 months after Gilmore left the hospital.10 Gilmore had undifferentiated carcinoma with 1 of 11 nodes positive yielding a T2, N1, M0 Stage IIB tumor, generally a tumor associated with poor, longterm survival.7 Against the odds, Gilmore died in 1963 living 30 years after surgery. Graham and Gilmore remained friends for the remainder of

Figure 4. American Association for Thoracic Surgery Program, 16th Annual Meeting, 1933.

Figure 5. Ochsner and DeBakey's graphic representation of the correlation between lung cancer rate and automobile and tobacco production. (Reproduced with permission from Archives of Surgery 12:221, 1941. Copyright 1933, American Medical Association.)12

Graham's life. To this point in his career, in addition to performing the first pneumonectomy, Dr Graham's contributions included the Empyema Commission, which was estimated to have saved thousands of lives, the discovery of cholecystography to image the gallbladder, and playing the leading role in developing both general surgery and thoracic surgery training paradigms in the United States.11 Among these, Dr Graham believed that the pneumonectomy was his most important contribution, but in my mind his greatest contribution was yet to come. In 1941, Ochsner and DeBakey12 were the first to speculate that there was a relationship between cigarette smoking and lung cancer. Figure 5 from Ochsner and DeBakey's article is a graphic representation of a correlation of the death rate per 100,000 population from cancer of the lung with the production of tobacco and automobiles in the United States during the 17-year period between 1920 and 1936. They concluded from this graph that “whereas there is no significant relation between the production of automobiles and cancer of the lung, there is an obvious parallelism between the increased production of tobacco and carcinoma of the lung.” Dr Graham was originally a skeptic and remained dubious. He felt that Ochsner and DeBakey's data were not convincing and that one could produce similar growth curves for other items during that

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CT SURGERY AT WASHINGTON UNIVERSITY time period. To Alton Ochsner, circa 1940, Dr Graham tongue-in-cheek suggested that if you compared the sales curve for “silk stockings” to the incidence of lung cancer “they too may be considered an etiologic factor.”13,14 Ironically 10 years later, it was Dr Graham with then medical student Ernie Wynder who published the first statistical scientific confirmation of the relationship between smoking and cancer that brought the issues to the world's attention.15 Again to Alton Ochsner, but nearly a decade later during preparation for the American Cancer Society meeting in 1949 at which Wynder was going to present their data, Graham wrote, “Al, I am afraid I owe you an apology,” after Wynder presents our data, “I may have to eat humble pie.”12 Ernie Wynder was a third-year medical student at Washington University when he approach Dr Graham with a request to interview hospital patients to investigate a relationship between smoking and lung cancer. Wynder remembered that Dr Graham had 2 reservations, (1) “The first was that he rarely saw double primaries; after all, if smoking had such an important role maybe people ought to have more than one cancer” and (2) “He had seen patients who had given up smoking a long time before they developed lung cancer.”16 The latency period was obviously unknown. Graham, however, agreed to let Wynder interview patients at Barnes Hospital during his spare time (Fig. 6). The purpose of Wynder and Graham's study was to determine the importance of various factors on the induction of bronchogenic carcinoma such as smoking, job, urban vs rural environment, and others.15 Wynder interviewed 605 men with lung cancer and compared them with 780 general hospital patients without cancer. They defined smokers as having at least a 20-year history of light (one-half pack per day), heavy (one pack per day), or chain (more than

Figure 7. (A) Patients who smoked were more likely to have cancer than the patients who did not smoke. (B) The relationship between smoking and cancer was consistent at all the age groups beyond 40 years. (C) Women demonstrated a relationship between smoking and cancer, but it was not as profound. Based on the data from Wynder and Graham.15 (Color version of figure is available online.)

Figure 6. Dr Graham and Ernie Wynder, 1954. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

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one to two packs per day) smoking. They found that heavy and chain smokers were more likely than nonsmokers to have lung cancer (Fig. 7A) and that this relationship was consistent at all age groups beyond 40 years (Fig. 7B). They also found a similar,

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CT SURGERY AT WASHINGTON UNIVERSITY but much less convincing relationship in women (Fig. 7C), noting that many women with cancer did not smoke, obviously not understanding the concept of secondhand smoke at that time. The summary of their results included (1) Men who did not smoke rarely developed lung cancer, (2) Not all long-term heavy smokers developed lung cancer, (3) The more heavily a man smoked, the greater was his likelihood of developing lung cancer, and (4) Smoking played a similar but less evident role in women. These findings stimulated Dr Graham to study the effect of smoking in the laboratory. He developed the “Smoking Machine” in the early 1950s, which simultaneously “puffed” 60 cigarettes and collected the tar (Fig. 8). This line of work yielded a series of 5 landmark articles definitely linking smoking and cancer in a cause-andeffect relationship, the final article of which was published posthumously.17-21 Alton Oschner published a book titled Smoking and Cancer in 1954, which summarized all the evidence used to indict cigarettes.22 Dr Graham wrote the foreword in which he advocated for radical social action:

What is going to be done? … Are the radio and television networks to be permitted to continue carrying the advertising material of the cigarette industry? Isn't it time that the US Public Health Service at least make a statement of warning?

