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THE DEVELOPMENT OF THORACIC SURGERY
[SEPT. 26, 1936
ADDRESSES AND ORIGINAL ARTICLES THE DEVELOPMENT OF THORACIC SURGERY * BY FERDINAND SAUERBRUCH PROFESSOR OF SURGERY IN THE UNIVERSITY OF BERLIN
I SHOULD like first to recall the great pathfinders and pioneers which Great Britain has produced and whose names are indissolubly associated with the development of our science. I refer to Carson,
Stokes, Macewen, and others. While thinking of these illustrious names I should like to associate with them in my memory those of the great countrymen of yours who have laid the foundation-stone of our surgical art, and have amplified our knowledgethe names of Hunter, Harvey, Lister, and Simpson. Thoracic surgery is to-day a standard branch of medical science. In the last three decades it has systematically developed into a definite field of major surgery. From the close anatomical and physiological relations in the individual organs and their dependence on the physical laws of the thorax it became evident that research into individual surgical problems and their technical solution constantly brought up new problems and new methods in this sphere. The nature of this development is especially characterised by an exchange of ideas both on technical and on clinical matters which kept pace with the growing experience and achievements of general surgery. Much was also learnt from the progress made in other fields of medical science. The fact that our branch had many and varied connexions with internal medicine and theoretical medicine was of especial value to us, particularly in the circulation of the blood, the respiratory organs, and the treatment of pulmonary tuberculosis. All these advances, however, recede into the background in comparison with the significance of the fundamental change which has undergone our conception of the course of the disease. This change has taken place during the last fifty years, and it has cleared the way for a new method of thought with regard to functional and biological relationships. The personality of the patient once more takes the centre of the stage. Historical Survey The attitude of the last century was characterised by the endeavour to understand diseases from a pathological and anatomical point of view, and to localise them according to the ideas of Morgagni and Virchow. It is true that the ruling doctrine on diseases of the abdominal cavity opened up a new epoch of successful treatment for some diseasesone needs only to refer to appendicitis and cholelithiasis. It was inevitable that the wish should arise to extend surgical treatment to other cavities of the body. At first the theory was held that in the same way simple and radical measures could be successfully applied in various diseases of the thorax and its organs. The treatment of empyema, for instance, developed in this direction. The " siphon drainage " recommended first by Potain and then by Bulau was rejected ; the open evacuation of pus by means of rib resection came more and more to be preferred. * A lecture delivered before the Newcastle and Northern Counties Medical Society and the Society of Thoracic Surgeons of Great Britain and Ireland
5900
on
Nov. 15th. 1935.
Surgeons had the idea that empyema was only a particular form of abscess which, according to surgical theory, must be opened as widely as possible. The number of deaths that occurred with this treatment in the influenza epidemics of the ’eighties and ’nineties was horrifying. In the meantime only a few surgeons realised the causes of these failures. They realised that they were not so much due to the seriousness of the disease, but to inefficient methods of procedure, which paid no attention to the particular kind of empyema, or to the effects on the heart and lungs of opening the thoracic cavity. The effects were the same as in open pneumothorax, and resulted in a fluttering of the mediastinum. The fate of these patients and of those suffering from injuries to the lungs was terrible. The treatment was mainly symptomatic, and almost half of them died. Abscess cavities in the lungs, which had formerly been treated here and there, were now opened more frequently. The results were necessarily limited. If there were no adhesions between the inner surface of the thorax and the outer surface of the lung, the operation could not be carried out as planned on account of the open pneumothorax. The prevalent doctrine of the anatomical localisation of diseases gave an impulse to the operative treatment of tuberculosis of the lungs. Experiments on animals led to the belief that resection of the lobes of the lung, which was occasionally performed in the early stages of phthisis, was justified. The high mortality resulting from these attempts, and also from the operative drainage of cavities, led more and more to their being given up. They were unsuccesful because the nature of phthisis had not been understood, and because the methods were inadequate. Individual successes, such as those of Macewen and Tuffier, which were attained under especially favourable conditions, could not hide the truth of this fact. Other methods of surgical treatment of tuberculosis began more hopefully. They aimed at compression of the diseased organ either by letting air into the thoracic cavity-that is, by a pneumothorax-or, in certain forms of the disease, by removing parts of the ribs. EARLY METHODS
Artificial pneumothorax.-Already, at the beginning of the last century, considerable improvement was observed in cases where either exudation or a sponIn 1882 taneous pneumothorax had occurred. Forlanini endeavoured to imitate the example of nature, and achieve a retraction or compression of the diseased lung by an artificial pneumothorax. Cailley was the first to utilise this for the successful arrest of serious haemorrhages. In the meantime, no attention was paid to Forlanini’s method, although he was able to secure practical successes. Thoracoplasty.-At the same time, Quincke and Carl Spengler suggested compression of the cavities in the fibrotic form of tuberculosis by means of removing one or more ribs. They supported their theory by the observation that when the tissue surrounding the focus of the disease, especially the chest wall, was sufficiently pliant, cavities could heal themselves by means of concentric shrinkage. If, however, this process failed owing to the rigidity of the chest wall or if its eccentric pull resulted in an enlargement of the cavity, it was necessary to mobilise the resistant ribs so as to eliminate this really contradictory action of nature and to give free play to the forces of repair. Extrapleural rib resection near the N
724
cavity was often applied but with no very convincing The plan, clear and accurate as it was, success. foundered on the rocks of insufficient technique ; the time was not ripe. Progress was necessary first in the fundamentals.
advance came at the turn of It resulted at first from Rontgen’s discovery, for the X ray picture made it possible all of a sudden to carry out a pathological and anatomical examination of the living man. It gave a tremendous impetus to a course of action the onesidedness of which had already begun to be felt. By means of a more certain and complete diagnosis rontgenology opened up an epoch of thoracic surgery which is now making systematic progress.
Radiography.-This
the century.
The differential-pressure procedure was introduced in 1904. I have to thank my teacher Mikulicz for inspiring me in the work that resulted in this simple technical method. It resulted from a clear consideration and accurate assessment of the physiological pressure relations in the thoracic cavity and the elasticity of the lung which controlled them. At one blow surgery was freed from a restriction which had long hampered it. Operations on the lungs, the mediastinal organs, and the wall of the thorax could be ventured on without fear of the dangers of an open pneumothorax or the fatal mediastinal flutter. Thus a break was made away from the conservative treatment of injuries to the lungs and certain wounds in the lungs were treated by operation. FURTHER ADVANCES
It
became
clear, however, that
one could only one’s way. It was realised that a deliberate extension of thoracic surgery must be preceded by the solution of certain physiological and general pathological problems. And so a search was made for the laws governing the origin and the course of inflammation of the thoracic cavity and its organs. Even the type and the quantity of the exudations were different from those of the abdominal cavity. The peritoneum responds to mechanical and inflammatory injuries, mostly with fibrinous exudates, which lay the foundation for an early capsulation of the focus of the disease. The pleura is prone to serous exudation which greatly hampers treatment after intrathoracic operations. Liability of these serous effusions to secondary infection has often had disastrous results despite technical soon
advance slowly and by
feeling
success.
