FIFTY YEARS OF THORACIC SURGERY*

JOHN ALEXANDER, M.D. Professor of Surgery, University of Michigan Medical School ANN ARBOR, MICHIGAN

NESTHESIA, asepsis and antisepsis American, wrote of “the extreme inherent gave the surgery of fifty years ago a diffrcuIties and dangers which must be met A firm foundation upon which to in our attempts to invade the thorax,” and build. Thoracic surgery, of course, shared Taeufert, a German, asserted that surgeons in the stimuIus these three great discover- were we11 aware that most operations in the ies gave to experimenta and cIinica1 sur- chest, perhaps with the exception of empy- gery but the advance of thoracic surgery ema operations, will give onIy Iimited was necessariIy heId in abeyance unti1 resuIts, whiIe Stephen Paget, an EngIish- roentgenoIogy was discovered in 1893 and, man, introduced a book, “The Surgery of to a Iess extent, unti1 bronchoscopy, esoph- the Chest,” which he pubIished in 1896, by agoscopy, thoracoscopy, bronchography saying that the time was ripe for the and respiration under differentia1 pressure presentation of the vaIuabIe facts he had were stiI1 Iater made avaiIabIe. coIIected “because there are signs that we These tooIs are now used aImost daiIy in have reached a stage in this portion of our every active thoracic surgery cIinic and are art beyond which, on our present Iines, we rightIy considered as indispensabIe. WhiIe cannot advance much further.” Manning reading many case histories of fifty years wrote in 1894, “The Iungs were among the ago, I was constantIy aware of the over- Iast [interna organs] to receive systematic wheIming difficuIties the clinicians of that treatment by operations” and he added time faced in attempting to determine the that such operations were few, having nature, size and exact position of intra- foIIowed experiments on animaIs or having thoracic Iesions without the use of roent- been undertaken as a Iast resort in incur- genology and bronchoscopy; and it is not abIe cases. Only WiIIiam LeMoyne WiIIs, surprising that the scope of thoracic sur- professor of descriptive and surgica1 anat- gery was then greatIy limited and that the omy at the University of Southern CaIi- clmrca1 resuIts were shockingIy bad when fornia, among the authors whose writings judged by present-day standards. The of fifty years ago I have read, expressed an difficulty of exact IocaIization of a smaI1 or optimistic opinion about the future devel- even medium-sized puImonary abscess for opment of thoracic surgery, predicting that surgica1 drainage by physical signs alone, with improvements in surgica1 methods the without the aid of roentgenoIogy, is appar- successfu1 partia1 Iobectomies he carried ent to the innumerabIe surgeons who have out experimentaIIy on animaIs would, experienced difficuIty in IocaIizing smaI1 within ten years, be justihabIe in man and abscesses even with the combined use of that they wouId be as successfu1 as ovar- physica signs, x-ray and bronchoscopy. iotomy, when performed by competent The probIems presented in an attempt to surgeons. remove an intrabronchia1 foreign body It is of interest that fifty years ago (I 890) without the aid of bronchoscopy or roent- David W. Cheever published an articIe, genoIogy may readiIy be appreciated. “Old and New Surgery,” in the Boston So great were- the obstacIes to progress MedicaI and SurgicaI JournaI, in which he from the groping thoracic operations of discussed with justifiabIe satisfaction the fifty years ago that DeForest WiIIard, an great surgica1 progress that had been made *From the Department of Surgery, University of Michigan. 217 218 American fournal of Surgery Alexander-Thoracic Surgery JANUARY,1941 during the preceding fifty years. He spoke that spontaneous absorption of the pus with gratitude of the boon of anesthesia wouId occur, and an aImost equaIIy strong and antisepsis, which had been introduced body of opinion opposed to the indefiniteIy during that fifty-year period, and of their proIonged needIe aspiration of pus. enabIing a surgeon to operate without haste AIthough the diagnosis of empyema was and without fear of the terribIe conse- IargeIy based upon the ascultatory and quences of a graveIy infected wound. He other we11 known methods of physica pointed out the frequency with which examination, severa physicians pubIished pyemia, phIebitis, erysipeIas and prolonged pIeas for the frequent earIy use of expIora- wound suppuration foIIowed the operations tory needle aspiration as a diagnostic of that earIier period, the frequent neces- measure in doubtful cases, rightIy reason- sity of amputation for infected compound ing that earIy diagnosis and the earIy fractures, and the use of a stab incision for institution of adequate treatment wouId the division of a constricting hernia1 ring greatIy improve the end results. Goggans, because of the virtua1 certainty that an an American, cited his own experience of open dissection wouId cause suppuration. 