Norbert Gschwend is known internationally for his work in the surgical treatment of rheumatoid arthritis. He practises at a private clinic in Zurich and has built its reputation. His warm and attentive welcome was matched by the atmosphere prevailing in his department.

 

GschwendM.O. Mr. Gschwend, if it’s all the same to you, let’s begin at the beginning...

N.G. My name is Norbert Gschwend and I was born in 1925, so I shall be 70 next year. I was born in Rapperswil, a very pretty little town on Lake Zurich. My father was a general practitioner. All my studies were at Zurich University, apart from 6 months in Rome. I always wanted to be a general surgeon. It never occurred to me in my student days that I might become an orthopaedic surgeon, since I thought of this as a non-surgical specialty, involving mainly the application of casts and the prescription of supports and appliances. So I studied general surgery, and my thesis was in obstetrics.

M.O. How did you become involved in orthopaedics?

N.G. By chance. I wanted to continue my surgical training at St. Gall Hospital, but had to wait a year for a place in surgery. So I asked my boss what I should do while I was waiting.

He told me, “If you want to go into general surgery, there are two possibilities. Either you can do radiology, which will help you a great deal in interpreting films of the stomach and colon, or you can do orthopaedics, so that at least you will know what sort of shoe supports to prescribe after leg fractures.” So I went to the Balgrist as an unpaid volunteer. The consultant there was Mr. Francillon, who had a vast theoretical knowledge of the subject and a fairly conservative attitude to treatment methods. But his senior registrar was Maurice Müller, an enormously dynamic character.

M.O. Was this the decisive encounter?

N.G. Absolutely. He was the one who convinced me that orthopaedics was really the up and coming field in surgery. After one semester I had a sound insight into orthopaedic surgery and, since I was not being paid, this was the ideal opportunity to travel. I asked Maurice Müller’s advice and he suggested four alternatives: go to Germany, to Max Lange near Munich; Italy, to the Rizzoli Hospital in Bologna; France, to Merle d’Aubigné at the Cochin; or England and the Royal National Orthopaedic Hospital. I thought: “Not Germany, because I speak German; not Italy, because Italian is my mother tongue; not Paris, because I did French at school. But I don’t speak English, because I took Greek and Latin instead, so I’ll go to England." The semester that I spent in England was where I discovered team work. There they already had a system of subspecialties, each of which was directed by outstanding individuals. And everybody got along fine with everybody else. I was convinced from the outset that this was only way in which the complex pattern of disease could effectively be confronted.

M.O. What next?

N.G. I finished my general surgery and took up an appointment at Balgrist Hospital in 1956, as registrar in orthopaedic surgery. Eighteen months later Maurice Müller left the hospital and advised the boss to take me on as the new senior registrar. After only a year and a half as registrar I didn’t really feel ready for this. But I had no choice, because if I didn’t jump in at the deep end I would have had someone as my boss who, unlike Maurice Müller, would not have had much to show me. So I accepted the post. I was the only senior registrar, and deputised for the consultant when necessary. But the existing team was very dynamic. The first two registrars were Weber and Morscher; Scheier, who is my colleague, was also there as well as Pierre Scholder of Lausanne. I think this experience was very good for me because I had no choice but to face problems and cope with them in a specialty which was developing very rapidly. After 4 years in this post at the Balgrist, I decided to apply to the Schulthess Hospital.

M.O. Why did you leave the Balgrist?

N.G. This was a natural career move. The only way I could have stayed would have been to take over from my boss, but he was nowhere near retirement age. Also, at that time there were only three orthopaedic hospitals in Switzerland; there was the Lausanne Orthopaedic Hospital, where Louis Nicod was consultant; the Balgrist, which was the largest with 160 beds; and a small orthopaedic unit of less than 30 beds in Berne at the Inselspital, with Professor Dubois. I heard that at the Schulthess Hospital they were looking for a successor to the present surgeon, who himself was the son-in-law of the old Professor Schulthess.

M.O. Who was Professor Schulthess?

