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SURGERY WITHIN THE PAST FOURTEEN YEARS3.
BY
WILLY MEYER,
M.D.
NEW
YORK
MR. PRESIDENT AND GENTLEMEN: - I am sure the members of the Council of
our Association will not consider it a breach of secrecy on my part - the
secrecy which usually surrounds the deliberations of such a body - if I say a
few words with reference to how it came to pass that I am standing before you
to-day.
It was our intention to
divide this review, and we had asked Dr. W. S. Halsted of Baltimore and Dr.
Henry H. Janeway of New York each to consider one half of it. Unfortunately,
the heavy work on the shoulders of these gentlemen did not permit them to
accept our proposition. We then communicated with Dr. Samuel Robinson of Santa
Barbara, Cal., who, as you know, up to a late date represented thoracic surgery
at the Mayo Clinic. Dr. Robinson also was unable to comply with our request. In
this dilemma our aggressive president, at the time of the last council meeting,
divided the gordian knot and simply. - I would almost say - "charged" me,
although he was courteous enough to "ask" me, to take over this part of the
program. As a council member I could not refuse, and so I stand before you
to-day, but without any MS. With all the other work on my hands to be
fulfilled, it was simply impossible to prepare notes, and so I must ask you to
be satisfied with my extemporaneous efforts.
What I intend to present is a review of the evolution of thoracic
surgery within the past fourteen years, or, to word it differently, "a
bird's-eye view of the present status of thoracic surgery."
It is a little more than a century ago that a French physician, by the
name of Itard, first described what he then, and later the medical world,
called "acute pneumothorax." If one side of the thorax is wounded and the
pleural cavity is opened, a collapse of the lung on the wounded side is the
immediate and inevitable consequence, except previously formed adhesions
between pulmonary and costal pleura prevent such a collapse. Now, what is it
that happens when the thorax is opened, let us say, e.g. by a stab wound
in an intercostal space in an affray on the street? Immediately air rushes into
the pleural cavity and this normal atmospheric pressure, being greater than the
normal pressure within, compresses the lung, for, as you all know, the lung,
under physiologic conditions, is kept distended in the thorax by virtue ofnegative pressure
that exists within the chest. Therefore, air rushes into the pleural cavity as
soon as it is opened, thus disturbing the physiologic equilibrium. On account
of its elasticity the lung contracts to a very small organ around its hilum.
Air fills the space formerly occupied by the lung. This condition, with its
immediate clinical pathologic consequences, is called "acute pneumothorax." It
has been the stumbling block for almost a century to the proper development of
the surgery of the chest. I cannot, of course, here go into details and state
what will happen in a case of acute pneumothorax. I will merely say that soon
after the occurrence of a unilateral acute pneumothorax and its first violent
sequelae with reference to frequency and depth of respiration, dyspnea sets in.
This is principally due to the so-called "fluttering (or flapping) of the
mediastinum." The latter, and with it the heart and the large blood vessels,
are pushed toward the other, unopened, side, with each inspiration, on account
of the increased atmospheric pressure over the exposed lung, thus reducing the
space of the opposite pleural cavity. With expiration the mediastinum returns
to its former position or is pushed further outward. The mechanism prevents
proper inspiratory distension and the necessary expiratory collapse of the lung
on the healthy side. In other words: besides the total collapse of the lung on
the injured side, the normal exchange of the gases, also on the opposite side,
is interfered with. Carbonic acid is retained in the blood, and this retention
soon produces dyspnea and irritates the circulatory center which, in turn, increases
the volume of blood in the collapsed lung. It usually does not last long before
the one lung is unable to uphold the necessary function of life. The
accumulation of CO, with its deleterious effect increases, finally ending in
the patient's death.
As said before, it is this danger of an acute pneumothorax that has
been the stumbling block in the development of intrathoracic surgery, and
nothing else.
True enough, surgeons everywhere went ahead regardless of the risk
involved. If you look through the surgical literature you will find any number
of intrathoracic operations recorded, particularly resections of the chest wall
for tumor, and extirpation of lobes of the lung, carried out successfully,
without keeping the lungs properly inflated. But in manyof these cases it was
the accidental presence of adhesions or bands between the lung surfaces and
chest wall that prevented a total collapse of the- lung and, therewith, the
appearance of the acute pneumothorax with its sequelae; or the surgeon pulled
on and steadied the lung (Mueller), preventing in this way the mediastinal
fluttering. Certainly, such operations speak for the courage of the surgeons.
Others, mindful of the imminent danger, made use of apparatus that
promised to avoid the acute pneumothorax. Thus Quėnu of Paris, in the
middle of the '90's of the last century, worked out an apparatus on the lines
of a diver's helmet, in which the patient's head was placed together with a
sponge saturated with chloroform; and Tuffier of Paris soon after advocated the
use of insufflation for the performance of operations requiring the incision of
the pleura. They tested their suggestions by animal experiments which one of
them at least followed up by operations on the human subject in the hospitals
of Paris.
America, too, has a right to be proud of what has been accomplished in
this field. I am referring to the pioneer work done by Fell with the O'Dwyer
tube, and the apparatus constructed by Matas of New Orleans on the basis of the
Fell-O'Dwyer tube, for artificial respiration. In 1898 Parham of New Orleans
made use of Matas' apparatus in a resection of the chest wall for tumor, the
first recorded thoracic operation under differential pressure in this country.
His patient recovered.