Other researches into the absorption of fluid made clear the importance of the extensive lymphatics of the pleura, the lungs, the diaphragm, the mediastinum, and their many mutual connexions. The influence of various states of distension in the case of inflation and retraction of the lungs on the distribution and stream of the blood in the heart and the lungs was proved. Of especial value for the surgeon was the discovery that the blood coagulation in the thoracic cavity under the influence of the movement of the organs, especially the heart, takes place more easily than in other parts of the body. Researches into the anatomical and functional results of putting out of action large parts of the lung show us what enormous powers of adaptation and substitution the lungs have. Phrenicotomy.-Experimental surgery on the oesophagus inevitably involves inquiry into the importance ofthe movement of the diaphragm and the possibility ofstopping it. Phrenicotomy had already been applied in 1904. As will be seen it later achieved special significance for the treatment of pulmonary tuberculosis. The results of further experimental
studies were confirmed later by observations made in the living. One recognises the dangers of the severe and even fatal pleural reflexes that are especially liable to occur in operations on the mediastinum, even from swabbing, but also whilst severing adhesions and ligaturing large bronchi. One learns to avoid them by operating with special delicacy in this field, and by the very slow and gentle constriction of the bronchi. Ligature.-The evidence of air in the left side of the heart and in the cerebral vessels after injuries to the lungs, and the recognition of the risk of aspiration during operations on the neck and the upper mediastinum, in the right side of the heart and the course of the pulmonary artery has resulted in a methodical progress by way of prevention. Severing of lung tissue, especially if cicatricial, is not undertaken on principle until preliminary ligature have been made in order to avoid air embolism in the
greater circulation. Positive-pressure respiration is also employed prophylactically in operations on the mediastinum and the throat. It results in an increase of pressure and prevents the aspiration of air into the right half of the heart and the veins draining into it.
Exploratory thoracotomy.-Clinical diagnosis also is rendered considerably more certain by operative findings ; ideas as to the nature of the disease are frequently supplemented or improved, thereby diagnostic thoracotomy has acquired the same significance as diagnostic laparotomy. New thera. peutic plans arise. Suture of an injured heart is now a practical surgical exercise since Rehn demonstrated its possibility by his excellent technique. Under these influences an interest for thoracic surgery had been awakened in both surgeons and physicians. Later, confidence was added to this interest when the first major operations in intrathoracic diseases and injuries were successful. Modern Methods Thus through a course of gradual development the soil was prepared for the seed to which as yet no attention had been paid. Old surgical proposals were remembered and it was hoped that they might now be successful. The old ideas of Quincke and Spengler and the procedure of Forlanini became once more the centre of interest. Leading lung specialists realised the great practical importance of pneumothorax therapy and endeavoured to improve it. Firstclass work was done in this field by Murphy, Saugmann, and Brauer. RIB RESECTION
The discovery that in cases of one-sided tuberculosis this treatment could not always be carried out on account of adhesions, revived the old mobilisation of the thoracic wall introduced by Quincke. Brauer showed that there is in principle no difference between pneumothorax and extensive rib resection. Both methods work by facilitating relaxation of the lung. Where artificial insufflation fails on account of adhesions, removal of ribs is indicated. It must, however, be applied to the whole lung. Anterior rib resection.-The first operation of this kind was performed by Friedrich following the old plastic method of Schede. He exposed the 2nd-10th ribs and removed them extrapleurally as far as the insertion. The first patient survived this serious operation and was cured. After this, however, there were a number of failures, and but for this striking success in this first case-a seriously ill consumptivethe development of the procedure would probably have been seriously retarded. Physicians were
725
convinced, however, of the
correctness of the basic
idea, and turned their attention to ment in the technique.
an
improve-
performed the operation in two carefully graduated stages. By this means the chief evil effects of the operation, especially the dangerous fluttering of the mediastinum, were avoided, and the mortality decreased considerably. The only disadvantage was the necessity of operating twice. In a few cases there were pulmonary hernise as well as functional disturbances of the shoulder-girdle and spinal column as a result of the almost complete We first
removal of the ribs.
It was necessary therefore the Brauer-Friedrich operation by an
supplant improved procedure. to
Paravertebral resection.-As the result of anatomical
research we concluded that the removal of paravertebral portions of ribs was more effective for the compression of the thorax than a resection even of larger axillary or sternal portions. In the case of posterior resections the ribs follow the movement of the lungs. The wall of the thorax is, so as to speak, displaced into the chest in so far as the soft rib cartilages permit it. It further became evident that besides this lateral compression of the thorax downwards, a further reduction could be achieved from above if a lowering of the whole chest wall could be effected. This was easily attainable by resection of the first rib. Thus, as a result of many attempts, we achieved the method now adopted in our clinic-paravertebral resection of the first to the eleventh rib. Its advantage is chiefly found in the support given to the mediastinum, since the firmness of the thoracic wall is preserved in spite of an extensive reduction of the thoracic cavity. In this manner the action of the heart and the expansion of the other lung are not hampered. When comparing this method with other methods of rib resection, this fact is very important. Other methods available are those proposed by Brauer and Wilms. THORACOPLASTY IN THE TREATMENT OF PHTHISIS
The surgery of
pulmonary
tuberculosis is thus
contemporary with the beginning of deliberate thoracic surgery. The new sphere of work which was thus opened up presented three principal problems. First, the systematic development of method. This was shown in all phases of the operation of paravertebral rib resection : position, local an2esthesia, suture of the wound, and bandaging. Naturally, one learned to
adapt
the
surgical procedure
to the demands of
individual cases-namely, to extend the operation two or more stages when indicated. Supplementary operations too, the so-called corrective plastics, were elaborated for cases in which inadequate success attended the original paravertebral rib over
resection.
