Back to Founding of AATS
BY S. J. MELTZER, M.D., LL.D.
NEW
YORK
We are on the point of starting a new National Medical Society. It is a
part of the duties of the presiding officer to state at such an occasion the
aims and scope of the society and the reasons for its creation. But the present
officer feels that first of all he owes a duty to the members and to himself to
tell something of the circumstances which gradually brought him into the
Presidential Chair of an Association for Thoracic Surgery. The little story is
perhaps worth telling. When about forty years ago, I began my very modest
career as an experimental investigator in the domain of medicine, I had no
reason to anticipate that one day the honor would be conferred upon me to
preside over a body of progressive physicians who wished to discuss
particularly the surgery of the chest. I began my career by introducing stomach
tubes into my esophagus. There seems to be no clear connection between this
heroic act and thoracic surgery. But by good will a series of loose events can
be detected and forged together into a chain capable of connecting both end
points. My studies of the physiology of deglutition ripened in me the general
conception that the phenomenon of inhibition is an important factor in all functions
of the animal body. This conception of the mechanism of life never left me. It
was a working factor in my studies of the respiratory function. When later,
about twenty years ago, I came across the depressing action of magnesium salts,
it then occurred to me that the magnesium is perhaps the representative of
inhibition in the animal body. This view became a working hypothesis in our
numerous investigations of the action of magnesium salts. Further on, in the
attempts to utilize our new knowledge for therapeutic purposes, we soon
realized that magnesium may inhibit the function of respiration. Now magnesium
salts leave the circulation quite rapidly, and any danger from an inhibition of
respiration could be met by temporary artificial respiration. But there were no
satisfactory methods of artificial respiration which could be readily used in
such emergency cases. The manual methods were entirely insufficient for our
purpose. In our search for efficient methods we developed, Auer and I, the
method of intratracheal insufflation. You probably remember the little battle
between differential pressure and intratracheal insufflation. It occurred only
eight years ago; but it seems now like history. When I presented my paper on
intratracheal insufflation at the New York Academy of Medicine, my views were
opposed,in the interest of conservatism in
surgery, by three able surgeons. Now, these same surgeons are among the
principal founders of the American Association for Thoracic Surgery, and my
being the first presiding officer of the Association is due exclusively to
their generous spirit and not' to any merits of mine. This is my little story
of how the introduction of a stomach tube carried a mere medical man into the
presidential chair of a National Surgical Association.
Now I am coming to the performance of my duties, namely, to tell of the
aims and scope of the Association and to give the reasons for its creation. Of
course this could have been done better by the real founder of the association,
by the member who is going to give us a review of the evolution of thoracic
surgery in the past fourteen years and who by right should have been the
occupant of this chair. But he willed it otherwise. As the name indicates, the
chief aims of the Association are the advancement of the knowledge of and skill
in thoracic surgery. It is expected that a greater progress will be attained in
this line of medical research by focusing the attention of a group of practical
surgeons to the thoracic cavity, by working together with physicians and
surgeons, who are interested in special diseases of the thoracic cavity and its
adjoining regions, and by working together with various experimental
investigators in these fields.
Is it necessary to single out the thoracic cavity for special activities
and is the thoracic cavity not part and parcel of the domain of all general
surgeons? In looking for light on this question I did not have to go far to
discover the fact that the thoracic cavity apparently has no special attraction
for most of our leading surgeons. I shall cite only two illustrative instances.
The program of the American Medical Association reflects the medical and
surgical activities of the entire country. In looking over the program of the
coming meeting, as it was published a few weeks ago in the Journal of the
Association, I found that there were numerous papers on abdominal surgery
sufficient to crowd the programs of two surgical sections with an overflow into
the Section of Gastro-enterology; but there was not a single paper on thoracic
surgery. Then I glanced through the volumes from the Mayo Clinic. They show us
the sort of work which is done in this brilliant surgical institution. I found
only two or three papers belonging to the domain of thoracic surgery and these
paperswere written by a member of our Council
while he was on the staff of the Mayo Clinic. Wonderful work is being done in
this Clinic on organs below the diaphragm and above the thorax; but there is
practically complete silence on intra-thoracic organs, at least so far as
surgery is concerned.
