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The 1900 tuberculosis epidemic—Starting point of modern thoracic surgery
SPECIAL LECTURE
The 1900 Tuberculosis Epidemic-Starting Modern Thoracic Surgery
Point of
Andreas P. Naef, MD University of Lausanne Medical School, Lausanne, Switzerland
Introduction by Joseph I. Miller, Jr At this time I would like to call to the podium Dr Hawley Seiler, who will introduce our distinguished guest lec-
turer. Doctor Seiler is our Association historian, and it is our pleasure to have him here this morning.
Introduction of Dr Naef by Hawley H. Seiler Doctor Naef received his early thoracic surgical training in Zurich, and this was followed by years of further training in various United States centers such as Boston, Los Angeles, and Rochester, and with Max Chamberlain, one of our first honorary members and his very close friend. He was the first thoracic surgeon in Switzerland, performing the first lobectomy in 1947 and doing the first cardiac operation in Switzerland in 1951. He is past professor of thoracic surgery at the University of Geneva and the University of Lausanne medical schools. In the late 1960s I was privileged to participate in a thoracic surgical panel in Montreaux, Switzerland. Although much of the business of that meeting is lost to memory, one outstanding incident remains fresh and clear in my mind. Sitting next
E
ver since your former President Hawley Seiler invited me in 1971 here in Tampa to present a guest lecture on "Conservative operations for peptic esophagitis with a stenosis in Barrett's esophagus," I wondered if I really deserved this distinction along with such outstanding pioneers as Herbert Sloan and Marc Ravitch-but I will try to live up to it today! In earlier publications [l, 21, I reviewed what could be called "the dawn of thoracic surgery," when general surgeons faced with exceptional situations performed an occasional operation in the chest, such as Tuffier's apical resection in 1891; Torek's esophagectomy in 1913; Henry Souttar's one and only operation for mitral stenosis, in 192.5-a quarter of a century before Bailey; and Graham's famous first pneumonectomy for lung cancer in 1933. These were all occasional chest operations on the busy schedule of general surgeons. Chest surgery proper was limited to draining empyemas or lung abcess, a thoroughly discouraging field in this preantibiotic era. An occasional lobectomy for incurable bronchopulmonary Presented at the Thirty-ninth Annual Meeting of thc Southern Thoracic Surgical Association, Wesley Chapel, FL, Nov 5 7 . 1992. Address reprint requests t o Dr Naef, 12, ave Villardin, CH-1009 Pully, SwitLerland.
8 1993 by The Society of Thoracic Surgeons
to me on the panel was a dapper, urbane, vibrant, highly intelligent young Swiss thoracic surgeon, Andreas Naef. We became fast friends and have renewed this transatlantic friendship many times over the years at many meetings, at many locations. Our last encounter was in Toronto at the annual meeting of the American Association for Thoracic Surgery, where Dr Naef was present as Griffith Pearson's honored guest and was elected to honorary membership in that august body. I am honored and pleased to present our only international honorary member and my dear friend, Professor Andreas Naef of Lausanne, who will speak on the 1900 tuberculosis epidemic, the starting point of modern cardiothoracic surgery.
