The Surgery for Pulmonary Tuberculosis

Abstract

The history of surgery for tuberculosis from 1885 to 1950 reflects the history of thoracic surgery during that period. A steady stream of patients with apparently hopelessly advanced disease presented an enormous challenge to surgeons of that period. Much of what we have learned concerning the special problems of thoracic anatomy, technique, and anesthesia, as well as preoperative and postoperative care, came from this group of patients. However, the most enduring contribution of this period was a better understanding of respiratory physiology. Indeed, many pioneers in clinical lung physiology, both here and abroad, initially were stimulated by the problems of tuberculosis surgery, and some of our own observations will be emphasized here. The early surgeons were members of a small club who often cited each other by name in their publications, but did not bother to include references. Sometimes they devoted more than 100 pages to a minor change in technique; other times, they described major contributions in a single paragraph. Originally, of course, they were all general surgeons. Thoracic surgery was established with the founding of the American Association for Thoracic Surgery in 1918, and a colorful and individualistic approach was preserved in that group. During my first presentation to that Society in 1950, the Chairman, Dr. Edward O'Brien, restrained the speaker's time with a silver six-shooter; Dr. Max Chamberlain, presenting his experiences with segmental resection for tuberculosis (1), extended his time with a shotgun previously hidden behind a curtain, which he aimed at Dr. O'Brien. The introduction of antimicrobial drug therapy greatly increased the safety of tuberculosis surgery, but at the same time, the need for such surgery decreased rapidly. Today, a call in the operating room for a Tuffier retractor, a Lilienthal guillotine, or a Doyen raspatory meets with puzzled frowns from the nurses and an indulgent smile from the resident, who invariably suggests a sternal splitting approach as a better alternative —the passing of an era. The brevity of this review does not permit mention of all the great contributors to the field. Rather, an attempt is made to give the reader a feeling for an era, and for the almost insurmountable difficulties of major thoracic surgery initially performed without general anesthesia, without an understanding of respiratory physiology, and, for a long time, without blood transfusions. Some space is devoted to artificial pneumothorax, because its development was so intimately related to other forms of collapse therapy, because much subsequent surgery was designed to deal with the failures and complications of pneumothorax, and because our understanding of many physiologic principles is derived from experiences with artificial pneumothorax. Surgeons were preoccupied with treatment of cavities and, therefore, with mechanical detail. For a long time, they were less impressed with the contribution of Robert Koch than with another discovery made 3 yr later, that of Konrad Roentgen. Indeed, before radiography, a rational approach to surgery for tuberculosis was impossible. Perhaps one should not attempt to single out the greatest contributors in a field where so many made progress in small steps. In this country, many would think first of John Alexander, the founder of American tuberculosis surgery, whereas Alexander himself selected Sauerbruch as his most illustrious predecessor (2). My own reading over the years brings to mind a physician rather than a surgeon as the one who might have contributed more to the progress of tuberculosis surgery than any other person. Ludolph Brauer of Marburg and later of Hamburg had such a keen understanding of both anatomy and physiology that he was able to suggest to surgeons step by step many of the major improvements in collapse therapy during the first 20 yr of this century. He was the first to appreciate the physiologic consequences of paradoxical chest wall motion and therefore prescribed subperiosteal rather than total rib resection. Later, he developed positive-pressure breathing both for anesthesia and to counteract paradoxical motion. He was probably the first to appreciate the importance of preoperative evaluation of respiratory function. Among his many other contributions, he first defined pneumonosis, a condition that was described 20 yr later as alveolar-capillary block. The earliest rational concepts for promoting healing of tuberculosis were based on autopsy findings that there was necrosis with cavitation, and that this was largely confined to the cephalad third of the lungs. It was believed that three mechanical factors prevented healing of these cavities: (7) the constant traction exerted on the cavity's walls by the static elastic recoil of the surrounding lung; (2) the dynamically augmented traction from the act of breathing; (3) the diminished apical blood and lymph perfusion due to the human upright posture. The first two of these factors were discussed more than 150 yr ago (3). Scientific evidence for the latter came only with Cournand's first recording of human right heart pressure in 1944 and the brilliant deductions therefrom by Dock (4). It comes as no surprise, therefore, that for the 100 yr before effective chemotherapy, phthisiologists and surgeons alike were preoccupied with mechanical means for preventing cavities and for promoting their closure.

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