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At the 1918 meeting of The American Association for Thoracic Surgery,
Willy Meyer was forced to curtail his discussion of pulmonary surgery due to
limitations of time. Yet he clearly noted the trend toward expansion of this
field. In this surgery, he stressed the necessity of controlling postoperative
pneumothorax and infection, and was soon to endorse underwater drainage which
had been reported by another Founder (Dr. Kenyon): Although the pioneering work
of Sauerbruch and others merits itscredit, the contributions of numerous
Founders cannot be passed over lightly.
As control of acute postoperative pneumothorax by differential pressure
became better understood and more individuals became versed in application of
the various methods, particularly intratracheal insufflation, pulmonary surgery
took on new life. Matas, in 1899, using a Fell-O'Dwyer tube with a bellows and
later a pump which he built himself, reported on the management of acute
traumatic pneumothorax. Using his method, Parham, an associate of Dr. Matas and
later a member of the Association, soon resected a large chest wall tumor.1. Nathan Green,. in 1906, found positive
pressure methods entirely safe for experimental lobectomy in dogs.2
Robinson and Sauerbruch, in 1910, reported their technique of lung resection
with a comparison of the methods of mass hilar ligation, thoracoplasty and
hilar ligation, and subpleural lung transplant and subsequent excision.3.
Before 1910, with only rare exceptions, pulmonary lesions were generally
considered in the internist's field. The trend toward surgical intervention
received its impetus from Dr. Howard Lilienthal. He possessed the requisite
courage and, by 1910, was able to report "The First Case Of Thoracotomy In A
Human Being Under Anesthesia By Intratracheal Insufflation". Although little of
a definitive nature was accomplished for this patient who suffered from a
chronic lung abscess, successful completion of the operation nevertheless
prompted others to employ the surgical approach.4.
One early departure from strictly medical management of pulmonary
disease was drainage of an acute or subacute lung abscess. For those who wish
to learn first-hand of the hair-raising experiences of the early days, a
reading of one of Dr. Lilienthal's reports is recommended.5. In a relatively short, but yet
splendid discussion, he covered practically all aspects of the problem.6
He related the method of anesthesia to the support of cardio-respiratory
function and the risk of aspiration. He emphasized differentiating the
obliterated from the open pleural space and made recommendations for handling
of the latter. He pointed out the risk of hemorrhage from drained abscesses and
the necessity for division and ligation of traversing vessels. He observed that
the recent soft wall abscess frequently had a rapid recovery after drainage
while the old abscess with the rigid wall usually required unroofing and
subsequent thoracoplasty. In such cases, he noted an increased incidence of
bronchial fistulae for which thoracoplasty or tissue graft was suggested.
Lilienthal began to alter his approach after he had only 3 cures in 14
operations on 11 patients for either pulmonary abscess or bronchiectasis, in
which he had used only drainage and thoracoplasty. His comment on a case is
enlightening:
"I am by no means proud
of this result even though it compares favorably with many of those reported in
recent literature. If we are ever to accomplish anything like an actual cure in
these almost hopeless cases, it will be by means of direct surgical attack with
actual removal of the bronchiectatic mass."
Willy Meyer -
individual division of bronchus.
Willy Meyer -
bronchial closure.
Willy Meyer -
individual ligation of vessels.
This experience forced him to conclude that change was in order. He
emphasized the need for accurate diagnosis between lung abscess and
bronchiectasis. The place of radiography and bronchoscopy was stressed. The
success with drainage in lung abscess was compared to its failure in
bronchiectasis. The frequent necessity for secondary operations made him lean
to excision although he feared its risk.
A report made only two years later indicated that Lilienthal was
following his convictions. In six of seven patients, he resected single or
multiple lobes with four cures. One death followed attempted resection. It is
of interest to note that Lilienthal first used a vacuum cleaner for
postoperative drainage in these cases. These excerpts illustrate the magnitude
of change in two two years:7.