Figure 9. Dr Graham (smoking) with Elliott Cutler and Harvey Cushing, circa 1933. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

Dr Graham's provocative words were eventually heard, although it took 12 years for the Surgeon General's warning to appear on cigarette packs in 1966, and 16 years before the television ban on cigarette advertisements in 1970. Until 1953, Dr Graham himself was a habitual smoker reportedly unless asleep, in the operating room, or on rounds (Fig. 9).23 Under pressure from his friends and colleagues, after all he had now proven the evils of smoking, he eventually quit. In January 1957, he developed a persistent cough and underwent a chest radiograph, which demonstrated a large left upper lobe mass, diffuse bilateral nodular infiltrates, and a widened mediastinum. He showed the film to his partner Dr Thomas Burford (51st AATS President) who, without knowing it was Dr Graham's film, concluded it was obviously bilateral cancer of the lung. In a letter to Ernie Wynder written February 6, 1957, Dr Graham summarized his illness24:

I suppose you have heard by this time … about the irony that fate has played on me. … I was very anxious for you to be one of the first ones to know about my illness… because of our long and happy cooperation in the enterprise of trying to defeat the enemy who seems to have got the best of me now.

Figure 8. Dr Graham and the Smoking Machine, 1953. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

Dr Graham died in Barnes Hospital at the age of 73 years on March 4, 1957. His death note was countersigned by both Dr Burford and Dr Thomas B. Ferguson (62nd AATS President). Dr Graham's influence remains profound even today as

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CT SURGERY AT WASHINGTON UNIVERSITY demonstrated by the following personal correspondence in 2014 from Dr Stuart A. Yaffe, a family practice physician practicing in Springfield, IL25:

I happened to be a resident in surgery at St. Louis City Hospital on the day that Dr. Graham died. At that time many of the house staff throughout the city of St. Louis were smokers, and I would estimate that probably over 90% of us stopped smoking on that day. … I am 87 years old and remember that day very vividly. I do not know how many of us are left who can appreciate what Dr. Graham did but I feel that I owe my life to him in view of the act that I did stop smoking well over 50-some years ago. Inspirational recollections indeed from someone outside the thoracic surgical community in testament to the influence of what I consider Dr Graham's most important contribution to the field—the epidemiologic and experimental scientific demonstration of the causal relationship between smoking and lung cancer. If you are interested in reading more about Dr Graham, I would like to offer 2 notable collections that include (1) When Dr Graham stepped down as the Bixby Professor of Surgery, the retirement speech from his celebratory dinner November 30, 1951 was published in its entirety in the Annals

Figure 10. Brian Blades, Thomas Burford, Evarts Graham, and Edwin “Pete” Churchill (left to right) at Dr Graham's retirement party at the Hotel Jefferson in Saint Louis, November 30, 1951. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

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Figure 11. Dr Thomas and Mrs (Libby) Ferguson greeting guests at the Centennial Symposium honoring Dr Graham in 1984. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

of Surgery (Fig. 10)26,27; and (2) Dr Ferguson and Dr Samuel A. Wells, Jr. (Bixby Professor of Surgery from 1981-1997) organized a Centennial Symposium for Dr Graham on what would have been his 100th year. Leaders from around the world convened in Saint Louis to celebrate Dr Graham's many contributions (Fig. 11). The transactions of the symposium were published in the November 1984 issues of the Journal of Thoracic and Cardiovascular Surgery.28 WASHINGTON UNIVERSITY CHIEF #2: THOMAS H. BURFORD (1951-1968) Dr Burford's nickname was “Black Tom,” not because of his jet-black hair but the strict military temperament that accompanied him throughout his career (Fig. 12).29 Dr Burford was born in 1907 in Central Missouri. His father was a railroad

Figure 12. Thomas H. Burford, date unknown. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

