2020, Number 1
Memories of a general surgery service and its surgeons. Part 1
Full text
10.35366/92714
Language: English/Spanish [Versi?n en espa?ol]
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ABSTRACT
Timeline of the General Surgery Service and the general surgeons of the General Hospital of the National Medical Center of the Mexican Social Security Institute 1963-1981 (HG of the CMN of the IMSS). That disappeared with the 1985 Earthquake, without a doubt it was an important part of the History of General Surgery in Mexico. In these articles we honor and honor our teachers who forged and gave us professional life. I hope that many surgeons will send similar memories to our magazine to enrich our cultural heritage of Surgeons and General Surgery in Mexico.History, emulation of time, repository of actions, witness of the past, example and notice of the present, warning of the future.
Miguel de Cervantes
Manuel Quijano Narezo and most of the notable and eminent surgeons of the original General Surgery Service have passed away. Undoubtedly, they deserve to be remembered and honored for their personal and "team" work, which forged an important part of general surgery in Mexico.
PRESENTATION
In this historical description –one could say, novelistic– of the General Surgery Service and of the surgeons who participated in the beginnings of the General Hospital of the National Medical Center of the Mexican Social Security Institute (HG of the CMN of the IMSS), I have allowed myself to remember an important part of my professional training, which I gladly share with all general surgeons and which, of course, I would live again with. Because, as the phrase goes, "to remember is to live".
Emotions come together when trying to write down memories with the utmost veracity; there is almost always the risk of omitting something, as memory fails. For the same reason, I apologize for the involuntary omissions and for the lack of information that prevents me from being more accurate in this description.
Recently, after the passing of some surgeons that we will describe below, I was present at academic events that lacked well-deserved posthumous words for them. The leaders at that time did not consider doing so, probably because they were not aware of the historical value of their actions and what they did to improve general surgery in Mexico, that which led us to be what we are today. History in war and politics is written by the victors, but in real life, only those who witness it know it; this is one of them.
Henry Sigerist insisted that the history of medicine can be a useful mediator between ancient humanism and modern science, an idea that seems almost forgotten today. During his lecture in Leipzig, Sigerist placed the history of medicine within a larger cultural context and called for a research program.1
To know what happened and why it happened, I must go back to the origins of the facts, which, indisputably, undergo changes by man, by the need to improve circumstances. Furthermore, according to the historian Enrique Flores-Cano, it is a way of teaching the diversity of human beings and their creativity in their social development.2
The purpose of this story is to describe, but above all, to pay tribute to the physicians and surgeons who forged us. As a surgeon of the General Surgery Service of the General Hospital of the CMN of the IMSS where I participated during those years, it is remarkably interesting to recall the historical evolution of a general surgery service that, in its time, was a leader in attendance and academic production for congresses, avant-garde in many surgical pathologies and in the training of surgeons. Sharing these historical facts of general surgery, I believe, will allow us to know each other better, to understand our surgical past and to prepare ourselves better for the future.
My time at the HG of the CMN of the IMSS was relatively short, only four years as a resident and seven years as a surgeon. Although, undoubtedly, the most important thing was to be there in the best years of productivity, development, academic research, and recognition.
Once again, through this story, I thank each one of those who participated in my professional training, because I am indebted to them. During my stay, I received preparation like many fellow residents, but very few of us had the opportunity to collaborate professionally in that advanced medical care center and to receive praise –in my case, undeserved– for their hard work during the first 10 years.
Cicero said that "history is testimony of time, light of truth, life of memory, teacher of life, reflection of antiquity".3 Through these lines, I invite all general surgeons in Mexico to send reviews and biographies of their teachers, so that the annals of the Mexican Association of General Surgery may be enriched with this information and, at the same time, so that new generations may better understand and know the evolution of general surgery in Mexico.
To improve the quality of the subject and its description, I invited Dr. Rafael Alvarez Cordero, a brilliant surgeon, and an outstanding writer, who lived and actively participated with his professional work in these stories. I would like to take this opportunity to thank him for his time.
ORIGIN
On October 15, 1943, the President of the Mexican Republic, General Manuel Avila-Camacho, issued an agreement to unify the Health and Public Assistance Services. At that time, the acting secretary was Dr. Gustavo Baz-Prada, who assumed that great responsibility; in this way, with the objective of avoiding duplicity and unnecessary expense, he sought greater coordination to achieve sufficient efficiency and increased hospital coverage throughout the Mexican Republic. I will tell you more about this later.
