Interactive Cardiovascular and Thoracic Surgery 2:219-226(2003)
© 2003 European Association of Cardio-Thoracic Surgery
The mid-century revolution in thoracic and cardiovascular surgery: Part 1
A.P. Naef
12 avenue Villardin, CH-1009 Pully-Lausanne, Switzerland
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1. Introduction
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"We only see so far because we stand on the shoulders of giants." (Isaac Newton)
"The farther backward you can look, the farther forward you are likely to see." (Winston Churchill)
The 1961 ‘History of Thoracic Surgery’ by Richard Meade will always remain the classic reference document for future scholars of our history. Very little can be added to this author's monumental 900 pages of meticulous historical research. My own 1990 ‘Story of Thoracic Surgery’ told 30 years or two generations later, literally reports the story in an abridged, more personal manner. Unfortunately both books are out of print. Several more recent autobiographical accounts may become of interest to future historians, but essentially add very little to the knowledge about a surgical field born after the turn of the 19th to the 20th century. I therefore could have abstained from writing one more story about a very well-documented evolution, except for the desire to describe what was in fact ‘the real mid-century revolution of cardio-thoracic surgery’. At the same time I wanted to evoke this fascinating story as a personal experience, possibly meaningful for future historians and surgeons. The recent death, on July 21, 2000 of Ake Senning (Fig. 1), one of the outstanding pioneers in European cardio-thoracic surgery, or the tragic suicide in Buenos Aires, on Saturday July 29, 2000 of Rene Favarolo (Fig. 2), the first to establish aorto-coronary bypass surgery in 1967, reminds us that the generation of pioneers who actually were active witnesses of this revolution is rapidly disappearing and that it may be high time to recapture, as an active participant, the birth of modern thoracic and cardiovascular surgery during the three or four mid-century decades from 1940 to 1960.
It goes without saying that this extraordinary explosion of a new specialty did not happen without cause. First it was part of a general medical revolution from penicillin (1940) to cortisone, renal dialysis, the Engström-ventilator, pacemaker, hip prosthesis, the heart–lung machine and transplantations – a development once more well described in the recent book by James Lefanu ‘The Rise and Fall of Modern Medicine’.
Second, and more specifically, the rise of modern cardio-thoracic surgery was the outgrowth of our general surgical heritage at the beginning of our century, an evolution I will recapitulate in my prologue. The isolated, almost accidental exploits of general surgeons, such as Rehn's cardiac suture (1897) or Tuffier's partial lung resection (1891) were followed some decades later by the pioneering general thoracic surgeons between the two World Wars, among others John Alexander, Tudor Edwards, Edward D. Churchill, W. Rienhof, Evarts Graham or Alfred Blalock, Gross, to name only a few.
This ‘Story of the Mid-Century Revolution in Thoracic and Cardiovascular Surgery’ is meant to be a personal account of the thrilling experience of a surgeon discovering, year after year, decade after decade, an entirely new field. Compared to the long and slow evolution of medicine and surgery from Ambrose Pare (1517–1590) and Laenec (1781–1826) (Fig. 3) to Billroth (1821–1894), Sauerbruch, and Tuffier, the dramatic sequence in the shortest possible time from the blue-baby operation (Blalock 1945) to closed commissurotomy (1948), to Lillehei and Kirklin (1954), in just two decades, the birth of cardio-thoracic surgery was in fact a surgical revolution. If I accentuate the events I witnessed personally and the pioneers I admired, I make no claim whatsoever to present one more comprehensive history of thoracic surgery such as was so perfectly written 40 years ago by Richard Meade.
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Fig. 3 (a) ARENE LAENEC (1781–1826). Outstanding pioneer in diagnosis and treatment of chest disease. Discovered the method of auscultation using his (first) wooden stethoscope. (b) Laenec's wooden stethoscope for direct auscultation.