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CT SURGERY AT WASHINGTON UNIVERSITY conductor. After his undergraduate education at University of Missouri, Columbia, he attended Yale Medical School and graduated in 1936. Dr Burford did his general surgery and thoracic surgery residencies at Washington University. and immediately after his training, he entered the Army. His first assignment was in Bou Hanifia, Algeria in November 1942 to support the Tunisian landings. Dr Burford's greatest contributions to the field were the consequence of his time in the Mediterranean Theatre during World War II, which are summarized in the Surgeon General's multivolume textbook series “Surgery in World War II.”30,31 A total of 2 volumes of the 20 volume set were dedicated to thoracic surgery and published in 1963 and 1965. Dr Burford contributed greatly to each volume. The first book summarized the administrative considerations and general management policies including the development of dedicated Thoracic Surgery Centers. The second book focused on specific types of chest wounds and their treatment regimens as developed during the war including “wet lung” (posttraumatic respiratory insufficiency), selective thoracotomy in the field, selective removal of foreign bodies, early aspiration for traumatic hemothorax, and decortication for organizing hemothorax. Dr Burford was part of the Second Auxiliary Surgical Group under the direction of Col. Edward Churchill, Chief Consultant in Surgery in the Mediterranean Theatre (28th AATS President and Chief of Surgery at Massachusetts General Hospital [MGH]). The “Second Aux” included 27 general surgeons and 5 thoracic surgeons including, Major Reeve Betts, Capt. Lyman Brewer (54th AATS President), Major Paul Samson (48th AATS President), Major Lawrence Shefts, and Major Burford. Between the Tunisian landings and the end of the war in Italy, the 5 thoracic surgeons cared for 2267 casualties with thoracic and thoracoabdominal injuries. World War II yielded a new problem in thoracic surgery, hemothoracic empyema. During World War I, Dr Graham had the largest experience treating empyemas as part of the Empyema Commission, but these infections were the consequence of measles or influenza. In World War II, high-velocity weapons often led to retained hemothorax, which served as a fertile breeding ground for bacteria (Fig. 13). In April 1943, at the Chest Center in Bizerte, Dr Burford performed the first decortication in World War II for chronic retained hemothorax. At that time, the British emphasized the firmness of the peel but championed only “turning out the clot,” which included a limited thoracotomy and drainage but left the peel intact. The results were not great

Figure 13. Organizing hemothorax with a thick encircling peel.31

yielding, a 55% chronic empyema rate. Burford speculated, “It might be worthwhile to cut through it [the peel] and see what lay underneath.”30 He had the opportunity when 2 patients presented with uninfected organizing hemothoraces 5 weeks after injury. Dr Burford used a soldier, an American, as the control and turned out the clot with a less than ideal result. For the other soldier, a German, he cut into the peel after which normal lung herniated through the opening. He stripped off the entire peel like “pulling off a glove,” which resulted in total lung reexpansion and full recovery. Delorme had published the technique 50 years ago for empyema,32 but its application did not become the mainstream and had never been tried for retained hemothorax until Dr Burford brought the procedure to the forefront of modern wartime surgery. Figure 14A demonstrates healthy soldiers from WWII after decortication when compared with Figure 14B, which depicts chronic invalids from WWI after standard treatment. Major Burford received the Legion of Merit for his contributions (Fig. 15). After the war, Dr Burford returned to join the faculty at Washington University. and was named Chief of Thoracic Surgery in 1951. During Dr Burford's tenure, he changed the focus of the division from thoracic to cardiovascular surgery. Dr Burford's philosophy was that on a scale of priorities, “Being right is more important than being liked.”33 During his tenure, Dr Burford trained 50 residents whom he said had “absolute competence” and had developed a fierce loyalty to their chief.29 He was very proud of the residents he trained, “I have never transplanted a heart, attempted a 3-valve replacement, or bypassed a vein to a coronary artery, however, all of these feats have been accomplished by my trainees.”33 Dr Burford was a founding officer and second president of the Society of Thoracic Surgeons (STS) in 1965. In his 1970 AATS

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Figure 14. (A) Healthy soldiers from WWII after decortication compared with (B) chronic invalids from WWI after “conservative” treatment of chronic empyema.31

Presidential address, he spoke on “Being the Chief” and focused on Cicero's quote, “Not only is there an art in knowing a thing, but also a certain art in teaching it.”33 Dr Burford felt strongly that a Chief of Thoracic Surgery must possess this art. In addition, he noted that the Chief must above all earn respect, “it cannot be commanded or demanded.” Dr Burford stepped down as Chief in 1968. “I would advise all directors of training not to linger too long. Go out a winner!” he proclaimed. “Qualified younger men should be entrusted with the major responsibilities of training and teaching. They have the zest and the energy to inspire and far more patience with immaturity.” He continued his clinical practice until he died of emphysema in 1977 at the age of 69 years. He like Dr Graham, was a lifelong smoker.