However, this and similar cases remained isolated. They were
interesting cases, and there it ended. More concerted action resulted when the
differential pressure idea was conceived anew by F. Sauerbruch in 1903. He had
been charged by his chief, the late Prof. v. Miculicz of Breslau, to find a method
which would make work on the thoracic viscera as safe as that in any other
cavity of the human body. As you all know, the construction of "Sauerbruch's
Negative Chamber" in the following year was the result of this work. Thus, the
year 1904 marks the real beginning of thoracic surgery by the transpleural
route. The apparatus designed for experimental work consisted of a box with the
animal's head outside and the body inside. A cut-out in one of the short sides
of the rectangle served for the passage of the neck. The air pressure within
was reduced, by machinery, to a degree equaling the normal physiological
conditions within the chest. This having been done, transpleural incisions
could be made in every intercostal space, right and left, or large flaps of the
chest walls be raised: the animal continued to breathe as if nothinghad happened. When
conditions were reversed and the animal's head was put inside of the box and
the body outside and the air pressure within the box was correspondingly
increased, the same phenomena were observed. On the basis of the artificial
reduction of air pressure within the chamber below the normal atmospheric
pressure, 760 mm. mercury, this operative procedure was called "operation under
negative pressure"; the reverse, "operation under positive pressure." The
method as such was termed "operating under difference in air pressure;" or,
briefly, "under differential pressure."
It was but natural that an aggressive and scientific man like the late
Prof. v. Mikulicz at once tried to put the method into practical use. It took
but a few months before the Breslau Clinic was prepared to operate on human
beings within a chamber of about 500 cubic feet contents, constructed of iron
and glass. The results were published briefly by Sauerbruch in 1904 and created
a stir in the surgical world. Whoever could went to Breslau to see what they
were doing there. I may mention that I personally was fortunate enough in 1904
to see Sauerbruch do a resection of the esophagus in a dog in the negative chamber,
an account of which I briefly laid down in a paper read before the New York
Surgical Society in the same year. Soon the chamber was introduced in many
capitals of Europe. At our hospital we thought of importing one, but Sauerbruch
himself advised me not to do it, because the chamber, expensive as it was, had
not been sufficiently developed. A few years went by.
In 1908, just ten years ago, we assembled here in Chicago for the
meeting of the American Medical Association. One of the topics for discussion
before the Surgical Section was: "Intrathoracic Surgery." Sauerbruch himself
had come over as the guest of the Surgical Section. There were present also
Professor Schafer of London, and among others the two pioneers in thoracic
surgery from New York, Dr. H. H. Janeway and Dr. Nathan W. Green, the latter
our present secretary. I had the honor to open the discussion. It was a day
never to be forgotten, as we all stood there on the platform, trying to bring
out the advantages of negative and positive pressure!
As you will perhaps remember, at that time there was quite a divergence
of opinion as to which of the two methods was the better for the patient. A
physiologic society of renown had declared itself in favor of negative
pressure, for the simple reason that it was more physiologic. So we in New York
decided to try to speedily solve this question that was then agitating the
surgical world, by building a chamber,on Sauerbruch's principles, which would
allow of a quick change from one pressure to the other, without the necessity
of moving patient, instruments, and everything else. Up to that time an
operation begun under negative pressure had to be finished under negative
pressure, and if it had been commenced under positive pressure, it had to be
finished under positive pressure. You must permit me to dwell at some length on
this important point, because it alone was the guiding star which prompted us
to construct the chamber which is now at the Thoracic Pavilion of the Lenox
Hill Hospital, New York City. The apparatus was built with the help of my
brother, Julius Meyer, a consulting engineer, whom I had succeeded in
interesting in this subject. It permits of changing the pressure from negative
to positive and vice versa with the greatest ease, and without changing the
position of the patient. But we never made any experiments on the sick human
being. Why not? Because it was soon shown that positive pressure in the sick
human being was in its effect equal to negative pressure, provided the
operation did not last too long, and means were provided for eliminating the
effect of the continuous positive pressure on the right ventricle of the heart.
Further developments in methods of differential pressure followed in
quick succession at that time. First appeared the so-called "mask method,"
represented by a very ingenious, but complicated apparatus of Brat and
Schmieden, which was soon followed by that excellent device of Tiegel. In both
a stream of oxygen, supplied by tanks, carries the anesthetic to the lung. The pressure
in the lung is maintained by making the patient expire either against a strong
valve (Schmieden) or a water column (Tiegel). The latter author proved that "one
millimeter" of pressure of pure oxygen is sufficient, after the chest has
been opened, to maintain life and avoid the appearance of the symptoms of acute
pneumothorax. His apparatus is widely used in European clinics.
Almost in the same year, our honored President, Dr. S. J. Meltzer, came
out with the fruit of his work, done in conjunction with ours, his new
world-renowned and. generally accepted method of intra-tracheal insufflation.
Standing here before you, at the first gathering of the American
Association for Thoracic Surgery, and having the pleasure of seeing Dr. Meltzer
preside, I trust I may be permitted to touch upon a personal matter. Dr.
Meltzer mentioned in his inaugural address to-day that, in the discussion
following his presentation of the matter before the New York Academy of
Medicine his views were opposed, in the interest of conservatism in surgery, by
three surgeons.
Inasmuch as I was one of the three, I would, in explanation, here state
that I had been asked by the then v president of the Academy, to participate in
a "symposium on thoracic surgery." So I was obliged to write a paper, at the
time when we were just erecting the negative chamber at our hospital in the
thoracic pavilion then under construction. At that very time it was reported to
me that Dr. Meltzer had stated that in his opinion thoracic operations on human
beings could be done in a much simpler way than by working in the negative
chamber; that a catheter in the trachea and bellows was all that was needed.
He, a physiologist who had always done scientific surgical work on animals,
certainly found these paraphernalia sufficient. I personally had meanwhile seen
and learned to admire the absolutely reliable working of the mechanism of the
chamber, without the possibility of doing the slightest harm to the patient. In
my remarks on that memorable evening at the New York Academy of Medicine, I
therefore tried to impress upon my colleagues the great importance of absolute
safety. I stated that no matter what apparatus we might use in thoracic surgery
on the usually much run down human being, it must be so constructed that it
could not possibly do harm to the patient. I further stated that I would be
only too happy to personally use intratracheal insufflation as soon as it was
sufficiently perfected to render it safe under all conditions. As outward proof
of the sincerity of this statement, we set aside a large space, next to the
negative chamber and the positive pressure box in our pavilion, for thoracic
operations done with the help of differential pressure apparatus other than the
two just mentioned. I made this same explanation to our honored President
publicly before, at the Annual Dinner of the American Gastro-Enterological
Association in Baltimore, a few years ago, and I wish to bring this out again
today, also in the light of a controversy Dr. Meltzer and I had in one of the
Medical Journals of New York at that time. I want to lay stress upon the
statement that I for my part have never been in opposition, but rather in full
accord with his splendid discovery. The fact is that I personally have been
among the very first in New York to use intratracheal insufflation in thoracic
operations upon the human subject.