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2. Prologue
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Theodore Billroth (1821, Bergen (Rugen)–1894) (Fig. 4) was one of the great surgical ancestors of the 19th century. He is well remembered for his lifelong friendship with Johannes Brahms, and a technique for gastric resection called ‘Billroth I and II’. His reputation has been tarnished by his condemnation of any surgical approach to the heart – shortly before his colleague Ludwig Rehn (1849–1930) reported the successful repair of a cardiac stab wound in 1886. Billroth is supposed to have said that ‘any surgeon who would attempt an operation on the heart should lose the respect of his colleagues’. Yet the Yale historian Sherwin Nuland told me that he was unable to trace any such statement in Billroth's writings, and in my own search through the 51 published lectures of Billroth's ‘Surgical Pathology’ I could not find it either. However, Nissen traced down a then still surviving assistant of Billroth, Anton von Eiselsberg (1860–1939) who recalled his chief maybe making such a remark in passing but not publishing it. Be that as it may, Billroth's remark, just as an identical one by the British surgeon Sir Henry Paget, at the time expressed the general opinion of surgeons everywhere, and for many decades to come, that the time was just not ripe for the advent of cardiac surgery.
Ferdinand Sauerbruch (1875–1951) (Fig. 5) is of course another prestigious, albeit somewhat overrated name in thoracic surgery. His name is associated with the famous negative pressure-operating chamber (Fig. 6), as well as with the surgical treatment of tuberculosis. His textbook ‘Die Chirurgie der Brustorgane’ first published in 1918 and translated into English by Lawrence O'Shaughnessy (Fig. 7), whose pioneering career was cut short during the catastrophic evacuation of the British army at Dunkirk in 1940. The negative pressure chamber was actually the idea of Johann von Mikulicz (1850–1905), Professor of surgery at the University of Breslau, today Wroc aw in Poland. Von Mikulicz was a famous gastrointestinal surgeon who tried unsuccessfully to operate on the esophagus under positive pressure anesthesia by way of a face mask. Looking for a solution he put his assistant Sauerbruch in charge of a research project to solve the problem of open pneumothorax during chest operations. The famous ‘Negative Pressure Chamber’ harboring in a cramped space the patient – his head outside for respiration and anesthesia – as well as the perspiring operating team, eventually turned out to be a blind alley. The method was published with von Mikulicz in 1904 "Über Operationen in der Brusthöhle mit Hilfe der Sauerbruch'schen Kammer". In 1908 Sauerbruch visited the USA to draw attention to his negative pressure chamber at the meeting of the American Medical Association. At the end of his visit he did not take the bulky contraption home to Berlin, but left it with the prominent New York thoracic surgeon, Willy Meyer (Fig. 8), an unconditional advocate of the concept. Meyer and his brother Julius, an engineer, continued research and designed what they called a ‘universal pressure chamber’, allowing either negative pressure with the surgeon inside, or positive pressure by a small box for the patient's head, the surgical team working on the open chest outside at atmospheric pressure. In 1911 this highly complex construction was installed, and used for a series of operations at the thoracic surgical service of the German – renamed Lenox Hill – Hospital during World War I.
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Fig. 5 FERDINAND SAUERBRUCH (1875–1951). Early thoracic pioneer. Developed negative pressure chamber for thoracic surgery. First textbook for thoracic surgery in 1918.
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Fig. 7 LAWRENCE O'SHAUGHNESSY (1900–1940). Promising British thoracic and cardiac surgeon. Published abridged translation of Sauerbruch's textbook. Died tragically during the British army evacuation at Dunkirk (1940).
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Fig. 8 WILLY MEYER (1858–1922). New York pioneer, admirer of Sauerbruch and the negative pressure operation chamber. Founder of the American Association for Thoracic Surgery in 1917.
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In the meantime, in 1909, at the Rockefeller Research Institute, Meltzer (Fig. 9) and Auer developed the logical solution of ‘intratracheal positive pressure ventilation’, a method which applied clinically would solve the problem of open pneumothorax during chest operations. In 1910 the young surgeon Elseberg was the first to use intratracheal positive pressure anesthesia for one of Lilienthal's thoracotomies at the Mount Sinai Hospital in New York. Meyer, however, was too intelligent a man not to recognize eventually the superiority of Meltzer's positive pressure ventilation by intratracheal intubation. As for the ‘universal chamber’, which had taken so much of Meyer's time and energy – a machine worthy to be kept at the Smithsonian Museum – it had to be dismantled and sold, as scrap metal in 1928 because the growing Lenox Hill hospital had no space for it. ‘Sic (transit?) gloria mundi’.
