Surgical Treatment Of Pulmonary And Cardiac Disease
Dr. P. Warren
Professor, Faculty of Medicine, University of Manitoba
Surgery began with the treatment of external disorders, such as fractures, wounds and superficial abscesses. The inside of the body was hidden territory and the heart was the last to be entered.
The Pleural Space
One exception was the drainage of empyema- the formation of pus in the pleural space. Hippocrates said, "if a pleurisy lasts 20 days then it forms an empyema and if it does not rupture then death will occur". He would identify the side of the chest that bulges or in some would shake the patient and listen for a succussion splash- in such cases he recommended opening the chest to drain it often inserting a tin tube. Diagnosis became easier in the eighteenth century when Auenbrugger with percussion identified pleural fluid early. But there was controversy about the benefit or risk of draining it or not. Sometimes opening the chest caused asphyxia because the lung collapsed and sometimes the clean fluid putrefied and became foul pus. For instance in 1835, Dupuytren, Napoleon's surgeon, developed an empyema and, although prepared for surgery, decided that "he would rather die at the hands of God than of surgeons" - he lived 12 days. In the 1840s, the French Academy of Medicine studied the treatment of empyema to produce guidelines for its treatment.
They used as evidence surgeons's experience with patients, statistical data and the effects on experimental drainage in dogs with conflicting results. But eventually Hippocrates's advice to drain prevailed and, in 1843, thoracocentesis became a standard approach to empyema by Trousseau. Thoracocentesis is the insertion of a large trocar (pointed cannula) into the pleura attached to a syringe. There were some opponents for when introduced to Boston one critic said "I would sooner send a bullet into the chest than plunge in a trocar".
Surgery Before the Nineteenth Century
Without anesthesia surgeons were renowned for the speed of their operations as the only means to curtail the agony of the patient. Their skills were still used on such matters as amputations, aneurysms of limb arteries and occasional external growths. A well known diarist Fanny Burney (1811) described her successful mastectomy thus:
when the dreadful steel was plunged into the breast- cutting through veins -arteries-flesh-nerves- I needed no injunction not to restrain my cries. I began a scream that lasted intermittently during the whole time of the incision....so excruciating was the agony...the operation, including the treatment and dressings lasted 20 minutes!
In the mid-nineteenth century, two major advances gave the breakthrough that led to the triumphs of surgery over many disorders.
The first advance was anesthesia- Humphry Davy (1778-1829) discovered nitrous oxide and was aware of its effects on the nervous system if breathed (laughing gas) but unfortunately did not use it for to ameliorate surgery. It was however used at parties, showing that behaviour such as ecstasy and raves by young people are nothing new. Ether was also used at such affairs. In 1842, Clarke in the USA used ether for a dental extraction and in the same year Long tried it for surgery in Georgia. But serious use of anesthetics as they were to be called was given by Wells (1815-48) with nitrous oxide for dental extraction in Boston. In 1846, Morton (1819-68) used ether in Boston. Shortly after the practice was taken up in Britain and in 1847 Simpson (1811-70) introduced chloroform and used it particularly in obstetrics. The first professional anesthetist was John Snow (1813-58) who is also renowned for his work as an epidemiologist on cholera and the Broad Street pump. Once Queen Victoria had tried anesthesia for child-birth it became fully respectable.
Now with the patient asleep the surgeon could take his time and the trauma that predisposed to their infection was lessened.
The second advance was the prevention of infection. Under appreciated was the move to cleanliness in hospitals and the value of the nursing profession. Florence Nightingale (1820-1910) in 1859, before bacteria had been identified as the source of infection, wrote:
It cannot be necessary to tell a nurse that she should be clean, or that she should keep her patient clean- seeing that the greater part of nursing consists in preserving cleanliness.
The next active step was the introduction of antisepsis - Joseph Lister, (1827-1912), was the son of the developer of the achromatic lens and the new microscopes. He studied physiology, in particular inflammation, and then chose surgery as a career. He married the daughter of his Professor of Surgery at Edinburgh and then moved to Glasgow. There he studied the sepsis that bedeviled surgery. For instance 6 out of 16 patients he operated on for tuberculosis of the wrist died of gangrene; the miasma had got in.
He recognized that the gangrene was putrefaction and read that Pasteur had suggested that this was related to fermentation by living organisms. Since the organisms were in the air. Lister became convinced that he must clean the air and thus keep the wound clear of organisms- he chose carbolic acid (phenol) that had been found to control the disease typhoid that was spread in sewage. Lister soaked the dressings he used in carbolic and sprayed carbolic into the air over the operation. The results revolutionized surgery and his seminal paper was published in The Lancet in 1867 -- 11 cases of compound fracture, none died of sepsis.