suppuration was performed by the terrible two-stage method, leaving a necrotic lobe to slough out of a leftopen thoracotomy after hilar strangulation by the Shenstone tourniquet and mass-suture ligation. The purpose of today's presentation is to show that the transition from occasional chest operations toward our specialty started with the escalating increase of indications for the surgical treatment of pulmonary tuberculosis (TB) between World Wars I and 11. Parenthetically, I think that the recent comeback of an unfortunately often drug-resistant TB in relation to acquired immunodeficiency syndrome, drug addiction, mass migration, and new slums is of course a serious public health problem, but rarely a surgical problem. Nevertheless, thoracic surgeons should not altogether consider TB a definitely historical disease. It is amazing that before the outbreak of the acquired immunodeficiency syndrome epidemic society had forgotten the threat of contagious diseases, although not so long ago, just before World War 11, when I was a medical student in Paris, syphilis was an everyday reality in the wards of Paris hospitals, and poliomyelitis killed or crippled uncounted, mostly young people, not to speak of TB, the major cause of death at all ages. Tuberculosis undoubtedly played a key role in the Ann Thorac Surg 1993;55:1375-8
0003-4975/93/$6.00
1376
SPECIALLECTURE NAEF TUBERCULOSIS AND THORACIC SURGERY
Ann Thorac Surg 1%3;55:13758
development of pulmonary medicine and surgery. The important milestones were the following: RenP Laenec’s “Traite du Diagnostic des Maladies du Poumon et du Coeur” in 1819. Robert Koch’s discovery of the tubercle bacillus in 1882. The TB sanatorium for isolation and cure by bed rest in a healthy climate, initiated by Brehmer in Germany (1854), Spengler in Davos (1889), and Edward Trudeau in Saranac Lake (1884). According to history the very first ”sanatorium” was established more than 2,000 years ago on the hills above Naples by Galen himself. Artificial pneumothorax, introduced by Carlo Forlanini in 1882. Closed thoracoscopy for cautery division of pleural adhesions, described by Jacobaeus in 1911. This technique, developed at the time to acrobatic perfection by some TB specialists, was completely forgotten until its recent rebirth. In short, the therapeutic approach to pulmonary tuberculosis up to about 1930 was essentially nonsurgical. Following a meticulously regulated routine, patients spent years hoping for cure or awaiting death in the resigned and morbid sanatorium atmosphere described by Thomas Mann in his famous Magic Mountain (Fig 1). Minor surgical therapy evolved from the principle of artificial pneumothorax and endoscopic adhesiolysis, in other words, on the basis of pulmonary immobilization by ”collapsotherapy”: extrapleural pneumothorax or open pneumolysis when extensive adhesions could not be overcome by the closed Jacobeus operation, and phrenicectomy to reduce respiratory movements by diaphragmatic paralysis. These procedures were conceived and performed by physicians, often themselves former TB patients, who tried to break away from the frustrating passivity of “bed rest.” Some of these medical men were highly skillful and monopolized the field before surgeons could get into the act-a lesson to be remembered today. After these minor procedures the first really surgical operation was thorucoplusty. Some kind of rib resection to collapse underlying pulmonary cavities had been tried a long time earlier and goes back, among others, to the publication of our Lausanne physician Edouard de Cerenville in 1885. In 1922 the physician Ludolf Brauer, leading authority for pneumothorax therapy in Germany, intending to imitate the pneumothorax effect, developed a thoracoplasty prescribing the exact length of each rib to be resected in every individual case. After having his patients operated on by his surgical colleague Paul Friedrich, he thought that he could do a better job himself and became indeed the leader in the field. It should be remembered that most, if not all operations were performed under local anesthesia to allow cough and expectoration during operation, thus avoiding contamination of healthy lung by tuberculous secretions. By the 1930s and early 1940s surgeons in Great Britain-
Fig I . Bed rest on open air bairony. Strwinier and winter i n Daoos in 1900. (Reprinted with pcrinissioii from Nncf A P . Pioneers on the road to thoracic s u r p r y . 1 Tlzorac Cardiovasc Siirg 1991;101:377-H4.)
