"STOP AT THE PLEURA !" : THE PROBLEM OF THE OPEN CHEST AND THE EARLY HISTORY OF THORACIC SURGERY

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Frederic W. Grannis Jr. MD

On an unknown date in the summer of 1883 the first planned pulmonary resection was carried out by a brilliant young surgeon, H.M. Block, in what was then called Danzig, East Prussia, now Gdansk, Poland. Block had earlier carried out experimental studies in animals that proved that pulmonary resection and repair of cardiac wounds were possible. In 1882 he had presented his laboratory experience with pulmonary resection at the Congress of the German Society for Surgery in Berlin. He was impatient to apply the skills developed in the research laboratory to patients. For his first operation he chose a young female relative with a diagnosis of bilateral pulmonary tuberculosis. He performed a thoracotomy in order to resect the diseased lung. Although the details of the operation are not known, we can reconstruct what must probably have happened. The patient's respiration would have become rapid and labored soon after the chest was opened. The mediastinum would have shifted toward the opposite hemithorax and the girl's heart rate become rapid, the pulse faint. Cyanosis and shock would quickly have brought the operation to its tragic end. It is reported that no evidence of tuberculosis was found in the resected specimen. A public investigation was made into the circumstances of the surgery. A few days later, the short, brilliant career of H.M.Block ended with a self-inflicted gunshot wound to the head. A contemporary, Mosler, is quoted from a lecture in 1883,

"The first attempt of this kind had such an exceedingly tragic ending that every sensible surgeon should be warned to resist the temptation to make any further trial of the method."

There had almost certainly been other failures in surgical cases like this one that had gone unreported (few surgeons are anxious to broadcast their disasters). We can be sure of this, for we know that it was clearly understood by surgeons writing at the time, that to open the chest was to kill the patient. Dieffenbach's admonition to "stop at the pleura" was obeyed by all prudent surgeons. Over fifty years passed from the time of Block's ambitious but foolhardy attempt, until safe, routine, open chest surgery became a reality. The story of the solution of the problem of the open chest is an instructive and entertaining one, with elements of high tragedy and rollicking comedy. Heroes and scoundrels, wizards and buffoons strut the stage. The tale is valuable not only with regard to the subject matter but also in its illustration of the tortuous path that mankind takes in its progress.

The development of anesthesia in the 1840s and the discovery of the principles of antisepsis by Lister twenty years later led to a revolution in surgery. Surgeons, for the first time, had the luxury of adequate time and relatively placid conditions in which to work, and the patients were not killed off by infection in the post-operative period as often as before. Surgical clinics sprang up throughout Europe, and surgeons aggressively, and by and large successfully, began to attack some of the problems that had tormented mankind through the ages. By the turn of the century most of the specialties of surgery were already in a vigorous adolescence, while thoracic surgery remained a sickly stepchild, limited to resection of lesions of the chest wall and drainage of fluid collections and infections of the lung and pleura.

The basis for any review of the historical development of a particular technology must rest on the state of technology at the present moment in time, i.e., "modern" technique. This modern standard is a wobbly platform. A hundred years from now, one reading this manuscript would almost certainly be amused by what I will now call "modern."

• 1. Preoperative delineation of anatomy, physiology and pathology.
• 2. Endotracheal intubation and positive pressure ventilation, anesthesia.
• 3. Anatomical dissection and individual ligation of pulmonary vessels.
• 4. Secure bronchial closure.
• 5. Closed pleural suction drainage.
• 6. Postoperative monitoring, respiratory therapy and ventilatory support.
• 7. Antibiotic therapy.

At the time of Block's attempt at pulmonary resection none of these pieces of the puzzle were available to him. Before the chest could be safely opened and the lung operated upon, progress was clearly required in each of these areas. To elucidate the structure and function of the lungs, accurate diagnostic techniques were needed. A means of providing ventilation for the patient during surgery was required. Surgical techniques needed to be refined. Improved methods of respiratory care in the post-operative period were mandatory. If infectious disease was to be treated, effective antibiotics were needed.

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1. DIAGNOSIS:

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For surgical treatment to be a success, the surgeon must have a reasonably good idea of what the disease process is and where it is located. In 1895 Konrad Roentgen made his monumental discovery, and for the first time physicians and surgeons had a clear view of the lung and it's diseases in living patients. The spread of this roentgenographic or x-ray technique was very rapid. J.B. Murphy showed slides of chest roentgenograms during his lecture on chest surgery to the American Medical Association, in Chicago, in 1898.