168 aspirations of the pIeura1 cavity for a The tremendous progress that has been variety of purposes, without iI effect. made in thoracic surgery during the Iast He aspirated one empyema seventy-three fifty years is indicated by the Iimited scope times before he reaIized that, tube drainage of the surgery of the chest at the beginning was necessary! of this period and the fact that now virtu- As long as fifty years ago severa sur- aIIy every disease affecting the chest has geons recognized the fundamentaIIy impor- been successfuIIy operated upon. When the tant fact that needIe aspiration of the American JournaI of Surgery was estab- pIeura1 Auid during the earIy days of an Iished fifty years ago thoracic surgery was empyema gave time for the formation of Iimited to the treatment of injuries, pIeura1 firm pIeura1 adhesions at the Iimits of an and pericardia1 empyema, necrosis of bone, empyema cavity that had been reduced in abscess of the Iung, neopIasms of the size by the aspirations. When surgica1 thoracic waI1, drainage of tubercuIous drainage was carried out after these adhe- cavities and hydatid cysts, diIatation of sions had formed, onIy a localized abscess esophagea1 strictures and the remova of cavity, not the entire free pleura1 cavity, intrabronchia1 foreign bodies. was opened. EarIy drainage of an infected The advances that have been made dur- free pIeural cavity is notoriously dangerous ing the Iast fifty years in the whoIe fieId of and is IikeIy to Iead to chronic empyema. the medica sciences have been of particular These sound principIes were IargeIy lost service to thoracic surgery, enabIing it to sight of unti1 they were firmIy estabIished soIve probIems that had scarceIy been on experimenta grounds and we11 pubIi- seriously considered fifty years ago. The cized at the time of the WorId War by the resuIts of treatment of every surgica1 Empyema Commission of the United disease of the chest have been vastIy im- States Army, of which Commission Evarts proved during this fifty-year period. OnIy A. Graham was the chairman. did the management of empyema begin to In the earIy ISgo’s, as in 1940, there was approximate the modern treatment of this little agreement as to the best type of surgi- condition. caI drainage and, incidentaIIy, there was much discussion as to whether antiseptic EMPYEMA irrigations were vaIuabIe or dangerous. A The articIes pubIished in 1890 and I8gr few surgeons advocated onIy intercosta1 revea1 a strong body of opinion opposed to incision. In this country many advocated the then recentIy prevaIent practice of not the use of a tube in an intercosta1 incisidn, interfering with an empyema, in the hope whiIe abroad the majority of surgeons pre- NEW SERIESVOL. tt, No. 1 AIexander--Thoracic Surgery American Journal or Surgery 219 ferred the resection of a part of a rib foI- cavity, an increase in the negative pressure Iowed by tube drainage. In Germany there by means of a pump is IikeIy to do so. was strong support of BuIau’s water-sea1 tube drainage through an intercosta1 inci- PULMONARY ABSCESS sion, although some surgeons compIained The diffIcuIties invoIved in distinguishing of the frequency with which the smaI1 tube puImonary abscess from bronchiectasis or became occIuded by fibrin and dkbris. One empyema with bronchopIeura1 fistuIa, and surgeon heId open a drainage wound with in exactly IocaIizing an abscess, before hooks that were kept taut by an attached x-rays were available, as we11 as the reIa- rubber tube passed around the chest. tiveIy primitive surgica1 technic used, made In order to determine the Iower posterior the surgica1 treatment of pulmonary ab- Iimit of an empyema, Kuster made a smaI1 scess very unpopuIar. Among those sur- anterior incision through which he probed geons who coIIected the records of the the cavity for the best site for dependent known cases of surgica1 drainage, Rune- drainage, but the simpIer method of deter- berg, a German, found the Iargest number mination of this site by aspiration was -forty. Fewer than haIf of these patients aIready known, as was the fact that a were cured or improved. WiIIard found the postoperative eIevation of the diaphragm outcome had been successfu1 