History of Surgery Histoire de chirurgie -...

14335 Jan/96 CJS /Page 72

72 JCC, Vol. 39, No 1, février 1996

Dr. Norman Bethune’s recognition as a Canadian of renown resulted from his devoted work in China dur-ing the late 1930s. He had received a general surgical training, but his personal illness with tuberculosis ledhim to specialize in thoracic surgery. A surgical program at McGill University under Dr. Edward Archibald,a pioneer thoracic surgeon, was initially successful, but by the mid-1930s Bethune was rejected by McGilland Dr. Archibald. He became chief of thoracic surgery at the Hôpital du Sacré-Coeur outside Montreal.He developed thoracic surgical instruments and wrote numerous scientific papers. The outbreak of civilwar in Spain in 1937 attracted Bethune to oppose what he viewed as fascist aggression. He went to Spain,where he established the value of mobile blood banking. On his return to Canada in 1937 he becameaware of the escalating war between China and Japan. He joined the Chinese communist forces in north-ern China and spent 18 months doing Herculean mobile war surgery, while improving the state of medicalservices in primitive, depressing conditions. He died in 1939 at the age of 49 years of septicemia as a resultof accidental laceration of his finger during surgery. The Chinese have venerated Norman Bethune andstimulated his memorialization in Canada. His surgical record can be viewed as mixed in quality, but over-all his performance remains impressive for its achievement.

C’est à cause de son dévouement en Chine à la fin des années 30 que le Dr Norman Bethune est devenu unCanadien réputé. Il a reçu une formation en chirurgie générale, mais comme il avait lui-même souffert detuberculose, il s’est spécialisé en chirurgie thoracique. Il a connu du succès au début dans un programmede chirurgie entrepris à l’Université McGill, sous l’égide du Dr Edward Archibald, pionnier de la chirurgiethoracique. Au milieu des années 30, McGill et le Dr Archibald ont toutefois rejeté le Dr Bethune. Il estdevenu chef de la chirurgie thoracique à l’Hôpital du Sacré-Cœur, à l’extérieur de Montréal. Il a mis aupoint des instruments de chirurgie thoracique et produit de nombreuses communications scientifiques. Ledéclenchement de la guerre civile en Espagne, en 1937, a attiré le Dr Bethune qui s’opposait à ce qu’il con-sidérait comme une agression fasciste. Il s’est rendu en Espagne où il a démontré la valeur des banques desang mobiles. À son retour au Canada en 1937, il a appris l’escalade de la guerre entre la Chine et le Japon.Il s’est joint aux forces communistes chinoises dans le nord de la Chine et a passé 18 mois à faire un travaild’hercule dans une unité mobile de chirurgie de campagne tout en améliorant les services médicaux dansdes conditions primitives et déprimantes. Il est mort en 1939, à l’âge de 49 ans, d’une septicémie aprèss’être lacéré accidentellement le doigt au cours d’une intervention chirurgicale. Les Chinois vénèrent Nor-man Bethune et ce sont eux qui ont fait commémorer sa mémoire au Canada. Son bilan chirurgical peutêtre considéré comme de qualité mitigée, mais son rendement général demeure impressionnant par sesréalisations.

History of SurgeryHistoire de chirurgie

DR. NORMAN BETHUNE AS A SURGEON

Irving B. Rosen, MD, FRCSC, FACS*

*Professor, Department of Surgery, University of Toronto, Toronto, Ont.

Accepted for publication Apr. 12, 1995

Correspondence and reprints requests to: Dr. Irving B. Rosen, Room 478, 600 University Ave., Toronto ON M5G 1X5

Very few Canadians have madesuch an impact on world af-fairs and history as Dr. Nor-

man Bethune. This is ironic becauseuntil 1972 when the rapprochementbetween China and Canada occurred

he was not well known. However, thepersistent curiosity of Chinese dele-gates led to the declaration of Bethuneas a historically important Canadianwhose birthplace became a certifiedmemorial in 1976.

