Introductory Chapter: Pleura, A Surgical Perspective

1. Introduction: a surgical perspective through the centuries

Pleural pathology covers a vast chapter of benign and malignant thoracic diseases which may require invasive approaches for their diagnosis and treatment.

However, the present role of the thoracic surgeon in the management of pleural/thoracic disease is the tip of the iceberg of a very long journey which dates back thousands of years. It is a journey that starts with no knowledge of the human anatomy, physiology and basic medical sciences and where mistakes, attempts, improvements and eventually successes were the fundamentals of the present medicine and surgery.

The very first pathologies related to the chest and pleura reported in history relate majorly to thoracic traumas and thoracic wounds (e.g., penetrating injuries), caused accidentally or during fights/wars, and infections (e.g., empyema). Their treatment was the cornerstone for the present modern thoracic surgery.

2. Early reports of thoracic wounds and infections

The first historical reports of chest wounds and infections treated by doctors are described in the Edwin Smith papyrus, during the Ancient Egyptian Era.

Other reports of chest injuries and attempts at their treatment have been reported and described in several historical books, in which it is clear how the limited knowledge of the human anatomy and physiology and the total absence of basic infection management because of the then ignored micro-bacterial world were causes of almost certain death.

The “Iliad” by Homer, copiously report wounds and infections during the Trojan War [1, 2], as well as the French knight saga Chanson de Roland (Song of Roland), provides a long list of usually deathly chest wounds, in which the clear description proves that contemporary witnesses, including barber-surgeons, were already aware of this kind of injuries and their poor prognosis despite the treatments available in those times.

3. Empyema and surgery

Thoracic empyema is defined as the collection of pus in the pleural cavity and it is one of the very first pathologies on the scene of history of surgically treated chest diseases [3, 4]. The first recorded descriptions of invasive approaches to the chest cavity are found in the medical texts of ancient Greece in regards to the treatment of empyema as suggested by Hippocrates of Kos, whose teaching ubi pus (ivi) evacua has remained relevant throughout the ages. Hippocrates’ first treatment attempt was a conservative one, based upon herbal medications and physiotherapy. If the patient did not improve, open evacuation of the empyema was then undertaken [5].

‘First, cut the skin between the ribs with a bellied scalpel; then wrap a lancet with a piece of cloth, leaving the point of the blade exposed a length equal to the nail of your thumb, and insert it. When you have removed as much pus as you think appropriate, plug the wound with a tent of raw linen, and tie it with a cord; draw off pus once a day; on the tenth day, draw all of the pus, and plug the wound with linen. Then make an infusion of warm wine and oil with a tube, in order that the lung, accustomed to being soaked in pus, will not be suddenly dried out. When the pus is thin like water, sticky when touched with a finger, and small in amount, insert a hollow tin drainage tube. When the cavity is completely dried out, cut off the tube little by little, and let the ulcer unite before you remove the tube [6]’.

Sequelae of chest injuries and post-pneumonic empyemas (unidentified until percussion and auscultations were introduced in the mid-nineteenth century) are reported in ancient medical sources. The great Roman doctor Galen of Pergamon (Aelius Galenus or Claudius Galenus) advised the usage of metallic tubes in order to drain an empyema cavity [7], a teaching that did not change significantly through the Christian and Muslim medical practices of the Middle Ages [8]. Barber surgeons like Pietro d’Argellata refined and improved the chest drain insertion and thoracic irrigation to wash out the purulent fluids from the chest cavity. In this context, further improvements were adopted in time, such as a thoracentesis syringe and cannula for the irrigation of empyema [9, 10]. Permanent windows of the chest wall was a competing way of treating empyemas, with modern surgeons such as Joseph Lister and Charles M.E. Chassaignc who refined the technique. Excision of a segment of the rib was endeavoured by German, French and English surgeons, such as Paget in his book Surgery of the Chest [11]. The challenge of empyema, usually tuberculous in origin, led to the emergence of chest surgery in the late decades of the nineteenth century. Basic treatment for empyema consisted of rib resection and loose tamponade of the chest cavity with a gauze soaked in antiseptic (mercury/iodine). Between 15 and 20% of post-traumatic patients need surgery (rib resection and debridement), with a mortality comprised between 20 and 50%, likely related to streptococcal superinfections [12]. As depicted later in this chapter, the belief of a transcostal approach (chest tube) for the treatment of empyema lasted until long after the first World War.