in six of thirty might occIude a drainage tube that had coIIected cases; SI awyd found three re- been pIaced too Low. coveries among thirteen cases and Seitz With regard to the treatment of tubercu- four among nineteen. Gaston wrote in I 890 Ious effusions and empyemas there was no that there were thirty-six cases on record unanimity of opinion and no conception of and that “When S. Seabury Jones en- the fact that different types of empyema countered his first case nine years ago, he required different forms of treatment. was unable to find any reference to the Chronic tubercuIous and nontuberculous subject whatever in any of the text books. empyema was often we11 handIed by an His second case was observed in 1886.” Estlander or Schede type of thoracopIasty The effect of the d%icuIty in exactIy if proIonged adequate drainage had faiIed IocaIizing an abscess was to postpone to bring about a cure. drainage unti1 the patient had become AIthough certain writers of fifty years septic or unti1 the abscess had become so ago understood some of the principIes of Iarge that it couId be readiIy Iocalized by treatment of empyema, onIy Rickman aspiration. At this time the prognosis was GodIee of EngIand, among the authors I obviousIy bad in a great majority of the have read, seems to have understood the cases. LocaIization and drainage of second- disease so we11 that he managed his cases of ary abscesses were rareIy, if ever, under- empyema much as we do today. We now taken. GodIee stated that (in such Iate recognize the importance of earIy diag- cases) surgica1 drainage produced improve- nosis, and of aspiration until firm adhesions ment onIy to a certain point and that have formed which IocaIize the pIeura1 hemorrhage, cerebra1 abscess or other abscess. We then resect a portion of a rib compIications might then occur, or that the at the bottom of the empyema cavity, patient wouId have to use a drainage tube usuaIIy in the posterior axiIIary line, and indefinitely. make an incision through the bed of the rib GodIee recognized the danger that a onIy large enough to admit snugIy a tube diagnostic aspiration might cause an empy- as wide as one’s thumb, the outer end of ema if pIeura1 adhesions were not compIete this tube being placed beneath water in a at the site of the aspiration. He recom- jar. If this air-tight, negative-pressure type mended the suturing of the Iung to the of drainage does not soon cause expansion thoracic waI1 if adhesions were not found at of the Iung and compIete obIiteration of the the time of operation. 220 American Sournd of Surgery Alexander-Thoracic Surgery JANUARY,rg41

The technic of drainage was variously of chlorine gas, insuEIations of chIoride of performed. With or without the resection goId and sodium and subcutaneous injec- of a part of a rib, needle aspiration was tions of iodoform or creosote were variously foILowed by the introduction of a scaIpe1, tried. Weak soIutions of tincture of iodine, trocar or other instrument into the abscess. carboIic acid, siIver nitrate, corrosive A tube was then introduced into the subIimate, saIyciIic acid and other chemi- abscess, perhaps after emargement of the caIs were injected directIy into tuber- track with a finger or forceps. cuIous lungs, or into tubercuIous cavities ProbabIy the greatest advance made after aspiration of their contents. Some during the Iast fifty years in the treatment physicians found such treatment useIess, of pulmonary abscess was the accuracy of whiIe others found occasiona sympto- diagnosis and Iocahzation made possibIe by matic improvement. x-rays. This accuracy has increased to the MosIer, in Germany, and de CCrenviIIe, present time with the widening apprecia- in SwitzerIand, revived an interest in the tion of the value of IateraI and obhque, as surgica1 drainage of tubercuIous cavities we11 as postero-anterior, projections of the but, apart from a few cases of symptomatic x-rays that has occurred. Bronchoscopy has improvement, the resuIts proved to be made an important contribution to the disappointing. During the Iast few years determination of the segment of the Iung reIativeIy good resuIts have been obtained occupied by the abscess, and in the detec- from drainage (by direct incision or by a tion of foreign bodies, bronchia neopIasms catheter introduced by means of a trocar and other forms of bronchia occIusion, and cannuIa) of certain types of cavity, which are not rare etioIogic agents. particuIarIy that in which the draining Bronchoscopy and postma drainage bronchus has become obstructed. have proved successfu1 in