As a further method for the production of differential pressure must be
mentioned pharyngeal insufflation. It, too, bids fair to occupy an important
place in thoracic operations.
Thus we now possess four different useful methods for the purpose of
properly maintaining the "physiologic" working of the heart and lungs during
our thoracic work, viz., (1) the negative chamber andpositive pressure
box, (2) the mask apparatus, *(3) intratracheal insufflation and (4) pharyngeal
insufflation.
But, please bear in mind, that they all mean the application of either
negative or positive pressure, nothing else, and, that only the use of the
differential pressure method, - no matter what the apparatus - enables the
surgeon to work in the thorax with the same equanimity and tranquillity as in
the abdomen.
I have purposely dwelt at length - perhaps too much so - on the
development and importance of the use of differential air pressure in thoracic
operations; for, to my mind, it is on the thorough understanding and general
acceptance of this principle that the further evolution of this youngest and
last child of operative surgery largely depends. There are still a good many
surgeons, who claim that differential pressure is absolutely superfluous for
this kind of work, that we can open the thorax just as safely as we do the
abdomen, without any apparatus. But I say once more what I stated at a previous
discussion: take 100 patients, with no matter what kind of intra-thoracic
disease, and divide the pleura without apparatus, - I mean the "virgin" costal
pleura, a pleura that is nowhere adherent to the pulmonary pleura, - and
compare the resulting mortality from operation on these 100 patients with that
of another 100, in whom differential pressure by means of any one of the four
methods just mentioned was used. I am sure there will be a great difference.
The surgeons who did not use any apparatus will have a far greater mortality
than those who did use apparatus. I, therefore, consider it wrong at this time,
when we have at last found the means to overcome the acute pneumothorax - the
stumbling block to the safe evolution of thoracic surgery for almost a hundred
years, - I say, I consider it wrong, now, to simply dismiss the question of the
dangers of the acute pneumothorax and throw overboard, as superfluous, all the
work of the last two decades; I consider it wrong for any surgeon to-day to
refuse to accord a prominent place to differential pressure - be it with
chamber, box, mask apparatus, intratracheal insufflation or pharyngeal
insufflation - in the surgery of the chest. I also consider it wrong to draw
sweeping conclusions from the experience, gained from the treatment of war-wounds
of the chest, where conditions are altogether different than ordinarily.
Differential pressure alone has made thoracic work as safe as abdominal work;
it gives us the right, in doubtful cases, to advise exploratory thoracotomy
with almost the same assurance as we advise abdominal incision.
Then, standing on this safe basis of having accepted unconditionally
the necessity of maintaining artificiallythe physiologic difference in pressure
over the lung, after the chest has been incised, permit me to go with you as
briefly as I possibly can, over the present status of the surgery of the
various organs within the chest, as our President has charged me to-day.
What do we have to deal with anatomically? The chest wall, the pleura,
the diaphragm, the anterior and posterior mediastinum, the latter including the
esophagus, the heart with the large blood vessels (aorta and pulmonary artery)
the lungs and bronchi.
1. Chest
Wall. - Naturally, I will not speak of the acute and chronic inflammation
of the tissues that make up the chest wall, but I should mention the
traumatisms that occur in consequence of accidental fracture of the ribs,
including the wounds received in battle. However, as that also refers to the
lung in particular, I can deal with it later on.
With reference to the chest wall I will here only mention tumors
involving this area. I am sure that a number of. the surgeons present here have
done resection of the chest wall for this cause, for carcinoma, primary
endothelioma and secondary epithelioma, e.g. recurrence after extirpation of a
cancer of the breast, or for sarcoma, in this locality usually involving a
number of ribs and intercostal spaces; in brief, all tumors occurring in the
region known as the chest wall. With the help of any of the methods for the
establishment of differential pressure, we now safely enter the pleural cavity,
make out conditions with the hand introduced, and then cut out a window of any
desired size, making sure that we have operated within healthy tissue. If we
then close up the wound air-tight by carefully placed sutures, having blown up
the lung, or - better still, as I personally insist upon - using drainage in a
way which will allow airtight closure, with the lung distended, and at the same
time drain the pleural cavity, we shall see the mortality of this very simple
surgical procedure reduced almost to a minimum.
2. Pleura.
- The only type of pleural disease that interests us here is empyema. Inasmuch
as a number of papers on this subject are announced for the afternoon, I will
not go into this topic very deeply now, but would like to make a few remarks
reflecting my personal views on what I have seen in practice and read in the
literature.
The main difficulty in curing empyema promptly, i.e. to make the
lung expand so that the pulmonary pleura will again come into contact with the
costal pleura, has been that the fluid compressing it has been allowed to
remain too long before evacuation. Firm adhesions form during this period, bind
down the lung in many places, often also, in addition, amuch thickened,
chronically inflamed pulmonal pleura acts like a tight, broad envelope; not
seldom infiltrating intrapulmonary inflammatory foci will further resist the
desired expansion of the elastic lung tissue. To avoid a complicated convalescence
in empyema, Dr. Howard Lilienthal of New York has proposed the so-called "major
thoracotomy," which opens the thoracic cavity by a long, intercostal incision,
straight or curved, with or without division of a number of ribs posteriorly,
and at the same time permits investigation of the entire pleural cavity from
top to bottom.