Does the development of thoracic surgery receive attention and support
from our brilliant practical surgeons equal in extent and intensity to that
bestowed upon abdominal surgery? A fairly instructive answer to our query may
be obtained from the following analysis of the history of two similar incidents
in abdominal and thoracic surgery. It was about the same time, about the middle
of the last century, that a perityphlitic abscess (Hancock, 1848) and an
abscess of the pleural cavity (empyema) (Sayre, 1842) were incised for the
first time. Now let us compare the progress which followed both incidents. The
opening of the perityphlitic abscess did not only lead to the removal of the
appendix in acute stages of inflammation and to frequent interval operations
for appendicitis-the latter meaning the exposure of the normal peritoneum,
without trembling and with impunity; but it paved the way to the handling by
the surgeon of every organ located within the abdominal cavity and to very
frequent exploratory laparotomies for mere diagnostic purposes. In other words,
surgeons, great and of medium size, have nowadays no hesitation whatsoever in
opening the abdomen, exposing the normal peritoneum, and manipulating the
abdominal organs without urgent indications for its performance and without
fear of untoward results. Would the celebrated surgeons of half a century ago,
who surely considered the opening of a typhlitic abscess as an heroic act, have
admitted the possibility that a day will come when the normal parietal and
visceral peritoneum could be exposed and manipulated with absolute impunity?
Now let us look at the progress in thoracic surgery made during the
same period. It is true that one or the other surgeon pleads courageously nowadays
for an exploratory thoracotomy in cases of empyema; but we must bear in mind
that that which they wish to explore and manipulate is a simple or multilocular
abscess cavity and not the normal parietal and visceral pleura. Is there a
greater danger in exploration of the normal pleural cavity than the exploration
of the normal peritoneal cavity? Our leading conservative surgeons seem to
think so. But after the introduction of intratracheal insufflation, Carrel and
others have in numerous instances opened freely and simultaneously both pleural
cavities for the purpose of patching the thoracic blood vessels and other
operative procedures with complete impunity. Carrel and other experimental
thoracic surgeons could do it, because they employed methods which, above all,
insured the safety of the respiratory function. But our conservative surgeons
say that for the surgical work on the thorax the new, hazardous methods of
artificial respiration can be dispensed with, because the operations performed
upon the thoracic cavity of human beings can be carried out under simple
anesthesia without complicated methods. Here is the rub. The masters of
technique, and fearless operators in the field of abdominal surgery, when they
come to thoracic surgery confine their work chiefly to the abscess cavity of
the pleura, which, by means of the abscess wall and the newly formed adhesions,
protects the respiratory capacity of the lung in the other pleural cavity and
also the remaining respiratory power of the non-collapsible part of the lung on
the operated side.
Does the thoracic cavity possess features which distinguish it from
other serous cavities so as to merit particular attention? Indeed, it does, and
in a striking fashion. Every elementary textbook on physiology will tell you
so; only the successful operations upon the abscess cavities of the thorax dim
the vision of the surgeons. The opening of a normal pleural cavity causes a
complete collapse and immobility of the corresponding lung. In dogs, the
opening of one pleural cavity is, as a rule, sufficient to cause the death of
the animal. As to human beings, I believe that no experience is available to
answer this question; the opening of a pleural cavity was made, as a rule,
either in diseased conditions which may have caused adhesion of some part of
the lung or at least a complete isolation of the two cavities by means of a
thickened mediastinum; or the opening was made under some form of artificial
distention of the lung. Besides the respiratory mechanism, the thoracic cavity
harbors the chief organ of circulation. An interference with the activity of
this incessantly-beating organ may unexpectedly lead to danger, and even to
.immediate death. These serious problems confront the surgeon who has to work
in the thoracic cavity, in addition to the serious features which the surgeon
has to consider in dealing with all serous cavities.
I wish to emphasize here the significant fact that the additional
serious problems which confront the thoracic surgeons are essentially of a
physiological nature. Surgeons are generally well trained in anatomy, in
technique, and in mechanical manipulations. Here there is hardly any limit to
their courage and progressiveness. But when it comes to problems which have a
predominant physiological aspect an undesirable form of conservatism comes to
the fore.