THE EARLY YEARS

Born in Gravenhurst, Ont., in 1890in a Presbyterian manse, NormanBethune was a rambunctious youthwhose conflicting feelings for his


moralistic, authoritarian father and hisevangelistic, possibly unapproachable,mother influenced the developmentof his personality and may explain hisadult zeal for good deeds and clasheswith authority.One of three children, he venerated

his grandfather who had been a sur-geon and dean of Toronto’s TrinityMedical College School. At one pointhis grandfather had resigned his posi-tion at the university in protest over aschool regulation that barred non-Anglicans, resulting in a decrease indues-paying students. Surgical teach-ers at that time depended on studentfees for income.In 1909 Bethune entered the Uni-

versity of Toronto to study physiologyand biochemistry and gained second-class honours. From 1911 to 1912 heworked as a teacher and a lumberjack inthe frontier college. He entered the 2ndyear of medical school in 1912, butwith the outbreak of the First WorldWar in 1914 he volunteered as astretcher-bearer. He was wounded inFrance and invalided out in 1915. Afterhis convalescence, he completed a crashcourse in medicine and graduated withhis MD at the University of Toronto in1916. He joined the Royal Navy andsubsequently the early Canadian AirForce. In 1920 he embarked on surgi-cal postgraduate education in England.He worked at the West London Hospi-tal and the Royal Infirmary in Edin-burgh. In February 1922 he was admit-ted to the Fellowship in the RoyalCollege of Surgeons in Edinburgh. Thefollowing year he married Frances Pen-ney, the daughter of a conservative Ed-inburgh family, who had money, agood home and a good reputation. Fortheir honeymoon, they took a conti-nental tour, which included visits to Vi-ennese clinics, but after 6 months of funFrances’s money ran out.In 1924 Bethune became a physician-

surgeon in Detroit, a city that repelled

the young couple. He admitted pa-tients to the Harper Hospital forsurgery and taught part-time at whatis now Wayne State Medical School.Bethune’s practice was slow to de-velop, and he resorted to barter to getby. Furthermore, his domestic life washectic and difficult, so much so that in1925 Frances left for an extended visitto a friend and family. When she re-turned to Detroit in 1926, Bethune’spractice had “taken off.”During this time Bethune experi-

enced unusual fatigue and weight loss,and pulmonary tuberculosis was diag-nosed. In October 1926 he left De-troit for Gravenhurst under the careof Dr. Charles Parfitt, and that De-cember he was transferred to theTrudeau Sanatorium in the Adiron-dack Mountains, where patients re-ceived 6 months of care includingroom, board and medical attention for$15 a week. His wife initiated divorceproceedings in June 1927.Bethune was determined to be well.

He read Dr. John Alexander’s book onsurgery of pulmonary tuberculosis andwas convinced that an artificial pneu-mothorax would help him, since hesaw little hope for recovery with con-servative therapy. After some resistancefrom the medical staff, a resident physi-cian, Dr. Warren, agreed to giveBethune an artificial pneumothoraxwith a 65% collapse of his lung. Fol-lowing this he improved so rapidly thathe was discharged on Dec. 10, 1927,and for several years continued to re-ceive pneumothorax refills. His experi-ence with tuberculosis transformed hisattitude. He wanted to find somethinghe could do for the human race,“something great,” and he avowed hewould do it before he died.1,2

THE MONTREAL PERIOD

In April 1928, after a few monthsof laboratory work, he left for Mon-

treal, where he had been accepted as athoracic surgical fellow by Dr. EdwardArchibald, chairman of the Depart-ment of Surgery, McGill University,and surgeon-in-chief of the Royal Vic-toria Hospital, and himself a formertuberculosis patient and a pioneer inthoracic surgery. Dr. Archibald, a manof great clinical experience, main-tained a continuous flow of scientificpublications. Bethune not only as-sisted Archibald but did laboratory re-search work and taught residents andstudents. Initially all went well.Bethune wrote that Archibald was“the outstanding figure in chestsurgery in America and a most charm-ing fellow.”2 For his part, Archibaldlooked upon Bethune as “one of theyoungest and most brilliant surgeonson my service.”2