Figure 15. Col. Earle Standlee, Chief Surgeon of Mediterranean Theatre of Operations, presenting Major Burford Legion of Merit, 1945 (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

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WASHINGTON UNIVERSITY CHIEF #3: CLARENCE S. WELDON (1968-1983) The next 15 years at Washington University saw the explosion of cardiovascular surgery almost at the expense of general thoracic surgery. Dr Weldon was a gifted technical surgeon in both pediatric and adult cardiac surgery (Fig. 16). He completed his training and served as a junior faculty at Johns Hopkins under Dr Alfred Blaylock until accepting the position in Saint Louis. Dr Weldon was the 4th President of the Thoracic Surgery Directors Association in 1981 and 1982, an organization which was formed because of concerns that the thoracic training paradigm was being dictated by forces external to the Program Directors. Dr Weldon was known as, “a great mentor, a dedicated, and inspirational teacher,” and his commitment to resident education was embodied in this quote from a former trainee, “No other individual had as much pride and admiration for the accomplishment and success of his residents than Larry Weldon.”34 Dr Weldon developed hearing loss in the mid-1980s, which led to early retirement. He died of renal failure in 2006 at 77 years of age. Although Dr Weldon did not serve as AATS President during his tenure as Chief at Washington University, one of his senior faculty, Dr Ferguson, did serve in this role in 1982. Dr Ferguson was born in Oklahoma City, Oklahoma in 1923. His grandfather was a country physician and young Tom used to make rounds with him through the Indian Territories on horseback.35 Dr Ferguson did his undergraduate, medical school, and general surgery training at Duke University before coming to Washington University. for thoracic training with Drs Burford and Graham in the early 1950s. Dr Ferguson was AATS Secretary from 1968-1973 and editor of the Annals of Thoracic

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Figure 16. Clarence S. Weldon. (Courtesy: the Archives of the Division of Cardiothoracic Surgery, Washington University School of Medicine.)

Surgery from 1984-2000, his 17-year editorship being the longest of any Annals editor. Dr Ferguson, with Dr Burford, was one of only a handful of surgeons to be the President of both the STS and AATS. In his AATS Presidential address, he spoke of “The Crisis of Excellence” in which there was an “Inverse relationship between medical miracles and medical esteem.”36 He addressed 3 major issues in cardiothoracic surgery being: (1) Physician manpower— although we should understand supply and demand, we should avoid external manipulation; (2) Malpractice—we as physicians have been assumed “Guilty until proven innocent.” He noted that while medical care is a birthright, it does not guarantee a certificate of health; and (3) Cost Containment—“There is no free lunch.” Increased technology equals increased costs, there is simply no way around it. Dr Ferguson was on the faculty at Washington University from 1956 until his death in 2013 as Professor of Surgery, and while never the

Figure 17. Thomas B. Ferguson. (Courtesy: Historical Archives, Becker Medical Library, Washington University School of Medicine.)

Figure 18. James L. Cox. (Courtesy: the Archives of the Division of Cardiothoracic Surgery, Washington University School of Medicine.)

Chief, he was an indispensable, inspirational leader in our Division for more than half a century (Fig. 17). Dr Ferguson's career spanned the entire cadre of thoracic surgical chiefs at Washington University, a feat only matched by his partner, Dr Charles L. Roper, who trained in the mid-1950s and was on the faculty from 1959 until he died in 2015. WASHINGTON UNIVERSITY CHIEF #4: JAMES L. COX (1983-1997) Dr Wells recruited Dr Cox from Duke University to run the division in 1983 (Fig. 18). Dr Cox's mandate was to not only continue the great tradition of clinical excellence in the division, but to return its academic laboratory productivity to its earlier glory. Dr Cox was born in rural Arkansas.37 His father was a rice farmer. After medical school at the University of Tennessee, he did his surgical training and eventually joined the faculty at Duke University. Like Dr Ferguson, Dr Cox served as AATS Secretary from 1993-1998 and was the 81st AATS President in 2001. In his Presidential Address, he expounded the importance of globalization of health care, encouraging us to break down standard geographical boundaries so we can educate and provide care throughout the world.38 Dr Cox's most important contribution to our specialty is obvious, the Maze procedure to surgically treat atrial fibrillation. It is my contention that the