At that time, it was said that taking care of the health of the Mexican people was taking care of the health of the Nation itself, since only by improving the health of those who work could a healthy and strong Nation be built. To this day, those words are still valid.
The Ministry of Health and Assistance initiated a study to formulate and execute a project for the construction of hospital institutions, whose objective was to substantially improve medical care services for the population, considering that the old hospitals were hardly adaptable to function in accordance with the modern advances in medicine at that time. Thus, more than 200 hospitals, both large and small, were built throughout the length and breadth of our country and made up the figure that has gone down in history in terms of construction by a single health administration.4
Beyond the universal context, undoubtedly, that generation of politicians and health administrators were great characters. Their thinking went beyond the ordinary; they wanted institutions over time, such as Social Security, to grow and develop. Only then could the calculations of the capacity of the Ministry of Health of that environment be considered from another point of view but, when that happened, the hospitals undertaken would be at the level of quality of any hospital built by other institutions and organizations. And so, it happened in the field of health care.
But going back to the forties, the hospital network planned by the Secretaría de Salubridad y Asistencia (Ministry of Health and Assistance) had a special construction in mind for the country's capital, a large and complete medical center (unthinkable for its time), which would be superior to many existing ones and equal to others. When Dr. Baz was Minister of Health and Assistance (September 3, 1945) and a year before the end of his term, the law that created the Committee for the Projection and Construction of the Medical Center of Mexico was issued. Its objectives were to assist the population of the Federal District (Mexico's Capital city) and surrounding areas, with the most advanced medical advances of its time, reduce costs and improve social assistance. This law included the building of 12 large hospitals with modern equipment and technology that would cover all branches of medicine. It would be called the "Magna Ciudad de la Salud" (Great City of Health).
Figures 1 and 2 date back to 1945. In the first one, it is a model of three of the main establishments of the Medical Center of Mexico City. And in the second one, it is a composition in which the traffic circle of Cuauhtémoc Avenue can be observed (I do not know if it existed), and what would be several hospitals. At that time, the Hospital del Niño (Children Hospital), and the Instituto de Cardiología (National Cardiology Institute) had been finished, and three more hospitals were under construction.
The XXI Century National Medical Center of the Mexican Social Security Institute has a long history, dating back to the first half of the 19th century. Within its multiple hospitals, and within the walls of those hospitals, surely, there is a great variety of medical and patient histories, including those of the hospitals themselves. Throughout this memory, we will recount the origin and end of a general surgical service that existed at the General Hospital of the National Medical Center of the Mexican Social Security Institute.
INCEPTION AND EVOLUTION
On March 15, 1963, the President of Mexico, Mr. Adolfo López-Mateos, inaugurated the National Medical Center of the Mexican Social Security Institute (IMSS). At the inauguration he solemnly mentioned that the IMSS was celebrating its twentieth anniversary and that it would be memorable for bringing health and wellness to the country's workers (Figure 3).5
On December 1, 1958, Mr. Benito Coquet had been appointed director of the Mexican Social Security Institute by President Adolfo López-Mateos. During the first fortnight of his administration, he submitted for the consideration of the President of the Republic the names of the persons he would propose to the Technical Council of the Institute. Thus, Dr. Luis Méndez was appointed as Deputy General Medical Director; likewise, Dr. Bernardo Sepúlveda accepted the position of Head of the Department of Planning and Organization of Medical Services.
Mr. Benito Coquet wrote at that time:
The beginning of the activities of the Instituto Mexicano del Seguro Social, almost simultaneously with the planning and construction of the Medical Center, seemed to link, from its origins, one and the other. However, the Mexican Institute of Social Security (IMSS) was born as a decentralized organism of the state, and the Medical Center was projected as a dependency of the then newly created Ministry of Health and Assistance. Almost 19 years after the construction of the Medical Center began, the IMSS acquired by alienation what had been built until then and finished the construction of the different units that integrated it. The last one was the Medical-Surgical Hospital (which was finally identified as the General Hospital of the National Medical Center of the Mexican Institute of Social Security), and was finished and put into service on March 15, 1963.
So much for the words of Mr. B. Coquet [sic].
And as Mr. B. Coquet mentions, it did happen. History will point out what the Medical Center meant for the working population and for the advancement of medicine. For almost 25 years, it was an institution of which the country could be proud: it fulfilled a task for the good of Mexico and Mexicans. Furthermore, it was undoubtedly beautiful from an architectural point of view. It was a hospital complex whose labor, welfare, and academic attributes, gained during its existence, allowed it to boast of being the most important in Mexico and, probably, in Latin America.