Bethune threw himself into hiswork. He invented various thoracicsurgical instruments and contributed16 scientific articles to various jour-nals, usually on thoracic topics, overan 8-year period. He was now operat-ing on his own patients and had de-veloped a reputation for speed in thename of minimizing shock and dura-tion of anesthesia. Although some col-leagues were impressed with this facil-ity and his implicit concern for thepatient, others were taken aback bywhat appeared to be reckless operativetechnique. A clinical clerk stated: “Ibecame aware that Dr. Bethune’s pa-tients had a rocky time recoveringfrom surgery. In spite of our best care,we are losing patients operated on byDr. Bethune at an unusual rate.”2 Dr.Arthur Vineberg, a pioneer in myocar-dial revascularization, recalled an op-eration at which he assisted Bethune:

He was brilliant . . . and he had techni-cal skills but the kind of technical skillthat kills people because he always likedto go too fast. He did a thoracoplasty forDr. Archibald in front of a lot of sur-

NORMAN BETHUNE

CJS, Vol. 39, No. 1, February 1996 73


geons and he said “come on, Arthur, wewill show them how good we are” andout came three ribs. I said “Norman,this guy is going to bleed to death.”“No,” he said, “16 minutes from skin toskin” and the guy died.2

Archibald2 now began to viewBethune differently. Bethune, he said.“was a leader but a dangerous kind ofleader. . . . He is willing to take risksat the patient’s expense. . . . He had asuperiority complex and he was en-tirely amoral.” At rounds Bethune“would make a legitimate attempt tomake an explanation. Then beyond acertain point he was just engaged inthe most facetious and mocking sortof comments.”2 Another friend stated,“he was a bad drinker. . . . He pickedarguments and insulted people every-where we went.”2 When one ofBethune’s patients, who had beenconsidered a good risk, died after athoracoplasty, Archibald had hadenough, and in 1933 Bethune wasdismissed from the “Royal Vic” andMcGill University.Shortly after, he was hired by the

Hôpital du Sacré-Coeur, just outsideMontreal, as their first thoracic surgi-cal specialist (Fig. 1). Ironically, thisreflected an earlier endorsement byArchibald in support of Bethune’s ap-plication. He operated once a week,carrying out 250 procedures annually,and he also trained a younger Fran-cophone surgeon as a thoracic special-ist. Between 1933 and 1936 at thehospital, Bethune’s activities appearedadmirable and praiseworthy. He wasprobably the first surgeon in the worldto carry out bilateral thoracoplastiesand the first surgeon in Canada to doa pneumonectomy in a child under10 years of age.3 In 1932 Bethune be-came a member of the American As-sociation of Thoracic Surgery, and in1935 he became a member of its ex-ecutive).

He had remarried Frances in 1929,but they parted permanently in 1933.After witnessing a riot between policeand unemployed demonstrators, hevolunteered his free medical servicesto the Organization for the Unem-ployed and did the same for a YMCAclinic. He consorted with artists, left-ists and intellectuals. He was a man ofartistic bent, and he painted pictures,composed stories and wrote poetry.He lived a high life, and women foundhim attractive.In 1935 he attended the Interna-

tional Physiological Congress inLeningrad where he toured Russianmedical facilities and assessed theirmanagement of tuberculosis. Whenhe returned to Montreal, he joinedthe Canadian Communist Party as a“closed” member, which meant thathis membership was kept secret.4

He now addressed various organi-zations such as the Montreal MedicalChirurgical Society and the postgradu-ate assembly in Memphis, Tenn.,where he lauded Russia and socializedmedicine, and decried that a physician

should profit from a man’s ills. Heformed a group called the MontrealGroup for the Security of People’sHealth, which included health profes-sionals of different disciplines. Bethuneviewed tuberculosis as a social prob-lem, and he and the group developeda scheme for socialized health care,which they forwarded to political fig-ures and members of the medical pro-fession. The idealistic, detailed planwas ignored, much to Bethune’s cha-grin and disappointment.