I believe that I brought forward a sufficient number of reasons showing
the desirability of knitting together a group of medical men who possess the
necessary scientific preparations and the aptitude to work along lines which
will help us to advance the knowledge and the skill of thoracic surgery; in
other words, I gave you reasons for the creation of the Association for
Thoracic Surgery. In performing my duties as the president of the association I
may rest here my pleading the cause of the association, but I ask permission to
add some remarks on subjects which interest me as an active worker in the
problems belonging to the domain of our association.
I shall deal first with the method of intratracheal insufflation. I
entertained the conviction that the right of this method to permanent
citizenship in the domain of surgery has been established beyond a doubt. But
in looking over the literature I came across a paper which contains a rather
severe judgment against the method, rendered in a sharp, categorical manner.
The paper was written by a man who at all times is entitled to a respectful
hearing. But just at present he is the man of the hour; he will be the next
president of the great American Association; it was written by Dr. Bevan. It
is, perhaps, fortunate for a president of such a young and small society as
ours to be in the position to rub against the president of the largest national
society; my discussion with him may thus get a hearing. In a paper, entitled
"The Choice and Technique of the Anesthetic," published in 1915 in the Journal
of the American Medical Association (the issue for October 16), Dr. Bevan deals
among others with the intratracheal anesthesia. From his conclusions it is
sufficient to quote two which leave no mistake as to his x views. "The method
is dangerous," he begins, and finishes up by saying that, "On the whole,
therefore, intratracheal anesthesia has little place in practical surgery." On
what experience are these dicta of Dr. Bevan based? I received from a most
reliable source the information that no patient was operated in Dr. Bevan's
clinic by the method of intratracheal insufflation. If Dr. Bevan has seen the
method used elsewhere and with bad results, he should have expressly stated
that fact. On what information, then, did Dr. Bevan base his categorical
statement? He quotes the paper of Dr. Robinson of several years ago in which
fourteen hundred cases were collected with seven deaths. It is quite strange to
find that in striking contrast to Bevan's conclusions, Robinson, on the basis
of his statistics and observations, proves himself in this paper to be an
ardent supporter of the method. He says there, "Those of us who have managed
intratracheal anesthesia during general surgical operations are universally
impressed with the idealcondition which
exists." Did Bevan try to analyze the seven cases of death mentioned in
Robinson's paper? Well do I remember three cases. In one case the ether bottle
was reversed by mistake and pure ether was driven into the lungs; in another,
the nurse pushed the intratracheal tube, while being connected with the
pressure apparatus, deep into the bronchus, which led, of course, to rupture of
the lung. In a third case the patient was in a prone posture with the anterior
part of the neck hanging over the edge of the table; the patient was not looked
after, and it was discovered late that the insufflated air and ether mixture
had no chance of escaping. Does Dr. Bevan believe that these gross "errors" have
anything to do with the method as such? On the other hand, how does he explain
the facts that men like Dr. Elsberg, who used the method in more than twelve
hundred cases, and Dr. Peck, who used it in more than five hundred cases, never
encountered any accidents?
Without entering into a further discussion of the validity of Dr.
Bevan's dicta in this instance, I may be permitted to refer here to two
instructive statements. Tuffier, who is probably as good an authority on
thoracic surgery as Dr. Bevan (on invitation, he presented an extensive report
on thoracic surgery before the Surgical Section of the International Congress
in London in 1913) published an article in which he says, among others, that
according to his opinion, based upon personal experience with the method,
intratracheal insufflation anesthesia will be in the future the only method of
anesthesia for thoracic surgery.
In an article (submitted by the Section of Plastic and Oral Surgery and
approved by the Surgeon General, U.S.A.) published in the Military Surgeon for
May, 1918, the following simple statement is made: "The utility of
intratracheal anesthesia for certain types of operations is well established."
Perhaps I may add that in the many thousands of cases in which intratracheal
ether anesthesia was used not a single case of ether death occurred.
