Fifty years of thoracic surgery

NESTHESIA, asepsis and antisepsis A gave the surgery of fifty years ago a firm foundation upon which to build. Thoracic surgery, of course, shared in the stimuIus these three great discoveries gave to experimenta and cIinica1 surgery but the advance of thoracic surgery was necessariIy heId in abeyance unti1 roentgenoIogy was discovered in 1893 and, to a Iess extent, unti1 bronchoscopy, esophagoscopy, thoracoscopy, bronchography and respiration under differentia1 pressure were stiI1 Iater made avaiIabIe. These tooIs are now used aImost daiIy in every active thoracic surgery cIinic and are rightIy considered as indispensabIe. WhiIe reading many case histories of fifty years ago, I was constantIy aware of the overwheIming difficuIties the clinicians of that time faced in attempting to determine the nature, size and exact position of intrathoracic Iesions without the use of roentgenology and bronchoscopy; and it is not surprising that the scope of thoracic surgery was then greatIy limited and that the clmrca1 resuIts were shockingIy bad when judged by present-day standards. The difficulty of exact IocaIization of a smaI1 or even medium-sized puImonary abscess for surgica1 drainage by physical signs alone, without the aid of roentgenoIogy, is apparent to the innumerabIe surgeons who have experienced difficuIty in IocaIizing smaI1 abscesses even with the combined use of physica signs, x-ray and bronchoscopy. The probIems presented in an attempt to remove an intrabronchia1 foreign body without the aid of bronchoscopy or roentgenoIogy may readiIy be appreciated. So great werethe obstacIes to progress from the groping thoracic operations of fifty years ago that DeForest WiIIard, an American, wrote of “the extreme inherent diffrcuIties and dangers which must be met in our attempts to invade the thorax,” and Taeufert, a German, asserted that surgeons were we11 aware that most operations in the chest, perhaps with the exception of empyema operations, will give onIy Iimited resuIts, whiIe Stephen Paget, an EngIishman, introduced a book, “The Surgery of the Chest,” which he pubIished in 1896, by saying that the time was ripe for the presentation of the vaIuabIe facts he had coIIected “because there are signs that we have reached a stage in this portion of our art beyond which, on our present Iines, we cannot advance much further.” Manning wrote in 1894, “The Iungs were among the Iast [interna organs] to receive systematic treatment by operations” and he added that such operations were few, having foIIowed experiments on animaIs or having been undertaken as a Iast resort in incurabIe cases. Only WiIIiam LeMoyne WiIIs, professor of descriptive and surgica1 anatomy at the University of Southern CaIifornia, among the authors whose writings of fifty years ago I have read, expressed an optimistic opinion about the future development of thoracic surgery, predicting that with improvements in surgica1 methods the successfu1 partia1 Iobectomies he carried out experimentaIIy on animaIs would, within ten years, be justihabIe in man and that they wouId be as successfu1 as ovariotomy, when performed by competent surgeons. It is of interest that fifty years ago (I 890) David W. Cheever published an articIe, “Old and New Surgery,” in the Boston MedicaI and SurgicaI JournaI, in which he discussed with justifiabIe satisfaction the great surgica1 progress that had been made *From the Department of Surgery, University of Michigan.