such as Morriston Davis, Tudor Edwards, and Price Thomas-as well as surgeons in France, Switzerland, and the United States had taken over with a system I have called “itinerant surgery.” Instead of moving patients from the sanatoria to the city hospitals, surgeons traveled regularly to the sanatoria for monthly or weekly programs, operating on thousands of patients. The main reason for this system was of course the fear of contagion in the city hospitals. It is said that in 1841 the famous ”Brompton Hospital for Consumption and Chest Disease” was founded by a solicitor, Philip Rose, who was shocked by the fact that one of his employees presenting a dramatic tuberculous hemoptysis could not be admitted to any of the big hospitals. Even in my time, city hospitals refused to admit patients with open TB for fear of contagion. Aside from the fact that TB surgery was now taken over by trained surgeons, this “saddleback surgery,“ as the system was also called, introduced a close medico-surgical cooperation resulting in better surgical indications on the part of the physicians and a new, more physiologic approach by surgeons. Also, from the practical standpoint, surgeons finally started to make a living with their thoracic cases, being able to abandon remunerative appendectomies, cholecystectomies, or gastrectomies. Thus tuberculosis medically and economically established thoracic surgery as a separate specialty. Soon, still well before streptomycin (1944), some innovative pioneer surgeons considered resecting the parenchymal lesions rather than compressing them by chestwall tailoring. When Freedlander had the courage to present an unsuccessful lobectomy case for tuberculosis at the 1935 meeting of the American Association for Thoracic Surgery he was congratulated by two remarkably foreseeing men, Coryllos and Eloesser, whose names we should remember today. Otherwise he was received with general skepticism and outward critique by John Alexander, the premier TB authority at the time. Being a convinced
Ann Thorac Surg 1993;55:1375-8
advocate of thoracoplasty he "doubted whether lobectomy would ever be widely accepted for uncomplicated cavernous tuberculosis." Five years later, in 1940, Dolley and Jones prompted a lively discussion, 18 surgeons reporting a total of 19 pneumonectomies and 31 lobectomies. But most physicians and some conservative surgeons were still more than skeptical, and John Alexander again thought that "Accumulating experience will support my advice of caution." He definitely still favored thoracoplasty in all but a few very exceptional situations, prompting Eloesser to remark that "Michigan seemed to be the Maginot Line of thoracoplasty." It was a fitting analogy because the resistance against TB resection crumbled as rapidly as France's formidable Maginot fortifications when they were overrun by German onslaught in June 1940. Almost overnight TB resection became the daily routine on the schedule of a new generation of enterprising thoracic surgeons. Undoubtedly the spectacular rise of TB resection was due to a small group of pioneer surgeons who had the stamina to confront the hostile opprobrium of a conservative establishment, who insisted that local resection for a disseminated disease such as pulmonary tuberculosis was illogical if not outright irresponsible. Occasionally, however, in spite of their reservations, physicians faced with hopelessly advanced disease referred some desperate-risk cases such as destroyed lung. Thus surgeons initially had to prove their point in the most difficult situations. It is probably no coincidence that thoracic surgery was developed in your country. American surgeons descended from the pioneers who settled the North American continent from east to west under terrible conditions. These early settlers could not be stopped by traditional conventions and hierarchies. Their powerful individualistic energy, their readiness to take risks and work hard combined with an imaginative mind enabled them to survive. In a way, generations later, this genetic make-up
Fig 2. Richard H. Overholt (1901-1990). (Reprinted with permission from Naef AP. The story of thoracic surgery. Toronto: Hogrefe and Huber, 1990.)
SPECIAL LECTURE NAEF TUBERCULOSIS AND THORACIC SURGERY
1377
OPERATIVE PRELIMINARIES
Fig 3. The Overholt "face-down position" to prevent contralateral spread during operation. (Reprinted with permission from Nuef AP. The story of thoracic surgery. Toronto: Hogrefe and Huber, 1990.)
