Ann Thorac Surg 2002;74:1288-1290
© 2002 The Society of Thoracic Surgeons
Our surgical heritage
Thoracoscopy before Jacobaeus
Beatrix Hoksch, MD*a,
Hanno Birken-Bertsch, MAb,
Joachim M. Müller, MD, FACSa
a Department of Surgery Charité, Humboldt-Universität Berlin, Berlin, Germany
b Institute of Philosophy, Friedrich-Schiller-Universität Jena, Berlin, Germany
* Address reprint requests to Dr Hoksch, Department of Surgery Charité, Humboldt-Universität Berlin, Schumannstr. 20/21, 10117 Berlin, Germany
e-mail: hoksch{at}t-online.de
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Abstract
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In 1910 Jacobaeus described a procedure to which he referred as "Thorakoskopie." As a consequence, he is credited with having been the first to undertake an endoscopic exploration of the thorax. However, a published report by Gordon demonstrates that thoracoscopy was performed about 50 years earlier. Additionally in French, at least, the term "thoracoscopie" was well known long before Jacobaeus, although perhaps with a different meaning.
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Introduction
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Hans Christian Jacobaeus, a Swedish internist, is generally credited with having been the first to undertake an endoscopic exploration of the thorax [1–4]. In an article entitled "Ueber die Möglichkeit die Zystoskopie bei Untersuchungen seröser Höhlungen anzuwenden" ("On the Possibility to Use Cystoscopy to Examine Serous Cavities") appearing in 1910 in the Münchner Medizinische Wochenschrift, Jacobaeus described the procedure, to which he referred as "Thorakoskopie." One year later, Jacobaeus published further results of the "Laparothorakoskopie" in the same journal [5, 6]. It must therefore be reckoned as his achievement to have drawn attention to the therapeutic benefits of this procedure in the treatment of tuberculosis [7, 8]. There are still numerous articles today that deal with this operation, a technique sometimes also referred to as the "Jacobaeus’ procedure" [4, 9].
Jacobaeus himself is occasionally even said to have coined the term "laparothoracoscopie" [10]. On closer inspection, however, this is a claim that cannot be upheld. In French, at least, the term was well known long before Jacobaeus. The Grand Dictionnaire Universel (Volume 15) of 1876, for example, contains the entry "Thoracoscopie," which is defined as "exploration de la cavité thoracique" [11]. The entry does not identify the originator of the term "thoracoscopie," an expression that is composed of the Greek words "thorax" and "skopia" (visual examination). Volume 16 of this encyclopedia, published in 1878, gives a more detailed explanation. The "Thoracoscope" is described as an "Instrument pour observer les altérations des voies respiratoires et de la poitrine," that is, "Instrument for observing changes of the respiratory tract and of the lungs" [12]. This occurrence of the term is not the only one; nor is it the first, for it can also be found dictionaries such as the Complément du Dictionnaire de l’Academie Française of 1842 or the Dictionnaire National ou Dictionnaire Universel de la Langue Française of 1860 [13, 14].
These entries not only show that the term "thoracoscopie" is older than claimed by Lau and colleagues [10] as well as by others, but also bring up the question whether endoscopic examinations of the thoracic cavity may have been common as early as the nineteenth century, as otherwise the term "thoracoscopy" would not have been given a fixed place in an encyclopedia. The term, however, could also have been taken to denote—against the visual sense that etymology ("lung-watch") bestows on it—auscultation by means of a stethoscope. This was, in fact, the meaning in German at that time: German dictionaries explain "Thorakoskopie" as "Stethoskopie" [15, 16].
It is therefore not surprising that the assumingly first thoracoscopic examination is attested without being identified as "thoracoscopie." The Viennese physician Josef Grünfeld reports in an article published in 1879 on the history of endoscopy and endoscopic instruments that, according to Samuel Gordon, a certain F. R. Cruise "performed an endoscopic examination of a chest fistula using a binocular device that made his instrument more perfect" [17] (Fig 1).