The present war has tremendously assisted in the evolution of the
treatment of empyema. In all our many cantonment hospitals, in all the
hospitals at the front and, not the least, in the war hospitals at home,
particularly the Rockefeller War Demonstration Hospital of New. York City, this
subject has been given much study. We are looking forward with keen interest to
the presentation of the subject by representatives of the latter hospital at
this afternoon's session. It seems plausible to conclude that, if we take pains
to allow the lung to expand as early as possible and, further, take care that
all the fluid in the pleural cavity is thoroughly and continuously evacuated, a
rapidly increasing number of patients will not only be spared the annoyance of
weeks and months of sickness, but will likely be cured in a comparatively short
time. If we further employ a gentle procedure for permanent drainage, (Kenyon)
which at the same time permits of disinfecting the cavity with Dakin's solution
or dichloramine-T, and thereby dissolving or breaking into small pieces the
deposited masses of coagulated fibrin, it is to be hoped that we shall have
won. (See Annals of Surgery, August, 1918, Author, "Postoperative
Thoracic Drainage.")
3
Diaphragm. - I will not here consider the so-called "diaphragmatic
eventration," the condition, when, in consequence of the paralysis of one side
of the diaphragm, the contents of the abdomen have risen away up, but the
diaphragm as such is complete. I will just say a word on the real cases of
diaphragmatic hernia, when stomach with omentum and intestine have entered the
thoracic cavity through a real hole, a hernial aperture in the diaphragm.
At the meeting of the American Surgical Association just held in
Cincinnati, Dr. Downes of New York read an interesting article on a case of
diaphragmatic hernia. The definite diagnosis of the existence of such a
condition is naturally our first task. Formerly this was very difficult with
the help of the ordinary clinical methods of examination at our disposal.
To-day, we can prove the existence of such a hernia beyond the shadow of a
doubt. The re-rays, and particularlya stereoscopic radiograph have clearly
brought it to our eyes. In the case just cited, referring to a boy of nine
years, Dr. Le Wald of New York, the radiographist at St. Luke's Hospital, put
the boy, with a bismuth meal in his stomach, on his head. Naturally, everything
that was first in the abdominal portion of the stomach, passed now into the
supra-diaphragmatic section. The large air bubbles seen in the picture of the
patient in the erect posture above the diaphragm, became replaced by the
bismuth in the reverse posture. Certainly, a splendid demonstration. In this
particular case, an abdominal gastroenterostomy cured the patient. This will
not be possible in every case of this type. Sometimes a radical operation may
be required. The surgeon will then have to add thoracotomy to the abdominal
section, loosening the stomach all around and reducing it to its normal
position under the guidance of his eyes, with one hand in the thorax, the other
in the abdomen. If the rent in the diaphragm cannot be closed by suture, a
fascia graft, best of the fascia lata from the thigh, has to be transplanted on
it and carefully sutured in place.
In passing I will mention "transthoracic laparotomy," i.e.
reaching the organs in the vault of the diaphragm through the thoracic cavity
and an incision of the diaphragm. At the present time this route is especially
resorted to in cases of acute injury.
I am firmly convinced that in course of time many troubles involving
the anatomy of the thorax which now are still within the absolute domain of
internal medicine, will gradually become borderland cases. Referring to the
diaphragm I would mention persistent singultus, the intractable hiccough, as
being amenable to surgical treatment. If in a given case everything 'that
medicine offers has been tried without avail and the patient seems doomed by
this reflex spasm, an operation may still bring relief. We know that in
persistent hiccough following an abdominal opera-don, the impulse is carried to
the phrenic nerve of the side on which the operation was done. In such a case
the phrenic nerve could be exposed at the neck, crushed, but not cut, that is,
temporarily put but of commission, a procedure proposed by Henschen of Zurich
for the temporary inhibition of the working of the phrenic nerve, in place of
the permanent elimination of its action by resection.
4. Anterior
Mediastinum. - Acute suppurations of the sternum, producing accumulation of
pus within the anterior mediastinum have been often attacked before the modern
era of thoracic surgery. The sternum was perforated by drill or otherwise and
the cavity was drained.
A few words might be said on the surgical treatment of tumors of the
anterior mediastinum. Whoever has had a patient with advanced tumor of the
anterior mediastinum will agree, that these patients lead a life not worth
living. The result of the compression of the superior and inferior vena cava
and of important nerve trunks, makes their existence miserable. Formerly very
little could be done for these patients. To-day, too, a radical operation is
usually out of question. By the time when the patient reaches the surgeon, the
tumor which is usually malignant, so completely involves the important
structures, that it cannot be dissected out. All that can be done surgically is
a decompression of the thorax, same as we perform a decompression of the skull
in the case of an inoperable brain tumor. Friedrich proposes making the
transverse split of the sternum under differential pressure, from an
intercostal space of the one side to that of the other, while Sauerbruch
advises going ahead under local anesthesia, if possible, dividing the sternum
longitudinally from the jugulum down, and switching off side-ways into the
third right interspace. With sharp retractors in place, the two halves can be
sufficiently separated to permit of careful investigation. In case of
malignancy, the divided sternum will relieve the compression; and subsequent
treatment with radium and x-rays will perhaps bring better results than if the
bone were still complete.
A retrosternal thyroid or a tumor of the thymus which cannot be reached
from the neck, can, of course, be removed by this route.
5. Heart
and Large Blood Vessels. - I should much like to talk at length on the
surgery of the heart, aorta and pulmonary artery, but all that is still in part
"music of the future." You know of the, many successful attempts that have been
made in closing wounds of the heart by suture, and extracting foreign bodies,
broken needles, bullets, etc. It will forever remain Rehn's great merit to have
been among the first to boldly attack the heart and the first to successfully
close by suture a stab wound of the heart muscle.
I should further greatly like to speak at length of another bold attack
made on basis of animal experimentation by a colleague when he was already of
advanced age, Professor Trendelenburg, who tried to ascertain whether it would
be possible to still help patients with pulmonary embolism by operation.