Deft, rapid, and
sure
technique
was
indispensable
if only because of the state of the patient, who
of pulmonary tuberculosis for cases of unilateral disease of the fibrotic type. This should still be adhered to as far as possible, and only the experienced surgeon may go beyond these limitations. Where there is a free pleural space, pneumothorax is the procedure to be preferred in so far as is indicated by the type and the extent of the disease.. If, however, there are adhesions between the surface of the lung and the wall of the thorax an operative release is necessary. The state of the mediastinum is of decisive importance. If it is hard, firm, and dense, it will sustain the onesided burdening after the resection and there will be no danger. If, on the other hand, it is tender and soft, it will follow the changing intrathoracic pressure and move from side to side. As in the case of open pneumothorax, this mediastinal fluttering causes a displacing of the heart, a throttling of its vessels, and embarrassment to the other lung. Suffocation and death may be the result, as in the case of open pneumothorax. In judging the findings in the lungs, the character of the patient, the state of the so-called healthy side, and the general condition of the patient, the surgeon should consult an experienced specialist. From the very beginning of our work and in spite of our increasing experience we have stuck to this principle, and
Surgical treatment originally reserved
was
thus gained much for the patients as well as for ourselves. Of course the physician must be well acquainted with both the principles of surgical treatment and the possibilities of the individual procedures, and he must also, just as must the surgeon, have a thorough knowledge of the nature and peculiarities of tuberculosis. In more than 25 years’ work our clinic has constantly concerned itself with the general aspects of tuberculosis. For years we have adopted a higher medical standpoint, and critically refuted one-sided bacteriological or pathologico-anatomical doctrines. A short historical survey will make this clear to you. Before the fundamental work of Robert Koch tuberculosis was considered as a frankly hereditary or constitutional condition. With the rise of bacteriology it came to be considered as a purely infective disease acquired during life, and attempts were made to assess its seriousness according to the quantity and virulence of the bacilli in the organism. A large number of bacilli in one streak preparation of the sputum only too often alarmed both physician and patient, even if the general clinical impression was good. It is true that discerning physicians very soon realised the narrowness of this point of view. Their judgment of the patient’s condition was more influenced by the general status and the susceptibility and sensitiveness of his tissue. The revolution in thought which gradually came about is associated with the names of a number of excellent research workers and physicians. I should like to mention but one here, Karl Ernst Ranke. He was the first to recognise consequent laws in the course of tuberculosis, and laid them down in his doctrine of the primary complex, the stage of generalisation, and tertiary phthisis. He has enabled us to understand the varieties of tuberculosis.
was
sensitive, weakened, and often very seriously ill. Further, one learned to master accidents occurring during the operation. We have experienced various accidents of this kind, for instance even an injury to the subclavian artery in severing the first rib. We also expended equal pains on the careful and conscientious after-treatment of the patient, which entailed a thorough training of the nursing personnel. Above all, the success of the operation stands and falls on the selection of cases-in other words, the indications. Here I come to the second task in our work.
of the disease are and extent of the reaction thereto on the part of the connective tissue. In the so-called exudative form of the disease caseation and softening are especially prominent, while in the fibrous form exudation gives place to cicatrisation. The proliferation of the connective tissue which accompanies tuberculosis is a deliberate attempt of the body to limit the focus of the disease and finally to bring it to a cure. The value of a treatment depends on whether it is possible to strengthen an already existing fibrous reaction or to The
peculiarities
and
course
determined by variations in the
strength
726 stimulate one which is still lacking. General and Patients success of the operation is often astonishing. local measures may bring this about ; strengthening in an advanced stage of marasmus who have not left of the body by means of light and air, especially in their beds for years become once more fresh, strong, and a mountain climate, and suitable nourishment, capable of exertion. are especially effective. Mechanical and functional When in 1908 the first success of surgical treatment stimulants may be used to support the working of in cases of one-sided pulmonary tuberculosis became these elements, but there is no treatment which is known, many physicians doubted on principle whether valid for every patient. Here too the art of the serious phthisis could be healed in this way. Their physician consists in grasping the peculiarity of the attitude could easily be understood in view of the body and correctly applying the corresponding variable nature of tuberculosis and the incalculability measures. The question why in one patient there is of its course. Gradually, however, they gained one reaction and in another a different one is difficult confidence, all the more because the small early to answer. Among the many conditions which mortality was surprising in view of the seriousness operate together only a few can be studied from a of the operation. clinical, immuno-biological, humoral, and pathoIn 1914 I was able to report upon 172 operated logico-anatomical point of view. Special importance patients. In 122 cases extensive extrapleural resecis attributed first to one and then to the other. The tion was performed. Only 3 of these 122 died physician should endeavour to collect the individual immediately after the operation. In 1924, ten years results of these studies and to sum them up. Whether later, the early mortality in our clinic amounted to one speaks of a positive or negative allergy, of a 3-3 per cent. in 500 cases of thoracoplasty. In the weaker or stronger disposition, or constitutional or world statistics which Alexander drew up at this time, acquired resistance and sensitivity to infection, it is the cause of death within four weeks of the operation always a question of interpreting the individual amounted to 12 per cent. processes. The unit, however, is the peculiarity This early mortality is primarily dependant upon of the diseased body, which is conditioned by various the indications for which the operation is undertaken, factors. They are not all of equal value and unchangeand in recent years we too have sometimes had a able. Some are due to heredity, and these are the mortality amounting to from 6 to 8 per cent., as most important. Others are the result of environwe were continually having more patients sent to ment or the various injuries and diseases suffered us who often only showed very limited indications during the course of life. Next to the specific forces for operative treatment. To this must be added the which are produced by the tuberculosis itself, nonlate mortality, which amounted to 16 per cent. in the specific forces also play an important part. All, first few years after operation ; it is due to a change however, contribute to the peculiarity of the person. for the worse of the other side, to failure of the heart, The recognition of the fact that these too alter and or to a wrong selection of the patient. Over against can be artificially influenced has become the basis these figures one must set the fact that of untreated for the surgical treatment of tuberculosis also. tuberculosis patients in the third stage only 53 per - BspaM*.—And now I come to the healing processes cent. survive for one year, and only 22 per cent. for which can be observed after the removal of the five years. mechanical resistance of the thorax by surgical The successes achieved by thoracoplasty are means. therefore surprising and gratifying. Without regardCompression of the lung, accompanied by an ing our own statistics the six most important statistical extensive reduction of respiratory activity, leads to reports (Archibald, Bull, Gravesen, Franke, Kaystrom, a diminution of the cavities and a decrease in their Scherdtler) show that from a total of 1160 patients secretions. The flow of lymph is also slowed up and 42-3 per cent. have been actively following their congestion sets in. As in every case of cessation of professions for a year without any signs of disease. activity accompanied by lymphatic congestion, one The number of patients whom we have treated is sees here too a proliferation in the connective tissue, considerably over a thousand, so that our clinic which is considerably supplemented by an alteration probably has at present the largest amount of in the flow of the blood through the part in question. experience. Until recent years the number of our The nature and extent of this alteration of the circula- permanent cures amounted to 70-80 per cent. as a tion in the lungs have not yet been fully recognised. result of the strict selection of cases. As I have It is certain that in central relaxation of the lung an already mentioned, the average case operated on the blood takes of conduction place. being of a poorer type, this percentage is not now so optimal - BesMs.—In connexion with these anatomical and high ; it is still, however, 40-6 per cent. Contra-indication.-The unavoidable limitations of biological changes one observes an impressive clinical in condition. After a short the entire paravertebral rib resection, the development of which improvement rise in temperature and increase of sputum, the body I have described, made it necessary, at least in the temperature soon becomes normal. This initial but early period of surgical treatment of pulmonary usually transient pyrexia is due to flooding of the tuberculosis, to exclude cases where both lungs were circulatory system with the toxins that are squeezed affected, even when the findings on the one side made out of the lung when it is first compressed. The technical compression appear highly desirable. I sputum also decreases in a short time and finally am thinking here of a finding which will be familiar ; disappears altogether ; this is due to the anatomical large cavities in the upper lobe which have obviously changes in the lung, for the cavities become smaller, led to a spread of disease to the other side by means the congestion and decomposition of their contents of dissemination. Similarly, it was often impossible to apply this procedure on account of deterioration cease, the inflammation decreases, and new connective in the myocardium, or where the patient was of a tissue is formed. Very soon the general condition of the patient, the improved colour and expression considerable age. These patients could be benefited of face, and an increase in appetite and weight by the introduction of special procedures, attended indicate the desired success. The signs of toxic by no very great operative strain, but which at the absorption, headaches, debility, and perspiration same time could only achieve a limited mechanical stop. In cases of chronic hectic tuberculosis the effect-paralysing of the diaphragm and plombage.