may well have favored the spectacular conquest of thoracic surgery. During my training I have met many surgeons who belonged to that breed. One of them was my teacher, R. H. Overholt [3]. Born in 1901 in Ashland, Nebraska, he was a trained general surgeon who combined an imaginative mind, exceptional technical skill, and an uncanny clinical judgment enabling him to report extremely good results, frequently questioned by his critics (Fig 2). He minimized the dreaded complication of spill-over to the contralateral lung by operating with the patient in the face-down instead of the lateral position (Fig 3). Intent on sparing a maximum of healthy lung tissue, Dr Overholt was an early advocate of segmental resection. He described his meticulous technique in his still-classic textbook The Technique of Pulmonary Resection, published in 1947. Undoubtedly the generation of pioneer surgeons played an important part, but the message of my talk today is to state that without the enormous reservoir and backlog of chronic tuberculous patients languishing in the sanatoria all over the world, the explosive development of thoracic surgery may never have happened or at least would have been delayed considerably. Now, what about cardiac surgery? Today's cardiac surgeons should know that their foremost pioneers, Russel Brock, Charles Bailey, and Dwight Harken, began their career as "itinerant" TB surgeons in the sanatoria of Great Britain, Pennsylvania, and New England, and that at the beginning of their careers they made significant
1378
A n n Thorac Surg 1993;55:1375.43
SPECIAL LECTURE NAEF TUBERCULOSIS A N D THORACIC SURGERY
contributions to the field of general thoracic surgery. Bailey, in 1945, edited a still interesting textbook on the Diagnosis and Management of the Thoracic Pafient, whereas Brock, in 1947, published a beautifully illustrated book on the Anafomy of the Bronchial Tree with special reference to the surgery of lung abscess. As mentioned before, it had not been easy for these early thoracic surgeons to convince overcautious TB specialists to switch from thoracoplasty to resection. Therefore, when they opened the road to cardiac surgery, the usual resistance of conservative cardiologists came as no surprise to them. When Sir Henry Souttar had performed his first operation for mitral stenosis in 1925, a quarter of a century before Bailey, Sir James Mackenzie, the leading cardiologist at the time, declared that "the chief feature of mitral stenosis was the diseased myocardium, and that the stenosed valve was of secondary importance"!
Having been fortunate to obtain my early training and even more so my inspiration from these outstanding pioneers in general thoracic as well as cardiac surgery, before participating myself in the spectacular development of our field, I know that pulmonary tuberculosis was indeed the starting point of thoracic and cardiovascular surgery as the autonomous and dynamic specialty it is today.
References 1. Naef AP. The story of thoracic surgery. Toronto: Hogrefe and Huber, 1990. 2. Naef AP. Pioneers on the road to thoracic surgery. J Thorac Cardiovasc Surg 1991;101:377-84. 3. Berger RL. Thoracic surgery and the war against smoking: Richard H. Overholt, MD. Ann Thorac Surg 1992;37719-25.
The 1900 Tuberculosis Epidemic-Starting Modern Thoracic Surgery
Point of
Andreas P. Naef, MD University of Lausanne Medical School, Lausanne, Switzerland
Introduction by Joseph I. Miller, Jr At this time I would like to call to the podium Dr Hawley Seiler, who will introduce our distinguished guest lec-
turer. Doctor Seiler is our Association historian, and it is our pleasure to have him here this morning.
Introduction of Dr Naef by Hawley H. Seiler Doctor Naef received his early thoracic surgical training in Zurich, and this was followed by years of further training in various United States centers such as Boston, Los Angeles, and Rochester, and with Max Chamberlain, one of our first honorary members and his very close friend. He was the first thoracic surgeon in Switzerland, performing the first lobectomy in 1947 and doing the first cardiac operation in Switzerland in 1951. He is past professor of thoracic surgery at the University of Geneva and the University of Lausanne medical schools. In the late 1960s I was privileged to participate in a thoracic surgical panel in Montreaux, Switzerland. Although much of the business of that meeting is lost to memory, one outstanding incident remains fresh and clear in my mind. Sitting next
E
ver since your former President Hawley Seiler invited me in 1971 here in Tampa to present a guest lecture on "Conservative operations for peptic esophagitis with a stenosis in Barrett's esophagus," I wondered if I really deserved this distinction along with such outstanding pioneers as Herbert Sloan and Marc Ravitch-but I will try to live up to it today! In earlier publications [l, 21, I reviewed what could be called "the dawn of thoracic surgery," when general surgeons faced with exceptional situations performed an occasional operation in the chest, such as Tuffier's apical resection in 1891; Torek's esophagectomy in 1913; Henry Souttar's one and only operation for mitral stenosis, in 192.5-a quarter of a century before Bailey; and Graham's famous first pneumonectomy for lung cancer in 1933. These were all occasional chest operations on the busy schedule of general surgeons. Chest surgery proper was limited to draining empyemas or lung abcess, a thoroughly discouraging field in this preantibiotic era. An occasional lobectomy for incurable bronchopulmonary Presented at the Thirty-ninth Annual Meeting of thc Southern Thoracic Surgical Association, Wesley Chapel, FL, Nov 5 7 . 1992. Address reprint requests t o Dr Naef, 12, ave Villardin, CH-1009 Pully, SwitLerland.