In the commemorative book of the inauguration, in the first chapter dedicated to the General Hospital, it is striking that in the list of medical specialties installed in that unit, the General Surgery Service does not appear. However, this absence has an explanation. General surgery was considered in Mexico as a large appendix of gastroenterology (I do not know the origin of this condition and I think it that had no reason to be, since, for example, surgical services in European countries have always been considered independent). Bernardo Sepulveda, as head of the Department of Planning and Organization of Medical Services of the IMSS, appointed Dr. Luis Landa-Verdugo as a Chief of the Gastroenterology Service of the HG of the CMN of the IMSS. Both came from the Hospital de Enfermedades de la Nutrición, now known as the Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", where the General Surgery Service was attached to the Gastroenterology Service, so they adopted and installed that model of assistance and teaching, which persists to date.
The General Hospital of the CMN of the IMSS began its activities that same month of March of its inauguration (1963) (Figures 4 and 5). Thus, Dr. Gustavo Baz-Díaz Lombardo was the first General Surgeon who showed up and immediately started surgical activities. Dr. Francisco-Hidalgo Castro arrived as a Surgical Resident, already with a surgical training (incomplete?) from the Hospital of Nutrition Diseases. Dr. Jorge Bautista-O'Farrill joined in May, and three months after Dr. Hidalgo's arrival, Dr. Rafael Alvarez-Cordero was added as the second resident. And Dr. Vicente Guarner-Dalias joined the team in August of the same year.
According to Dr. Felix Ramirez Espinosa, an excellent former President of the Angiology Service, and a lover of his specialty origins, he mentioned that the General Surgery residency was an important pillar in the development of the General Hospital. This was the first surgical residency in that hospital, and therefore, it provided medical support to all the specialties that required it.6
The first months were of great surgical intensity. As has been reported, Dr. Baz practically lived in the hospital, since he operated in the morning, afternoon, and night shifts. Thus, the legend was born that in one weekend shift he operated on 38 patients, a record that was never surpassed by subsequent generations, including me (with a limit of 28 surgeries and that, unlike me, I had greater support with more residents). The first surgical teams were integrated, on the one hand, by Dr. Gustavo Baz-Díaz Lombardo and Dr. Francisco Hidalgo and, on the other hand, by Dr. Jorge Bautista-O'Farrill with Dr. Rafael Álvarez-Cordero.
In the following year, Dr. Francisco Hidalgo was incorporated as an attending surgeon, and Dr. Isauro Durán-Llamas and Dr. Carlos Godínez-Oropeza started the surgical residency.
Dr. Manuel Quijano-Narezo was invited to collaborate in the IMSS because of his prestige, being at that time one of the best surgeons in Mexico, who during the first two years served as director, but was appointed as assistant director. In addition to his professional prestige, he was endorsed for having performed, at the proposal of Dr. Jorge Bautista-O'Farril, the elective cholecystectomy of the Mexican President wife's, Gustavo Díaz Ordaz. Dr. Rafael Alvarez-Cordero was fortunate to have participated in that surgery.
Dr. Quijano was trained as a surgeon at the General Hospital of Mexico and was a surgeon at the Hospital of Nutrition Diseases. He was appointed as Director of the General Hospital of the CMN of the IMSS, and was Head of General Surgery service also, but accepted the medical-surgical system with the coordination of the Gastroenterology Service. At this stage, the academic and assistance activities were founded.
When Dr. Luis Landa began his leadership with iron discipline, he transmitted his responsibility in assistance, dedication to academia and invitation to research. At the beginning, the Gastroenterology Service occupied the entire seventh floor of the General Hospital, which had a T-shaped architectural conformation, so the north wing was occupied by male patients and the south wing by female patients. In the east-west segment were the Outpatient Services, the Clinical Research Laboratory, and the Biochemistry, Bacteriology and Amebiasis labs. The Endoscopy Service at that time was managed by Dr. José Ramírez-Degollado, a great pioneer in this field. By 1964, due to the great demand of gastroenterological patients, the hospitalization area was doubled so the sixth floor was integrated, reaching 100 beds.
According to this distribution of patients, there was a gastroenterologist and a surgeon for each section, so that Dr. Alfonso Perches and Dr. Jorge Bautista formed a single team. Dr. Antonio de León and Dr. Gustavo Baz-Díaz Lombardo formed another pair, as well as doctors Luis F. Cervantes and Vicente Guarner, and doctors Enrique Segovia and Francisco Hidalgo. And the rotation took place every year. For each of these sections, the 2nd, 3rd, and 4th year residents of General Surgery were added, as well as the Residents of Medical Gastroenterology specialty.