So, for the present, we must be satisfied to operate in the worst and
most hopeless cases of lung suppuration where there is little to lose and much
to gain. Later, with improvement in the technique, we may find that lung
surgery is no different from other surgery and that we shall operate in the
early cases with greater promise of cure.
After a fairly wide experience amounting in all to more than 26 cases
since 1910, I am convinced that palliative treatment should be reserved for
actually hopeless cases such as those of bilateral involvement or those in
which the condition in one lung is so extensive and complicated by adhesions
that extirpation is clearly impossible.
A single focus or multiple foci in one lobe, should be removed
surgically. And even when an abscess had extended so as to implicate
neighboring lobes in one single infected mass, it has been shown that
extirpation may be successfully performed.
Other Founders were investigating pulmonary excision. Nathan Green,
Samuel Robinson and Willy Meyer contributed to the literature frequently. All
were attempting to find an answer particularly to the high risk of
complications with hilar ligation. Willy Meyer was one of the first to offer
individual treatment of the bronchus and vessels as a solution. He stated that,
although this might not be feasible it still could reduce the incidence of
fistula and other sequelae.8.
In spite of the
contributions of many, the evidence justifies the designation of Dr. Lilienthal
as "The Father of Lobectomy".9.
Early in World War I, the British and French physicians had refrained
from any aggressive surgery in chest injuries. Lilienthal expressed his and
others' doubts about this in the following words.10.
During the present European conflict, much has been observed and there
has arisen a considerable bibliography. A standardization of treatment,
however, had not yet been formulated.
We have a noted tendency
to temporize and to avoid radical surgical procedures. From a fairly extensive
civil experience in these cases, we believe that so-called conservatism is
probably carried too far. We believe that with proper attention to the
anesthesia, to the maintenance of increased air pressures within the pharynx or
traches, with the help of a powerful rib-spreading retractor, cases of gun shot
wounds of thoracic viscera may be treated by radical surgical repair with a
decided improvement in mortality statistics and in the time of disability.
Dr. Lilienthal followed this course in military service and in 1919,
reported his experiences at Evacuation Hospital #8. He concluded from a series
of 67 cases of thoracic injuries that, in competent hands, one could depart
from the conservative with great safety. This dissertation on sucking and
penetrating wounds, retained missiles, hemothorax, and infection seemed to
justify major thoracotomy in many of these cases. This was a precursor to the
approach which became common in civilian life and yielded so many excellent
benefits during World War II.11.
Dr. Lilienthal, along with many others of his time, held a dim view for
tumors of the lung:12
Tumors of the lung (parenchyma) are almost unknown. They usually are
malignant. Often tumors spring from the bronchi or mediastinal lymph nodes and
invade the lung tissue. As a rule, by the time their presence is demonstrable
they are no longer suitable for radical surgical treatment.
That he eventually changed his mind seems indicated in his Presidential
address to the American Association for Thoracic Surgery:13
The clearly marked circular shadows of parenchymatous infiltration by
cancer will appear very early in the development of the disease; far earlier
than the ear can detect changes by percussion or auscultation. Whether we are
dealing with cancer or not, we have found something which must be explored. A lump
of similar size in the breast of a woman would call for immediate operation;
surely, a lump in the parenchyma of the lung calls for no less.
It is my firm conviction that such early lobectomy would be fully
justified and that the time is not far distant when this generation of surgeons
will be severely criticized for not urging operation before it is too late for
complete removal of the growth.
Willy Meyer - Jianu
gastrostomy - extrathoracic esophago-gastric anastomosis.
Willy Meyer - stapler
used by him in construction of Jianu tube.
In conclusion, Dr. Lilienthal made this significant statement:
I have taken this opportunity to present the subject of early operation
in lung cancer because this Association will radiate its educational influence
to all parts of our country and beyond its confines ...
The opportunity today is ours, and I hope and believe that another year
will bring reports of success in this almost untried branch from the Fellows of
the American Association for Thoracic Surgery.