727 Neither of these
really be regarded as independent rather to supplement or to for thoracoplastic operations.
can
operations ; they
prepare the way
serve
in PHRENICOTOMY
paralysis of the diaphragm has taken in its place surgical treatment more or less in a roundabout way. It was first applied in the surgery of the thoracic oesophagus. Thirty years ago, when I was still Mikulicz’s assistant, I concerned myself with experimental resection of the thoracic oesophagus. I succeeded, after removing a part of the oesophagus, in uniting the two lumens by displacing the stomach into the thoracic cavity through the diaphragm, but the suture did not hold because of the movements of the closed oesophagus. I had no success until I had cut the phrenic nerve and thus paralysed the diaphragm. Simple severance of the nerve in the neck on the anterior scalene muscle does not completely abolish motor impulses if there are any subsidiary branches. These join the trunk within the thorax and this necessitates evulsion, when the branch nerves are also removed. Immobilising the diaphragm reduces the respiratory movements of the inferior lobes. In this way the intra-abdominal pressure pushes the diaphragm against the lung, which is thus compressed and can relax. Elevation of the diaphragm may have a beneficial effect upon cavities in the lower part of the lungs, basic adhesions in the case of incomplete pneumothorax, and occasionally also upon upper lobe cavities. Phrenic evulsion has no importance of its own in the treatment of pulmonary tuberculosis. It is of value from a diagnostic point of view, however, in cases where the resisting capacity of the so-called intact side is uncertain and has therefore to be ascertained before any large operation is performed. The elimination of breathing surface occasioned by the rising of the diaphragm involves an increased strain on the opposite lung ; incompletely healed centres of the disease become noticeable on clinical and X ray examination, and so serve as warning’s This paralysing of the diaphragm for pulmonary disease has further indications. It may be employed Artificial
for persistent hiccough, especially where the syndrome is caused by malignant tumours, and occasionally in haemorrhages of the lung and in cardiospasm. The bilateral operation has given good results in cases of severe tetanus. PLOMBAGE
Soon after the first use of diaphragmatic paralysis in the surgical treatment ofpulmonary tuberculosis plombage was introduced. This makes it possible to obtain at a selected spot a graded mechanical effect by using more or less " plombe " material. Plombage is required in certain cases where the pleura is adherent. Through a small opening in the chest wall the lung is detached from the inner surface of the thorax and a space is made which is filled up with plastic paraffin. This compresses the relaxed and detached portion of the lung and solidifies. The treatment is mainly applied to cases of bilateral cavities and of severe haemorrhage from cavities, where a pneumothorax cannot be performed. This treatment too was originally applied in other branches of thoracic surgery. Tuffier proposed the plugging of adipose tissue for abscess of the lung. Baer
developed independently the scheme of plombage cases of pulmonary tuberculosis, and introduced paraffin as the filling to which he added per cent. in
of Vioform and 1 per cent. of bismuth carbonate. By adding these substances it is intended to create an antiseptic effect and to make the plombe visible
radiograms.
Disturbances in the healing around the plombe gave rise to new surgical problems. The foreign body penetrates now and again into the cavern owing to necrosis of its walls, which are badly vascularised. In consequence the patients expectorate small bits of the filling. This troublesome condition which is not without danger may be overcome by removing the plug. The essential part, however, is a thorough drastic removal of the overlying ribs and of the callosity of the plug’s bed. Only in this way is it possible to obtain sufficient relaxation of the adjacent lung and complete healing. TREATMENT OF CAVITIES AND ADHESIONS
These experiences led once more to the drainage of tuberculous cavities which was attempted vainly in the last century. In this roundabout manner therefore the surgical treatment of pulmonary tuberculosis has found its way back to the method with which it had begun. It is, however, a conditio sine qua non that drainage of tuberculous cavities should be preceded by a surgical reduction in the size of the thorax. This necessity was also demonstrated previously by experiences in the surgical treatment of lung abscess cavities with rigid walls. The only indication for opening tuberculous cavities is, however, if other methods of reducing fail on account of the rigidity its walls and continuous retention of pus produces a toxic reaction. I need not say anything with regard to the character and application of the endoscopic treatment of pleural adhesions established by Jacobaeus, but I am sure you will understand the attitude of the surgeon who prefers quick work under the control of the eye. He prefers to open the thorax at a suitable spot, and having effected a double ligature, to sever the adhesions after an operation which can be performed in five or ten minutes. The dangers attending cauterisation of adhesions that contain deformed cavities or largesized blood-vessels are well known. What must be absolutely reiected is cauterisation of extensive adhesions. These we must regard as symptoms of a healing process which should not be interfered with, but rather be promoted. Long years of experience with the vast numbers of patients sent to our clinic with the most serious complications and in an almost hopeless condition entitle me to point out again and again the necessity for strictly observing the indications and limitations, both of the operation of thorax adhesion cauterisation and of artificial pneumothorax. For many years it was indeed almost impossible to help patients suffering from mixed infection suppurating effusions of the pleura complicating rash operations of this type, and 95 per cent. of these patients died.