the nonsurgica1 During the last fifty years the greatest treatment of a smah group of patients and, advances in the treatment of puImonary through the teaching of Neuhof, increasing tubercuIosis have been through the uni- recognition has been granted to the vaIue versa1 adoption of coIIapse therapy and of of very earIy surgica1 drainage of a pul- the sanatorium, and through efforts to monary abscess in which a brief trial of suppIy a sufficient number of sanatorium nonsurgica1 measures has faiIed. Accurate beds to meet the demand for them. AI- IocaIization makes possibIe adequate drain- though ForIanini’s first publication recom- age after the remova of a short segment mending pneumothorax appeared in I 882, of onIy one rib and, as pIeura1 adhesions and de CerenviIIe’s report of his first are often present where the abscess is “reIaxing thoracopIasties” appeared in most superficia1, a one-stage operation is 1885, an active interest in coIIapse therapy often possibIe. These recent advances in did not arise unti1 approximateIy thirty diagnostic methods and surgica1 technic years ago. The first extensive thoraco- have improved the resuIts of treatment pIasty, that of Brauer and Friedrich, was tremendousIy. performed in 1907; the improved WiIms- Sauerbruch modification was introduced in PULMONARY TUBERCULOSIS 191 I ; the modern type of thoracopIasty Fifty years ago the treatment of pul- was not performed unti1 1928. monary tuberculosis was fumbling and Open thoracotomy for the division of whoIIy inadequate. The sanatorium princi- offending pIeura1 adhesions in cases of pie had been proposed but not wideIy pneumothorax was proposed by Friedrich adopted. Koch had recentIy discovered the in 1908, and the operation of cIosed intra- tubercIe baciIIus and there was great pIeura1 pneumonoIysis by means of a enthusiasm over the possibiIity of a cure of thoracoscope was introduced by Jacobaeus the disease with tuberculin. InhaIations in 1913. Paralysis of the diaphragm NEW SERIES VOL. LI, No. I AIexander-Thoracic Surgery American Journal of Surgery 221 through operations on the phrenic nerve the tube. A better understanding of was introduced by Stuerz in rgr I. Tuffrer, thoracic physioIogy has Ied to the tight in I 893, performed an extrapIeura1 pneumo- cIosure of such wounds or, if drainage thorax operation, which was sporadicahy shouId be necessary, to the use of an air- repeated by others until the operation was tight, water-sea1 drainage system. The revived without enthusiasm by Nissen in greatIy improved results that have been 1931, and with enthusiasm by MonaIdi in produced in recent years in the treatment 1933. The extrapIeura1 separation of the of neoplasms of the thoracic waI1 have been Iung from the thoracic waII and the fiIIing due not only to the technica improvement of the space created between them with just mentioned but to the earIy diagnoses gauze was carried out by Sarfert in rgo I; and operations that the universa1 use of the Tuffrer used a fihing of a free fat graft in roentgen rays has favored. 1910 and Baer used a paraffrn mixture in INTRATHORACIC NEOPLASMS 1913. A sound knowIedge of the effect of these The difficulty of diagnosis of ‘intra- operations upon the different types of thoracic neopIasms before the first cIinica1 tubercuIous Iesions was acquired sIowIy, as use of the roentgen rays in 1896, and of was a proper evaIuation of the inter-rela- bronchoscopy and esophagoscopy stiI1 Iater, tionship between the different operations, had the effect of making the surgical treat- and their usefuhress or Iimitation in the ment of such Iesions reIativeIy rare. Diag- management of bilateral Iesions. OnIy dur- nosis depended upon the clinica history, ing the Iast ten or tweIve years has coIIapse physica signs and needIe aspiration. The therapy been used in the leading sanatoria materia1 recovered by aspiration, whether of the worId with a fuI1 appreciation of its solid or fluid, might Iead to a diagnosis. vaIue and Iimitations, and with the produc- LittIe was published about neopIastic tion of astonishingIy good resuIts. The tumors of the lung and mediastinum and number of patients so treated has been too there was a genera1 feeIing that the great smaI1, in reIation to the tota number of majority were either sarcomas or carci- patients treated for tubercuIosis, greatIy nomas, for which surgical success wouId be to affect the tubercuIosis death rate. It is onIy a matter of Iuck, and the onIy routine probabIe that the death rate wiI1 be greatIy treatment for which was the aspiration of a reduced when al1 sanatoria