The next step in the development of pulmonary resection was anatomical dissection and individual vascular ligation. H.M. Davies of London performed a hilar dissection and ligation of individual pulmonary arteries and veins and sutured the bronchial stump closed, in 1912, in a patient with lung cancer. The brilliant Davies was severely injured in 1917 and lost the use of his right hand. He had to re-learn to operate left-handed and thus, did no further operations of this type. All pulmonary resections for twenty years following 1912 were done by the various techniques of mass ligature of the lobar hilum described above.
Churchill at Massachusetts General Hospital was disatisfied with his experiences with tourniquet lobectomy.
"Suturing this conglomerate mass of lymph nodes, large blood vessels and contaminated bronchi with chromic catgut has always been a revolting task to the surgeon whose horizon extends to the period of tissue repair. The surprising thing is not that the method is eminently successful but that it works at all."
Using endotracheal anaesthesia, Churchill began to perform lobectomy with hilar dissection, careful individual vascular ligations, and bronchial closure for lung cancer as early as 1931 at the Massachusetts General Hospital. Reinhoff, at John's Hopkins University independently developed the same principals and showed that it was unnecessary to do thoracoplasty on the post-pneumonectomy space . He reviewed the history of attempts to close the bronchial stump, described his extensive laboratory experiences with bronchial closure as well as his clinical experience. Churchill and Overholt in Boston demonstrated the techniques of surgical removal of individual segments of the lung- "segmentectomy".
It would appear that the simplest piece of the solution to the problem of the open chest, the necessity for post-operative closed pleural drainage to remove the gases and fluids that accumulate in the post-operative chest cavity, was actually one of the last parts of the puzzle to be solved. Sauerbruch lost patients to post-operative tension pneumothorax after lobectomy as late as the 1920s because of failure to drain the chest cavity.
The chest tube had been described by Thomas Davis in 1835; Pothen had added a siphon apparatus in 1869; and Playfair had described the underwater-seal in 1872. Bulau, an internist, used a practical system of chest tube underwater-seal drainage of the chest in the treatment of patients with empyemas. Brunn and Shenstone were the first thoracic surgeons to routinely utilize post-operative pleural drainage following pulmonary resection.
Molnar et al have recently published a historical review with the thesis that "Thoracic surgery was born in the field hospitals of World War I". They present convincing evidence that the experience of military surgeons played an important role in the development of safe pulmonary surgery. (Molnar TR, Hasse J, Jeyasingham K, Rendeki S. Changing dogmas: History of development in treatment modalities of traumatic pneumothorax, hemothorax and posttraumatic empyema thoracis. Chest 2004;77:372-8.)
One of the major problems facing the early surgeons was the tremendous volume of purulent secretions . Only after the use of the endotracheal tube was the flexible suction cannula introduced into respiratory care. Freckner, working in Sweden with Crafoord, first used a mechanical ventilator -the spiropulsator- in surgery. Mechanical ventilation of patients outside of the operating suite by Engstrom came about in response to the need imposed by a poliomyelitis epidemic in Denmark in the 1950s. By 1955 post-operative ventilators were used by Bjork and Engstrom. Arterial blood gas determinations were not widely used by clinicians in most hospitals in the U.S. until the 1960s.
Treatment of bacterial infection after thoracotomy was not possible until penicillin, discovered by Alexander Flemming in 1928, was mass produced during World War II. The discovery of Streptomycin by Selman Waksman and Albert Schatz in 1943 was quickly followed by it's clinical application at the Mayo Clinic by Hinshaw in April 1944.43 During my thoracic surgical rotation with O.T. "Jim" Claggett at the Mayo Clinic, I had the opportunity to meet the first patient treated with streptocycin, who was alive and well in 1970. Further contributions were made by Gerhard Domagck (Prontosil, thiosemicarbazones), Fox (isoniazid, INH) and Jorgen Lehmann (para-aminosalicylic acid, PAS). Combination use of these drugs allowed safe pulmonary resection for destroyed lung tissue and put an end to the dreadful deformity of tuberculous patients by thoracoplasty.
By the early 1940s the fruits of the pioneering efforts of all of these men had been tried, tested, and blended into an effective system of surgical technique that allowed pulmonary resection to be carried out with low mortality and morbidity. 43 To digress for a moment, I should comment that I have given little credit here to two men who have usually gotten the lion's share in historical reviews, Ferdinand Sauerbruck and Evarts Graham. Sauerbruck was the most powerful figure in European thoracic surgery into the 1950s and the author of the standard text. Although he did a large volume of thoracic surgery and established many useful techniques, most of his principles proved incorrect in the long run. He vigorously opposed positive pressure anaesthesia , pleural drainage and bronchial closure well into the 1930s. It is hard for us today to understand the tremendous influence this man had over his colleagues. Thorwald's portrayal of Sauerbruck's final days in his book "The Dismissal" paints a vivid picture of a rigid, domineering chief of surgery, who would brook no disagreement and had a dangerous stultifying effect on his specialty. Sauerbruch's own autobiography raises serious questions regarding his veracity and even his sanity. Perhaps a relatively irreverent attitude toward absolute authority in surgical chiefs, and the existence of a large and vibrant group of surgeons in private practice outside of universities in the U.S. was an important factor in allowing our surgeons to keep an open mind toward innovation and a respect for the contrary opinions of colleagues.
Evarts Graham made an important contribution during World War I in the treatment of empyema but his contributions to pulmonary resection before his pneumonectomy were limited to the horrifying operation of so called "cautery pneumectomy" wherein the lung was burned away with a red hot cautery . Pneumonectomies had been carried out before his case, and those done shortly afterwards were done with much more modern techniques. Graham played an important part in the development of thoracic surgical training in the U.S. and was also the first to statistically prove the markedly increased risk of lung cancer faced by cigarette smokers. Graham himself was a smoker, and died of lung cancer, outlived by his historic pneumonectomy patient, Dr. Gilmore.
Progress in thoracic surgery, as in other fields of medicine, is an outgrowth of cooperative effort by basic scientists in many disciplines and the culling from basic science, of pertinent information by clinicians, and translation and transplantation into practical, clinical medicine and surgical technique. Once the surgeon embarks on early clinical trials of such new techniques, he must scrupulously evaluate and criticize his own work and candidly publish his results so that his colleagues might, if they are receptive, avoid his mistakes and benefit from his successes. In this way there is a slow accretion of ever improving techniques and, in the end, facile, safe surgical operations that benefit mankind.
Frederic W. Grannis Jr. MD