Back to Founding of AATS
ANESTHESIA
Today, surgeons approach all operations involving the thorax with great
confidence in the anesthesiologist's ability to sustain the patient during the
operative period. They expect, and generally find, that adequate
cardio-respiratory function and satisfactory anesthesia can be maintained for
practically any length Of time to permit completion of an operation.
It has, however, not
always been so - and certainly not prior to 50 years ago. At that time, even
experimental thoracic surgery carried prohibitive mortality. It was quickly
recognized that these dire results were due to the loss of cardio-respiratory
function induced by acute open-pneumothorax. Both Dr. Meltzer and Dr. Meyer
stressed this physiological point in their papers at the First Annual Meeting
of the AATS.
S. Meltzer1. - The opening of a normal pleural cavity causes a
complete collapse and immobility of the corresponding lung.
W. Meyer2. - As said before, it is this
danger of an acute pneumothorax that has been the stumbling block in the
development of intrathoracic surgery, and nothing else.
Although a host of investigators researched possible solutions to the
problem, it remained for two Founders of the AATS (Meltzer and Auer) to finally
arrive at a technique which is the forerunner of our present successful
methodology. The history of this achievement is a story of persistent and
unselfish effort by many.
Although others antedated his research, Dr. Ferdinand Sauerbruch is
generally credited with originating the concerted attack on the problem. At the
behest of von Mikulicz, he constructed a chamber which exerted negative
atmospheric pressure on the open thorax. By this means, he succeeded in
maintaining respiratory function and, in 1904, was able to report its
successful experimental use. Dr. Willy Meyer witnessed its utilization during
that year and reported the event to the N. Y. Surgical Society on December 14.
In 1905, he published his first paper on this subject.3
At the same time, positive pressure methods appeared and were modified
and improved by a number of investigators including Brauer, Tiegel, Seydel, and
Robinson, the latter an AATS Founder. Spirited debate on the relative merits of
positive and negative systems became widespread.
In 1908, Sauerbruch demonstrated his chamber, on invitation, to the
Surgical Section of the A.M.A. in Chicago. Passing through New York on his way
back to Switzerland, he left the chamber with Willy Meyer for his experimental
use - it is rumored Dr. Sauerbruch's budget failed to provide sufficient funds
to take it home. Since space at the German Hospital was not available, the
chamber was installed at the Rockefeller Institute through cooperation of Simon
Flexner and Samuel Meltzer. On June 11, 1908, Dr. Meyer assisted Dr. Sauerbruch
in operating on a dog, utilizing negative pressure provided by the chamber.
After Sauerbruch's departure, Willy Meyer began intense and dedicated
research in an effort to improve the negative and positive chambers. Together
with his brother Julius, he built and worked with both chambers, finally
combining them in the Universal Chamber, constructed to exert either negative
pressure on the open chest or positive pressure, by means of a smaller chamber,
through the trachea.
A previously built positive pressure chamber was eventually moved to
the German Hospital (Lenox Hill) where in 1909, Dr. Meyer operated on the lung
of a child. This chamber, which could be dismantled and reassembled, was
transported several times and once even to Philadelphia for showing to the
American Surgical Association. In 1911, the Thoracic Surgery Pavillion at the
German Hospital was opened. Housing all types of positive pressure machines, it
was the first and only such unit ever to operate in the United States.
Experimental thoracic surgery on dogs, under positive and negative
pressure, continued at the Rockefeller Institute until December, 1913. In order
to avoid possible priority interference with its use, the Universal Chamber was
patented on January 2, 1912 (#1013800). This patent was assigned to the People
of the United States, providing unqualified evidence of Willy Meyer's selfless
devotion to the welfare of all through medicine.
Willy Meyer's
Universal Chamber
The entire story of the determination to alleviateacute pneumothorax
testifies to intense appreciation of the nature of the problem and dedicated
effort to solve it with success. Stress on principles involved, rather than on
didactic methods, gave great impetus to investigation of all possible
techniques. The fact that a particular method was eventually proven not as
practical and workable as another does not detract from the original value of
the research. The fact that Willy Meyer eventually adopted methods other than
negative-positive chambers testifies to his understanding of principles and
willingness to accept the best solution to a problem, even when contradictory
to his original approach.
It is characteristic of great men that their minds remain open to all
approaches during the search for solutions to common problems. Such was the
case with Willy Meyer and also with Samuel Meltzer, who had been instrumental
in providing space for his co-worker and friend at the Rockefeller Institute -
this in spite of the fact that he was himself intently following a totally
different tack in his work to prevent acute pneumothorax.
In his presidential address at the First Annual Meeting, Dr. Meltzer
summarized his experience as follows: His research work was originally and
primarily of a physiological nature. In his wide-ranging activity before 1900,
he had noted and investigated the depressant action of magnesium salts. He
first aimed this effect at possible use in controlling tetanus convulsions but
soon realized that such use often inhibited respiratory functions. Since he
knew the effect of these salts was short-lived due to rapid excretion, any
danger from inhibition of respiration could be met by temporary artificial
respiration. Manual methods proved insufficient for his purposes. It was this
problem of sustaining respiration that led him to devise the method of
intratracheal insufflation. Many years before, O'Dwyer, working on respiratory
obstruction of diphtheritic origin in children, had modified the old Fell Tube.