As a matter of fact, thoracostomy, i.e., the externalisation of the empyema cavity by unroofing, was another option that went through several modifications in the years, starting from the Eloesser flap introduced in 1935 [13] to the Clagett procedure which required daily packings [14, 15]. George R. Fowler and Edmond Delorme pioneered the exeresis of the thick visceral pleura (decortication) in 1894–95 [16]. It was Lilienthal who reintroduced lung decortication for early-stage empyema on the basis of his experiences in the American Expeditionary Force in Europe [17]. Debridement and decortication became an option as soon as general anaesthesia and intubation were established during and after the Second World War. Such surgical improvements along with the introduction in the 1930s of Sulphonamides and later on, in 1943, of Penicillin, drastically revolutionised the treatment of thoracic empyema and their outcomes [18].

4. Tuberculosis, artificial pneumothorax and surgery

Tuberculosis has been known since the Old Testament [19], properly defined clinical and pathologic features depicted in detail in the mid-nineteenth century [20]. In 1882, Robert Koch identified the organism responsible for tuberculosis, proving the sine qua non cause of the disease. Remedies for phthisis comprised supportive care provided mostly by sanatoriums and Carlo Fontanini’s artificial pneumothorax.

4.1 Carlo Fontanini’s artificial pneumothorax

During his entire professional career, Carlo Fontanini from Pavia, Italy, devoted a great deal of time and effort to the study of tuberculosis contributing extensively to the medical literature on this subject. Forlanini’s epoch-making treatise on the rationale of artificial pneumothorax was printed in the Gazzetta degli Ospedali & delle Cliniche di Milano, Volume 3, No. 68, Page 537, August 23. His reasoning was based on the observations of other clinicians as well as of his own, noticing that spontaneous pneumothorax, with or without pleural effusion, had a favourable effect on the course of pulmonary tuberculosis [21]. His apparatus introduced nitrogen into the pleural cavity through a large hypodermic needle, and in doing so, produced a pneumothorax. However, an artificial pneumothorax was frequently unsuccessful as a therapy for tuberculosis because of the presence of pleuropulmonary adhesions. This complication was accounted for with the use of the thoracoscope, firstly utilised by HANS Christian Jacobaeus from Stockholm in 1910, who is considered the father of the thoracoscope. The thoracoscope favoured the identification and clearance of adhesions through their digital manipulation setting the basis, in due time, for minimally invasive thoracic surgery [22, 23].

However, Forlanini’s artificial pneumothorax was challenged by another attempt of treating tuberculosis; in fact, in 1937, at the Brompton Hospital in London, James E.H. Roberts reported 33 operations of extrapleural pneumothorax, which is the collection of air in the space between parietal pleura and endothoracic fascia.

4.2 Thoracoplasties as a surgical treatment for tuberculosis

Extrapleural thoracoplasties, in those times, was preferred because of the lack of safe anaesthesia; this surgical procedure aims at definitely resecting the pleural space with ribs and periosteum, intercostal neurovascular bundles and intercostal muscles.

Several surgeons in the years modified the technique, even by performing them in several stages. In fact, by the 1920s, staged operations became favoured as a result of the publication of Ernst F. Sauerbruch, André Maurer (Paris) and Walther Graf (Dresden) [24]. Those procedures were performed either under local anaesthesia or ether/chloroform masks narcosis, in spontaneous breathing.

Sauerbruch added drainage to the cavity and performed it in two-three stages to avoid mediastinal shift.

Remodelling the chest wall following thoracoplasty was achieved by means of omentum or muscle apposition in the years to come. By the early 1950s, thoracoplasty plombage with or without pneumoperitoneum had replaced artificial pneumothorax as the primary procedure.