THE SPANISH CIVIL WAR

In 1936 the Spanish Civil Warbroke out.5–7 Supported by Hitler,Mussolini and the Catholic Church,General Franco led a military uprisingafter the election of a popular frontcoalition that included socialists, anar-chists and communists. Bethune,burning with a desire to fight fascism,resigned his various hospital appoint-ments, boarded a ship in Quebecarmed with medical supplies and in1936 set out for Spain supported bythe Canadian Committee to AidSpanish Democracy, a group led byProtestant ministers but really staffedby Communists. Bethune did not actas a surgeon but conceived of a planto initiate a mobile blood bank servicethat would bring resuscitative transfu-sion to battlefront field units. Bethunewrote:

We have succeeded in unifying all re-maining transfusion units under us.We are serving 100 hospitals and casu-alty-clearing stations in the front linesof Madrid and 100 kilometres from thefront of the sector to central. . . . This isthe first unified blood transfusion ser-vice in army and medical history. Plansare well under way to supply the entireSpanish anti-fascist army with pre-served blood. The “institute” is now op-erating on a 1,000 kilometre front.2

ROSEN


FIG. 1. Norman Bethune, 1934, self-portrait dur-ing his 2nd year at Hôpital du Sacré-Coeur.(Courtesy of National Archives of Canada, National Film Board Collection, PA 116909)


The Spanish recognized Bethune’sachievement by granting him thehighest military rank held by any for-eigner in the medical service.2 A mo-bile blood transfusion service was es-tablished and organized by Bethune,and he was awarded greater responsi-bilities for the administration and ex-pansion of the service. This type ofblood bank facility became officiallysanctioned as an integral part of warsurgery during the Second World Warand has since become an establishedtenet of war surgical service. This rep-resents a remarkable contribution.Bethune, a mercurial, compul-

sively active man, whose aim was toresuscitate both military and civilianwounded, soon encountered the bru-tality of an unlimited war endured bythe civilian population. He was ex-posed to frightened and horrifiedcivilians escaping the horrors of warby advancing nationalist troops in thesouth of Spain. Of this aspect of warBethune wrote:

The farther we went, the more pitifulthe sights became. . . . Thousands of chil-dren . . . we counted 5,000 under10 years of age — at least 1,000 of thembarefoot and many of them clad only ina single garment . . . the incessantstream of people became so dense wecould barely force the car throughthem. . . . We were heavily bombed byGerman and Italian fascist airplanes .. . the moans of the wounded children,shrieks of agonized mothers, curses of themen rose in . . . a pitch of intolerable in-tensity.2

At that time Bethune had becomequite unstable and was drinkingheavily, so it was not surprising thathe soon came into conflict withSpanish authorities. He became per-sona non grata and was actually es-corted home by two Canadian Com-munists, McLeod and Kashton. In

Canada he was received as a hero bymembers of the left and embarked ona cross-Canada lecture series to at-tract financial support for the Span-ish Republican cause. After continualdenial of his communist affiliation,he admitted membership in July1937. He was now 47 years old, andhis Canadian prospects looked dim.The Japanese capture of Beijing, inAugust 1937 focused his attentionon China. He felt that the Chinesescene was important and once moresaw this as a battle against fascist evil.In company with a Chinese-speakingnurse, Jean Ewen, and supported byAmerican friends, Bethune set sail forHong Kong on New Year’s Day1938.

THE CHINESE CONFLICTS

The China of 1938 presented acomplex geopolitical entity.8 TheJapanese, who had attacked China justa year earlier, were extending their oc-cupation of the country. The Com-munists and Kuomintang, both com-mitted to a China of greater nationalpride, had barely settled their seriousantagonisms by forging an anti-Japan-ese front. In Hankow, Bethune metwith Chou En-lai and then preparedto travel north to Yenan where MaoTse-tung and his communist survivorsof the long march were headquar-tered. McClure, the future moderatorof the United Church and medicalmissionary, found Bethune inT’ungK’uan to warn him of a Japan-ese intrusion after following the trailof an alcohol-seeking “long nose.”McClure reported “he [Bethune]didn’t feel himself a Canadian . . . veryparanoid about anybody in thoracicsurgery . . . they thwarted him . . .very bitter.”9