ROYAL MINERAL WATER HOSPITAL, BATH.-The
appeal for a meeting
a
new
hospital
at the Vintners’
The site for the
is
likely
to
be launched at
Hall, London, this
autumn.
building is being cleared in Peterstreet area, Bath, and already sums amounting to 50,000 have been offered by Mr. Sidney Robinson of Bath, and new
daughter, Mrs. Prince of Beckington. This is about quarter of the whole amount which has to be raised. Last year the hospital received 1198 patients from Wales, Scotland, Ireland, and the Channel Isles as well as from 38 English counties. his a
ADDRESSES AND ORIGINAL ARTICLES THE DEVELOPMENT OF THORACIC SURGERY * BY FERDINAND SAUERBRUCH PROFESSOR OF SURGERY IN THE UNIVERSITY OF BERLIN
I SHOULD like first to recall the great pathfinders and pioneers which Great Britain has produced and whose names are indissolubly associated with the development of our science. I refer to Carson,
Stokes, Macewen, and others. While thinking of these illustrious names I should like to associate with them in my memory those of the great countrymen of yours who have laid the foundation-stone of our surgical art, and have amplified our knowledgethe names of Hunter, Harvey, Lister, and Simpson. Thoracic surgery is to-day a standard branch of medical science. In the last three decades it has systematically developed into a definite field of major surgery. From the close anatomical and physiological relations in the individual organs and their dependence on the physical laws of the thorax it became evident that research into individual surgical problems and their technical solution constantly brought up new problems and new methods in this sphere. The nature of this development is especially characterised by an exchange of ideas both on technical and on clinical matters which kept pace with the growing experience and achievements of general surgery. Much was also learnt from the progress made in other fields of medical science. The fact that our branch had many and varied connexions with internal medicine and theoretical medicine was of especial value to us, particularly in the circulation of the blood, the respiratory organs, and the treatment of pulmonary tuberculosis. All these advances, however, recede into the background in comparison with the significance of the fundamental change which has undergone our conception of the course of the disease. This change has taken place during the last fifty years, and it has cleared the way for a new method of thought with regard to functional and biological relationships. The personality of the patient once more takes the centre of the stage. Historical Survey The attitude of the last century was characterised by the endeavour to understand diseases from a pathological and anatomical point of view, and to localise them according to the ideas of Morgagni and Virchow. It is true that the ruling doctrine on diseases of the abdominal cavity opened up a new epoch of successful treatment for some diseasesone needs only to refer to appendicitis and cholelithiasis. It was inevitable that the wish should arise to extend surgical treatment to other cavities of the body. At first the theory was held that in the same way simple and radical measures could be successfully applied in various diseases of the thorax and its organs. The treatment of empyema, for instance, developed in this direction. The " siphon drainage " recommended first by Potain and then by Bulau was rejected ; the open evacuation of pus by means of rib resection came more and more to be preferred. * A lecture delivered before the Newcastle and Northern Counties Medical Society and the Society of Thoracic Surgeons of Great Britain and Ireland
5900
on
Nov. 15th. 1935.
Surgeons had the idea that empyema was only a particular form of abscess which, according to surgical theory, must be opened as widely as possible. The number of deaths that occurred with this treatment in the influenza epidemics of the ’eighties and ’nineties was horrifying. In the meantime only a few surgeons realised the causes of these failures. They realised that they were not so much due to the seriousness of the disease, but to inefficient methods of procedure, which paid no attention to the particular kind of empyema, or to the effects on the heart and lungs of opening the thoracic cavity. The effects were the same as in open pneumothorax, and resulted in a fluttering of the mediastinum. The fate of these patients and of those suffering from injuries to the lungs was terrible. The treatment was mainly symptomatic, and almost half of them died. Abscess cavities in the lungs, which had formerly been treated here and there, were now opened more frequently. The results were necessarily limited. If there were no adhesions between the inner surface of the thorax and the outer surface of the lung, the operation could not be carried out as planned on account of the open pneumothorax. The prevalent doctrine of the anatomical localisation of diseases gave an impulse to the operative treatment of tuberculosis of the lungs. Experiments on animals led to the belief that resection of the lobes of the lung, which was occasionally performed in the early stages of phthisis, was justified. The high mortality resulting from these attempts, and also from the operative drainage of cavities, led more and more to their being given up. They were unsuccesful because the nature of phthisis had not been understood, and because the methods were inadequate. Individual successes, such as those of Macewen and Tuffier, which were attained under especially favourable conditions, could not hide the truth of this fact. Other methods of surgical treatment of tuberculosis began more hopefully. They aimed at compression of the diseased organ either by letting air into the thoracic cavity-that is, by a pneumothorax-or, in certain forms of the disease, by removing parts of the ribs. EARLY METHODS
Artificial pneumothorax.-Already, at the beginning of the last century, considerable improvement was observed in cases where either exudation or a sponIn 1882 taneous pneumothorax had occurred. Forlanini endeavoured to imitate the example of nature, and achieve a retraction or compression of the diseased lung by an artificial pneumothorax. Cailley was the first to utilise this for the successful arrest of serious haemorrhages. In the meantime, no attention was paid to Forlanini’s method, although he was able to secure practical successes. Thoracoplasty.-At the same time, Quincke and Carl Spengler suggested compression of the cavities in the fibrotic form of tuberculosis by means of removing one or more ribs. They supported their theory by the observation that when the tissue surrounding the focus of the disease, especially the chest wall, was sufficiently pliant, cavities could heal themselves by means of concentric shrinkage. If, however, this process failed owing to the rigidity of the chest wall or if its eccentric pull resulted in an enlargement of the cavity, it was necessary to mobilise the resistant ribs so as to eliminate this really contradictory action of nature and to give free play to the forces of repair. Extrapleural rib resection near the N
724
cavity was often applied but with no very convincing The plan, clear and accurate as it was, success. foundered on the rocks of insufficient technique ; the time was not ripe. Progress was necessary first in the fundamentals.
advance came at the turn of It resulted at first from Rontgen’s discovery, for the X ray picture made it possible all of a sudden to carry out a pathological and anatomical examination of the living man. It gave a tremendous impetus to a course of action the onesidedness of which had already begun to be felt. By means of a more certain and complete diagnosis rontgenology opened up an epoch of thoracic surgery which is now making systematic progress.
Radiography.-This
the century.
The differential-pressure procedure was introduced in 1904. I have to thank my teacher Mikulicz for inspiring me in the work that resulted in this simple technical method. It resulted from a clear consideration and accurate assessment of the physiological pressure relations in the thoracic cavity and the elasticity of the lung which controlled them. At one blow surgery was freed from a restriction which had long hampered it. Operations on the lungs, the mediastinal organs, and the wall of the thorax could be ventured on without fear of the dangers of an open pneumothorax or the fatal mediastinal flutter. Thus a break was made away from the conservative treatment of injuries to the lungs and certain wounds in the lungs were treated by operation. FURTHER ADVANCES
It
became
clear, however, that
one could only one’s way. It was realised that a deliberate extension of thoracic surgery must be preceded by the solution of certain physiological and general pathological problems. And so a search was made for the laws governing the origin and the course of inflammation of the thoracic cavity and its organs. Even the type and the quantity of the exudations were different from those of the abdominal cavity. The peritoneum responds to mechanical and inflammatory injuries, mostly with fibrinous exudates, which lay the foundation for an early capsulation of the focus of the disease. The pleura is prone to serous exudation which greatly hampers treatment after intrathoracic operations. Liability of these serous effusions to secondary infection has often had disastrous results despite technical soon
advance slowly and by
feeling
success.