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Fig 1. Endoscope of Francis Richard Cruise 1865 (From Reuter HJ, Reuter MA. Philipp Bozzini und die Endoskopie des 19. Jh. Stuttgart, Max-Nitze-Museum, 1988; with permission of H. J. Reuter).
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Who was Cruise? And what is the nature of the endoscopic examination of the chest that he was reported to have performed? According to the Concise Dictionary of Irish Biography, Sir Francis Richard Cruise was born in Dublin in 1834, worked at the Mater Misericordiae Hospital, and filled for many years the office of Senator of the University of Dublin and of the Royal College of Physicians in Ireland from 1884 to 1886. In 1901 the late King Edward appointed him Honorary Physician in Ordinary in Ireland. Already as a student he devoted much of his time to the "light guide technique," as endoscopy was referred to at that time. He can therefore be considered a pioneer in the use of endoscopy in Ireland. He died in 1912, just at the time when Jacobaeus was attracting public attention with his thoracoscopic examinations [18, 19].
In 1865 the British Medical Journal published a report entitled "Endoscopy" about a meeting of the Medical Society of the King and Queen’s College of Physicians on March 15, 1865 [20]. At this meeting, Dr F. R. Cruise presented an "endoscope," which he used for examining "various organs and body cavities" [21]. The instrument Cruise used was a modification of the endoscope developed by the French physician A. J. Desormeaux. Cruise successfully used this instrument for cystoscopy and other examinations. Desormeaux had been working on developing the endoscopic technique for a long time and with unrelenting perseverance, despite innumerable setbacks and animosities. He used the term "endoscope" for the first time in 1853 for an instrument he presented at the Medical Academy in Paris [22].
Cruise is said to have advanced endoscopy by improving the light source, and he was able to use the instrument for diagnostic purposes. At the above-mentioned meeting, he presented his examinations of the urethra and the urinary bladder. One year later, in 1866, Samuel Gordon (himself "Physician to the Hospitals, and Lecturer on the Practice of Medicine in the Carmichael School of Medicine") published a report on a thoracoscopy performed with a binocular endoscope developed by Cruise in the Dublin Quarterly Journal of Medical Science [23]. Under the heading "Clinical Reports of Rare Cases Occurring in the Whitworth and Hardwicke Hospitals," this article presented a case summarized as "Most Extensive Pleuritic Effusion Rapidly Becoming Purulent; Paracentesis; Introduction of a Drainage Tube; Recovery; Examination of Interior of Pleura by the Endoscope." The report describes an 11-year-old girl admitted to Whitworth Hospital on April 27, 1866, for examination. The girl had a history of cough and pain in the left side of the chest that had persisted for about 2 months. The clinical examination revealed a pronounced tachypnea (respiration rate 68/min) and tachycardia (heart rate 140 beats/min) as well as general weakness. A thorough clinical examination yielded the diagnosis of a massive pleural effusion on the left side. The girl was treated by left-sided thoracic parasternal paracentesis between the third and fourth ribs on April 29, 1866. A greenish-yellow, "serum-like" fluid was discharged. Although the paracentesis was performed with great care (it was, in fact, a puncture performed using a Bowditch syringe), air was inadvertently introduced into the hemithorax. Because the patient’s condition showed continuous deterioration (a development that might have been primarily due to newly effused fluid that had by then become infected in conjunction with displacement of the heart to the right side), a second puncture was performed on May 2, 1866. Since pus was withdrawn through the syringe, a drain was placed. According to the report, the patient was given large amounts of port wine during this procedure (presumably to achieve some degree of anesthesia). The further course of the illness was extremely protracted. Putrid secretions were still being drained at the end of July 1866. However, the patient started to recover. The left side of the chest clearly showed more normal respiratory excursions, and the massively displaced heart had almost returned to its normal position. Nevertheless, the drain had to be changed repeatedly and could only be removed on January 13, 1867. A fistula developed through which there was continuous discharge of secretions. Only at the end of his report does Gordon mention that Cruise repeatedly inserted an endoscope into the interior of the chest (through the opening of the fistula) in the course of treatment and that, to his knowledge, this was the first time in the history of endoscopy that such an examination of the chest was accomplished. Gordon emphasized that the endoscopic examination was performed for regular inspection of the pleura and of the interior of the chest and that this technique, although not easy to perform, was essential for monitoring therapy. The appearance of this first published report demonstrates that thoracoscopy (ie, the diagnostic inspection of the chest cavity by means of an endoscope) was performed about 50 years before the publications by Jacobaeus. Lew A. Hochberg, who quotes from Gordon’s text, neither mentions Cruise as the doctor performing the examination nor comments on the fact that it was a thoracoscopy before Jacobaeus [24].