The way north was threatened bythe Japanese. In Yenan, Bethune metMao Tse-tung in his apartment, which

was a cave in the loess hills of thatarea. Bethune, Ewen and a Canadianmissionary, Dr. Richard Brown,formed a mobile medical unit to op-erate in the border region that thecommunists were defending againstthe invading Japanese. Brown andBethune were immediately occupiedwith treating the war wounded buttook time to deal with civilian prob-lems as well. They renovated and re-newed primitive facilities designatedas a hospital. After a few months,Brown had to return to his missionduties, leaving Bethune as the onlyqualified physician for 13 million peo-ple. Bethune became saintly, ab-stemious and dedicated in his work.He moved continuously and wrote,“if I did not have enough work to fill18 hours a day I would certainly feeldiscontented.” His range of surgerywas general and he could report “wedid 19 operations amongst 40 seri-ously wounded . . . 3 fractures of theskull were trephined, 2 amputationsof the thigh, 2 perforations of smallintestines, half a dozen bad fracturesin arms and legs and the rest smalleroperations.”2,3 (Fig. 2).While Bethune dedicated himself

to the care of the war-wounded andinjured Red Chinese troops, hequickly recognized that his Chinesecolleagues were completely untrainedin medicine or nursing and few hadany exposure to formal medical train-ing. Yet they were dedicated, intelli-gent, anxious to serve and aspired tobe of aid to suffering mankind.Bethune became their teacher. Everyother day from 17:00 to 18:00 hewould lecture on the fundamentals ofmedicine, illustrating this with knowl-edge of the basic anatomy and physi-ology of the human body. Bethunewrote: “the personnel . . . should besent . . . for an intensive two to threemonth course in surgical nursing andthe elements of surgery. . . . These

NORMAN BETHUNE



men returning to the Eighth RouteArmy (Chinese communists) shouldbe ‘seeded’ throughout the medicalservice and will be able to instruct oth-ers. . . . This will do for nurses but fordoctors other plans should be made.”Bethune was conscious of the lack ofmedical professional assistants andconstantly requested Westerners inthis capacity . He recommended “thesending away” of selected candidates(doctors) to Russia or to universitiesin China to be trained as fully quali-fied doctors. “This would take four tofive years . . . they in turn would grad-ually raise the standard throughoutthe sanitary service.” Trying to rem-edy these manpower problems, he de-signed and organized the conversionof a Buddhist temple to a model hos-pital, planned a medical school fortraining physicians and submitted aprotocol outlining this possibility, andprepared a basic text of informationthat could be assimilated by youthfulpeasant soldiers to this end. He wasassigned poorly trained individuals as“doctors” whom he respected and

trained and urged greater commit-ment to education and service.He worked indefatigably, and his

example of commitment was used toinspire the soldiers in military action.He rapidly became fatigued and ap-peared old. In August 1939 wrote“my health is pretty fair, teeth need at-tention, one ear has been completelydeaf for three months, but apart frombeing pretty thin I am okay.”2 OnOct. 28, 1939, while doing an openreduction and fixation of a fracturedtibia, he cut himself with an os-teotome and several days later oper-ated barehanded on a soldier whosehead injury had not been treated fordays. An abscess of his finger devel-oped, followed by axillary lym-phadenitis and fatal septicemia. Hecontinued to work until Nov. 12,1939, when he died. He was buried inan American flag because a UnionJack was not at hand.On his death there was an outpour-

ing of sorrow and mourning in China.A monument and tomb were createdin his honour, and there is a Bethune

Peace Hospital and Medical School ascommemorative monuments south-west of Beijing. His death was met inCanada by official silence, although in1943 the Canadian Congress ofLabour recommended a living monu-ment be dedicated to the work of Dr.Bethune. This was ignored by Macken-zie King’s Liberal government (Fig. 3).