8 1993 by The Society of Thoracic Surgeons
to me on the panel was a dapper, urbane, vibrant, highly intelligent young Swiss thoracic surgeon, Andreas Naef. We became fast friends and have renewed this transatlantic friendship many times over the years at many meetings, at many locations. Our last encounter was in Toronto at the annual meeting of the American Association for Thoracic Surgery, where Dr Naef was present as Griffith Pearson's honored guest and was elected to honorary membership in that august body. I am honored and pleased to present our only international honorary member and my dear friend, Professor Andreas Naef of Lausanne, who will speak on the 1900 tuberculosis epidemic, the starting point of modern cardiothoracic surgery.
suppuration was performed by the terrible two-stage method, leaving a necrotic lobe to slough out of a leftopen thoracotomy after hilar strangulation by the Shenstone tourniquet and mass-suture ligation. The purpose of today's presentation is to show that the transition from occasional chest operations toward our specialty started with the escalating increase of indications for the surgical treatment of pulmonary tuberculosis (TB) between World Wars I and 11. Parenthetically, I think that the recent comeback of an unfortunately often drug-resistant TB in relation to acquired immunodeficiency syndrome, drug addiction, mass migration, and new slums is of course a serious public health problem, but rarely a surgical problem. Nevertheless, thoracic surgeons should not altogether consider TB a definitely historical disease. It is amazing that before the outbreak of the acquired immunodeficiency syndrome epidemic society had forgotten the threat of contagious diseases, although not so long ago, just before World War 11, when I was a medical student in Paris, syphilis was an everyday reality in the wards of Paris hospitals, and poliomyelitis killed or crippled uncounted, mostly young people, not to speak of TB, the major cause of death at all ages. Tuberculosis undoubtedly played a key role in the Ann Thorac Surg 1993;55:1375-8
0003-4975/93/$6.00
1376
SPECIALLECTURE NAEF TUBERCULOSIS AND THORACIC SURGERY
Ann Thorac Surg 1%3;55:13758
development of pulmonary medicine and surgery. The important milestones were the following: RenP Laenec’s “Traite du Diagnostic des Maladies du Poumon et du Coeur” in 1819. Robert Koch’s discovery of the tubercle bacillus in 1882. The TB sanatorium for isolation and cure by bed rest in a healthy climate, initiated by Brehmer in Germany (1854), Spengler in Davos (1889), and Edward Trudeau in Saranac Lake (1884). According to history the very first ”sanatorium” was established more than 2,000 years ago on the hills above Naples by Galen himself. Artificial pneumothorax, introduced by Carlo Forlanini in 1882. Closed thoracoscopy for cautery division of pleural adhesions, described by Jacobaeus in 1911. This technique, developed at the time to acrobatic perfection by some TB specialists, was completely forgotten until its recent rebirth. In short, the therapeutic approach to pulmonary tuberculosis up to about 1930 was essentially nonsurgical. Following a meticulously regulated routine, patients spent years hoping for cure or awaiting death in the resigned and morbid sanatorium atmosphere described by Thomas Mann in his famous Magic Mountain (Fig 1). Minor surgical therapy evolved from the principle of artificial pneumothorax and endoscopic adhesiolysis, in other words, on the basis of pulmonary immobilization by ”collapsotherapy”: extrapleural pneumothorax or open pneumolysis when extensive adhesions could not be overcome by the closed Jacobeus operation, and phrenicectomy to reduce respiratory movements by diaphragmatic paralysis. These procedures were conceived and performed by physicians, often themselves former TB patients, who tried to break away from the frustrating passivity of “bed rest.” Some of these medical men were highly skillful and monopolized the field before surgeons could get into the act-a lesson to be remembered today. After these minor procedures the first really surgical operation was thorucoplusty. Some kind of rib resection to collapse underlying pulmonary cavities had been tried a long time earlier and goes back, among others, to the publication of our Lausanne physician Edouard de Cerenville in 1885. In 1922 the physician Ludolf Brauer, leading authority for pneumothorax therapy in Germany, intending to imitate the pneumothorax effect, developed a thoracoplasty prescribing the exact length of each rib to be resected in every individual case. After having his patients operated on by his surgical colleague Paul Friedrich, he thought that he could do a better job himself and became indeed the leader in the field. It should be remembered that most, if not all operations were performed under local anesthesia to allow cough and expectoration during operation, thus avoiding contamination of healthy lung by tuberculous secretions. By the 1930s and early 1940s surgeons in Great Britain-
Fig I . Bed rest on open air bairony. Strwinier and winter i n Daoos in 1900. (Reprinted with pcrinissioii from Nncf A P . Pioneers on the road to thoracic s u r p r y . 1 Tlzorac Cardiovasc Siirg 1991;101:377-H4.)