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Fig. 9 SAMUEL J. MELTZER (1851–1921). Inventor of intratracheal anesthesia at the physiology laboratory of the Rockefeller Institute, among other things. First President of the American Association for Thoracic Surgery (1918).
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As a thoracic surgeon Sauerbruch certainly owed his reputation to the exploding field of surgery for tuberculosis.
Certainly he performed hundreds of thoracoplasties still with a fairly high mortality. In the field of intrathoracic surgery he was undoubtedly far behind the standard set by British surgeons, such as Tudor Edwards at the Brompton Hospital, probably in part for lack of good anesthesia. Nevertheless during the 1920s and 1930s Sauerbruch was the most famous thoracic surgeon at the not less famous Charité Hospital in Berlin, and for many young American surgeons, the pioneers to come, a visit to Sauerbruch in Berlin was a must, just as for us young Europeans was a visit to Boston after 1945.
The textbook ‘Die Chirurgie der Brustorgane’, first published in 1918 was the classic bible at the time and reedited several times until 1930. I have only the abridged English edition by Lawrence O'Shaughnessy – a fascinating volume with beautiful illustrations of operative techniques, pathology specimens and instruments; illustrations which would honor any publication today.
Theodore Tuffier (1857–1929) (Fig. 10), the French surgeon should be considered as one of the amazing precursors in thoracic and cardiovascular surgery. Not only was he an outstanding clinical surgeon, but also he was constantly involved in experimental research in Paris as well as at the New York Rockefeller Institute with Alexis Carrel. His three most remarkable contributions were in the field of intratracheal anesthesia, pulmonary resection and experimental cardiac surgery. In 1896, with Hallion, he published his experiments on artificial respiration using intratracheal intubation with an inflatable cuff tube. Tuffier was also the first to describe extrapleural ‘pneumonolysis’ – extrapleural pneumothorax – with plombage by autologenous fat for collapsotherapy of tuberculous cavities. Extrapleural pneumothorax with or without plombage later became a frequent, less traumatic alternative, to thoracoplasty in the treatment of pulmonary tuberculosis. In 1891, using this technique of extrapleural pneumonolysis, he performed the first ever pulmonary resection for tuberculosis. To avoid the complications of an open pneumothorax Tuffier freed the tuberculous pulmonary apex extrapleurally before clamping the diseased lung tissue including the parietal pleura. He then resected the tuberculous apex finishing by a continuous suture over the clamp. It was certainly not a difficult operation, nor a recommended one by today's standards, but in Tuffier's days one had to have his imagination to conceive the technique. Finally, with Alexis Carrel (Fig. 11), he published his amazing paper on experimental open-heart surgery in 1914 (Fig. 12). Many operations on the cardiac valves were performed with caval occlusion. Although the heart did tolerate most of these aggressive procedures, all animals, not surprisingly, died of cerebral anoxia due to the caval occlusion. Nevertheless Carrel and Tuffier's experiments encouraged later surgeons like Elliot Cuttler to proceed with closed valvular surgery, knowing the heart being quite resistant to surgical aggression. Tuffier should be considered a real pioneer in clinical and experimental cardio-thoracic surgery.
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Fig. 10 THEODORE TUFFIER (1857–1929). Outstanding French all-around surgeon – pioneer in pulmonary and cardiac surgery. First partial lung resection (1891).
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Fig. 11 ALEXIS CARREL (1873–1945). Received 1912 Nobel Peace Prize for his work on vascular suture and organ transplantation.
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Fig. 12 Extract from ‘La Presse Medicale’, Wednesday, 4 March 1914 announcing paper on open-heart surgery by Carrel and Tuffier.
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Here I would like to close the prologue concerning what must be considered the ‘prehistoric period’, and turn to the intermediate era before World War II, when the authentic pioneer generation, still initially trained general surgeons, opened the road to modern cardio-thoracic surgery. I will dwell on three key events only – just as I could have chosen many other late 19th century leaders in place of Billroth, Sauerbruch or Tuffier.