The organization continued and by 1967, when Dr. Carlos Godínez finished his residency, he was accepted as an attending physician. At that time there were already four surgeons in the morning shift, and with him the afternoon and night shifts were completed, which started at 4 p.m. and ended at 8 a.m. the following day; Dr. Rafael Alvarez-Cordero, Dr. Carlos Godinez-Oropeza and Dr. Raul Gomez-Garza were the pioneers of this service. This is how it worked until 1972, when Dr. Gustavo Baz-Díaz Lombardo resigned to found and initiate the Health System of Ciudad Nezahualcóyotl of the State of Mexico. Dr. Carlos Godinez occupied the morning shift, and Dr. Luis Ize-Lamache, by then resident of the 3rd year bis (that was the name given to the fourth year of General Surgery residency) and Chief Resident, occupied the on-call shift. That same year, Dr. Ize was awarded a scholarship to attend the 1st Parenteral Nutrition Course in the United States of America, so upon his return he devoted himself to initiate the Parenteral Nutrition Service (and his night duty shift was occupied by the undersigned of this chronology). This assignment lasted for two years.
In 1975, the reorganization of the structure of the HG CMN of the IMSS, promoted by Dr. Gilberto Flores-Izquierdo, who replaced Manuel Quijano-Narezo as the head of the hospital, appointed Dr. Rafael Alvarez-Cordero as Chief of the Surgery Division, and Dr. Jorge Bautista-O'Farrill as Chief of the General Surgery Service. This way, the pairing of gastroenterology and surgery ended and, thus, another stage in the history of surgery began.
Dr. Rodolfo Rojas-Rubí covered the on-call duty and worked for a short time in the service. He was called by the General Director of IMSS to organize the VIP (very-important people) Patient Service, where he discovered his administrative and political skills, which later led him to hold various administrative positions in the Institute of Security and Social Services for State Workers (ISSSTE) and in the Ministry of Health and Assistance (SSA). In the same year, Dr. Raul Gomez-Garza arrived to continue the work of Dr. Gustavo Baz in the Health System of Ciudad Nezahualcóyotl, and Dr. Roberto Blanco-Benavides and Dr. Gustavo Ramirez-Wiella joined the Surgery Service.
Soon after, the changes continued. Dr. Vicente Guarner replaced Dr. Rafael Alvarez-Cordero in the Surgery Division for a brief period. The latter left that position when he migrated to the "La Raza" Medical Center of the IMSS to be responsible for the General Surgery Service.
The general surgery residents who were fortunate enough to be forged in that mixed gastro-surgery service attended the joint sessions, in addition to our surgery classes. Thus, we participated in the bibliographic, radiological and pathology sessions.
Dr. Manuel Quijano-Narezo, first Director of the CMN General Hospital, wrote: "this hospital was the flagship of the National Medical Center and contributed, like no other, to give academic and professional prestige to the Mexican Institute of Social Security".6 The participation of the Gastroenterology Service of the CMN HG of the IMSS in the national congresses of the Mexican Association of Gastroenterology was particularly important, with up to 40% of the free papers, and the same percentage in conferences, symposia, and round tables. For example, the VII National Congress of Gastroenterology held in 1971, where 20 free papers were presented out of 60 (33%), and in the IX National Congress of Gastroenterology in 1975, the number of free papers presented was 32%.
The Gastroenterology (and Surgery) Service was in force from 1963 to 1975, and during those years, its image grew both in the Republic and abroad, due to the protocols of gastrointestinal pathologies, as well as research. This is evidenced by the important number of physicians from Central and South America who acquired surgical skills in this service. The gastrointestinal topics in which the Gastroenterology Service was always at the forefront were: portal hypertension, management of peptic disease, treatment of pancreatitis (in 1980, 600 patients documented by Dr. Lopez-Fournier, who personally told me about it). The first studies of morbid obesity, treatment of complications of amebiasis, liver pathologies, and parenteral nutrition.
