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The specialty of thoracic surgery was born in the convergence of two worldwide plagues. These were tuberculosis, as old as humankind, and avian influenza, which struck a war-wearied world in the winter of 1917 and killed more people than the bubonic plagues of the Middle Ages. Today, with tuberculosis becoming resistant to antituberculous drugs, avian flu beginning to appear around the world, and the world weakened again by war and the new pestilence of AIDS, it seems entirely possible that thoracoplasty may become the once and future operation.
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First coming to prominence in Europe in the late nineteenth century for the treatment of chronic infections in the chest with complicating space problems and bronchopleural fistulas, thoracoplasty began to receive greater attention in the United States at the time of the 1917 to 1918 influenza epidemic. The most lethal complication was empyema thoracis. The mortality in some of the 29 army camps surveyed was as high as 70%.1 A pneumonia commission and subsequently an empyema commission were appointed to study the problem in the clinic and the laboratory. In the amazing period of 1 year, through the efforts of these two commissions, mortality was reduced to an average of 4.3%.2 As reported by Graham in his insightful book, Empyema Thoracis, two early examples of productive research delineated the adverse effects of open pneumothorax on ventilation and the differing pathology between complicating infection with Streptococcus hemolyticus or Pneumococcus,3 the former being much more common. Associated with this pleural disease were a large number of patients with complicating space problems and bronchopleural fistula.
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At about the same time, the other impetus for thoracoplasty was developing in the treatment of tuberculous residua when it was recognized that healing could be accelerated by collapse of residual cavities. Many techniques were employed for this, including pneumothorax, pneumoperitoneum, and even the very first videothoracoscopy, which was used to release apical adhesions.4 Not infrequently, these patients developed infected spaces requiring thoracoplastic procedures, and it was a short step from thoracoplasty for complicating spaces to thoracoplasty as the primary procedure. Enthusiasm for this procedure as an alternative to prolonged, sometimes lifelong commitment to a sanitorium can be imagined from a story told to me by a Greek colleague whose mother had an eleventh rib thoracoplasty performed in three stages by Professor Sauerbruck before World War II using local anesthesia!
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The most enthusiastic American proponent of thoracoplasty was John Alexander5 of the University of Michigan, who applied and evaluated the procedure in a large group of patients. A contemporary tale from this period was shared with me by one of his residents, who, along with this fellow trainee, noted that, paradoxically, the application of thoracoplasty to nontuberculous pulmonary cavities was associated with an increased mortality, a concept he only reluctantly accepted.
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Thoracoplasty can be considered in four broad categories:
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