Other researches into the absorption of fluid made clear the importance of the extensive lymphatics of the pleura, the lungs, the diaphragm, the mediastinum, and their many mutual connexions. The influence of various states of distension in the case of inflation and retraction of the lungs on the distribution and stream of the blood in the heart and the lungs was proved. Of especial value for the surgeon was the discovery that the blood coagulation in the thoracic cavity under the influence of the movement of the organs, especially the heart, takes place more easily than in other parts of the body. Researches into the anatomical and functional results of putting out of action large parts of the lung show us what enormous powers of adaptation and substitution the lungs have. Phrenicotomy.-Experimental surgery on the oesophagus inevitably involves inquiry into the importance ofthe movement of the diaphragm and the possibility ofstopping it. Phrenicotomy had already been applied in 1904. As will be seen it later achieved special significance for the treatment of pulmonary tuberculosis. The results of further experimental
studies were confirmed later by observations made in the living. One recognises the dangers of the severe and even fatal pleural reflexes that are especially liable to occur in operations on the mediastinum, even from swabbing, but also whilst severing adhesions and ligaturing large bronchi. One learns to avoid them by operating with special delicacy in this field, and by the very slow and gentle constriction of the bronchi. Ligature.-The evidence of air in the left side of the heart and in the cerebral vessels after injuries to the lungs, and the recognition of the risk of aspiration during operations on the neck and the upper mediastinum, in the right side of the heart and the course of the pulmonary artery has resulted in a methodical progress by way of prevention. Severing of lung tissue, especially if cicatricial, is not undertaken on principle until preliminary ligature have been made in order to avoid air embolism in the
greater circulation. Positive-pressure respiration is also employed prophylactically in operations on the mediastinum and the throat. It results in an increase of pressure and prevents the aspiration of air into the right half of the heart and the veins draining into it.
Exploratory thoracotomy.-Clinical diagnosis also is rendered considerably more certain by operative findings ; ideas as to the nature of the disease are frequently supplemented or improved, thereby diagnostic thoracotomy has acquired the same significance as diagnostic laparotomy. New thera. peutic plans arise. Suture of an injured heart is now a practical surgical exercise since Rehn demonstrated its possibility by his excellent technique. Under these influences an interest for thoracic surgery had been awakened in both surgeons and physicians. Later, confidence was added to this interest when the first major operations in intrathoracic diseases and injuries were successful. Modern Methods Thus through a course of gradual development the soil was prepared for the seed to which as yet no attention had been paid. Old surgical proposals were remembered and it was hoped that they might now be successful. The old ideas of Quincke and Spengler and the procedure of Forlanini became once more the centre of interest. Leading lung specialists realised the great practical importance of pneumothorax therapy and endeavoured to improve it. Firstclass work was done in this field by Murphy, Saugmann, and Brauer. RIB RESECTION
The discovery that in cases of one-sided tuberculosis this treatment could not always be carried out on account of adhesions, revived the old mobilisation of the thoracic wall introduced by Quincke. Brauer showed that there is in principle no difference between pneumothorax and extensive rib resection. Both methods work by facilitating relaxation of the lung. Where artificial insufflation fails on account of adhesions, removal of ribs is indicated. It must, however, be applied to the whole lung. Anterior rib resection.-The first operation of this kind was performed by Friedrich following the old plastic method of Schede. He exposed the 2nd-10th ribs and removed them extrapleurally as far as the insertion. The first patient survived this serious operation and was cured. After this, however, there were a number of failures, and but for this striking success in this first case-a seriously ill consumptivethe development of the procedure would probably have been seriously retarded. Physicians were
725
convinced, however, of the
correctness of the basic
idea, and turned their attention to ment in the technique.
an
improve-
performed the operation in two carefully graduated stages. By this means the chief evil effects of the operation, especially the dangerous fluttering of the mediastinum, were avoided, and the mortality decreased considerably. The only disadvantage was the necessity of operating twice. In a few cases there were pulmonary hernise as well as functional disturbances of the shoulder-girdle and spinal column as a result of the almost complete We first
removal of the ribs.
It was necessary therefore the Brauer-Friedrich operation by an
supplant improved procedure. to
Paravertebral resection.-As the result of anatomical
research we concluded that the removal of paravertebral portions of ribs was more effective for the compression of the thorax than a resection even of larger axillary or sternal portions. In the case of posterior resections the ribs follow the movement of the lungs. The wall of the thorax is, so as to speak, displaced into the chest in so far as the soft rib cartilages permit it. It further became evident that besides this lateral compression of the thorax downwards, a further reduction could be achieved from above if a lowering of the whole chest wall could be effected. This was easily attainable by resection of the first rib. Thus, as a result of many attempts, we achieved the method now adopted in our clinic-paravertebral resection of the first to the eleventh rib. Its advantage is chiefly found in the support given to the mediastinum, since the firmness of the thoracic wall is preserved in spite of an extensive reduction of the thoracic cavity. In this manner the action of the heart and the expansion of the other lung are not hampered. When comparing this method with other methods of rib resection, this fact is very important. Other methods available are those proposed by Brauer and Wilms. THORACOPLASTY IN THE TREATMENT OF PHTHISIS
The surgery of
pulmonary
tuberculosis is thus
contemporary with the beginning of deliberate thoracic surgery. The new sphere of work which was thus opened up presented three principal problems. First, the systematic development of method. This was shown in all phases of the operation of paravertebral rib resection : position, local an2esthesia, suture of the wound, and bandaging. Naturally, one learned to
adapt
the
surgical procedure
to the demands of
individual cases-namely, to extend the operation two or more stages when indicated. Supplementary operations too, the so-called corrective plastics, were elaborated for cases in which inadequate success attended the original paravertebral rib over
resection.
