The emergence of general thoracic surgery in North America as a surgical subspecialty distinct from general surgery, congenital heart surgery, and adult cardiac surgery occurred through dramatic and tumultuous changes that once threatened but ultimately strengthened the integrity of the discipline. The discipline evolved from general surgery in the early 1900s in response to chest morbidities prevalent at that time, primarily tuberculosis and World War I-related trauma. Hence, the systems established to guide thoracic surgery were shaped by general surgeons. War continued to play a role in shaping surgery. In the 1940s, surgeons caring for soldiers in World War II struggled to manage the life-threatening chest injuries caused by modern weaponry. This spurred technological innovation during and after the war. By the 1950s, new knowledge and technology began to lift the physical and psychological barriers to surgery within the chest, including the heart. The technical achievement of extracorporeal circulation by John Gibbon, first used in humans successfully in 1953, allowed the extension of cardiac and congenital heart surgery into more complex problems, leading to new fields of specialization in myocardial revascularization, valve surgery, and heart transplantation in the late 1960s. These changes occurred as antibiotic use reduced the incidence of tuberculosis and the need for pulmonary surgery. Soon, combined cardiothoracic surgery programs began to form at leading academic centers.

The union between thoracic and cardiac surgery, however, was not altogether ideal, and thoracic training often played second fiddle to cardiac training. In 1981, Dr. Donald Paulson, President of the American Association for Thoracic Surgery, focused on the inadequacy of training in general thoracic surgery. In his presidential address, he stated: “Failure to correct the imbalance in training of thoracic surgery has resulted in a vacuum, which could lead to disintegration of the specialty.”¹ By the 1990s, the realm of general thoracic surgery was so eclipsed by the dramatic developments in cardiovascular disease that funding in combined cardiothoracic programs began to be diverted in favor of cardiac training.

This pattern was played out largely in the United States, United Kingdom, and Europe, and threatened the ability of such programs to attract top-notch general thoracic surgeons. In an editorial published in 1991 in the Annals of Thoracic Surgery, the President of the American Association for Thoracic Surgery, Dr. John Waldhausen, addressed the broad concern that American thoracic surgery programs were failing to attract the “brightest candidates.” Later that year an educational workshop was convened in Snow Bird, Utah, to define the deficiencies in American thoracic surgery.

Meanwhile, although similarly influenced by the pace of development in cardiac and congenital heart surgery, events transpired somewhat differently in Canada, where dedicated resources were committed to a separate general thoracic service and training program. Dr. F. Griffith Pearson, the first Chief of the first Division of General Thoracic Surgery at Toronto General Hospital, is widely known for his role in establishing thoracic surgery as a bona fide surgical subspecialty in North America. You can read his personal account of the Toronto experience in the Foreword to this book.

Dr. Pearson had tremendous impact in the field of general thoracic surgery² and is widely regarded as the father of thoracic surgery in North America. Throughout his tenure as Chief of the thoracic division at Toronto General Hospital (1967–1984) and subsequently as a staff surgeon until he retired in 1999, he oversaw important developments in lung transplantation, thoracic oncology, and clinical and basic research, mentoring many surgical leaders around the globe. American surgeons with an interest in general thoracic surgery were attracted to the Canadian programs. After training, the many successful graduates of these programs brought their experiences and commitment back to the United States, where lack of specific funding for thoracic surgery training had led to a shortage of qualified surgeons as described above.