Etiologic diagnosis lagged behind, since microbiology was still in its early development, and cytology was not widely available until the 1930s. Rigid bronchoscopy was introduced in 1898 by Killian and improved and popularized by Chevalier Jackson in Philadelphia in the early 1900s. By 1928 Vinson, at the Mayo Clinic, had a large experience with diagnosis of bronchogenic carcinoma by bronchoscopy. Transthoracic needle biopsy of the lung was performed as early as 1927 at Memorial Hospital in New York, by Craver.

PHYSIOLOGY:

The clinical surgeon must have a solid grounding in physiology in the process of devising new surgical techniques. It would have been impossible for him to do so in earlier times, when one reflects upon the fact that some of the best scientific minds of the 18th century were in agreement that the lung was a refrigeration unit to dissipate the heat generated by the vigorous action of the heart! Clearly, a plan of treatment based on so grossly inaccurate a physiological basis would be doomed to failure. Even the genius William Harvey regarded the lungs as auxiliary pumps designed to help fill the heart.

The anatomic description of the alveoli and pulmonary micro-circulation required the microscope, and hence was not demonstrated until the elegant studies of Marcello Malpighi in the late 1680s. Members of the English "Invisible College" solved the enigma of lung function with the discovery of the respiratory gases. Boyle and Hooke demonstrated that air was necessary for both life and combustion. Richard Lower showed that air was needed to turn dark venous blood into bright arterial blood. John Mayow discovered a "nitro-aerial spirit" that maintained life but disappeared following combustion. Oxygen was not discovered (and named) until 1775, by Antoine Laurent Lavoisier. Lavoisier is another of our cast of characters who met a tragic end, in his case, on the guillotine, in Paris on May 8, 1794. Abbe Spallanzini was the first to show that animal tissues took up oxygen and produced carbon dioxide. The importance of carbon dioxide, the hydrogen ion and their interrelation were not well understood until the research studies of J.H. Haldane and a comprehensive model of the respiratory gases was not put together until 1946! This ignorance of what is now basic knowledge had tremendous negative implications for the surgeons and anesthesiologists of the time. Furthermore, clinicians, then as now, were slow to recognize the importance of the new information coming out of research labs, and failed to apply the new knowledge in the care of their patients, as we shall see.

ANATOMY:

The functional anatomy of the lung was a great puzzle. The course of blood in the pulmonary circulation was first described by Michael Servetus. Servetus also came to a sorry end when he disputed theology with his former friend John Calvin and was burned at the stake in Geneva in 1553. The first comprehensive description of the anatomy of the lung was by Ewart in 1889. His book however must have had a limited circulation, for it is seldom cited in the bibliographies of the early pulmonary surgeons. The lack of a detailed knowledge of the segmental anatomy of the lung is evident in the illustrations in Straub's textbook Surgery of the Chest as late as 1932. This was partly responsible for the crude techniques used in early operations. As detailed studies of lung anatomy became available, more elegant, "anatomic" resections were carried out by Reinhoff, Churchill and Blades. The first extensive studies of the surgical anatomy of the lungs were carried out by Kent and Blades in 1940, but even they did not think that the anatomy of the upper lobes would allow for lobectomy. Comprehensive anatomic studies resulted in the classic monographs of Brock and Boyden.

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2.ANAESTHESIA:

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Most surgical cases in the early 20th century were performed by the open drop method. The only equipment needed was the "rag and bottle". The anaesthetic agent, commonly ether or chloroform, was dripped in liquid form onto a face mask. The patients own respiratory center monitored blood gas levels, and his chest musculature provided the ventilation. This system worked tolerably well for most general surgical cases but was inadequate for thoracic surgery. It was early recognized that once a hole was created in the chest wall, air would be sucked in through the incision because of the negative pressure in the pleural cavity. Negative intrathoracic pressure would be lost, the lung would then collapse, the mediastinum would shift toward the unopened side and the patient would quickly die. Murphy described his experiments and clinical experiences with open pneumothorax during his address to the American Medical Association in 1898. Graham's investigations on the cause of death of American soldiers who had open drainage of empyema following influenza and pneumonia, in France during World War I, revealed that once a hole in the chest wall larger than the laryngeal apperture was created, ventilation would effectively cease.