Deft, rapid, and
sure
technique
was
indispensable
if only because of the state of the patient, who
of pulmonary tuberculosis for cases of unilateral disease of the fibrotic type. This should still be adhered to as far as possible, and only the experienced surgeon may go beyond these limitations. Where there is a free pleural space, pneumothorax is the procedure to be preferred in so far as is indicated by the type and the extent of the disease.. If, however, there are adhesions between the surface of the lung and the wall of the thorax an operative release is necessary. The state of the mediastinum is of decisive importance. If it is hard, firm, and dense, it will sustain the onesided burdening after the resection and there will be no danger. If, on the other hand, it is tender and soft, it will follow the changing intrathoracic pressure and move from side to side. As in the case of open pneumothorax, this mediastinal fluttering causes a displacing of the heart, a throttling of its vessels, and embarrassment to the other lung. Suffocation and death may be the result, as in the case of open pneumothorax. In judging the findings in the lungs, the character of the patient, the state of the so-called healthy side, and the general condition of the patient, the surgeon should consult an experienced specialist. From the very beginning of our work and in spite of our increasing experience we have stuck to this principle, and
Surgical treatment originally reserved
was
thus gained much for the patients as well as for ourselves. Of course the physician must be well acquainted with both the principles of surgical treatment and the possibilities of the individual procedures, and he must also, just as must the surgeon, have a thorough knowledge of the nature and peculiarities of tuberculosis. In more than 25 years’ work our clinic has constantly concerned itself with the general aspects of tuberculosis. For years we have adopted a higher medical standpoint, and critically refuted one-sided bacteriological or pathologico-anatomical doctrines. A short historical survey will make this clear to you. Before the fundamental work of Robert Koch tuberculosis was considered as a frankly hereditary or constitutional condition. With the rise of bacteriology it came to be considered as a purely infective disease acquired during life, and attempts were made to assess its seriousness according to the quantity and virulence of the bacilli in the organism. A large number of bacilli in one streak preparation of the sputum only too often alarmed both physician and patient, even if the general clinical impression was good. It is true that discerning physicians very soon realised the narrowness of this point of view. Their judgment of the patient’s condition was more influenced by the general status and the susceptibility and sensitiveness of his tissue. The revolution in thought which gradually came about is associated with the names of a number of excellent research workers and physicians. I should like to mention but one here, Karl Ernst Ranke. He was the first to recognise consequent laws in the course of tuberculosis, and laid them down in his doctrine of the primary complex, the stage of generalisation, and tertiary phthisis. He has enabled us to understand the varieties of tuberculosis.
was
sensitive, weakened, and often very seriously ill. Further, one learned to master accidents occurring during the operation. We have experienced various accidents of this kind, for instance even an injury to the subclavian artery in severing the first rib. We also expended equal pains on the careful and conscientious after-treatment of the patient, which entailed a thorough training of the nursing personnel. Above all, the success of the operation stands and falls on the selection of cases-in other words, the indications. Here I come to the second task in our work.
of the disease are and extent of the reaction thereto on the part of the connective tissue. In the so-called exudative form of the disease caseation and softening are especially prominent, while in the fibrous form exudation gives place to cicatrisation. The proliferation of the connective tissue which accompanies tuberculosis is a deliberate attempt of the body to limit the focus of the disease and finally to bring it to a cure. The value of a treatment depends on whether it is possible to strengthen an already existing fibrous reaction or to The
peculiarities
and
course
determined by variations in the
strength
726 stimulate one which is still lacking. General and Patients success of the operation is often astonishing. local measures may bring this about ; strengthening in an advanced stage of marasmus who have not left of the body by means of light and air, especially in their beds for years become once more fresh, strong, and a mountain climate, and suitable nourishment, capable of exertion. are especially effective. Mechanical and functional When in 1908 the first success of surgical treatment stimulants may be used to support the working of in cases of one-sided pulmonary tuberculosis became these elements, but there is no treatment which is known, many physicians doubted on principle whether valid for every patient. Here too the art of the serious phthisis could be healed in this way. Their physician consists in grasping the peculiarity of the attitude could easily be understood in view of the body and correctly applying the corresponding variable nature of tuberculosis and the incalculability measures. The question why in one patient there is of its course. Gradually, however, they gained one reaction and in another a different one is difficult confidence, all the more because the small early to answer. Among the many conditions which mortality was surprising in view of the seriousness operate together only a few can be studied from a of the operation. clinical, immuno-biological, humoral, and pathoIn 1914 I was able to report upon 172 operated logico-anatomical point of view. Special importance patients. In 122 cases extensive extrapleural resecis attributed first to one and then to the other. The tion was performed. Only 3 of these 122 died physician should endeavour to collect the individual immediately after the operation. In 1924, ten years results of these studies and to sum them up. Whether later, the early mortality in our clinic amounted to one speaks of a positive or negative allergy, of a 3-3 per cent. in 500 cases of thoracoplasty. In the weaker or stronger disposition, or constitutional or world statistics which Alexander drew up at this time, acquired resistance and sensitivity to infection, it is the cause of death within four weeks of the operation always a question of interpreting the individual amounted to 12 per cent. processes. The unit, however, is the peculiarity This early mortality is primarily dependant upon of the diseased body, which is conditioned by various the indications for which the operation is undertaken, factors. They are not all of equal value and unchangeand in recent years we too have sometimes had a able. Some are due to heredity, and these are the mortality amounting to from 6 to 8 per cent., as most important. Others are the result of environwe were continually having more patients sent to ment or the various injuries and diseases suffered us who often only showed very limited indications during the course of life. Next to the specific forces for operative treatment. To this must be added the which are produced by the tuberculosis itself, nonlate mortality, which amounted to 16 per cent. in the specific forces also play an important part. All, first few years after operation ; it is due to a change however, contribute to the peculiarity of the person. for the worse of the other side, to failure of the heart, The recognition of the fact that these too alter and or to a wrong selection of the patient. Over against can be artificially influenced has become the basis these figures one must set the fact that of untreated for the surgical treatment of tuberculosis also. tuberculosis patients in the third stage only 53 per - BspaM*.—And now I come to the healing processes cent. survive for one year, and only 22 per cent. for which can be observed after the removal of the five years. mechanical resistance of the thorax by surgical The successes achieved by thoracoplasty are means. therefore surprising and gratifying. Without regardCompression of the lung, accompanied by an ing our own statistics the six most important statistical extensive reduction of respiratory activity, leads to reports (Archibald, Bull, Gravesen, Franke, Kaystrom, a diminution of the cavities and a decrease in their Scherdtler) show that from a total of 1160 patients secretions. The flow of lymph is also slowed up and 42-3 per cent. have been actively following their congestion sets in. As in every case of cessation of professions for a year without any signs of disease. activity accompanied by lymphatic congestion, one The number of patients whom we have treated is sees here too a proliferation in the connective tissue, considerably over a thousand, so that our clinic which is considerably supplemented by an alteration probably has at present the largest amount of in the flow of the blood through the part in question. experience. Until recent years the number of our The nature and extent of this alteration of the circula- permanent cures amounted to 70-80 per cent. as a tion in the lungs have not yet been fully recognised. result of the strict selection of cases. As I have It is certain that in central relaxation of the lung an already mentioned, the average case operated on the blood takes of conduction place. being of a poorer type, this percentage is not now so optimal - BesMs.—In connexion with these anatomical and high ; it is still, however, 40-6 per cent. Contra-indication.-The unavoidable limitations of biological changes one observes an impressive clinical in condition. After a short the entire paravertebral rib resection, the development of which improvement rise in temperature and increase of sputum, the body I have described, made it necessary, at least in the temperature soon becomes normal. This initial but early period of surgical treatment of pulmonary usually transient pyrexia is due to flooding of the tuberculosis, to exclude cases where both lungs were circulatory system with the toxins that are squeezed affected, even when the findings on the one side made out of the lung when it is first compressed. The technical compression appear highly desirable. I sputum also decreases in a short time and finally am thinking here of a finding which will be familiar ; disappears altogether ; this is due to the anatomical large cavities in the upper lobe which have obviously changes in the lung, for the cavities become smaller, led to a spread of disease to the other side by means the congestion and decomposition of their contents of dissemination. Similarly, it was often impossible to apply this procedure on account of deterioration cease, the inflammation decreases, and new connective in the myocardium, or where the patient was of a tissue is formed. Very soon the general condition of the patient, the improved colour and expression considerable age. These patients could be benefited of face, and an increase in appetite and weight by the introduction of special procedures, attended indicate the desired success. The signs of toxic by no very great operative strain, but which at the absorption, headaches, debility, and perspiration same time could only achieve a limited mechanical stop. In cases of chronic hectic tuberculosis the effect-paralysing of the diaphragm and plombage.