Certainly, the majority of these unfortunates die within a few hours after the
catastrophe has set in. You all know of Trendelenburg's operation, - he exposes
pulmonary artery, temporarily compresses it in conjunction with the aorta, by
means of an elastic tube, makes a small incision into the vessel and, with a
special forceps, extracts the thrombus from the embolized artery. The operation
has been done on the human subject quite a number of times abroad. One patient
lived four days and then pneumonia took him away. I have no doubt that with the
application of differential pressure these operations will lose a great deal of
their severity. I have tried the operation on the dog in our experimental work
at the Rockefeller Institute, incising the pulmonary artery, entering it with
forceps and then closing it by suture, and could show him with the wound healed
before the New York Surgical Society. According to Trendelenburg all dogs thus
operated upon, died at the Leipzig Clinic experiments. Why? I believe, because
they did not use differential pressure. We employed it and the dog recovered.
So far I have not performed the operation on the human subject. We can, of
course, not' do it without the permission of the family and when this has been
obtained, it will frequently be too late. To ask such permission before
the primary operation is not well feasible.
A few words on the treatment of thoracic aneurysm. Much work has been
done in this chapter. You know of the most interesting experiments of
compressing the vessel with metallic bands or with strips of fascia as proposed
by William S. Halsted of Baltimore. To-day the operation of choice is "wiring"
of the aneurysm. William T. Lusk of New York, has given this operation quite
some study and has greatly improved its details. He exhibited a good deal of
patience and perseverance in finding a comparatively safe method of introducing
many feet of carefully prepared wire of a special alloy into these sacs. The
wire will touch the aneurysmatic wall in many places. With the help of
electrolysis an eschar is then produced at the place of contact, which invites
a deposit of fibrin over the inner surface of the sac, strengthening its wall.
With this method some remarkable results have been obtained. One of Lusk's
patients, a workingman, returned to his work of cutting stones, another one
could carry heavy weights on his shoulders. One of my patients who had been
bed-ridden for months, coughing blood, and whom others considered a
consumptive, was again able to climb four or five flights of stairs for many
months.
Wiring does not mean a real cure, inasmuch as in almost 100 per cent,
of the cases the trouble is dependent on a syphylitic infection. The latter
needs most careful additional treatment. Particular care, it seems, must be
taken with the use of larger doses of salvarsan. Gummatous deposits in the wall
of the sac have been repeatedly observed; if too rapidly absorbed, they, in
turn, may give rise to perforation. I have personally seen this in an early
case of this type.
The treatment of some type of valvular disease of the heart, by
operation too,, is still "music of the future"; but it will eventually come
under the surgeon's care in special cases. Carrel, with his wonderful
experimental work and the late Jeger of Breslau have begun to pave the way in
this direction. It is not Utopian, to imagine that the surgeon's knife may in
the future in some 'way or other reach the place of the trouble and bring help,
e.g. in a case of stenosis of the bicuspis or tricuspis, and that thus also
this type of heart disease may some day become borderland. The treatment of
almost every disease within the chest will likely become borderland in course
of time. For almost all the specialties join hands in the chest.
In conjunction with this last statement I would -venture here to answer
a question of our honored President in passing, which he once put to me in
private. He asked: Why call this Association "The American Association for
Thoracic Surgery?" It should at least be called "The American Association for
Thoracic Medicine and Surgery." I answered that the thorax had been the domain
of the internists as long as medicine exists. Thoracic surgery could not come
forward on account of the acute pneumothorax, that stumbling block. Now, at
last, also this cavity of the body had been safely opened to surgery. Real
advance to cure many affections, hitherto inaccessible, could now be made. We
surgeons wanted the internists, the anatomists and physiologists, we wanted the
specialists for tuberculosis, for laryngology, the neurologists, we wanted, in
fact, almost every specialty to join hands with us in the thorax. Therefore, I
would plead: Let us continue to call this young gathering of mutually
interested colleagues "The American Association for Thoracic Surgery."
But I must leave the heart and large blood vessels, much as I should
like to talk further on the subject and its future possibilities, - and pass
over to
The Posterior Mediastinum. This being correlated with the surgery of
the oesophagus, I will discuss this subject later in connection with the
oesophagus and first turn to
6. The Lungs and Bronchi.
- To discuss fully the present status of bronchial and lung surgery would take
several hours. With the limited time at my disposal, I shall be able to only
briefly touch upon the subject.
The treatment of acute inflammation of the lung, pneumonia, will
probably forever remain in the hands of the internist. Still, significant
onslaughts have been made to get other specialties to assist him in his big
task. I think here not only of serology; I would mention our President's
personal work, his artificial production of pneumonia in dogs, and his hope of
perhaps finding a way to help these patients with intra-tracheal insufflation,
I would further mention the desire of one of our foremost bronchoscopists of
New York, once expressed to me in private, when I had to operate on a very sad
case of early bronchiectasis, following tonsillectomy, in a young lady. He
wished to have the chance, in such a case, as soon as sign of pneumonia
appeared, to introduce the bronchoscope and try, by means of suction or
otherwise, to help these patients. I am mentioning these points merely to show
how the specialists join hands when it comes to the treatment of the organs
within the thorax. But up to date, acute pneumonia, in the early stages, with
or without pleurisy, belongs to the internist.
Still, there is one type of acute inflammation of the lung that clearly
belongs to the surgeon, and that is acute septic embolic pneumonia; when
suddenly in a patient, who, for example, had been subject to frequent attacks
of phlebitis of the leg, due to varicose veins, a small infected thrombus is
loosened and driven into the pulmonary artery as an embolus, usually into the
central portion of the same. These patients are immediately deathly sick,
temperature 105-106°, rapid pulse, general malaise, etc. The very high
polynuclear blood count will show the beginning gangrene. In former years,
these patients were left without treatment and frequently they died. To-day, as
soon as the diagnosis has been made on basis of the history, clinical
examination, the x-ray and other methods at our disposal, it is our duty to
suggest to the patient if he is well enough, otherwise to his family, that he
permit us to cut down upon the lung to palpate it and, with a special stitch,
to attach the infiltrated region to the chest wall, if there be no adhesions,
and incise the focus either at the same sitting, or a few days later at a
second stage. This type of pneumonia belongs to surgery.