CONCLUSIONS

In 1960 I was assisting the emeri-tus chairman of the Department ofSurgery, University of Toronto, Dr.Robert Janes. We were doing a sca-lene node biopsy, and Dr. Janes men-tioned that a thoracic surgeon had in-jured the subclavian artery during theprocedure and was compelled to do aforequarter amputation and then hadthe temerity to describe it as an inter-esting case. “Really, Sir,” was my re-joinder. “Yes,” Dr. Janes said.“Bethune was his name. Have youever heard of him?” I said I certainlyhad. Dr. Janes continued: “poor Nor-man was a classmate, you know.”There was a pause. “A drunkard, youknow.” Another pause and then Pro-fessor Janes concluded: “of such stuffare heroes made.” That was a bitterremark but a prophetic one.In 1979 a conference sponsored by

the Bethune Foundation was held atMcGill University to recognize the40th anniversary of Bethune’s death.Among the speakers was Dr. H.Rocke Robertson, former chair of theDepartment of Surgery of McGill aswell as its former principal and vice-chancellor. Dr. Robertson was tactful,but his judgement of Bethune wasdefinite when he stated:

I would support Dr. Archibald’s viewthat Bethune’s claim to fame should notbe based upon his abilities as a thoracicsurgeon. . . . I do however have to admitsome bias. I was a student of Dr.

ROSEN


FIG. 2. Bethune operating in China in 1939 without gloves or mask. (Reproduced from Stewart R:Bethune, New Press, Toronto, 1973.)


NORMAN BETHUNE


Archibald’s. . . . It is entirely possiblethat the very qualities that caused someof Bethune’s colleagues to criticize hiswork in chest surgery, his speed of handand decision may have rendered him asuperb military surgeon.5

Despite the decades that hadelapsed since Bethune’s death and theclarification of his contributions fromboth a medical and a social point ofview, Dr. Robertson had difficultiesgiving up the traditionalist, establish-ment view of Bethune’s activities. Hemay have conceded Bethune his goodrecord as a military surgeon, but onlyto utilize such faint praise to condemnBethune’s main work as a thoracic sur-geon.The overall evaluation of Bethune

as a surgeon is complex and does notcomply to a uniform judgement. Sur-geons of great academic repute suchas Archibald, Janes and Robertsonviewed Bethune as an inadequate sur-

geon. Their assessment of Bethunewas undoubtedly influenced by theirview of him as an immature personal-ity who abused alcohol. Bethune wasneither respectable nor predictable.His dismissal from McGill Universityoccurred early in his career as a tho-racic surgeon. His subsequent devel-opment was affected by his peregrina-tions in the name of his humanitarianfeelings. His record of service at theHôpital du Sacré-Coeur is unassail-able.5 He was a man who developedsurgical instruments and strove tocontribute intellectually to his surgicalspecialty. His contribution of mobileblood banking, initiated in Spain, wasof historical importance. In China hefound his epiphany as a surgeon. Hefinally found the universal admirationfor his heartfelt commitment to never-ending work that was only ended by aself-inflicted wound, which bears theinevitable suspicion of a quasi-suicidal“accident” in Freudian terms. He was

unusual and he was unstable, but hislife and work proved complex and ad-mirable, showing the fallacy of glibdismissal that is understandable byconventional thinking.The University of Toronto has rec-

ognized Bethune’s achievements byplacing a plaque in his honour in thefoyer of its medical school not too farfrom a similar plaque commemoratingProfessor Janes.

References

1. Allan T, Gordon S: The Scalpel andthe Sword, McClelland & Stewart,Toronto, 1989

2. Stewart R: Bethune, New Press,Toronto, 1973

3. Stewart R: The Mind of NormanBethune, McGraw-Hill Ryerson,Toronto, 1990

4. MacLeod W, Park L, Ryerson S:Bethune: the Montreal Years, JamesLorimer, Toronto, 1978

5. Shephard D, Levesque A: NormanBethune— His Times and His Legacy,Canadian Public Health Association,Ottawa, 1982

6. Thomas H: The Spanish Civil War,Penguin Books, Toronto, 1986

7. Orwell G: Homage to Catalonia,Harcourt Brace & Company, NewYork, 1980

8. Fairbank J: The Great Chinese Revo-lution 1800–1985, Harper & Row,New York, 1986

9. Scott M: McClure, Canec, Toronto,1977

FIG. 3. Bethune dead, with Stars and Stripes in proximity, used because Union Jack was not available.(Reproduced from Stewart R: Bethune, New Press, Toronto, 1973.)

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