use coIIapse comphcating pIeura1 effusion. The drainage therapy with maxima1 efficiency. of an occasiona dermoid cyst was reported and, incidentaIIy, hydatid cysts were oper- THORACIC WALL NEOPLASMS ated upon with reIative frequency. About Operations on thoracic wal1 neopIasms fifty years ago PhiIIips cohected 138 cases were performed rather frequently fifty of hydatid cyst of which thirteen were years ago. LittIe mention was made of operated upon with nine recoveries and benign Iesions and, apparently, most were four deaths; he found that aImost a11 those sarcomas. The successful removal of some not operated upon, or mereIy aspirated, huge tumors of the ribs or sternum was died. reported, as we11 as a considerabIe number In an 1892 issue, of the British Medical of surgicaIIy fata cases. Among the articIes JournaI, Rickman GodIee wrote as foIIows: of that period, I note that the surgeons “Amongst a good many cases of cancer of often used an open drainage tube in the the lung or mediastinum, I have never yet thoracic waI1 after an operation that met with one that at a11 suggested the opened the pIeura1 cavity for an uninfected possibiIity of removal by operation. Such lesion, and I suppose that some of the operations have, however, been suggested, deaths were due to a “sucking pneumo- but the circumstances under which there thorax” that resuIted from the presence of can be even a chance of success must be 222 American Journal of Surgery AIexander-Thoracic Surgery JANUARY, ,941

exceedingly rare; and thus-aIthough, in mained, the thorax being compIeteIy fiIIed animaIs, portions of Iung may be Iigatured by the remaining portions of the Iungs. off and removed without producing any At approximateIy the same time Quenu very serious symptoms, I do not think this and Hartmann proposed, on the basis of is at a11 a promising branch of surgery” human cadaver experiments, the paraverte- and, in 1894, J. A. Manning wrote, bra1 resection of two-centimeter Iengths of “Tumors, which are so eagerIy attacked the third, fourth and fifth ribs as affording everywhere eIse, are respected when they a better surgica1 approach to Iesions in the invoIve the Iung, save onIy those with ffuid dome of the thorax than the usuaIIy pro- contents.” In 1883, however, KriienIein posed infracIavicuIar incision. AIthough successfuIIy removed a portion of a Iung this incision had not then been used in containing a waInut-sized recurrent sar- man, it has been rediscovered a number of coma six months after having resected the times during the last fifty years. A stiI1 huge primary tumor from the thoracic waI1, greater contribution to the future success- and in I 89 I TuffIer successfuIIy resected the fuI surgica1 management of intrathoracic apica portion of a man’s lung for a tuber- neopIasms and other conditions, was the cuIous Iesion. SeveraI indirect references report by TuffIer and HaIIion, in 1896, of were made during this period to the suc- their animaI experiments in preventing cessfuI remova of the traumaticaIly herni- coIIapse of the Iung by the use of chIoro- ated portion of a Iung. WiIIiam LeMoyne form insumation through an intratrachea1 WiIIs, of Los AngeIes, Iearned from W. W. tube introduced through the Iarynx. They Keen, RosweII Park, Senn and Fenger in found that this procedure enabIed them to I 892 that none of them had ever removed a operate on the esophagus, vagus and part of a Iung, except in cases of traumatic sympathetic nerves and other intrathoracic puImonary herniation, abscess “or simiIar structures without upsetting the puImo- condition.” nary circuIation.. This discovery is one of the A number of surgeons occupied them- vitaIIy important foundations upon which seIves fifty years ago with the experimenta the successes of modern thora.cic surgery remova of portions of a Iung. BogIiano, have been built, and yet it was not put to Patek and SaiIer, of PhiIadeIphia, under- cIinica1 use unti1 many years Iater. took to remove whoIe Iobes from dogs but The first successfu1 remova of an entire the animaIs died from gangrene of the Iobe of a Iung in man was accompIished by stump and empyema. They succeeded, KGrte in 1907. The patient was suffering however, in three partia1 Iobectomies and from bronchiectasis; Kijrte first removed one tota Iobectomy by drawing the part the right Iower Iobe and, as puImonary of the Iung to be resected out of the chest secretions continued, Iater’removed a part through a very short intercosta1 incision of the right middIe Iobe and the patient and suturing the stump of the resected part made a complete recovery