Let me in passing say that the diagnosis of pathologic conditions
within the chest has tremendously advanced in the course of the last years, and
this is attributable principally to the advent of the stereoscopic x-ray
pictures, as also to peroral endoscopic methods of examination.
In the discussion of chronic inflammations I shall omit that of
syphilis of the lung. The disease, of course, exists, and if diagnosed, must
first be treated by an antisyphilitic regime. I have lately seen such a case in
consultation, having been called in to decide the necessity of surgical
intervention. We helped the patient by means of persistent antisyphilitic
treatment,without operation. After months of severe and
tormenting illness, he is now almost well.
I say, omitting syphilis, we now have to consider two large classes of
suppurating lung disease; a non-specific and a specific one, calling
specific here "tuberculous." The non-specific is represented by bronchiectasis,
and the specific by tuberculosis.
Whoever has studied the subject of bronchiectasis, will never leave it
again. It is so fascinating. I cannot here dwell at length on the diagnosis.
All I would say is, that a patient who shows all the symptoms of advanced
tuberculosis, cough, sputum, not infrequently mixed with blood, night sweats,
fever, clubbed fingers and toes, but in whom tubercle bacilli have never been
found, is in over 90 per cent, of the cases a bronchiectatic. The clinical
signs often are extremely scarce. Percussion and auscultation yield very meagre
results. If one then analyzes the sputum [a 24 hours' collection] the
well-known three layers will be found. The x-ray will sometimes support the
diagnosis; frequently it is of little assistance. But the bronchoscope is of
the greatest help in rendering the diagnosis and localizing the source of the
suppurative process.
Let me say right here, Mr. President and gentlemen, it is my firm
belief that within a few years we shall have in every well-conducted hospital a
reliable bronchoscopist and esophagoscopist, or if not every hospital should
create this special position, one and the same specialist can serve a number of
hospitals. But he must be a man of whom we know that he will not do harm in
introducing the instruments, a man who is able to properly interpret what he
sees, who, with the proper aspiration and irrigating apparatus, takes care that
first all the secretion of the bronchial tree of the affected lung is
aspirated, so that he is able to diagnose from which bronchus and from which
branch of the bronchus the pus is oozing. He will then be able to tell us
whether one or more lobes are affected. We must be sure of him that he does not
make a guess, but states what he has definitely seen. Therefore, bronchoscopy
is of such vital importance in making a refined diagnosis in suppurating lung
disease.
Bronchiectasis is a disease originally of the bronchi,
secondarily involving the lung tissue, whereas tuberculosis in the majority of
cases is originally a disease of the pulmonary parenchyma, secondarily
involving the bronchi. Let us keep that clearly in mind. A few years ago I was
severely criticised by a well-known New York colleague, who was writing on
bronchiectasis because I had begun an article of mine on this subject with the
words: "Bronchiectasis is a disease of the bronchial tree, not of the pulmonary
parenchyma." In part he was right in his criticism because I had omitted the
word "originally." Let me repeat, therefore, and let us bear in mind, that
bronchiectasis is originally, that means anatomically, a disease of the
bronchial tree. But being an inflammatory process, the pulmonary parenchyma will,
of course, always become very soon, often simultaneously similarly involved.
With reference to the etiology, bronchiectasis is frequently
consecutive to pneumonia, -the latter developing into this unfortunate
condition. It is furthermore, often produced by aspiration, of solid bodies as
well as of liquids. This aspiration very frequently happens during
tonsillectomy. We all have seen these sad cases: a young man or woman, 19-20
years of age, tonsillectomy; blood aspiration; suppurative disease of the lung;
death. To-day the men who work in that specialty are in duty bound to use
methods which will prevent such a result.
In advanced cases of bronchiectasis cavities are found in the bronchial
system and adjacent lung tissue, which make the section cut of the lung appear
like a honey comb. Within the walls of these cavities lime salts are frequently
deposited. They become hard; the entering bronchus constricts in the sequence
of ulcerating processes, and, within, the secretion has the chance to
decompose. The formation of real cess pools in the lungs is the result. The
patients often do not cough up, but in the real sense of the word, on coughing,
"vomit" the contents in their lung or lungs, so that the muco-pus runs out of
their mouth and nostrils simultaneously. It may be of such foul odor, that
institutions are obliged to isolate these cases. I once operated upon a girl of
19 years who had been in solitary confinement for this reason for more than
eight months.
But what is to be done? Just a few words. As everywhere else, we can
here carry out either conservative or radical surgical treatment. The latter is
always operative. Up to a short time ago^ it was believed that only operation
could bring relief. However, what is to be done if both sides, or all three lobes
of the right lung are affected? One year ago a young girl came under my care,
sent by a colleague from the Golden Gate, who had had repeated attacks of what
seemed to be bronchiectasis, subsequent to tonsillectomy. On her way across the
continent she was so sick that her mother thought she would die. The case was
carefully analyzed at our hospital. The bronchoscopist, Dr. Yankauer, found the
entire right lung diseased. Radical operation, pneumectomy, the extirpation of
the entire right lung would have meant a very serious interference in thedelicate girl, and
the mother wished to try and save the life of her child above everything. We
agreed to do what was first, several years ago, tried in France, though in
different fashion, later in Germany, viz., to irrigate the bronchial tree with
antiseptic solutions, with the patient always in a slight Trendelenburg
posture, first under general anesthesia, later on under local anesthesia,
making use of a special tube, ingeniously constructed by Dr. Yankauer. The
bronchial system of the right lung was systematically irrigated with Lugol's
solution of gradually increasing strength. To-day the patient is apparently
well, she is back in school, having gained almost 25 pounds.
If a solid body has been aspirated into the bronchial tree, causing
suppuration, it becomes the province of the trained bronchoscopist to find and
extract it, and therewith, in many instances, arrest and cure^ the disease. In
some cases additional operative treatment is indicated.