Changes in the hospital organization chart also occurred in the services. In 1975, the Gastro Surgery Service was disrupted and separated into General Surgery and Gastroenterology. Thus, the General Surgery Service was born at the General Hospital of the IMSS National Medical Center. Its first chief was Dr. Jorge Bautista- O'Farrill. The entire sixth floor of the hospital was assigned to General Surgery Service, with one section for female patients and the other for male patients. The surgeons who initiated this transition were Dr. Carlos Godínez-Oropeza, Dr. Luis Ize-Lamache, and Dr. David Olvera-Pérez, in the morning shift. In the afternoon, Dr. Marco Antonio Alarcón, former resident of the same service, born in Nicaragua and naturalized Mexican citizen later, used to work. At night, Dr. Roberto Blanco-Benavides, and Dr. Gustavo Ramirez-Wiella, the latter an excellent surgeon with surgical training in England, took over, so that the service was "injected" with other surgical criteria. The demand for surgical assistance continued to increase, so they soon began to collaborate in the morning shift. The fifty beds quickly became insufficient, reaching nearly 200, considering that patients from other services remained in their beds when they were operated on and were not transferred to the sixth floor or to the Convalescent Hospital. This service remained active until 1981, when the IMSS authorities, in accordance with the Almá-Atá Declaration of 1978,7 decided to reorganize the health care services. There were only six years of activity and productivity of the General Surgery Service of the HG of the CMN of the IMSS.
Under the direction of Dr. Jorge Bautista-O'Farrill, we continued with the same academic activities, and with bibliographic, radiological, and pathological sessions, and increased the number of surgeries by implementing elective surgery in the afternoon shift. Surgical production remained at around 7,000 surgeries per year, by adding all shifts and services: morning, afternoon, and emergency service.
Following the provisions of the Almá-Atá Declaration, health services were divided into three levels of care: the first level of care, which is the closest to the population, where health care needs could be solved with health promotion activities, disease prevention, and others. At this gateway to health care, there are low complexity facilities, such as general clinics, health centers, polyclinics, and others, where approximately 85% of the most prevalent problems are solved. The second level of care included hospitals and establishments providing care in the disciplines of internal medicine, general surgery, gynecology-obstetrics, pediatrics, and psychiatry. It is considered that, between the first and second levels, up to 95% of the population's health problems can be solved. At the third level, which deals with the less prevalent problems, complex pathologies that require special procedures and high technology, 5% of the medical/surgical problems are solved. This perfectly explains the design applied at that time. The head of the academic course of general surgery remained in the HG of the CMN of the IMSS, but the assistance service underwent an irreversible change. In the new Hospital de Especialidades del Centro Médico Siglo XXI there were 20 to 25 surgical beds for "third level" surgery with about 25 general surgery residents and attending physicians (I do not know the correct number). The result has been a great disappointment in the doctor-patient-academic and care-production relationship.
The General Surgery Service was transferred to second level hospitals, leaving only a special third level surgical service, a transcendental change that forced the surgeons to accept this new disposition, or else to resign. Surgeons Bautista, Godínez and Olvera chose the second option. These changes opened the doors for the arrival of surgeons trained in that hospital, and with a remarkable surgical trajectory. Dr. Andrés Proal was appointed as Chief of the third level Gastro-surgical Service together with two collaborators: Dr. José Luis Ibarrola and Dr. Luis Sigler. But, from this date on, that is another story... that ends in 1985 with the macro earthquake that hit Mexico City.
Other physicians from the Gastroenterology Service that I will always remember with great affection for their friendship and the knowledge they passed on to me are Luis F. Cervantes (†), Miguel Stoopen, Alfonso Perches, Miguel Tanimoto (†), Enrique Segovia, José Antonio Vásquez-Saavedra, Norberto Treviño-García Manzo, and Antonio de León.
Finally, I wish I could name all the general surgery residents who passed through the HG of the IMSS CMN, but the list is large, and I would probably incur in faults that could hurt susceptibilities. Many of them are famous on their own merits, some within the IMSS, and others in other institutions. For example, it is enough to point out that 30% of the presidents of the Mexican Association of General Surgery were residents of the service that concerns us today.
In the following chapters, we will present every one of the physicians and surgeons whose professional work, from 1963 to 1981, played an important role in the history we are relating. They will be presented in chronological order, because by understanding the facts, we will be able to better understand the historical evolution of the surgical service that it became.
REFERENCES
AFFILIATIONS
1 Associate Member of the Mexican Association of General Surgery.
Ethical considerations and responsibility: Data privacy. In accordance with the protocols established at the author\'s work site, the author declares that he has followed the protocols on patient data privacy and preserved patient anonymity. The informed consent of the patient referred to in the article is in the possession of the author.
Funding: No financial support was received for this work.
Disclosure: The author declares that he does not have any conflict of interest in carrying out this work.
CORRESPONDENCE
Dr. David Olvera Pérez. E-mail: docolvera2@gmail.comReceived: 02/27/2019. Accepted: 08/07/2019