from his disease. in the intercosta1 incision. TuffIer’s experi- Another dramatic advance was made in ment, reported in 1891, is especiaIIy note- 1931 when Nissen, of BerIin, successfuIIy worthy. In a dog he resected two-thirds of removed an entire bronchiectatic Iung; the the superior Iobe of the right Iung and six second successfu1 tota pneumonectomy days Iater one-third of the superior Iobe of was that of Cameron Haight, of Ann Arbor, ‘the Ieft Iung, suturing the stumps into the in 1932. The foIIowing year Evarts Graham incisions in the intercosta1 muscIes. He was the first successfuIIy to remove an kiIIed the dog seventeen days after the first entire Iung for carcinoma; the patient is operation and found compIete pIeura1 ad- now, more than seven years after the opera- hesions around the right-sided stump and tion, we11 and free from any evidence of complete, but Iess we11 organized, adhesions recurrence. Graham’s successfu1 case repre- on the Ieft side; no pneumothorax re- sented the first curative treatment of New SERIES VOL. LI, No. I Alexander-Thoracic Surgery American Journal of Surgery 223 cancer of the Iung in the history of medicine successfulIy sutured in patients desperately and during the last seven years has hugeIy ill of Ioss of bIood or cardiac tamponade. stimuIated an interest in the earIy diag- Dramatic advances, such as were not nosis of cancer of the lung. dreamed of fifty years ago, have been made While the remova of benign and malig- in cardiac surgery during recent years. In nant neoplasms of the Iung and mediasti- 1923, ElIiott Cutler divided the two leaves num was a great rarity fifty years ago, it is of a stenotic mitral valve. Although this a commonplace occurrence today in active operation has never been successfully re- thoracic surgery clinics, where the mortal- peated, Cutler’s first patient survived the ity rate is surprisingly low and the percent- operation, was clinicalIy improved and age of cures high. Such an advance has been lived for severa years. A considerable made possible by the use of diagnostic number of successfu1 puImonary emboIec- roentgen rays, endoscopy, differentia1 pres- tomy operations have been reported since sure anesthesia and, importantIy, a proper Kirschner’s first successful case in 1924. appreciation of thoracic physiology in rela- Sauerbruch, in 1931, resected an aneurysm tion to the preoperative, operative and of the right ventricle, “the size of a child’s postoperative care of patients requiring head,” and three and a half months later large intrathoracic operations. the patient appeared to be entirely weI1. A large number of cures of constrictive cardiac disease by the operation of peri- HEART AND PERICARDIUM cardiectomy have been produced during Fifty years ago a number of successful the present century. The experimental and cases of aspiration of, or drainage of, effu- cIinica1 work of CIaude Beck during recent sions or empyemas of the pericardial cavity years in coronary disease and cardiac con- were reported and J. McF. Gaston wrote, tusion is outstanding; as is well known, the “Surgery has thus, with impunity, invaded various operations he has devised in order the citadel of life.” F. P. Percher, however, to improve the blood suppIy of the myo- complained that, “Throughout the country cardium, has given great relief to a number a vast number of cases [of pericardial of patients suffering from grave coronary effusion] escape detection and treatment, occlusion. The successful ligation of a either medica or surgical.” Unfortunately patent ductus arteriosis by Gross and this is still true today, in spite of the advent Hubbard, in 1938, -was soon foIlowed by a of the x-ray, because a pericardial effusion considerable number of similar successful or empyema is often not thought of as a operations by Jones and Dolley, and by compIication of a serious illness and is not others. recognized until an autopsy is performed. Although fifty years ago pathoIogists had FOREIGN BODIES IN THE BRONCHI found evidence of heaIed wounds of the Before x-rays were available the localiza- heart, I know of no record of that time in tion of foreign bodies, especially those in which suture of a cardiac wound had been the bronchi, was difficult and inaccurate, attempted. Roberts made a strong plea for being dependent upon physical signs and, the making of an attempt but Paget ex- at the time of operation, upon palpation by expressed his opinion that suture was probing. Fifty years ago, before broncho- not practical because, he believed, small scopy became available, the