N.G. He founded the hospital back in 1896. In 1912 he also founded the Balgrist Hospital, where he was Professor of Orthopaedics, but he treated his patients privately at the Schulthess Clinic. He had an international reputation in the field of scoliosis. In the old days, several wards in the hospital were full of all the equipment he had invented. When I arrived, my predecessor, Doctor Hallauer, had no registrar. 90% of the patients were children suffering mainly from spastic paralysis and the sequelae of poliomyelitis. The average stay for these patients was around 150 days. Some with scoliosis stayed for 4 years. There was also a department of vocational rehabilitation for girls, run by the highly dynamic Frau Hallauer, Professor Schulthess’s daughter. In the year before I arrived, my predecessor had performed about 20 minor operations such as Achilles tendon lengthening or correction of hallux valgus, and he thought he was doing too much surgery!

M.O. Did you have a plan when you started?

N.G. I had been very impressed by the teamwork I saw in England, and from the beginning, that was what I wanted to achieve.

But the first few years were very hard. I had only one Sudanese assistant, who was enormously keen to assist with surgery, but wrote not a word. I had to keep all the medical records myself. What is more, for the first seven years I was only able to operate two days a week because I had to do all the clinics and daily rounds for the entire hospital. Finally, we had only one operating theatre, dating from the previous century. I started my lists at 7 in the morning, and never finished before 8 in the evening and sometimes midnight.

M.O. How were the facilities transformed?

N.G. I started in very decrepit premises, with a skeleton staff. There was only one fully qualified nurse in the place and I was assisted in theatre by a nurse who was also ran the radiology department and the laboratory. Without the enthusiasm and help of my wife and of the anaesthetist, Mrs. Langemann, I could never have done it. There was no money, but, worse still, there were plenty of debts. The annual subsidies from the city of Zurich and from the Canton were ridiculously low, and the patients paid 70 Swiss francs per day, which did not cover the operating expenses. In theory, the private patients’ fees were supposed to balance out the costs for the other patients. But in the beginning, most were not private, and this increased the deficit dreadfully. At the end of 6 months it looked as if the hospital would have to close because the debts were too heavy.

M.O. How did you get round this?

N.G. I was lucky enough to operate on a very rich and extremely generous patient. I had performed an osteotomy of the hip, which was fortunately successful. She asked me one evening, “Why do you do your rounds at 8.30 every night when you have five children?” I replied, “What else can I do? I have an assistant who doesn’t keep any records; I have only one operating theatre, so that a great deal of time is wasted between operations; I myself have to act as assistant porter, because we can’t get the patients out of the wards; I have no consulting room; and I have invested all my money in equipment which is the minimum necessary to perform the operations.” She then told me that she was going to make a donation. I thought it would be 10,000 francs at the most, but not at all, she wanted to give me 200,000 francs. The next day she went on, “You mentioned that you had debts, do you know how much these add up to?” I didn’t know exactly, but I found out without delay, and the total was half a million Swiss francs. Two days later she had covered these debts. Later she made us a donation of one million francs.

Thanks to this providential gift, it was possible to plan the building of a new theatre and the modernisation of the hospital. My generous benefactor also financed the laminar air flow unit and the video system in the operating theatres.

M.O. Sounds like a fairy story!

N.G. Well, it does rather. But you also have to know how to help providence. When the Dean of the Faculty of Medicine, who was the head of the rheumatology department, had a problem with his knee, he insisted that I should operate, but he did not want this to be known generally, so as not to upset his hospital colleagues. So he said to me: “I have a house in Ticino, would you come and do the operation in Ticino?” I replied, “No, that’s impossible, because if there were any complications I would be in Zurich and you would be in Ticino. I’ll do the operation on Saturday and nobody will know that you had it done here; then I’ll take you back to your house myself on Sunday evening.” He agreed, and on the morning of the operation I told the nurse to put the Professor at 6 o’clock in the morning in the corridor outside the theatre, because there was no sterile transfer zone. I arrived at 6.30 and mentioned in passing to the Dean that patients had to enter the operating theatre directly from the corridor, and what a pity it was that we did not even have a prep. room. The operation went very well, but he realised that something had to be done for this hospital. And as he was the best friend of the Minister of Health ... I admit it was a bit naughty, but it worked.

M.O. How did you manage to balance the hospital budget after that?