Thus by the end of the century surgeons could take their time since the patient was asleep and pain free and antisepsis prevented the disaster of an infected wound. This can be shown in Canada at McGill where Roddick (1846-1923) introduced antisepsis to Canada-he went on to found the Medical Council of Canada. In 1882 bacteria were identified in the pus of empyema and it was now understood that opening the pleura could infect it with bacteria- hence simple effusions could putrefy.
In time antisepsis became asepsis. Simple cleaning of the operative site, the use of masks, the washing of hands and in due course the use of rubber gloves were found to be the only measures necessary to exclude infection. The spray that made the operating theatre an unpleasant place to the work could be safely dropped. Lister had been made Lord Lister in recognition of his work acknowledged that he had been wrong, even if for the right reasons, and in 1890 spoke on the subject of empyema at a World Congress and said of his carbolic spray: "As regards the spray, I feel ashamed that I should ever have recommended it for the purpose of destroying the microbes in the air". He forecast aseptic techniques but hesitated to change his own practice: "I have not yet ventured to make the experiment on any large scale, although I have long had it in contemplation. It is a serious thing to experiment on the lives of fellow men, but I now believe the time has arrived when it may be tried". The need to soak the dressings in carbolic was also dropped. In 1919, Alexander Fleming (later discovered penicillin), studied the effect of antisepsis on tissue healing and showed that the carbolic etc. impaired the function of the body's inflammatory cells and so did more harm than good.
Others had recognized the value of asepsis. For instance in Obstetrics, several people had already addressed the horrors of post delivery putrefaction of the uterus that killed many young mothers (puerperal sepsis). In 1773 Gordon recommended cleanliness in labour wards and in 1846 Ignaz P.Semmelweiss, Hungary, faced a 10-30% mortality in puerperal women particularly if delivered by doctors rather than midwives. He noted that doctors came from autopsies to the deliveries and reasoned that they spread contagion - he insisted on hand washing and dropped the mortality to 1%. However his work was ridiculed and he lost his reason.
Faced by the vast numbers of patients with tuberculosis and with the mainstay of therapy being prolonged bed rest in the fresh cold air of Sanatoria the question was asked as to whether one could rest the lung in some other way. In 1882 Forlanini, (1847-1918), Italy introduced the artificial pneumothorax in which air was injected into the pleural space causing the lung to collapse and so rest. But frequent repeat injections of air were needed to replenish it. In 1886 de Cerenville (1843-1915) introduced rib resection for tuberculosis so collapsing the underlying lung.
From this there developed various surgical approaches to collapse the lung - thoracoplasty. In due course lung resection was introduced for tuberculosis and the chronic infection of bronchiectasis. Pneumonectomy, removal of the whole lung for cancer was first performed by Ewarts Graham (1883-1957) in 1933 -he later did the first such surgery for lung cancer and he himself died of lung cancer with his patient still surviving. Tragically he was one of the first surgeons to equate lung cancer with smoking. In 1933 Edward Archibald (1872-1945) at McGill refined the technique and introduced modern Pneumonectomy. Archibald is called the Father of Thoracic Surgery in North America. Archibald had had tuberculosis and been in the Saranac Lake Sanatorium in 190 where he learnt thoracoplasty and began his career as a thoracic surgeon. Another Saranac Lake patient was Norman Bethune who also became a thoracic surgeon at McGill. He was a communist, went to the Spanish Civil War and introduced mobile blood transfusions there. He then joined Mao Tse Tsung's red army in China and died there of sepsis contracted by a skin puncture during surgery - a hero to the Chinese people.
The stage was set for heart surgery. Two medications contributed to the possibility. One, heparin, dealt with the problem of the blood clotting when the great vessels and heart were opened. The other, curare, paralyzed the patient so that the spontaneous breathing that hampered intra-thoracic surgery could be controlled.
Jay McLean (1891-1957) was a medical student at Johns Hopkins who wanted to become a surgeon and in his second year he asked the Professor of Physiology, William Howell, for a project that he could solve and publish in one year. Howell asked McLean to sort out the active agent related to bloodclotting from cephalin, an extract of brain tissue.
McLean worked night and day and weekends and by December 1915 had finished. He was so thorough that he took a course in German so that he could read German literature.