removal of wounds do not need suture and large ones those foreign bodies that could be IocaIized wouId kil1 the patient before suture was was obviously difficult and the attempt fre- possible. Rehn, however, in 1897, success- quently failed. As some foreign bodies can fully sutured a cardiac wound in a man who be expelled either through the rima glottidis apparently was about to die. In succeeding or through a tracheotomy incision, and as years a Iarge number of wounds have been some patients with bronchial foreign bodies 224 American Journal of Surgery AIexander-Thoracic Surgery JANUARY, 1941 are not acuteIy iII, there was an incIination than it is at present with the aid of x-rays not to attempt remova unIess the situation for IocaIization and the esophagoscope for was desperate, or at Ieast unti1 pneumonia, direct inspection during the seizure of the or puImonary abscess or gangrene seemed object with speciaIIy designed instruments. imminent. RemovaI was undertaken by One of the most fascinating accompIish- means of various types of forceps, hooks ments of modern surgery was the successfu1 and spoons introduced through a tracheot- compIetion of an antethoracic esophagus, omy incision. In one case a Iong corkscrew buiIt of skin and jejunum, by Herzen, in was made to engage an impacted cork but IgoT, for a patient who had an impassabIe its remova proved impossible. DeForest esophagea1 stricture. Four weeks after WiIIard, in 1891, carried out experiments operation the patient was abIe to eat on dogs in order to determine whether it bread, chopped meat, eggs, et cetera, pass- wouId be feasibIe to remove intrabronchia1 ing these foods through the surgicaIIy con- foreign bodies by means of a transpIeura1 structed tube in front of the chest into the approach and an opening of the bronchus stomach. in the hilum of the Iung. He found the risk Another dramatic operation was the of severe hemorrhage enormous, and that successfu1 remova of a cancerous esopha- Ieakage of air from the incised and sutured gus in rg I 3 by Franz Torek. The esophagus bronchus lead to tension pneumothorax was divided we11 beIow the neopIasm, the after cIosure of the chest; most of the dogs Iower divided end was invaginated and the he operated upon died. neopIasm and upper thoracic esophagus With the advent of x-rays and broncho- were dissected from the mediastinum and scopy and the deveIopment, chieffy by drawn out of an incision in the anterior ChevaIier Jackson, of ingenious instru- cervica1 triangIe, where the tumor and ments for the grasping of a11 sorts of foreign redundant esophagus were cut off and the bodies, attempted remova of foreign esophagea1 stump sutured to the skin. In bodies has become highIy successfu1 and 1925, Torek reported that more than eIeven safe. When the procedure is carried out years after operation the patient, then before serious puImonary infection has seventy-eight years of age, was a11 right and deveIoped, the patients usuaIIy recover happy, and that any food that was cut or compIeteIy. RareIy, foreign bodies become chewed into a fineIy divided state passed Iodged in a part of the Iung that is inacces- through the rubber tube that was used to sibIe by bronchoscopy, or become so firmly connect the cervica1 esophagostomy and imbedded by scar tissue in accessibIe the gastrostomy openings. bronchi that they cannot be disIodged with safety. In such cases, the periphera1 foreign CONCLUSION bodies may be removed by pneumonotomy, Even the factua1 narration of the changes but those in large bronchi may require in surgicai procedure that have taken pIace partia1 or tota Iobectomy, which may aIso in a seIected group of thoracic conditions be required because of a severe compIicat- does not adequately express the tremen- ing bronchiectasis. dous advance that has taken pIace in the practice of thoracic surgery during the Iast ESOPHAGUS fifty years. The most striking change has Fibrous or carcinomatous stricture of the not been the improvement in the technic esophagus was we11 managed fifty years of individua1 operations but the fact that ago by bouginage or intubation. As esopha- today operations are being successfuIIy goscopy was not then avaiIabIe, however, performed in great numbers for aImost instrumentation was carried out in diffrcuIt every disease affecting the thoracic organs, cases through an esophagostomy opening. whereas fifty years ago thoracic operations Obviously, the remova of foreign bodies in were reIativeIy rare and were Iimited to the the esophagus was infinitely more dificuIt treatment of a very few conditions.