N.G. Firstly, the number of private patients increased gradually and also I asked all members joining our team at various times to repay a certain percentage of their fees to the hospital. Finally, once we were recognised as an essential institution, state subsidies improved considerably. But I didn’t want to put myself in a position of superiority compared to my colleagues, with better treatment than they had; we are all on the same salary here. I have had many disapproving comments from consultants at other hospitals, but I explain to them that if you really want to form a team with individuals who actually take responsibility in each particular area, you have to show an example and give up the privileges of a consultant. When Scheier, my successor at the Balgrist, who had done a lot of work in scoliosis, wanted to start practising privately I suggested that he came here with the same rights as myself. Then in 1971 I asked Baumgartner to come and take charge of rheumatology and rehabilitation. Later, the new generation joined us, with Munzinger and Drobny for lower extremity surgery, Grob and Dvorak for the spine, Simmens for the upper extremity, and Kaufmann in paediatric orthopaedics.

M.O. Did you carry on teaching during this period?

N.G. Yes, I always kept up my lecturing and publishing. In this country, even if you are in private practice, you can stay within the university system as a Privatdozent . Then after 6 years of postgraduate teaching and publications, you can become a professor. This is the path that I took; I became consultant in rheumatology to the University Hospital. It was there that I saw many cases of rheumatoid arthritis and acquired some experience of this disease. At the end of 6 years, I became an assistant professor. This does not mean that I have a Chair, but I am part of the university teaching staff.

M.O. Did you receive a salary as a Privatdozent?

N.G. A token payment. They are two a penny at the faculty.

M.O. You have published a great deal on arthroplasty in RA. Which joint did you start with?

N.G. The first prosthesis was the GSB elbow; then the GSB knee. GSB stands for Gschwend, Scheier and Bähler. Bähler is a remarkable orthopaedic technician. Then there were GSB prostheses for the wrist and fingers. For the fingers, the implants were too constrained, and loosening was a problem. The main thrust was in elbow and knee replacement.

M.O. How did you design your implants in practice?

N.G. When we first started, total prostheses were mainly hinged, and their implantation involved considerable bone loss. My initial idea was to design a prosthesis which would have the advantages of minimal resection as with resurfacing prostheses, while retaining the stability of the hinged ones. This could be achieved with a migrating axis. The GSB 1 had a migrating axis with almost physiological kinematics in the sagittal plane up to 80°; the kinematics then became completely physiological with the GSB 2 and 3, since these models had only a virtual axis. The engineer drew sketches or built prototypes, and together we progressively improved the models.

M.O. Your elbow prostheses seem to provide remarkable results.

N.G. They really do, and I must say in all modesty that I currently know of no other elbow replacement which has been as successful, even in post-traumatic indications. We have reviewed more than 200 cases to date, and their long-term prognosis is fully comparable with that of a total hip or total knee prosthesis. I would like to emphasise here the importance of strict evaluation of outcome. For some years we have had a former consultant rheumatologist who also trained as an orthopaedic surgeon and who devotes her entire time to the evaluation of the results of our arthroplasties. In Switzerland, it is much easier to follow up patients than anywhere else. In Germany, you have to go through the family doctor. In Italy, this seems to be very difficult. In the States, in view of the distances, follow-up is often by telephone. Here, there is no problem in recalling patients, but the funds must be available. This is why we decided, with Scheier and Bähler, to pay the royalties for our inventions into a fund which is used for evaluation and continuing education. Thanks to these funds I have been able to give all our young colleagues strong encouragement to teach, to become active members of the new societies in their particular fields of expertise, and to publish their results.

M.O. Does your private facility play a part in university education?

N.G. In Switzerland, teaching is not the preserve of the public hospitals, the way it is in countries like France. At our centre, we have registrars and senior registrars completing their orthopaedic training, and we provide the same level of training as the other university teaching hospitals. For a long time now, we have been regarded very much as a "public" hospital, to the point where, as soon as we decided to build a new centre, to modernise our facilities, the Canton and the Minister of Health made available to us, free of charge, a 20,000 m2 building plot.

M.O. At the end of a career devoted to the surgical treatment of rheumatoid arthritis, have you identified any major therapeutic principles?