727 Neither of these
really be regarded as independent rather to supplement or to for thoracoplastic operations.
can
operations ; they
prepare the way
serve
in PHRENICOTOMY
paralysis of the diaphragm has taken in its place surgical treatment more or less in a roundabout way. It was first applied in the surgery of the thoracic oesophagus. Thirty years ago, when I was still Mikulicz’s assistant, I concerned myself with experimental resection of the thoracic oesophagus. I succeeded, after removing a part of the oesophagus, in uniting the two lumens by displacing the stomach into the thoracic cavity through the diaphragm, but the suture did not hold because of the movements of the closed oesophagus. I had no success until I had cut the phrenic nerve and thus paralysed the diaphragm. Simple severance of the nerve in the neck on the anterior scalene muscle does not completely abolish motor impulses if there are any subsidiary branches. These join the trunk within the thorax and this necessitates evulsion, when the branch nerves are also removed. Immobilising the diaphragm reduces the respiratory movements of the inferior lobes. In this way the intra-abdominal pressure pushes the diaphragm against the lung, which is thus compressed and can relax. Elevation of the diaphragm may have a beneficial effect upon cavities in the lower part of the lungs, basic adhesions in the case of incomplete pneumothorax, and occasionally also upon upper lobe cavities. Phrenic evulsion has no importance of its own in the treatment of pulmonary tuberculosis. It is of value from a diagnostic point of view, however, in cases where the resisting capacity of the so-called intact side is uncertain and has therefore to be ascertained before any large operation is performed. The elimination of breathing surface occasioned by the rising of the diaphragm involves an increased strain on the opposite lung ; incompletely healed centres of the disease become noticeable on clinical and X ray examination, and so serve as warning’s This paralysing of the diaphragm for pulmonary disease has further indications. It may be employed Artificial
for persistent hiccough, especially where the syndrome is caused by malignant tumours, and occasionally in haemorrhages of the lung and in cardiospasm. The bilateral operation has given good results in cases of severe tetanus. PLOMBAGE
Soon after the first use of diaphragmatic paralysis in the surgical treatment ofpulmonary tuberculosis plombage was introduced. This makes it possible to obtain at a selected spot a graded mechanical effect by using more or less " plombe " material. Plombage is required in certain cases where the pleura is adherent. Through a small opening in the chest wall the lung is detached from the inner surface of the thorax and a space is made which is filled up with plastic paraffin. This compresses the relaxed and detached portion of the lung and solidifies. The treatment is mainly applied to cases of bilateral cavities and of severe haemorrhage from cavities, where a pneumothorax cannot be performed. This treatment too was originally applied in other branches of thoracic surgery. Tuffier proposed the plugging of adipose tissue for abscess of the lung. Baer
developed independently the scheme of plombage cases of pulmonary tuberculosis, and introduced paraffin as the filling to which he added per cent. in
of Vioform and 1 per cent. of bismuth carbonate. By adding these substances it is intended to create an antiseptic effect and to make the plombe visible
radiograms.
Disturbances in the healing around the plombe gave rise to new surgical problems. The foreign body penetrates now and again into the cavern owing to necrosis of its walls, which are badly vascularised. In consequence the patients expectorate small bits of the filling. This troublesome condition which is not without danger may be overcome by removing the plug. The essential part, however, is a thorough drastic removal of the overlying ribs and of the callosity of the plug’s bed. Only in this way is it possible to obtain sufficient relaxation of the adjacent lung and complete healing. TREATMENT OF CAVITIES AND ADHESIONS
These experiences led once more to the drainage of tuberculous cavities which was attempted vainly in the last century. In this roundabout manner therefore the surgical treatment of pulmonary tuberculosis has found its way back to the method with which it had begun. It is, however, a conditio sine qua non that drainage of tuberculous cavities should be preceded by a surgical reduction in the size of the thorax. This necessity was also demonstrated previously by experiences in the surgical treatment of lung abscess cavities with rigid walls. The only indication for opening tuberculous cavities is, however, if other methods of reducing fail on account of the rigidity its walls and continuous retention of pus produces a toxic reaction. I need not say anything with regard to the character and application of the endoscopic treatment of pleural adhesions established by Jacobaeus, but I am sure you will understand the attitude of the surgeon who prefers quick work under the control of the eye. He prefers to open the thorax at a suitable spot, and having effected a double ligature, to sever the adhesions after an operation which can be performed in five or ten minutes. The dangers attending cauterisation of adhesions that contain deformed cavities or largesized blood-vessels are well known. What must be absolutely reiected is cauterisation of extensive adhesions. These we must regard as symptoms of a healing process which should not be interfered with, but rather be promoted. Long years of experience with the vast numbers of patients sent to our clinic with the most serious complications and in an almost hopeless condition entitle me to point out again and again the necessity for strictly observing the indications and limitations, both of the operation of thorax adhesion cauterisation and of artificial pneumothorax. For many years it was indeed almost impossible to help patients suffering from mixed infection suppurating effusions of the pleura complicating rash operations of this type, and 95 per cent. of these patients died.
ROYAL MINERAL WATER HOSPITAL, BATH.-The
appeal for a meeting
a
new
hospital
at the Vintners’
The site for the
is
likely
to
be launched at
Hall, London, this
autumn.
building is being cleared in Peterstreet area, Bath, and already sums amounting to 50,000 have been offered by Mr. Sidney Robinson of Bath, and new
daughter, Mrs. Prince of Beckington. This is about quarter of the whole amount which has to be raised. Last year the hospital received 1198 patients from Wales, Scotland, Ireland, and the Channel Isles as well as from 38 English counties. his a