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CT SURGERY AT WASHINGTON UNIVERSITY development of the Maze procedure represents the most appropriate progression from laboratory studies to clinical application for any surgical procedure in any surgical subspecialty. Dr Cox worked closely with 2 individuals in particular to develop the Maze procedure, Dr John Boineau and Dr Richard Schuessler. Dr Boineau died in 2011, but Dr Schuessler, who is a PhD Research Professor of Surgery, currently holds the longest tenure in our division, having joined the faculty in 1984. Throughout the 1980s and 1990s, Dr Cox and his team systematically moved from the bench to bedside in the development of this transformative procedure. They published a series of 4 articles in the Journal of Thoracic and Cardiovascular Surgery in 1991 that outlined their experimental process and culminated with a description of the first Maze procedure in man.39-42 Article I: Summary of current concepts of the mechanisms of atrial fibrillation and flutter.39 This article described the anatomical and electrophysiologic basis of atrial fibrillation and flutter. An early theory suggested potentially 2 circuits in the right atrium (between the superior and inferior vena cava) and left atrium (between the pulmonary veins and appendage). The initial surgical attempt was the atrial transection procedure first performed on October 16, 1986, which resulted initially in normal sinus rhythm but reverted to atrial fibrillation 5 months postoperatively. Article II: Intraoperative electrophysiologic mapping and electrophysiologic basis.40 This article reported human electrophysiologic studies, which demonstrated multiple macroreentrant circuits that were fleeting in nature. They determined the need to develop a surgical procedure based on the principles of a maze in which

they could interrupt common conduction routes and direct the impulse from the sinoatrial node to the atrioventricular node along a specific route. Article III: Development of a definitive surgical procedure.41 The team used magic marker initially on excised hearts to come up with the maze pattern they thought might work. They then made incisions and sutured them back together to save as visual models. Experimentally, they tried to balance adding incisions to increase effectiveness while removing incisions to decrease complexity. Article IV: Surgical technique.42 Dr Cox described the surgical technique for the first Maze procedure performed in man. After obtaining institutional review board approval, the first Maze procedure was performed at Barnes Hospital on September 25, 1987. The team continued its work, and in 1995 published 2 more landmark articles that described the modification of the Maze procedure (maze III), which remains the anatomical foundation for treatment of atrial fibrillation today.43,44 Dr Cox left Washington University in 1997, but returned a few years later and remains today as the Evarts A. Graham Emeritus Professor of Surgery. During his tenure as the Chief at Washington University, Dr Cox assembled a world-renowned faculty of superstars, a virtual “Who's Who” of cardiothoracic surgery in the late 1980s and early 1990s (Fig. 19). At the risk of surely leaving out many important contributors, I will note that in addition to Drs Ferguson, Roper, and Boineau seated in the first row, Dr Cox's faculty during his tenure included Thomas L. Spray (89th AATS President); Larry R. Kaiser (Dean of the medical school at Temple University); Nicholas T. Kouchoukos (STS President in 2000);

Figure 19. Dr Cox with his faculty and residents, 1989-90. (Courtesy: the Archives of the Division of Cardiothoracic Surgery, Washington University School of Medicine.)

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CT SURGERY AT WASHINGTON UNIVERSITY Bill B. Daily (highly respected Saint Louis area surgeon); Carolyn M. Dresler (international antitobacco activist); John C. Laschinger (Food and Drug Administration Medical Officer); Michael K. Pasque (who holds the longest tenure in our division for a surgeon, having joined the faculty in 1988); T. Bruce Ferguson, Jr. (Dr Tom Ferguson's son); eventually Charles B. Huddleston, R. Morton “Chip” Bolman III, Hendrick B. Barner, Thoralf M. Sundt III (97th AATS President); and so many more including Drs Joel D. Cooper (84th AATS President) and G. Alexander Patterson (90th AATS President) who would later serve as the fifth and sixth Chiefs of our Division (Fig. 20).

WASHINGTON UNIVERSITY CHIEF #5: JOEL D. COOPER (1997-2005) Dr Cooper was born in Charleston, WV and attended Harvard College and Harvard Medical School.45 He did his surgical training at MGH and general thoracic training at the University of Toronto with Dr Griff Pearson (70th AATS President). He remained on the faculty in Toronto for 16 years before coming to Washington University in 1988 as the Section Chief in General Thoracic Surgery. Dr Cooper was responsible for initiating the General Thoracic Track as a training pathway option in the Washington University residency program. After Dr Cox's departure in 1997, Dr Cooper started his tenure as Chief of the Division of Cardiothoracic Surgery. In 2004, he served as the 84th AATS President. Dr Cooper's most important contributions to our field are 3-fold:

Figure 20. Drs Alex Patterson (left) and Joel Cooper (right). (Courtesy: the Archives of the Division of Cardiothoracic Surgery, Washington University School of Medicine.) (Color version of figure is available online.)