Conservative operative treatment in bronchiectasis has been
particularly urged by men who "have been in it," men who have seen adverse
results following more radical work. One of these was the late Prof. Friedrich
of Kðngsberg, formerly of the University of Marburg, Germany. When he visited
us here in 1909, he urged me, not to go ahead too quickly in attempting
lobectomy of which I had just then seen such splendid results in the dog. He
said: "If you go ahead too radically, you may easily give thoracic surgery on
human beings a black eye." With this advice of an experienced man in mind, I
faithfully traveled through the entire line of more conservative surgical
procedures, excepting artificial pneumothorax, for it was seen by Volhard in an
advanced case, that after this had been done faithfully for years, with
apparent success, the disease appeared unabated when the gas insufflation was
discontinued.
Volhard's case was an advanced one. To-day I would certainly advise
producing an artificial pneumothorax in the early stage of suppurating lung
affection, following the aspiration of blood. Tewksbury's remarkable statistics
(Jour. Am. Med. Ass'n, Feb. 2, 1918) speak volumes in this direction. In
view of the results obtained by him, this method seems to be the operation of
choice. Some of his cases may have represented lung abscess in the early stage.
So far a definite line of differentiation between lung abscess and
bronchiectasis in their incipiency, has not been drawn as far as diagnosis is
concerned.
For the surgery of advanced cases of bronchiectasis, I personally have
tried pneumotomy, as well as all the conservative operative methods known for
carnifying and compressing the lung, such as ligationof branches of the
pulmonary artery, followed by thoracoplasty; I have also done a wedge-shaped
resection of the lung for the same trouble and performed lobectomy. I have seen
cure or improvement in not too far advanced cases by means of more conservative
methods, and believe they can be conscientiously practiced in some patients. But
in advanced cases there is only one method that can cure, and that is
lobectomy. My first attempt with this operation in the human being was made in
1909, in a boy of nine years. When stitching up the crushed bronchus, the
patient quite suddenly died, probably as a result of vagus reflex. We have
gradually increased our knowledge as to the best way of doing lobectomy in
America, particularly through the" efforts of Howard Lilienthal of New York and
Samuel Robinson of Santa Barbara, Cal., formerly of the Mayo Clinic. We have
learned how best to treat the bronchial stump. Very much, naturally, has still
to be learned in order to make lobectomy a less dangerous operation. Personally
I believe that arranging for a wide access to the lung and amputating the diseased
lobe, as we do for example, a kidney in nephrectomy, will probably yield best
results. As a matter of necessity, I shall have to skip details in this cursory
review.
One word yet about the surgical treatment of advanced pulmonary
tuberculosis. Our President, in his inaugural address, has just proposed, "that
large intercostal incisions should be made for the treatment of pulmonary
tuberculosis. If the procedure does not interfere with the respiration, that
is, if it proves that the mediastinum sufficiently protects the respiratory
activities of the lung in the opposite cavity, steps should be taken to keep
the incision open for a longer period."
I am not ready to discuss his proposition at this moment.
However, if we inject and reinject air instead of nitrogen into the
pleural cavity we have, it seems to me, what Dr. Meltzer wants, in part at
least. Incisions in the intercostal spaces will, I fear, have the tendency to
rapidly contract by granulation. They - will further expose the pleural cavity
and surface of \the lung only to the eventual healing effect of the atmospheric
air (oxygen), but not the intrapulmonary foci.
If we can inject and re-inject nitrogen or air into the pleural sac the
lung will be and remains compressed and can then reap the benefit of long rest
and compression. But what about patients with advanced pulmonary tuberculosis
in whom the pulmonary pleura is firmly attached to the costal and there are one
or more suppurating cavities in onelung? At the present time these patients
will die if a proper operation is not performed. Here again, medicine and
surgery to-day join hands. Advanced pulmonary tuberculosis has become a
borderland disease. Fruitful work in this connection has been done,
principally, by Friedrich, Sauerbruch and Wilms. The result aimed at is most
thorough compression with every means we know. The diseased lung can be
thoroughly compressed in the following manner: resection of a sufficient number
of ribs, tenth to second or to first inclusive, so called "extrathoracic thorocoplasty,"
if necessary, also sometimes of the inner portion of the clavicle under
regional plus local novocaine anesthesia; then by phrenicotomy for paralyzing
the respective half of the diaphragm, which latter by the intraabdominal
pressure will then gradually ascend 3 to 4 ribs and permanently stay there,
finally also by Tuffier's operation which first loosens and then compresses the
apex, with a plomb that remains permanently in situ (apicolysis). The
walls of a round cavity, kept before permanently distended by the pleural
adhesions, will thus drop together to one that has the appearance of a narrow
slit. Fever and night sweats often disappear, the sputum becomes free from
bacilli and greatly reduced in quantity or cease entirely, the lung itself becomes
carnified, due to the pronounced connective tissue formation on basis of the
chronic hyperemia, dependent on the collapse.
It has been shown that at least two thirds of these otherwise
absolutely lost patients can still be improved or cured.
Tumors of the lung are treated just the same as an advanced
suppuration. Lobectomy can bring a cure in cases that come to operation early.
7. Posterior
Mediastinum. - The principal disease that interests us under this heading
is cancer of the oesophagus. Lack of time does not permit me to even briefly
consider the treatment of acute mediastinitis, foreign bodies in the oesophagus
diverticula, cardiospasm, benign cicatrical strictures, etc., etc.
Cancer of the oesophagus is the most benign of all carcinomas in our system.
It is more benign than cancer of the colon, at least in so far as its
pathologic dignity is concerned. One of the reasons for this is that the
greater percentage of these tumors are of the squamous-celled type, the kind of
tumor, we so often meet with on the face and otherwise on the surface of the
body (epithelioma), and which in the latter location is treated with the
greatest benefit by radium, a fact known to you all.
