The early days of pneumonectomy for lung cancer.
There is no doubt that the widespread habit of cigarette smoking,
which commenced among the troops in the First World War and which became
almost universal in the second, was responsible for the rise in
incidence of cancer of the lung throughout the Western World to its
position today as the commonest cause of deaths from malignant disease.
KEYWORDS Lung cancer / Pneumonectomy
(Care and treatment)
Lung cancer (History)
Pneumonectomy (Patient outcomes)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: Feb, 2012 Source Volume: 22 Source Issue: 2|
In the majority of patients, treatment can only be palliative. Cure
can be achieved, in early cases, in those who are also fit for a major
operation, by radical surgery, either of the affected lobe, (lobectomy)
or of the whole lung, (pneumonectomy).
As far back as the 1880s, a number of surgeons showed that experimental animals could survive removal of one lung. The first pneumonectomy in man was performed in 1895 by Sir William McEwen in Glasgow; he simply scooped out a lung that had been almost destroyed by tuberculosis. Four weeks later he obliterated the large space left behind by resecting the overlying ribs, (thoracoplasty) and the patient was well 11 years later.
Surgeons had two major problems to overcome in planning partial or total lung excision. The first was how to deal with the pedicle of bronchus and major pulmonary vessels. Initially a tourniquet was applied, to the hilum to produce necrosis of the lung tissue, which was subsequently excised. Later, the hilum was clamped and a mass ligature or suture used, with the eventual development of today's technique of dissection and individual ligation or suture of the main hilar structures.
The second, and indeed the more difficult problem was that of anaesthetising the patient, since opening the chest, of course, results in total collapse of the lung on that side. The standard technique was simply to use a tight-fitting mask over the patient's mouth and nose to keep the lungs inflated; usually the stomach as well would become distended with gas. Ferdinand Sauerbruch, in Breslau, Germany, after a series of experiments in dogs, built a large negative pressure chamber which contained the body of the patient and the whole surgical team. The patient's head projected through an aperture in the chamber so that the anaesthetist could put him to sleep. With the chest open at low pressure, the lung would remain expanded. The idea was workable, but only under almost impossible working conditions for the surgeon and his assistants.
It was the development of the endotracheal tube by Ivan Magill and Stanley Rowbotham in the First World War that really signalled the way forward for modern thoracic anaesthesia. In fact, this apparatus was devised at Queen Mary's Hospital, Sidcup so that the plastic surgical team there, in the First World War, headed by Harold Gillies, could get on with their work on facial reconstructive surgery on the wounded soldiers - its use in thoracic surgery was an invaluable spin-off. The invention of a cuffed endotracheal tube, to enable air-tight inflation of the normal lung, while the bronchus to the affected lung was sealed off by the cuff, was an important advance. The landmark year for modern dissection pneumonectomy for lung cancer was 1933, when Evarts Graham, in April of that year carried out this procedure on a 48 year old gynaecologist. A lobectomy had been planned, but the growth was found to extend into the lower lobe. The pulmonary vessels were tied and the bronchial stump cauterised to destroy the mucosa and then closed with catgut. In case a postoperative collection of pus developed in the pleural cavity, (empyema), a thoracoplasty was carried out, removing long lengths of ribs three to nine, in order to reduce the size of the residual chest cavity. The patient survived a stormy postoperative period, complicated by the development, (in spite of the thoracoplasty), of an empyema and of a broncho-pleural fistula, made a full recovery and outlived his surgeon, who himself died of carcinoma of the lung in 1957.
In that same year of 1933, four more surgeons carried out successful pneumonectomies for lung tumours. Edward Archibald in Montreal removed a lung for bronchiectasis and sarcoma. William Reinhoff in Baltimore resected a benign lung tumour in a child of three and a lung cancer in a 24 year old man. His first pneumonectomy took 30 minutes and the second one and a half hours; he must have been a superb technician! The two further successes were performed by Richard Overholt of Boston and John Alexander of Anne Arbor later that year.
Evarts Graham, with his first successful pneumonectomy, deserves special mention. He was born in 1883, the son of a professor of surgery in Chicago, graduated from Rush Medical School in that city in 1907 and was appointed professor of surgery in St. Louis in 1919. There he devised the first radiographic demonstration of the gall bladder, using iodine-labelled phenolphthalein, which is excreted in the bile and is also radio-opaque. Until ultrasonography, it was the standard method of X-raying the gall bladder. During the pandemic influenza outbreak in 1918 there were numerous cases of acute streptococcal empyema. In this condition the pus is watery compared with the thick material seen in chronic empyema and the more common staphylococcal empyema. Open drainage was associated with extremely high mortality - in the region of 70%. Graham used closed, underwater drainage, which reduced the mortality to 15%. Any one of Graham's three contributions to medical science would keep his memory bright.
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Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.
Provenance and Peer review: Commissioned by the Editor; Peer reviewed; Accepted for publication March 2010.
About the author
Professor Harold Ellis
Emeritus Professor of Surgery, University of London; Department of Anatomy, Guy's Hospital, London
No competing interests declared
by Professor Harold Ellis
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