The enormous benefit that might ensue from endoscopy (also with regard to exploring the interior of the chest) had already been recognized by the originator of endoscopy, Philipp Bozzini, as early as 1807. In his work entitled Der Lichtleiter oder die Beschreibung einer einfachen Vorrichtung ihrer Anwendung zur Erleuchtung innerer Höhlen und Zwischenräume des lebenden animalischen Körpers ("The Light Guide or the Description of a Simple Device and its Use for Illuminating the Interior Cavities and Spaces in Living Animal Bodies"), he prophesied, "Some [...] events might become very instructive through the use of the light guide. When a lung abscess has opened to the outside, there is no doubt that, if the light guide can be advanced just as far as the edge of the lung abscess, it will be possible to partly or fully observe the movements and peculiarities of the abscess. Its deterioration or improvement in comparison to the treatments that have been applied will be useful for treatment and pharmacology just as the comparison with the patient’s symptoms will benefit semiotics" [25]. The fact that it took 50 years before further advances in thoracoscopy were made may be attributable to a still inadequate understanding of the physiology of respiration and of the chest and to the lack of proper instruments. Once these insights had been gained and the technical conditions were met at the beginning of the 20th century, thoracoscopy began to establish its position in the spectrum of diagnostic and therapeutic procedures. It is likely that neither Jacobaeus nor the German Georg Kelling, who performed endoscopic examinations of the abdominal and thoracic cavities in animals independently of Jacobaeus, knew of Cruise and his examinations because, at least in their publications, no mention is made of him [1, 2, 8, 10]. Cruise himself never published anything on the thoracoscopy that he performed. It may furthermore be assumed that, with the spread of the endoscopic technique, examinations of the interior of the chest were performed in France as well. Whether such examinations fell under the term "Thoracoscopie" found in the dictionaries cited at the beginning of this report is unclear. French histories of medicine such as that by Maurice Bariéty and Charles Coury do not mention thoracoscopic examinations before Jacobaeus [26].
In 1914 the German Gustav Killian declared, "The endeavor to enter the interior of the body and to make the way free for the eye goes through all centuries" [27]. Therefore it would not be surprising if others also tried to inspect the thoracic cavity before Jacobaeus and perhaps also before Cruise. It is well known for instance, that with the help of specula and candlelight, practitioners of former times examined the rectum, vagina, and mouth [10, 27]. The Danish physician Christian Fenger used this technique to treat wounds during the French-German war of 1870 to 1871 and reported on his experiences in the Wiener Medizinische Wochenschrift under the title, "About the endoscopy of gunshot wounds" [28].
Yet, in the absence of any other published reports on thoracoscopy before Cruise, we can (thanks to Gordon) give credit to Sir Francis Richard Cruise as having been the first physician to have performed a documented thoracoscopy.
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Acknowledgments
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We thank Pascale Bernard (Analyses et Traitments Informatiques du Lexique Français [ATILF]) in Nancy, France, for drawing our attention to occurrences of "thoracoscopie" in the dictionaries even earlier than the Grand Dictionnaire; and Kenneth M. Ralston, PhD, San Francisco, CA, for help with the manuscript.
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References
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Introduction
