The History of Surgical Procedures for Emphysema

I was sent a humorous greeting card by one of our lung transplant recipients some time ago. On the cover it shows one of life’s couch potatoes complaining about her lot in life, with the text, “Life is so hard.” On the inside the text reads “It’s breathe, breathe, breathe all the time.” Well, considering who is on the cover of the card, it is rather humorous. However, there are many for whom its not funny. I am referring to patients suffering from end-stage lung disease, tethered to an oxygen tank, whose life is centered around a wheelchair, for whom each breath is a struggle. It has been exciting that in the last 10 to 12 years there are some new surgical procedures that have brought hope and relief to this group of patients. Today I would like to review with you the evolution of surgical procedures for chronic obstructive pulmonary disease. The anatomic changes associated with emphysema were described two centuries ago. Even earlier, veterinary descriptions of the lungs, in what was termed “broken winded” horses, depicted the changes of emphysema. In a text by Baillie in 1793, there is included a description of emphysematous lungs at autopsy. He noted that “in opening into the chest it is not unusual to find that the lungs do not collapse but that they fill up the cavity completely on each side of the heart. When examined their cells appear full of air so that there is seen upon the surface a prodigious number of small white vesicles” [1]. In his accompanying atlas, Baillie illustrated his autopsy findings. This particular drawing (Fig 1) is of the lungs of Dr Samuel Johnson, whose autopsy was performed by Dr Baillie. However, it was the famous French physician and anatomist Rene Laennec who systematically described both the clinical and pathologic features of emphysema. In his famous treatise on diseases of the chest first published in the French literature in 1817 [2], Laennec noted that “in pulmonary emphysema the size of the vesicles”—by that he meant the air spaces—“is much increased and less uniform. The greater number equal or exceed the size of a millet seed while some attain the magnitude of a hemp seed, cherry stone, or even fresh beans.” He noted that at autopsy “the lungs seem as if confined in their cavity, and when exposed instead of collapsing as usual, they rise in some degree and project beyond the borders of the thorax.” He noted that on percussion, “the whole chest yields a very distinct sound, and instead of its natural compressed shape it exhibits an almost round or globular outline, swelling out both before and behind. This conformation of the chest is sufficiently remarkable to have enabled me sometimes to announce the existence of emphysema from simple inspection.” Although the pathologic changes associated with emphysema were described 200 years ago, the pathophysiology of chronic obstructive pulmonary disease was poorly understood until the latter half of this century. This lack of understanding, however, did not prevent the trial of numerous operations directed at the consequences of emphysema. Thus Freund, in 1906, observing the fixed state of the thorax, which was capable of very little respiratory movement, proposed costochondrectomy. To improve movement of the chest wall, Freund did a costochondrectomy of the upper ribs on one side, and sometimes on both sides. Others, focusing on the distention of the chest, proposed thoracoplasty to reduce the size of the chest. Noting the depressed, flattened configuration of the diaphragm, physicians made attempts to restore it to a more normal position. These attempts included the use of abdominal belts, as proposed by Gordon in 1934 [3], phrenic crush as proposed by Allison in 1947 [4], and the use of pneumoperitoneum as proposed by Gaensler in 1950 [5]. Actually the abdominal belts and the pneumoperitoneum did improve pulmonary function, but both proved to be rather cumbersome and impractical means of achieving a rather modest improvement. From autopsy findings showing diminished vascularity in emphysematous lungs, Crenshaw and Rowles [6], in 1952, proposed pleural abrasion to create systemic-topulmonary collateral blood flow in the hopes of improving lung function. Osler Abbott, made famous by the Abbott Award of this Society, in fact proposed denervation of the lung. There were a whole series of denervation experiments and clinical applications. In an article he published in 1953 [7], he described pulmonary plexectomy, pulmonary artery, periarterial sympathectomy, upper dorsal sympathectomy, and a partial resection of lung. This was followed by one of the most unphysiologic, controversial, and infamous operations in all of surgical history: glomectomy, the excision of the carotid body for both asthma and emphysema. The initial report by Nakayama [8] in 1961 contained almost 4,000 cases done in Japan. A subsequent publication by Dr Richard Overholt [9] included more than 800 cases. It should be noted that subjectively more than 80% of the patients felt they had benefited from this procedure, which we now know has Presented at the Forty-second Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9–11, 1995.