(1) Working with Dr Hermes Grillo at MGH as a resident, Dr Cooper did extensive research into the cause of tracheal stenosis in patients after ventilation with a tracheostomy or endotracheal tube. Dr Cooper determined that tube cuffs were inelastic, requiring high pressures to occlude the trachea, which would stretch, causing damage.46 He developed a cuff that would conform to the trachea and fill the space at low pressure. Dr Grillo and Cooper's low pressure cuffs nearly eliminated postintubation stenosis at the cuff site. (2) Dr Cooper is credited with performing the first successful single-lung transplant. In his 1986 New England Journal of Medicine article, Dr Cooper and his colleagues (including Dr Patterson) reported 2 patients undergoing successful transplantation.47 Prior attempts had been made by others, but the results had been universally poor. Dr Cooper working with Dr Patterson in the laboratory, developed a protocol that included weaning steroids preoperatively, excluding patients on ventilators, using an omental flap to support the bronchial anastomosis, and using cyclosporine for induction. (3) At Washington University in 1995, Dr Cooper's team, including Dr Patterson, first championed lung volume reduction surgery for end-stage chronic obstructive pulmonary disease.48 They reported 20 patients who, after excision of 20%-30% of each lung, had improved pulmonary function with an increase in FEV1 of 82%, increase in 6-minute walk of 60%, and improved quality of life. WASHINGTON UNIVERSITY CHIEF #6: G. ALEXANDER PATTERSON (2005-2014) Dr Alec Patterson was born in Canada and attended Queens University in Kingston before completing his surgical and general thoracic training at the University of Toronto.49 He joined the faculty in 1982 and received the Gold Medal in Surgery from the Royal College in Canada. Drs Cooper and Cox recruited Dr Patterson to Washington University in 1991 as Director of the Lung Transplant Program. Dr Patterson was AATS Treasurer from 2003-2007, served as the 90th AATS President in 2010, and has been editor of the Annals of Thoracic Surgery since 2015. Dr Patterson's most important contributions to our field, in addition to the work he did to support Dr Cooper's contributions noted earlier, was the development of the initial surgical technique for double lung transplantation and the first successful procedure on November 26, 1986 in a 42-year-old woman with α2-antitrypsin deficiency.50 In 1988, he presented 2 articles that

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CT SURGERY AT WASHINGTON UNIVERSITY described his experimental work in primates, the first successful double lung transplant, and a series of 6 successful transplants that laid the groundwork for widespread application.50,51 Dr Patterson's initial technique of en bloc transplantation of both lungs evolved into the current technique of sequential, bilateral, and single-lung transplantation with the input of Drs Kaiser and Pasque at Washington University in the early 1990s.52 At Washington University, we find Dr. Patterson’s most important contribution to be his Presidential Address at the AATS meeting in 2010 during which, he outlined a new model of Professionalism and Culture of Safety that has become an integral part of our operating room culture and day-to-day lives in the Division of Cardiothoracic Surgery and Department of Surgery under Dr Timothy J. Eberlein.53 WASHINGTON UNIVERSITY CHIEF #7: RALPH J. DAMIANO, JR. (2014-PRESENT) Our seventh and final chief to date remains Dr Ralph Damiano who began his tenure in 2014. Dr Damiano was born in White Plains, New York, did his undergraduate training at Dartmouth and medical school at Duke University. He then completed his surgical training (aka the “Decade with Dave”) at Duke. After his tenure on the faculty at the Medical College of Virginia and Penn State University, Dr Damiano joined the faculty at Washington University in 2000 as the Section Chief of Cardiac Surgery. Dr Damiano has been the Editor for Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery since 2008, the official journal of the International Society for Minimally Invasive Cardiac Surgery, of which he was president in 2009.54 Dr Damiano performed the first robotic coronary bypass operation in North America in 1998,55 but more importantly through extensive laboratory work, which continued with Dr Schuessler, he developed a methodology using radiofrequency ablation that allows even an average surgeon to perform the complete lesion set of the maze III procedure safely without the complex, technical challenge that the cut-and-sew surgical approach mandates. The Cox-

1. Simone JV: Understanding academic medical centers: Simone's Maxims. Clin Cancer Res 5:2281-2285, 1999 2. Moon MR: In the Words of the Presidents: American Association for Thoracic Surgery. Lawrence, Kansas, Allen Press, 2017

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Figure 21. Dr Damiano is trying to convince Dr Cox that the Cox-Maze IV procedure using radiofrequency ablation is just as good as the cutand-sew Maze III procedure. (but I don't think Dr Cox is buying it!) (Color version of figure is available online.)

