SURGERY WITHIN THE PAST FOURTEEN YEARS^3.

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.