Using the open drop method, therefore, the surgeon had only a very short time to complete his operation and reclose the chest if the patient was to survive. One method used was to quickly pull the diseased lung through a small thoracotomy incision. The lung tissue would plug the opening and seal the pleural cavity allowing continued effective ventilation. This technique would obviously only be effective for relatively small lesions in the periphery of the lung, removable by wedge resection. Today's surgeon is rarely pressured by the clock, but time constraint was one of the most important factor in the techniques chosen by the early surgeons.

In 1904, at the German Surgical Congress, in Berlin, two new anaesthetic techniques, designed to surmount the open chest problem, were proposed. First, Ferdinand Sauerbruck, from the surgical clinic of the famous von Mickulykz at the University of Breslau, introduced his method of "unterdruck" (low pressure) ventilation. The lungs were maintained expanded after thoracotomy by keeping the experimental animal's entire body inside a negative pressure chamber (at minus 15cm of H2O), while the head remained outside of the chamber with the anaesthesiologist. Next, Breuer described the benefits of "uberdruck" (high pressure) anaesthesia, where the lung was kept expanded by placing the patients head in a glass, positive pressure chamber. The battle over which of these two methods was preferable was carried on over the next 30 years with sometimes rediculous results. In 1897 French surgeons had operated in a diving bell. In 1909 American surgeons suggested operating in an airplane. Surprisingly, the "unterdruck" method took the early lead . Sauerbuch and von Miculicz built a negative pressure operating room large enough to accomodate an entire surgical team, in which successful thoracic operations were carried out. Sauerbruch built one of these rooms as late as 1918 in Munich. Chamber in Breslau It is difficult for us to understand today why "unterdruch" should have prevailed, but it can probably be explained as largely due to the forceful personality of Sauerbruck, who went on to become the acknowledged leader of thoracic surgery in Europe and Surgeon-General of the German army during World War II. He eventually had to accept the superiority of the positive pressure technique, but as late as 1937, he still felt that endotracheal intubation was unnecessary and dangerous. Sauerbruch so dominated and cowed his associates and contemporaries that little further progress in anaesthetic techniques issued from Germany. Major progress, had however already begun and would continue in France, England and the United States.

Reliable delivery of positive pressure to the lungs was only possible by intubation of the trachea, and most surgeons were unwilling to perform a tracheotomy just to deliver an anaesthetic. Endotracheal intubation through the mouth and bellows inflation of the lung had been tried sporadically by many physicians, starting with Vesalius, but the first systematic use was by the Frenchman Depaul, who intubated and resuscitated neonates in the mid-1800s. DePaul tube Joseph O'Dwyer of New York developed a practical method of endotracheal intubation for the treatment of diphtheria which was applied in thousands of cases and resulted in a gratifying decrease in the mortality of that fearful disease. Fell, of Buffalo, New York, used a crude device to maintain ventilation in patients suffering from drug overdose

The French surgeons Tuffier, Quenu and Doyen, and Milton in Egypt, all used positive pressure during thoracotomies in the last few years of the 19th century. In the U.S., the combined Fell-O'Dwyer apparatus was used by Parham and Matas in New Orleans in 1898 to perform positive pressure surgical anaesthesia. Meltzer and Auer, of the Rockerfeller Institute in New York , described the method of endotracheal insufflation in 1909 and provided more experimental and clinical information. This method was practical and capable of supporting life without respiratory muscle contraction.

Safe, reliable placement of a tube in the trachea requires direct vision of the larynx. Kirstein introduced direct laryngoscopy in 1895 , and in 1907 Jackson improved the laryngoscope and produced the instrument that is still in use today . The Jackson laryngoscope was used by Elsberg in clinical thoracic surgery in New York City following 1910.

Eisenmenger first described a cuffed endotracheal tube in 1893, and Tuffier did experiments to determine safe levels of positive pressure ventilation. A practical design for general use was first introduced by Guedel in 1928.

Such tubes were not in common use until the early 1930s. Archibald was the first to utilize an endobronchial blocker balloon to avoid aspiration of purulent secretions from the infected lung. Guedel in 1934 was also the first to routinely use intermittent positive pressure breathing (IPPB) to control ventilation intraoperatively in intubated patients. In 1938 the first operative use of ventilators was made with the Freckner "Spiropulsator" in Sweden. Griffith introduced curare to facilitate intra-operative controlled ventilation in 1942.

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