N.G. I feel that the most important thing is to have a holistic approach to the patient. Really, the secret in this type of surgery is to draw up a treatment plan with priorities. It is not enough to understand the disease; the most important thing is to know the individual patients and identify their precise needs. With the help of an occupational therapist, patients must state what they want the surgeon to do to improve their everyday quality of life. Our surgical approach is very similar to that of Willy Souter in Edinburgh. If you take 5 criteria - pain, function, appearance, complications and lasting results, and award 4 points for each, the optimum score is 20 points. Based on this score, there are three categories of operation. The first includes operations which have a high probability of success, for which the score would be at least 15 points. This applies, for example, to correction of the forefoot, total knee replacement, total hip replacement, fusion of the metacarpophalangeal joint of the thumb and, here, total elbow replacement. In order to win the patient‘s confidence, we start with an operation from this first category.

M.O. What are the other categories?

N.G. Ankle replacement, for example, is an operation which would come into the third category. Fusion of the wrist is in the second category, as is synovectomy. For synovectomy, a very interesting multicentre study was published in Moscow in 1983, concluding that pain and function after 10 years were improved, while radiological findings remained the same as for a conservatively treated joint.

M.O. Who takes the decisions regarding surgical priority?

N.G. These are group decisions, taken by the surgeon, the rheumatologist and the occupational therapist. In occupational therapy, we have scales for assessing the disability status. This allows us to see what problems each patient had in brushing their hair or walking, 5 years ago. Then, when the situation has clearly worsened, the decision can be taken to operate. But the problem with rheumatoid arthritis is not only what a patient is like, but what he or she looks like. The disease does not affect the patient's personality, but this is something which only friends and family will know. The disease changes the patient’s outward appearance and figure - in other words, it interferes with the image presented by the patient to his or her fellow human beings. It is this loss of physical grace which is difficult to accept for the patient who limps and has grossly deformed hands. This loss is particularly striking in beautiful women who, within a few years, may be destroyed to the point where they can no longer look after themselves. I am amazed by the number of RA patients who can still laugh and joke in spite of their severe disability. You see these roses - they were given to me by a lady with RA on whom I operated recently; what an amazing attitude to life! These patients are grateful if you can help them to sleep, to move from one room to the other without too much pain, or if you can make them able to do their hair or wash themselves.

M.O. Do you think that surgery should be carried out earlier?

N.G. Absolutely. I feel that these days it is perfectly possible to diagnose lesions at an early stage, and that no time should be lost. This is particularly the case for the shoulder. According to our statistics, the signs of shoulder involvement appear on average only 7 years after the start of the disease. Often the involvement of other joints masks the disease in the shoulder, the evaluation of which is distorted by scapulo-thoracic compensation. Now, with MRI and arthroscopy, lesions can be detected at an early stage, and we feel that they should be treated early, if necessary at the same time as surgery to the hand, foot or knee. Rotator cuff tears are not improved by waiting, and advanced destruction of the glenoid cavity presents enormous problems in reconstruction.

M.O. You have succeeded in gathering together a team of orthopaedic surgeons who are highly specialised in their fields, but isn’t fragmentation of knowledge a worry, bearing in mind that the overall view of the patient is so important?

N.G. There is certainly a risk, but this can be minimised if close contacts are maintained between the heads of department. We see each other almost every day. We lecture to each other on our fields of expertise, to ensure that we are all kept up to date with developments in each subspecialty. Also, we discuss treatment indications together, and there is no need to make appointments to ensure that a particular specialist is present. This is the advantage, compared with a large organisation, of working in a hospital with only 120 beds. Apart from these daily discussions, all heads of departments meet every Thursday to report on their activities.

M.O. The system works when there is a co-ordinator who is respected by everyone, but will it still be the same when you are no longer here?

N.G. We have already thought of this, and have opted for a Chairman of Orthopaedic Surgeons and a Chairman of Rheumatologists, who are appointed for three years. If a Chairman proves to be a capable administrator and a skilful diplomat in his or her dealings with the authorities, it should be possible to extend their term of office.

M.O. A final question. You have achieved many of your initial objectives, but do you have any regrets?

Not professionally, I think, because I have achieved much more than I expected. My only regret is a family one. My wife and 6 children feel that we have not spent sufficient time together.

This is perhaps why none of my 6 children has become a doctor. But there is also a societal phenomenon here. My father, who was a general practitioner, worked extremely hard, up to the age of 97, and devoted very little time to us; however, we did not feel neglected, and all three of us became doctors. In any case, I do not see how you can be a surgeon 8 hours a day when patients are ill 24 hours a day. Certainly, responsibilities can be shared, but when 3 people share one responsibility, no-one is really responsible.