There is another point which I wish to bring out here. Intratracheal
insufflation is generally discussed from the point of view as a method of
administering anesthesia. It is overlooked that it provides the patient during
the anesthesia with a luxurious artificial respiration. It is not generally
appreciated how important this point is. Auer and I found that ether has a
curare-like action upon the endings of-the motor nerves, and Githens and I found
that during ether anesthesia both the diaphragm and the phrenic nerves lose
some of their irritability. It is no doubt that during ether anesthesia an
element of asphyxia is present. Now, thisfact
is very important, especially when one works in the neighborhood of the heart."
When the individual receives efficient artificial respiration simultaneously
with the ether anesthesia the heart may be handled with practical impunity. It
is different when the respiration is insufficient; the heart often responds to
each touch with a series of irregular beats which in some hearts may lead to
ventricular fibrillation and a heart death.
The so-called pharyngeal method of anesthesia, of which Bevan and other
surgeons are now speaking favorably, is, of course, incapable of providing
efficient artificial respiration. It is different with the pharyngeal
insufflation which I described about a year ago and the efficiency of which I
have recently demonstrated to hundreds of military medical officers and other
interesting parties.. But I do not intend to dwell here on this subject.
Finally, as the president of the Association for Thoracic Surgery, I
shall avail myself of the opportunity and the privilege to make one or two
remarks on topics of human thoracic surgery. It seems to me that the most
desirable object in thoracic surgery is the proper development of exploratory
thoracotomy with the object of using it in the same manner and for the same
purpose as exploratory laparotomies are used, that is, in the first place for making
a proper diagnosis. I risk making the statement that in some conditions the
exploratory incision in itself may even exert a therapeutic effect. In some
instances exploratory laparotomies undoubtedly influence favorably pathological
processes in the abdominal cavity. I have a theory for it; but I shall not
dwell upon it now. At any rate, an exploratory thoracotomy may lead to a proper
understanding as to the therapeutic measures which could be employed now or
later. On the other hand, I would rather counsel conservatism in the attempts
to perform untried and unstudied methods of operation. An occasional success
rapidly leads to repetitions and numerous failures, and this discredits
thoracic surgery. Patient, practical, and experimental studies should be the
means of paving the way to the final success in thoracic surgery.
My second suggestion is rather bold, and I am well aware that it will
not be acceptable to most of you if to any. Nevertheless, I am throwing out
this suggestion, looking upon it as a seed which may perhaps take root
somewhere some day. I propose that large intercostal incisions should be made
for the treatment of pulmonary tuberculosis. If the procedure does not
interfere with the respiration, that is, if it proves that the mediastinum sufficiently
protects the respiratory activities of the lung in the opposite cavity, steps
should be taken to keep the incision open for a longer period. If the lung of
the opposite side is also affected, the same procedure should be followed out
later when the first incision is healed. The idea underlying this suggestion
has nothing in common with the method of treatment by means of insufflation of
nitrogen in the pleural cavity. Forlanini's method is based upon the
supposition that rest will act as a curative agent. The ideal rest of the
kidneys does not prevent development and progress of tuberculous processes in
their parenchyma. My suggestion is stimulated by the experience of the curative
effect of laparotomy upon tuberculous peritonitis; the introduction of nitrogen
or oxygen into the peritoneal cavity exerts no such curative action. We should
bear in mind that the treatment of tuberculous peritonitis by laparotomy owes
its origin to mistaken diagnoses which were made by Spencer Wells in England
and by Van De Walker in this country. In years gone by nobody would have
thought of suggesting the treatment of tuberculous peritonitis by an abdominal
incision, and if it had not been for the accidental errors in diagnosis, it
might never have been performed. So far we do not possess a clear explanation
of the nature of the-therapeutic effect of the laparotomy; but there is no
doubt as to the fact of the therapeutic result. Thoracotomy may exert a similar
therapeutic effect. If we could only test and establish the fact of therapeutic
action, the explanation of the effect may wait in thoracotomy as it has had to
wait in laparotomy. I venture to throw out the further hypothesis that the
moderate distentions of the partly adherent exposed lung may rather prove to be
a favorable factor in the possible therapeutic action of a thoracotomy. I have
my reasons for this hypothesis, but I shall not discuss them; I think I have
done more than enough by venturing to make the bare statement.
I do not expect to live to see my suggestion taken seriously and
tested. But, you see, a physiologist rushes in where surgeons fear to tread.
