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.