Esophageal lesions interested many Founders who devoted extensive experimental and clinical effort to finding their solutions. A variety of approaches mirrored successive failures. Advance followed strenuous work. By 1917, improvement in methods had fostered a host of acceptable procedures. Yet even today, their hopes have not been realized - the search for solutions is still pursued.

The nebulous status of esophageal surgery was stated by Lilienthal in 1917:^1.

Nowhere in the body is there more need for gentleness and asepsis than in transpleural operations upon the digestive tract. The high mortality in operations upon mediastinal structures has been due to either shock or infection. To combat shock, it is proposed to block the vagus with cocaine or some other drug in the region of the aortic arch and hilus of the lung.

To avoid infection, the esophagus should not be opened within the thorax unless one is prepared to remove it in toto, because so far, no reliable method of aseptic closure exists.

Cardiospasm was and still is a thorny problem. Willy Meyer used longitudinal plication often supplemented by esophago-gastrostomy. Adrian Lambert's crushing clamp through a gastrostomy was designed to avert infection and secure an adequate esophago-gastric junction.^2. Lilienthal, after mobilization, incised the muscularis with subsequent bouginage over a string.^3. Today, have we advanced?

Many Founders contributed significantly to resectional surgery of the esophagus. Willy Meyer, in 1904, saw Sauerbruch resect a dog's esophagus under differential pressure. He reported this to the New York Surgical Society. ^4. This stimulated him to more research and he soon reported a method for aseptic esophago-gastric resection and reanastomosis. This was an ingenious effort to avoid post-operative infection. ^5. After the death of four patients in whom the method was used, his comments may astonish some: ^6.

In conclusion I would say that the road into the thoracic field is rough and stony, strewn with many depressing disappointments. Still, the work is so fascinating and there are also so many inspiring experiences that I have no doubt thoracic surgery will soon become a favorite branch of our science and form an integral part of the routine work of our hospitals.

Thoracic surgery should be done at the hospital, not only for the sake of asepsis, but also on account of the strongartificial light needed for the work in the depth of the thorax. Only in such emergency cases in which the removal of the patient to the hospital would clearly jeopardize his life should intrathoracic work be done at this home; electric reflectors would then have to be carried along.

Nathan Green and Henry Janeway were impressed by the frequent infection after operation. Green devised a button which they used for aseptic anastomosis.^7. In spite of some success with these methods they searched for improvement. Some achievement is reflected in this report:^8.

These considerations, and the fact that our latest experience with the suture has been more favorable, have influenced us to doubt the advantage of the use of a button for the union of the esophagus with the stomach after a resection of a portion of both these organs. The objections above mentioned do not apply to the use of the button for a lateral anastomosis. Its use for this purpose is a decided gain and has transformed such an operation in our hands into a, comparatively speaking, safe procedure. In the operation for resection, however, the choice between the needle and thread and the button may be still debatable.

By a special technic developed by one of us (H.H.J.) we have been able to resect one to one and one-half inches of the esophagus and all of the stomach to the pylorus. We now have (February, 1910) three perfect recoveries out of five operations of this kind. In all the needle and thread has been used to accomplish the anastomosis. We believe, therefore, that this operation will have a definite field of usefulness.

This work bore fruit when Dr. Torek completed the first successful resection of the thoracic portion of the esophagus. The following details are from Dr. Torek's own report on the operation:^9.

I shall not enter into the details of the operation, but simply outline the most important parts of it. Instead of seeking access by going through two different intercostal spaces and dissecting off the scapula or by resecting several adjacent ribs, procedures recommended by others, I incised through the whole length of the seventh intercostal space, from the posterior end of which I extended the incision upward by cutting through the angles of the seventh, sixth, fifth and fourth ribs, which gave a much better exposure and is far simpler. The greater ease of access enabled me to dissect the pneumogastric nerves more carefully, and, to my great satisfaction, the pulse never wavered during the procedure, remaining between 93 and 96. The dreaded vagus collapse had therefore been safely avoided. The great difficulty of dissecting that part of the esophagus which passes behind the arch of the aorta was overcome by ligating a number of the thoracic branches of the aorta and lifting it forward. Last, but perhaps most important, to avoid the danger of leakage from the upper stump of the esophagus, I eliminated the esophagus from the pleural cavity altogether. This was done by dissecting the organ loose from its attachments all the way up to the neck and bringing it out through an incision at the anterior border of the left sternocleidomastoid muscle. Thus the pleural cavity could not possibly become infected from that source.

Willy Meyer - second and third steps in extrathoracic esophago-gastric anastomosis.

Willy Meyer - selected steps in intrathoracic esophago-gastric anastomosis. (Continued on following page.)

Nathan Green - one type of button he devised for closed anastomosis. Others of different design by him were also used.

Janway and Green - selected steps in intrathoracic esophago-gastric anastomosis.

Fig. 257.-Schema showing Gaub-Jackson operation for excision of oesophageal diverticulum. At A, the oesophagoscope is represented in the bottom of the pouch after the surgeon has cut down to where he can feel the oesophagoscope. Then the oesophagoscopist causes the pouch to protrude as shown by the dotted line at B. After the surgeon has dissected the sac entirely free from its surroundings, he makes traction upon the bottom of the sac, as shown at H, while the oesophagoscopist inserts the oesophagoscope down the lumen of the subdiverticulat oesophagus, as shown at C. The oesophagoscope now occupies the lumen the patient will need for swallowing. It remains for the surgeon to amputate the redundancy, without risk of removing any of the normal oesophageal wall, or risk of leaving part of the redundancy unremoved.

Chevalier Jackson - method of visualizing diverticulum of esophagus for excision.

Crump - sausage skin apparatus for delineating extent of esophageal lesions.

The thorax was closed without drainage. The patient made a good recovery. Some of the stitches were removed on the fourth day; the remainder were removed on the seventh day, when the wound proved to be completely closed. Pulse, respiration, and temperature had become normal by the fifth day.

This esophageal resection by Franz Torek was the theme of Willy Meyer's paper delivered at the 1913 A.M.A. Convention, which, because of its failure to excite response, stimulated Dr. Meyer to Founding of the NYSTS and AATS.

It would be quite remiss to pass over three Founders who preached the virtues of Endoscopy in this x and allied fields. Dr. Chevalier Jackson needs no delineation since he was the primary advocate. However, Dr. Crump with his sausage skin, and Dr. Yankhauer were valiant contributors in the really lean days. The difficulties they had to overcome were not small. Instruments were not readily available. Some had not even been designed. It was often necessary not only to invent but also to construct the instruments. Yet by dint of constant teaching and research, the field developed to such an extent that Willy Meyer, at a later date, urged that thoracic surgery be performed only in hospitals where the services of a trained endoscopist were available.