McLean studied the effects of brain, liver and heart extracts on blood and to his surprise clotting was retarded not accelerated! Howell was skeptical of the results and so McLean placed in front of him a beaker of cat's blood with his "antithrombin" added and said call me when it clots- he was never called. Maybe because of this tactlessness McLean left and took no further part in the research Howell 1918 extracted the responsible agent "antithrombin" from the liver and called it heparin but he could only make small quantities. Help came from Canada where Charles Best, of Toronto drew on his experience of preparing insulin for treatment of diabetics. Best formed a team in 1928 and using cattle lungs could prepare large quantities of pure heparin by 1936. Gordon Murray (1936-42) of Toronto used heparin to prevent postoperative thrombosis in surgery for the first time. In the late 50's Murray pioneered coronary artery surgery and heparin became essential for the heart-lung machines that were essential for effective heart surgery.
The South American poison arrows described by Peter Martyr d'Anghera in 1516. The poison was called curare and in 1812 Benjamin Brodie, (1783-1862) the well known English surgeon, showed that a curarised animal could be kept alive with artificial respiration. The great French physiologist Claude Bernard 1850 showed that curare worked at the neuro-muscular junction. In 1858 curare was tried as a treatment for the sever muscle spasm of Tetanus. By 1935 pure curare had been isolated and in 1942 Harold Griffith and Enid Johnson, of Montreal, first used it during surgery as a muscle relaxant. Now breathing could be controlled making lung surgery easier.
Common Heart Diseases and Surgery
The further problem of stilling the beating heart so that there was sufficient time to operate on it faced the surgeon. Moreover if the circulation was stopped then the lack of blood flow damaged the brain and other organs. The cardiac surgeons faced two common heart diseases that could be helped by surgery.
Congenital Heart Disease
Blalock with the knowledge afforded from the work of Abbott and Taussig began surgical corrections of the defects but with a beating heart only partial corrections could be done.
Rheumatic Mitral Stenosis
Rheumatic fever damaged the cardiac valves producing either stenosis or regurgitation of the blood. The commonest lesion was mitral stenosis. In 1902 Lauder Brunton, (1844-1916), England described experiments on animal heart valves and human cadavers and proposed dividing the stenosed mitral valve. This was done in 1923 by Elliott Cutler (1888-1947), Harvard, who incised the mitral valve cusps of an 11-year-old girl who lived another 4.5 years.
The results proved often to be temporary for the valve re-stenosed. Also damage was often produced because the procedure was blind and surgeons could not see what they were doing. Definitive repair of congenital defects also meant that the heart had to be opened. How could one stop the heart, open it and operate under direct observation without the cessation of circulation leading to irreversible brain or other organ damage?
Two initial approaches were taken. Manitobans were involved in both.
W.G. 'Bill' Bigelow, (1913-.) is the son of a Manitoba rural doctor at Souris. He went to medical school in Toronto. He became interested in frostbite and studied hypothermia. He joined the Canadian Army Medical Corps and he was at the Normandy landings and developed skills in arterial repairs. A further example of how so often the horrors of war have stimulated advances in medicine. He then studied heart surgery under Blalock at Johns Hopkins. Bigelow recalls "One night I awoke with a simple solution to the problem; cool the entire body, reduce oxygen requirements, interrupt the circulation and open the heart". He studied hibernation in "ground hogs" but did not solve how they do it. He turned his attention to cooling dogs and then moved on to cooling humans. With the body cooled the circulation slowed and the reduced metabolic activity of the brain meant that it could survive for about 5-6 minutes of open heart surgery. Bigelow also developed the prototype cardiac pacemaker.
The Cardio-Pulmonary Bypass
In the nineteenth century, there were attempts to oxygenate the blood artificially but the first serious work was done in Minneapolis by a research team led by C.W. Lillehei (1918-1999). They learned that the brain would survive at one tenth of normal blood flow.
One of his team was Morley Cohen, St Boniface Hospital, who as a research fellow developed dog to dog cross circulation and showed that they would survive a low blood flow. In 1954 this approach was used for human surgery by attaching a son, who had a hole in his ventricular septum, to his father. They closed the ventricular septal defect successfully but the child died of pneumonia on the 11th day. The second and third patients survived. In the next year they did 44 cases. They were criticized for facing a 200% mortality in their surgery but the only ill effect was that one mother had a partial stroke. Lillehei with de Wall developed the bubble oxygenator, heart-lung machine, with which the heart and lungs could be by-passed and the circulation maintained to vital organs with the heart stopped.
Morley Cohen returned to St. Boniface Hospital and started heart surgery in Winnipeg. The Heart Lung machine became standard for heart lung surgery when the circulation has to be stopped and today valves are replaced and defects closed regularly.