CORRESPONDENCE

“Classics” and Total Pneumonectomy To the Editor: I was delighted to discover the new section, ”Classics in Thoracic Surgery,” in the April, 1980 issue, and, in particular, the discussion by Prof. Rudolf Nissen of his first total pneumonectomy in 1931 and the sub- sequent development of the technique of pneumo- nectomy (Ann Thorac Surg 29:390, 1980). His ac- complishment was undoubtedly a milestone in the development of thoracic surgery.

Prof. Nissen indicated, however, that his opera- tion and those of Haight and Graham were ac- complished by mass ligature techniques. They were, according to Lindskog [l], subtotal pneumonec- tomies insofar as complete removal of proximally situated lesions was concerned. As Prof. Nissen stated: “The turning point in the technical develop- ment of total pneumonectomy, particularly for bron- chogenic malignancy, is represented by . . . success- ful mediastinal dissection.” I had the pleasure of reviewing the history of modern pneumonectomy in 1970 [2], and will remind readers of the Annals of the important contributions made by Drs. Edward Archibald and William Rienhoff, Jr., to this “tum- ing point.”

Just two years after Nissen’s historic operation and three months after Graham’s well-accounted subtotal pneumonectomy by the mass ligature technique (on 5 April 1933), Edward Archibald of the Royal Victoria Hospital, Montreal, and McGill University (on 7 July 1933), and William Rienhoff, Jr., of The Johns Hop- kins Hospital, Baltimore (on 24 July 1933), each ac- complished successful one-stage, total pneumonec- tomies by mediastinal dissection and individual ligation of the hilar components. Each carried out the pneumonectomy as planned and conceived from prior clinical and laboratory experience, and, despite the reported success of the mass ligature technique, neither considered this technique the appropriate approach to total one-stage pneumonectomy [2]. As Prof. Nissen wrote in his “Classic,” “In the ensuing 47 years, little has been added to the technique of total pneumonectomy. . . .”

Because of their pioneering contributions to the conclusive technique for total pneumonectomy, I urge that appropriate attention be paid to Edward Archibald and William Rienhoff, Jr., as the “Fathers of modem pneumonectomy,” equally with the other pioneers in thoracic surgery.

John J . White, M.D., C.M. Division of Pediatric Surgery Albany Medical College of Union University Albany, NY 12208

References 1. Lindskog GE: A history of pulmonary resection.

Yale J Biol Med 30:187, 1957 2. White JJ: Edward Archibald and William

Rienhoff, Jr.: fathers of the modern pneumonec- tomy: an historical footnote. Surgery 68:397, 1970

Editor‘s Reply When claims of priority arise, which they inevitably do, we always refer readers to Dr. Franz Ingelfinger’s excellent editorial in The New England Journal of Medicine (290:740, 1974), where he discussed his reasons for never accepting claims of priority.

Decreased Bleeding with PEEP To the Editor: In a recent article, Ilabaca and co-workers [Ann Thorac Surg 30:281, 19801 reported decreased bleed- ing of patients ventilated with positive end-ex- piratory pressure (PEEP). The concept of increased intrathoracic pressure acting as an internal hemostat also had been raised by some members of our De- partments of Thoracic and Cardiovascular Surgery, and Cardio-Thoracic Anesthesia.

To test this hypothesis, we designed a prospective, randomized study* that included 80 patients who underwent elective coronary revascularization. Half of the patients had controlled mechanical ventilation and 10 cm H,O of PEEP. The other half had controlled mechanical ventilation and zero end-expiratory pres- sure. Our results conflict with those reported by Ilabaca and associates: we found no difference in the amount of postoperative blood loss in either group.

It is well known that PEEP can have adverse he- modynamic effects. Therefore, we would not rec- ommend the use of PEEP to control postopera- tive bleeding unless additional, properly controlled studies support the findings of Ilabaca and co- workers.

Andrew Zurick, M.D. Jorge Urzua, M.D. Michel Ghattas, M.D. Delos Cosgrove, M .D. Department of Cardio-Thoracic Anesthesia Cleveland Clinic 9500 Euclid Ave Cleveland, OH 44106

“Zurick AM, Ghattas MA, Cosgrove DM, et al: Failure of PEEP to decrease postsurgical bleeding. In preparation.

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