such as Morriston Davis, Tudor Edwards, and Price Thomas-as well as surgeons in France, Switzerland, and the United States had taken over with a system I have called “itinerant surgery.” Instead of moving patients from the sanatoria to the city hospitals, surgeons traveled regularly to the sanatoria for monthly or weekly programs, operating on thousands of patients. The main reason for this system was of course the fear of contagion in the city hospitals. It is said that in 1841 the famous ”Brompton Hospital for Consumption and Chest Disease” was founded by a solicitor, Philip Rose, who was shocked by the fact that one of his employees presenting a dramatic tuberculous hemoptysis could not be admitted to any of the big hospitals. Even in my time, city hospitals refused to admit patients with open TB for fear of contagion. Aside from the fact that TB surgery was now taken over by trained surgeons, this “saddleback surgery,“ as the system was also called, introduced a close medico-surgical cooperation resulting in better surgical indications on the part of the physicians and a new, more physiologic approach by surgeons. Also, from the practical standpoint, surgeons finally started to make a living with their thoracic cases, being able to abandon remunerative appendectomies, cholecystectomies, or gastrectomies. Thus tuberculosis medically and economically established thoracic surgery as a separate specialty. Soon, still well before streptomycin (1944), some innovative pioneer surgeons considered resecting the parenchymal lesions rather than compressing them by chestwall tailoring. When Freedlander had the courage to present an unsuccessful lobectomy case for tuberculosis at the 1935 meeting of the American Association for Thoracic Surgery he was congratulated by two remarkably foreseeing men, Coryllos and Eloesser, whose names we should remember today. Otherwise he was received with general skepticism and outward critique by John Alexander, the premier TB authority at the time. Being a convinced
Ann Thorac Surg 1993;55:1375-8
advocate of thoracoplasty he "doubted whether lobectomy would ever be widely accepted for uncomplicated cavernous tuberculosis." Five years later, in 1940, Dolley and Jones prompted a lively discussion, 18 surgeons reporting a total of 19 pneumonectomies and 31 lobectomies. But most physicians and some conservative surgeons were still more than skeptical, and John Alexander again thought that "Accumulating experience will support my advice of caution." He definitely still favored thoracoplasty in all but a few very exceptional situations, prompting Eloesser to remark that "Michigan seemed to be the Maginot Line of thoracoplasty." It was a fitting analogy because the resistance against TB resection crumbled as rapidly as France's formidable Maginot fortifications when they were overrun by German onslaught in June 1940. Almost overnight TB resection became the daily routine on the schedule of a new generation of enterprising thoracic surgeons. Undoubtedly the spectacular rise of TB resection was due to a small group of pioneer surgeons who had the stamina to confront the hostile opprobrium of a conservative establishment, who insisted that local resection for a disseminated disease such as pulmonary tuberculosis was illogical if not outright irresponsible. Occasionally, however, in spite of their reservations, physicians faced with hopelessly advanced disease referred some desperate-risk cases such as destroyed lung. Thus surgeons initially had to prove their point in the most difficult situations. It is probably no coincidence that thoracic surgery was developed in your country. American surgeons descended from the pioneers who settled the North American continent from east to west under terrible conditions. These early settlers could not be stopped by traditional conventions and hierarchies. Their powerful individualistic energy, their readiness to take risks and work hard combined with an imaginative mind enabled them to survive. In a way, generations later, this genetic make-up
Fig 2. Richard H. Overholt (1901-1990). (Reprinted with permission from Naef AP. The story of thoracic surgery. Toronto: Hogrefe and Huber, 1990.)