Caverna treatment was another pressing problem due to deadly haemoptysis. It was Vincenzo Monaldi who refined staged transmural drainage as a very safe procedure (1939). Following a partial rib resection as a first step, he obtained a debridement of parietal-visceral adhesions through the instillation of irritative agents and, after 7–10 days, he inserted a tube through the area of the adhesions into the cavity, creating a real cavernostomy [25, 26].

It was only in 1936 that the first successful pulmonary lobectomy and pneumonectomy for tuberculosis were performed. In those days, post-lobectomy and post-pneumonectomy mortality for the treatment of tuberculosis was 20–25% for the former and up to 40–50% for the latter [24].

5. Chest wounds, penetrating chest injuries, gunshot wounds

In 1395, Guy de Chauliac, a leading physician-surgeon of the French medieval times, completed the most important surgical book of that time, Chirurgia Magna. In the second Doctrine of Chirurgia Magna, there are several comments regarding the lack of ancient writings on thoracic wounds and their treatment, acknowledging then non-linear treatment strategies between his contemporaries.

Basically, there were two schools of thought regarding the treatment of chest wounds, one advocated the open treatment of penetrating thoracic wounds using tents and drains to allow food and pus to escape the pleural cavity, the other, instead, advocated the immediate closure of the wound to prevent the entry of cold air and loss of heat [27]. This debate persisted for centuries.

Chest injuries developed a decisively worse prognosis as the more fatal gunshot wounds dominated from the sixteenth century onwards [28]. Giovanni da Vigo, an Italian surgeon and physician of Pope Julius II, was one of the first surgeons to explore firearm wounds, including those to the chest, in Practica Copiosa of 1514 [27].

In accordance with Guy de Chauliac, Vigo too points out the dilemma of the “open” vs. “closed” treatment of penetrating thoracic injuries, among which he was more inclined to the latter. Vigos’s work was accredited by a French military surgeon, Ambroise Paré, in the attempt of establishing guidelines to determine whether to choose an open or a closed treatment for penetrating thoracic wounds [29].

5.1 The introduction of aspiration to a chest drain

In 1707, Dominique Anel described a method for sucking wounds with a silver tube attached to a piston syringe which replaced a human mouth, a practice which was very common in those days, to such an extent that nobles and upper-class men would bring wound suckers with them when they had to fight duels [29, 30]. Following such invention, the surgical procedure now consisted of a cannula which allowed a catheter to be introduced into the pleural space, not only to the margins of the wound, and by applying an aspiration to it. In 1771, Adamus Birkholz added a reservoir container into Anel’s suction line, creating an early Potain aspiration [29]. In the following years, despite the advances made, there was still a lack of consensus on the optimal treatment management of chest wounds, comprising different techniques, ranging from the hypothetical necessity of closing at first the wound to avoid blood loss from the lung but making a counter opening which would evacuate the retained blood, as Valentine did in 1772, to Gurthrie’s method (early 1800s), which encompassed closing the wounds of the chest and watching for an increase in serous effusion for few days after the injury, indicating that the bleeding had likely stopped for, then, evacuating the blood with a trocar and cannula through a new opening or by reopening the original wound [31].

Larrey, a surgeon who treated Napoleon, believed that there was a danger of renewed bleeding if attempts were made to evacuate effused blood less than nine days from the initial injury [29].

It is therefore clear that, to this point of history, the only commonly accepted step forward in the management of penetrating injuries to the chest and consequent chest infections was to drain them. Regarding the how, that was still a dilemma.

During the American Civil War war, surgeons started to insert trocars in the chest to drain fluid retained in the pleural space while, in the same period, the Union forces were experimenting the use of airtight seals to impede airflow in open chest wounds. It is on Playfair, in 1873, the attribution to applying a water-sealed chest drainage system for the first time, as a successful treatment of a child with thoracic empyema [32]. Until that time, scarce information was known in regards of the intrapleural negative pressure, the reason why the management of chest traumas was only just successful until then.