Maze IV procedure was first described in 2004, and is an advance procedure that had facilitated widespread application of the Maze procedure around the world while maintaining optimal long-term results (Fig. 21).56

EPILOGUE As Dr Floyd Loop (78th AATS President) noted in his book Leadership in Medicine, “Personal history is based on recollections. If you don't write it, you will forget it.”57 So, for that reason, I would like to thank the editors of Seminars in Thoracic and Cardiovascular Surgery for the opportunity to write down our history so that it will not be forgotten. I hope you have enjoyed reading the history of the Division of Cardiothoracic Surgery at Washington University in Saint Louis as much as I enjoyed putting it together. Though I did not train at Washington University, I feel a profound sense of honor to have been a part of its history, a history that all began with Dr Evarts A. Graham nearly a century ago.

3. Mueller CB, Graham Evarts A: The Life, Lives, and Times of the Surgical Spirit of St. Louis. Hamilton, Ontario: BC Decker; 2002 4. Flexner A: Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. New York: Publisher Unknown; 1910

5. Alexander J: The training of a surgeon who expects to specialize in thoracic surgery. J Thorac Surg 5:579-582, 1936 6. Sloan H: The American Board of Thoracic Surgery. A Fifty Year Perspective. Evanston, Illinois: American Board of Thoracic Surgery; 1998

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CT SURGERY AT WASHINGTON UNIVERSITY 7. Blades B: Presidential address—A case report and miscellaneous comments. J Thorac Surg 36:285-300, 1958 8. Graham EA: The first total pneumonectomy. Tex Cancer Bull 2:2-4, 1949 9. Lilienthal H: Pneumonectomy for sarcoma of lung in a tuberculous patient. J Thorac Surg 2:600-615, 1933 10. Graham EA, Singer JJ: Successful removal of an entire lung for carcinoma of the bronchus. J Am Med Assoc 101:1371-1374, 1933 11. D'Amico TA: Historical perspectives of The American Association for Thoracic Surgery: Evarts A. Graham (1883–1957). J Thorac Cardiovasc Surg 142:735-739, 2011 12. Ochsner A, DeBakey M: Carcinoma of the lung. Arch Surg 42:209-258, 1941 13. Wilds J, Harkey I: Alton Ochsner, Surgeon of the South. Baton Rouge: Louisiana State University Press; 1990 14. Graham EA to A Ochsner [letter]. Historical Archives, Bernard Becker Medical Library, Washington University School of Medicine, February 18, 1949 15. Wynder EL, Graham EA: Tobacco smoking as a possible etiologic factor in bronchiogenic carcinoma; a study of 684 proved cases. J Am Med Assoc 143:329-336, 1950 16. Wynder E in conversation with CB Mueller. Historical Archives, Bernard Becker Medical Library, Washington University School of Medicine, March 11, 1992 17. Wynder EL, Graham EA, Croninger AB: Experimental production of carcinoma with cigarette tar. Cancer Res 13:855-864, 1953 18. Wynder EL, Graham EA, Croninger AB: Experimental production of carcinoma with cigarette tar. II. Tests with different mouse strains. Cancer Res 15:445-448, 1955 19. Graham EA, Croninger AB, Wynder EL: Experimental production of carcinoma with cigarette tar. III. Occurrence of cancer after prolonged latent period following application of tar. Cancer 10:431-435, 1957 20. Graham EA, Croninger AB, Wynder EL: Experimental production of carcinoma with cigarette tar. IV. Successful experiments with rabbits. Cancer Res 17:1058-1066, 1957 21. Croninger AB, Graham EA, Wynder EL: Experimental production of carcinoma with tobacco products. V. Carcinoma induction in mice with cigar, pipe, and all-tobacco cigarette tar. Cancer Res 18:1263-1271, 1958 22. Ochsner A: Smoking and Cancer: A Doctor's Report. New York: Messner; 1954 23. Olch IY in an interview with JF Newsome. Historical Archives, Bernard Becker Medical Library, Washington University School of Medicine, undated, circa 1977 24. Graham EA to Wynder E [letter]. Historical Archives, Bernard Becker Medical Library,