SPECIAL LECTURE NAEF TUBERCULOSIS AND THORACIC SURGERY
1377
OPERATIVE PRELIMINARIES
Fig 3. The Overholt "face-down position" to prevent contralateral spread during operation. (Reprinted with permission from Nuef AP. The story of thoracic surgery. Toronto: Hogrefe and Huber, 1990.)
may well have favored the spectacular conquest of thoracic surgery. During my training I have met many surgeons who belonged to that breed. One of them was my teacher, R. H. Overholt [3]. Born in 1901 in Ashland, Nebraska, he was a trained general surgeon who combined an imaginative mind, exceptional technical skill, and an uncanny clinical judgment enabling him to report extremely good results, frequently questioned by his critics (Fig 2). He minimized the dreaded complication of spill-over to the contralateral lung by operating with the patient in the face-down instead of the lateral position (Fig 3). Intent on sparing a maximum of healthy lung tissue, Dr Overholt was an early advocate of segmental resection. He described his meticulous technique in his still-classic textbook The Technique of Pulmonary Resection, published in 1947. Undoubtedly the generation of pioneer surgeons played an important part, but the message of my talk today is to state that without the enormous reservoir and backlog of chronic tuberculous patients languishing in the sanatoria all over the world, the explosive development of thoracic surgery may never have happened or at least would have been delayed considerably. Now, what about cardiac surgery? Today's cardiac surgeons should know that their foremost pioneers, Russel Brock, Charles Bailey, and Dwight Harken, began their career as "itinerant" TB surgeons in the sanatoria of Great Britain, Pennsylvania, and New England, and that at the beginning of their careers they made significant
1378
A n n Thorac Surg 1993;55:1375.43
SPECIAL LECTURE NAEF TUBERCULOSIS A N D THORACIC SURGERY
contributions to the field of general thoracic surgery. Bailey, in 1945, edited a still interesting textbook on the Diagnosis and Management of the Thoracic Pafient, whereas Brock, in 1947, published a beautifully illustrated book on the Anafomy of the Bronchial Tree with special reference to the surgery of lung abscess. As mentioned before, it had not been easy for these early thoracic surgeons to convince overcautious TB specialists to switch from thoracoplasty to resection. Therefore, when they opened the road to cardiac surgery, the usual resistance of conservative cardiologists came as no surprise to them. When Sir Henry Souttar had performed his first operation for mitral stenosis in 1925, a quarter of a century before Bailey, Sir James Mackenzie, the leading cardiologist at the time, declared that "the chief feature of mitral stenosis was the diseased myocardium, and that the stenosed valve was of secondary importance"!
Having been fortunate to obtain my early training and even more so my inspiration from these outstanding pioneers in general thoracic as well as cardiac surgery, before participating myself in the spectacular development of our field, I know that pulmonary tuberculosis was indeed the starting point of thoracic and cardiovascular surgery as the autonomous and dynamic specialty it is today.
References 1. Naef AP. The story of thoracic surgery. Toronto: Hogrefe and Huber, 1990. 2. Naef AP. Pioneers on the road to thoracic surgery. J Thorac Cardiovasc Surg 1991;101:377-84. 3. Berger RL. Thoracic surgery and the war against smoking: Richard H. Overholt, MD. Ann Thorac Surg 1992;37719-25.