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3. Thoracic surgery 1920–1940
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Revolutions never occur spontaneously but are always preceded by minor earthquakes. The mid-century revolution of cardio-thoracic surgery we lived through after 1945 was thus preceded by isolated exploits of daring general surgeons just before and during the war.
– The first pneumonectomy for cancer by Evarts A. Graham (Fig. 13) on April 5, 1933, was preceded by the pneumonectomies for benign disease by Rudolf Nissen (Fig. 14) and Cameron Haight both in 1932. Before these more dangerous and exceptional total pneumonectomies, a series of partial, less risky lobectomies was reported among others by Howard Lilienthal at the Mount Sinai Hospital in New York. Most of these early lung resections were done by the fairly crude (Shenstone) tourniquet method. The earlier hilar dissection pneumonectomies by Rienhof, Archibald and Overholt, also reported in 1933 but done a few weeks after the one by Graham, should be mentioned.
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Fig. 13 EVARTS A. GRAHAM (1883–1957) of St. Louis. Performed the first total pneumonectomy for cancer.
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Fig. 14 RUDOLF NISSEN (1899–1981) Professor of surgery in Basel, whose outstanding contributions to surgical advances go from his first total pneumonectomy for benign disease (1932) to the classical fundoplication operation for hiatal hernia. His autobiography, ‘Helle Blätter – Dunkle Blätter’ (1969) describes the life of a surgeon from the 1930s to the 1960s.
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– The first total esophagectomy for cancer by Franz Torek on March 14, 1913. Incidentally this operation somehow led to the founding of the American Association for Thoracic Surgery. When the New York surgeon Willy Meyer, an associate of Torek, presented this extraordinary case before an uninterested auditorium (no discussion) at the Annual Meeting of the American Medical Association he felt that thoracic surgeons needed a forum of their own. Therefore he first started the New York Association and then this was followed immediately by the foundation of the American Association for Thoracic Surgery in 1917 (Fig. 15), just before America's involvement in World War I. As for Torek, he never repeated his operation, and well-defined esophageal surgery had to wait another 25 years.
Finally the timid approach to the heart is represented by the ligation of a patent ductus in 1938 by Bob Gross, the first operation for aortic coarctation by Clarence Crafoord in 1944 and the blue-baby operations (Tetralogy of Fallot) by Alfred Blalock in 1945.
I will come back in more detail to most of the above-mentioned pioneers in my story of personal visits and contacts with these remarkable surgeons who actually made cardio-thoracic surgery happen. The cardio-thoracic surgeon of the year 2000 can in no way imagine the physical and psychological conditions under which these achievements were made by the pioneers in our field. Today it is indeed difficult to comprehend how these surgeons could go on doing lobectomies in the face of more than a 50% mortality, or how a few years later Bailey or Harken could persist in trying mitral commissurotomies after losing several patients ‘on the table’ or right after the operation.
Evarts Graham – no doubt one of the great men in thoracic surgery – after his first successful pneumonectomy in 1933, lost 19 patients in a row before another successful resection for carcinoma. This first generation of thoracic surgeons had to be inspired by what I call the spirit of the pioneers. As René Burnand, one of our TB specialists at the time, said "they were a generation of surgeons who had only the crudest armamentarium and who in spite of a few victories had to face a terrifying percentage of defeats, but had nevertheless the courage to persevere because they had the faith in the validity as well as the promises of their therapeutic concept".
I think that the title of ‘pioneer’ is often overused, but in the case of the men who opened the road to thoracic surgery the title is more than justified. They were by no means stubborn or cold blooded. The French ‘sang-froid’ means to ‘keep a clear head’ and to persevere means to stand firm and be dedicated, far from being stubborn. These men were convinced that they were on the right track and it was by their sense of competition, their physical and moral resistance, their vision and manual dexterity that they pushed the frontiers of 19th century surgery ahead and made 20th century cardio-thoracic surgery happen. I have thus briefly recalled the achievements of our predecessors before the ‘mid-century revolution’ I will turn to the personal experience of what could be called the third generation thoracic surgeons contribution to the rise of modern cardio-thoracic surgery in a following paper.
doi:10.1016/S1569-9293(03)00130-0
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Top
1. Introduction
2. Prologue