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Washington University School of Medicine, February 6, 1957 Yaffe SA to Damiano RJ, Jr [letter], personal communication, June 25, 2014 Churchill ED: Evarts Graham: Early years and the hegira. Ann Surg 136:3-11, 1952 Graham EA: Remarks of Evarts A. Graham at the dinner, November 30, 1951, honoring him on the occasion of his retirement as Bixby Professor of Surgery. Ann Surg 136:3-11, 1952 A collection of manuscripts from multiple authors presented at the Centennial Symposium for Evarts Ambrose Graham. J Thorac Cardiovasc Surg 88:801-906, 1984 Okada S, Moon MR: Historical perspectives of The American Association for Thoracic Surgery: Thomas H. Burford (1907–1977). J Thorac Cardiovasc Surg 145:621-625, 2013 Coates JB, editor. Surgery in World War II. Thoracic Surgery Volume I. Washington, D.C: Medical Department, United States Army. Office of the Surgeon General; 1963 Ahnfeldt AL, editor. Surgery in World War II. Thoracic Surgery Volume II. Washington, D.C: Medical Department, United States Army. Office of the Surgeon General; 1965 Delorme E: Nouveau traitment des empyemes chroniques. Gaz Hop Civ Milit 67:94-96, 1894 Burford TH: From whence to whither. J Thorac Cardiovasc Surg 62:167-175, 1971 Clarence S. Weldon: Obituary. The Baltimore Sun, August 6, 2006 Moon MR: Historical perspectives of The American Association for Thoracic Surgery: Thomas B. Ferguson (1923-2013). J Thorac Cardiovasc Surg 146:251-254, 2013 Ferguson TB: The crisis of excellence. J Thorac Cardiovasc Surg 84:161-171, 1982 Lawton JS, D'Amico TA: Historical perspectives of The American Association for Thoracic Surgery: James Lewis Cox. J Thorac Cardiovasc Surg 149:1235-1239, 2015 Cox JL: Presidential address: Changing boundaries. J Thorac Cardiovasc Surg 122:413-418, 2001 Cox JL, Schuessler RB, Boineau JP: The surgical treatment of atrial fibrillation. I. Summary of the current concepts of the mechanisms of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 101:402-405, 1991 Cox JL, Canavan TE, Schuessler RB, et al: The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 101:406-426, 1991 Cox JL, Schuessler RB, D'Agostino Jr HJ, et al: The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg 101:569-583, 1991

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42. Cox JL: The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg 101:584-592, 1991 43. Cox JL, Boineau JP, Schuessler RB, et al: Modification of the maze procedure for atrial flutter and atrial fibrillation. I. Rationale and surgical results. J Thorac Cardiovasc Surg 110:473-484, 1995 44. Cox JL, Jaquiss RD, Schuessler RB, et al: Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of the maze III procedure. J Thorac Cardiovasc Surg 110:485-495, 1995 45. Okereke IC, Cassivi SD, Moon MR: Historical perspectives of The American Association for Thoracic Surgery: Joel D. Cooper. J Thorac Cardiovasc Surg 151:1440-1443, 2016 46. Grillo HC, Cooper JD, Geffin B, et al: A lowpressure cuff for tracheostomy tubes to minimize tracheal injury. A comparative clinical trial. J Thorac Cardiovasc Surg 62:898-907, 1971 47. Toronto Lung Transplant Group. Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med 314:1140-1145, 1986 48. Cooper JD, Trulock EP, Triantafillou AN, et al: Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 109:106-119, 1995 49. Chang SH, D'Amico TA: Historical perspectives of The American Association for Thoracic Surgery: G. Alexander Patterson. J Thorac Cardiovasc Surg 148:2455-2457, 2014 50. Patterson GA, Cooper JD, Dark JH, et al: Experimental and clinical double lung transplantation. J Thorac Cardiovasc Surg 95:70-74, 1988 51. Patterson GA, Cooper JD, Goldman B, et al: Technique of successful clinical double-lung transplantation. Ann Thorac Surg 45:626-633, 1988 52. Kaiser LR, Pasque MK, Trulock EP, et al: Bilateral sequential lung transplantation: the procedure of choice for double-lung replacement. Ann Thorac Surg 52:438-446, 1991 53. Patterson GA: Non Solus—A leadership challenge. J Thorac Cardiovasc Surg 140:495-502, 2010 54. Damiano Jr. RJ: Surgical innovation in the information age: the heavy burden of great potential. Innovations (Phila) 6:283-288, 2011 55. Damiano Jr RJ, Ehrman WJ, Ducko CT, et al: Initial United States clinical trial of robotically assisted endoscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg 119:77-82, 2000 56. Gaynor SL, Diodato MD, Prasad SM, et al: A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation. J Thorac Cardiovasc Surg 128:535-542, 2004 57. Loop FD: Leadership and Medicine. Gulf Breeze, FL: Fire Starter Publishing; 2009

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