The Fell-O'Dwyer tube experienced significant success in O'Dwyer's hands while
he was intern at the hospital on Blackwell's Island in the East River. It
proved to be the groundwork for development of the Meltzer-Auer method.
Together with his son-in-law John Auer, Dr. Meltzer proceeded to
experiment with intratracheal insufflation. A tube was inserted into the
trachea through the glottis and positioned just above the bifurcation. This was
connected to a pressure bottle by means of a T tube with one of its openings
regulated by a screw clamp. Air at a pressure of 15-20mm of Hg in the bottle
was pumped into the trachea. Between the pressure bottle and the tracheal tube,
a manometer and bottles for ether and humidification were attached tothe apparatus. When
air was delivered into the trachea, its pressure was controlled by the
tightness of the clamp on the T tube and the ratio of the size of the trachea
to its in-dwelling tube. If the latter relation was correct, air escaped
retrograde up the trachea, around the tube, and out through the tracheostomy
and glottis but sufficient pressure was delivered to maintain the lungs in a
distended state. Under these conditions, the lungs remained pink, cardiac
action and blood pressure remained stable and, even with the entire anterior
chest wall removed, animals survived for more than four hours without any
rhythmic respiratory excursion.
When the relation between the trachea and its tube was not proper, the
lungs soon became cyanotic, cardiac action deteriorated, and death often
ensued. This danger was easily remedied, however, by disconnecting the tracheal
tube from the pressure bottle every 3 or 4 minutes, thereby allowing the lungs
to collapse. With the return of pulmonary circulation inhibited by the
abnormally high pressure, the lungs promptly regained their pink color. Even
though blood pressure varied frequently, animals were maintained in a
satisfactory state for many hours under Meltzer's method of intratracheal
insufflation.4.
Ardent discussion concerning the relative merits of pressure and intratracheal
systems became prevalent in medical literature and elsewhere. During a
symposium at the stated meeting of the N.Y. Academy of Medicine on February 17,
1910, both Dr. Meltzer and Dr. Meyer, among others, lucidly presented their
views on the subject. The closing paragraph of Dr. Meyer's paper foreshadowed
the coming event - namely, acceptance of intratracheal insufflation as a method
and its subsequent transformation into the endotracheal technique of anesthesia
so indispensible to present-day surgery in the thorax. To quote Dr. Meyer:5.
Shall the method of intratracheal insufflation which has been fairly
well tested by animal experimentation be applied to human surgery? I do not
consider it my province to come out here with such a definite advice. But I
wish to urge upon the progressive surgeons who are-not hopelessly tied to other
methods to familiarize themselves with this simple method in operations upon
animals. I am confident that they will then soon realize the great advantages
which it offers in its application in human surgery. I am not in doubt about
the future of the principles of this method, and it is the principle of the
method I am interested in and not the minor details of the so-called apparatus.
I risk even to prophesy that those who will have sufficient experience with it
will soon employ it as a routine method for anesthesia in operations upon any
part of the body.
Patent issued to Willy
Meyer and Julius Meyer for their Universal Chamber.
Consignment of the
patent to the People of the United States.
Fell-O'Dwyer apparatus
as used by Matas.
Fell-O'Dwyer apparatus
as later modified by Matas.
Intratracheal
insufflation - method of Meltzer and Auer.
Elsberg apparatus -
note bellows for emergency use.
Canula used by Nathan
Green.
At this symposium, the first successful use of intratracheal
insufflation in a human being was reported byDr. Elsberg. Although a neurosurgeon, he
was among the earliest to recognize the promise of the method and had worked
diligently at the Rockefeller Institute with Meltzer, Auer and Carrel to
perfect it. The following report, excerpted from the last paragraph of his
paper in the Medical Record,6 is 'a milestone in medical history:
The method may also be of great value in the treatment of asphyxia of
all kinds - chloroform and ether asphyxia, opium poisoning, asphyxia
neonatorum, coal gas poisoning, perhaps drowning, etc. We have resuscitated
dogs after all respiration and heart action had ceased for several minutes, by means
of intratracheal insufflation. I have kept a patient with myasthenia gravis who
had stopped breathing, alive for five hours by means of intratracheal
insufflation of air and oxygen. The patient was deeply asphyxiated when I was
called to see her in the hospital ward, and her heart action could only be
faintly heard. Without difficulty I passed a tube into her trachea through the
larynx and began intratracheal insufflation. Within a few minutes the patient's
color was pink and rosy and the heart action was re-established. For almost
five hours the patient was kept alive with a good pulse, although she never
once made a respiratory effort during that time. This is the first, and up to
the present time the only case in which the method has been used in the human
being.
The basic truth of the
value of such research work did not take long to make itself felt. In February
of 1910, Dr. Elsberg administered, by means of intratracheal insufflation, the
anesthesia for Dr. Lilienthal when he completed the first successful
thoracotomy, using this method, at Mount Sinai Hospital in New York.7
Its successful application in this case heralded the birth of endotracheal
anesthesia and sounded the knell for the chamber. The new method was
subsequently perfected and widely adopted to lay open without reservation the
entire field of thoracic surgery. Its present status harks back to the
original, determined search for a solution to the basic problem of acute
pneumothorax.