5.2 The first closed water-seal chest drain

In 1875, Gotthard Bülau applied a closed water-seal chest drainage to treat an empyema, as an alternative to the standard rib resection and open tube drainage in the acute phase or rib excision in the chronic phase [33]. In contrast to the popular opinion of the surgeons of that time, Bülau was the first to understand the importance of negative intrapleural pressure to obtain the re-expansion of a collapsed lung subsequent to thoracic empyema.

His method consisted in puncturing the pleural space and introducing a rubber catheter with a clamp inside the chest. The part of the drain outside the chest was then immersed in a bottle filled for one third with an antiseptic solution and unclamped, creating a siphon drainage which allowed pus to flow out from the chest [33, 34, 35]. The nineteenth century marked the advent of rubber tubes and the invention of standardised syringes and needles changed and improved the practice of chest tube thoracostomy.

During World War I, despite the above-mentioned improvements and treatment options (needle drainage of hemothorax, wound exploration and debridement, wound exploration for foreign body removal and closure of open pneumothorax with sutures), mortality was still high, estimated to be around 55% [36]. Furthermore, during World War I, recently invented tampons and Morelli’s occlusive rubber cuffs, which allowed for closure and simultaneous suction drainage, were in use in the control of airflow in open chest wounds [29]. Also, by that time, post-thoracotomy evacuation of fluid in the pleural cavity was recognised as an important way to avoid infection, and the concept of a flutter valve for uni-directional air movement within a drainage tube was spreading, but tube thoracostomy was not widely used yet for treating hemothoraces or pneumothoraces [31].

During World War II, it was clear to the surgeons that lung function restoration was the primary goal of treatment, with emphasis on wound debridement and pleural cavity drainage [37]. The modern three-chamber thoracic drainage system was first described by Howe in 1952 and in the Korean War (1950–1953), mortality decreased to 0.6–1.9% of major thoracic trauma patients who survived to be evacuated and treated. Also, the frequency of empyema due to penetrating chest wounds was reported to be 25–30%, decreased to 9% as hemothorax was approached with a more aggressive attitude [38, 39, 40, 41].

During the years, tube thoracostomy was finally accepted as the standard of care at the time of the Vietnam War. A significant improvement was developed by Heimlich in 1968, who designed a flutter valve to attach to catheters and replace the underwater drain bottles. Its advantages included sterility, disposability, simplicity, safety in the event of disconnection, and allowance for patient ambulation [42].

6. Conclusions

Thoracic surgery is a multi-fathered speciality, which gained recognition as a distinct surgical entity only in the 1950s. The development of such a specialistic surgery was possible because of the knowledge gained through, attempts, mistakes, improvements and eventually successes over hundreds of years. The post-war effect on the development of thoracic surgery was enormous. In the first decade after the war, thoracoplasties and empyema treatments for tuberculosis dominated thoracic surgery, but it was in the 1930s that small but decisive steps were taken in the direction of lung parenchymal resection. It was right in those days that oncological cases became a priority over the tubercular ones because of the introduction of new medical treatments available, (i.e., streptomycin, 4-aminosalicylic acid, isoniazid, pyrazinamide, cycloserine, ethambutol and rifampicin 1963).

The contribution to the development of a dedicated thoracic anaesthesia was a cornerstone in consolidating the results of thoracic surgery, especially with the achievement and standardisation of the single lung ventilation through a double-lumen endotracheal tube.

Another crucial step was the establishment of thoracic societies in the world by the earliest pioneers in thoracic surgery, such as the American Association of Thoracic Surgeons (AATS) in 1917 and the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) in 1934. The role of the Societies helped, in the beginning, through sharing surgical experiences and results to, then, cooperating in improving and standardising operating techniques, indications and treatments through an evidence-based methodology and teaching.

Such advances go hand in hand with the inexorable technological achievements in the thoracic surgery field, which greatly improved the standards of diagnosis and treatment in patients undergoing thoracic surgery for benign and malignant diseases, by increasing procedural safety, improving prognosis and reducing potential peri and post-operative complications.