Thoroughly aware that conditions accompanying and arising from the
resection of the oesophagus are complicated and still mean a great risk to the
patient, every thinking surgeon interested in this chapter was ready and only
too happy to have the effect of radium thoroughly tested in these cases. We
hailed it with intense satisfaction when such a trustworthy, reliable colleague
as Dr. H. H. Janeway took this matter up at the Memorial Hospital, New York,
and we were grateful -when he consented to give us a preliminary report on the
result of his experience at the March meeting of the New York Society for
Thoracic Surgery, three months ago. For, it stands to reason that if radium
could cure cancer of the oesophagus, we should not have to operate. Dr. Janeway
then reported 35 cases thus treated, of which some were much improved, but only
one was cured, and in this one a piece for microscopic examination could not
'be excised, to prove that it really was an epithelioma.
Mr. President and Gentlemen: Although Dr. Jane-way's preliminary
communication is, of course, not the final answer to this question, it is my
personal belief that the treatment of cancer of the oesophagus will revert to
operative surgery. If radium cannot cure these cases, surgery must learn to do
it, and we are fully justified in going ahead and trying further, in view of the
fact that medicinal treatment has a mortality of 100 per cent. At the present
moment the radical operation for cancer of the oesophagus is clearly indicated
in suitable cases. What we still lack mostly is the ability to render an early
diagnosis. Attempts have been made by colleagues abroad, as also by Crump and
Stewart of New York, to establish such an early diagnosis with the help of a
special method for x-ray examination. Special sounds have also been constructed
to find a beginning constriction on retracting the instrument.
But neither of these methods has as yet been entirely successful.
Still, I am convinced that with further unremitting efforts the early diagnosis
and, therewith, early operation will become a reality. Meanwhile, in these
years of trial and observation we have evolved a satisfactory method of
operation and of after-treatment. Every operator will agree that the surgery as
such, required in these cases, is not extraordinary, nor technically
particularly difficult.
To-day, after obtaining a wide access, as furnished by the curved
incision (Torek), we expose and resect the tumor in the posterior mediastinum,
invert and firmly close the distal end of the oesophagus, then extract the
proximal portion and transplant it extrathoracically under the skin of the
chest. A rubber tube connects the upper opening of the oesophagus with a
watertight gastrostomy-fistula. Through it the patient swallows any kind of
food as was proven byPerthes, and as Dr. Torek's brilliant case, the only
one on record of a cure after resection of the thoracic portion of the
oesophagus, so beautifully shows.
If gastrostomy is done by means of the Beck-Jianu method, that is to
say, if, with gastrostomy, an inferior oesophagoplasty is incidentally
performed, we may, in special cases, hope to at once reconstruct the entire
oesophagus extra-thoracically. Certain it is, that operative surgery can to-day
make a new oesophagus. There are prospects for further improvements.
The greatest danger in the operative treatment of cancer of the
oesophagus is found in a resection behind the aortic arch, the place where the
pneumogastrics and the sympathetic nervous system join hands and send their
branches to heart and lungs. This place represents the "Achilles tendon of
life." The tumors here are often very firmly attached; frequently they have
perforated the thin oesophageal wall and grown diffusely into the posterior
mediastinum, involving the vena azygos. This is particularly so after prolonged
sounding, done in the attempt at widening the stricture. Such preliminary
treatment, which is always absolutely contraindicated from the standpoint of
operative surgery, is the worst enemy of the surgeon. It often renders the case
inoperable.
Naturally, there are limits to radical operation. We are often
confronted with cases which simply are beyond the reach of surgery. But do we
ever think of excising a cancer of the pylorus that has grown into the liver
and into the pancreas? Thus there are also to be found tumors of the oesophagus
which simply cannot be excised. Let us leave these alone. We shall have done
our duty if we have ascertained, with the help of exploratory thoracotomy,
whether a tumor is operable or not. Certainly those that are situated between
the aortic arch and the diaphragm are the most favorable for operation, and
those adherent behind the aortic arch, the most unfavorable. I am sure, that,
if we get the cases early, many a patient's life will be saved and many more
will derive benefit from surgery, provided we make air-tight post-operative
thoracic drainage a conditio sine qua non. Inasmuch as we are going to
continue this question in the afternoon, I shall not dwell on it further now.
What has been said about cancer of the oesophagus, holds good for
cancer of the cardia. There are many surgeons who would not touch a patient
thus afflicted.But how shall we ever make progress in this chapter of
operative surgery, if we do not touch it?
I was greatly pleased to hear our President make a similar remark at
the last meeting of the New York Society for Thoracic Surgery, when the present
status of the treatment of cancer of the oesophagus was the topic of the
evening.
These cases, if left alone, die a most terrible death. Quite a number
can be diagnosed at a time when operation can still bring help. The surgeon's
hand if introduced into the vault of the diaphragm at the time of the
gastrostomy operation will make out mobility, glandular infiltration, etc., in
one word, the operability or inoperability of the .tumor. We have learned also,
how to deal with these cases technically. Already five cases of successful
operation for cancer of the cardia are on record. I believe that help could be
rendered to a great many more patients if we arranged our abdominal operation
for an intended gastrostomy in such a way that the thoracic operation could be
added at the same time, and particularly, if we practiced Ach's method of
inversion with extraction of the oesophagus, pulling it temporarily out of the
mouth, and then reinverting it under the skin, extrathoracically. This would
mean a one-stage operation, which seems to be the best for the patient,
provided his condition permits it. Often, however, operation in two or three
stages will be indicated.
I must close, gentlemen. As our President has said: the outlook for
thoracic surgery is wonderful. What particularly is to be emphasized is, that
the thorax to-day is not only open to surgery, but that it is "safely" open to
it. Let us further emphasize the fact that to-day there is not one angle or
corner in our entire system that the surgeon's knife cannot reach. The thorax
was the last fortress to be attacked, and it has been laid open safely to the
surgeon's knife by differential pressure methods.
I am sure that any one who has started work inintrathoracic surgery
will never give it up. It is ofsuch engrossing interest. However, in order to besuccessful, he should
provide himself with proper apparatus and practice post-operative safe
drainage.
It is to be hoped, that a constantly increasing number of men will
enter upon this fascinating work. Many minds working in the same direction will
get quicker results, for the benefit of suffering humanity.
