Ann Thorac Surg 2004;78:741-745
© 2004 The Society of Thoracic Surgeons
Our surgical heritage
Alejandro Posadas, Argentinian pioneer: thoracic surgery in the Western world in his time
Hugo Esteva, MDa*
a Division of Thoracic Surgery, Hospital de Clínicas "José de San Martín," Universidad de Buenos Aires, Buenos Aires, Argentina
* Address reprint requests to Dr Esteva, Av. San Martín 1039, Bella Vista, Buenos Aires 1661, Argentina
e-mail: hesteva{at}intramed.net.ar
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Introduction
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In November 1902, realizing that he was about to die, Alejandro Posadas (Fig 1), then aged 31, decided to travel to Europe to avoid local funeral homage [1]. On the one hundredth anniversary of his death, as a tribute to his austerity, this article wishes to draw attention to his work as a pioneer and founder of thoracic surgery in Argentina, as compared with the state of the art in the Western World. This article is based on the review of his book collection as well as that of Daniel Cranwell (an eminent contemporary surgeon and Posadas's classmate), both kept at the Library of the University of Buenos Aires School of Medicine. Both surgeons were close friends and interns together at the University Hospital (Hospital de Clínicas) [2]. Additional historical material from the Patrimoine Médical de Marseille and the Library of the School of Medicine at the University of the Méditerranée was also reviewed.
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Fig 1. Alejandro Posadas operating on a lung hydatid cyst in the Hospital de Clínicas de Buenos Aires. (This picture has been taken from his movie.)
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Biographic notes
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Alejandro Posadas, the son of a merchant from Vigo, Spain, who emigrated to Argentina, was born in 1870 in Saladillo, a small town in those days close to the Indian border in the middle of the province of Buenos Aires. He moved to the capital city in order to attend school at the Jesuit's College of El Salvador. In 1894, he graduated as a physician from the University of Buenos Aires.
As a student, he described coccidiodomycosis, initially called "psorospermiasis infectante generalizada" [3]. He not only characterized the clinical signs and symptoms of this disease, which until then was unknown in the world, but also clarified its anatomical, pathologic, and microbiologic properties in animal models. His mentor, Professor Robert Wernike, helped him to isolate the etiological agent of the disease known as "enfermedad de Posadas" [4].
Posadas' two surgical professors, Ignacio Pirovano and Alejandro Castro, did not have experience performing thoracic operations. Posadas, therefore, was a self-taught thoracic surgeon. After self-training in animal models and corpses he began to operate on pulmonary lesions "con pleura libre" (ie, entering the pleural cavity free from adhesions), a technique never before attempted in Argentina [5].
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International surgical landscape
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In those days, European books on surgery contained very few pages specifically dedicated to pulmonary pathology [6–9]. In Buenos Aires, no local chapters or articles on thoracic surgery had been published [10]. The most renowned medical publications were not in favor the surgical invasion of the thoracic cavity [11]. In hydatid disease only needle thoracentesis or other nonconventional treatments, such as continuous electrical current [12], were suggested, even accepting that medical treatment (actually just by observing the natural history of the disease) had a high mortality rate.
On the other hand, pleural cavity drainage for empyema was known from the time of Hipocrates. In fact, the idea had mythologic roots [13]. This practice decreased over the years but was rediscovered at the end of the 16th century [14]. Ambroise Paré [15] described a self-limited dedicated trochar to drain pleural effusions.
In the presence of a pleural cavity blocked by adhesions, this surgery was approached as a collection in any other location [16]. Davies Thomas commented in 1889: "There can be no doubt, that to Dr. Bird of Melbourne, Australian physicians are largely indebted for the conviction, that an abscess or suppurating hydatid in the lung should no more be sacred from the knife of the surgeon, than an abscess in the breast" [17].
The new challenge in the second half of the 19th century was to operate on pulmonary lesions in patients whose pleura was normal, when collapse of the lung could terminate the patient's life. Until the last decade of that century, most of the publications were isolated observations or international compilations, usually dealing with pulmonary abscesses or hydatid cysts [18–20]. The exception was the work of Davies Thomas, originally presented in 1885 [21], and published as a book in 1889 [17] including 8 cases that he personally operated on for pulmonary hydatid disease.
Posadas might have known about partial pulmonary resection to treat a costal osteogeneic sarcoma, an operation performed by Krönlein [22]. He might have been also aware of the ingenious extrapleural resection of the apex of the lung in a patient with tuberculosis by Tuffier [23], whose late outcome was good [24]. But probably he also knew of Block's suicide after his failed pulmonary surgery performed on a young female in 1881.
This account gives the reader an idea of the obstacles that a young surgeon would have to overcome to begin using such an unusual type of surgery in a faraway and isolated country as Argentina in 1896 (Fig 1).
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Approach to the pleural cavity
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Surgeons of the 19th century recognized the risks of opening the thoracic cavity in the absence of adhesions [14, 25].To demonstrate the presence of adhesions, they used to perform an exploratory puncture [16, 26]. Then it was popular to induce a chemical [26] or physical [16] limited pleurodesis to enable the surgeon to operate on the lung parenchyma during a second-stage operation. This technique was not always safe [26], nor convenient on account of the need for a second operation [25].
Consequently, some surgeons started to search for ways to compensate for the subatmospheric interpleural pressure [27]. There was an initial suggestion concerning the experimental use of a laryngeal tube with an inflatable balloon [28]. Nevertheless, at the beginning of the 20th century, practical surgeons still used "pleural anchorage" [29].
Moreover, the idea of draining the pleural cavity postoperatively [30] was then proposed to drain the potentially infected cavity [16] instead of reestablishing negative intrathoracic pressure. The drainage system, using a water sealed tube introduced by Bülau in 1891 [31], was strongly criticized when first published [32].
In 1903, the year after Alejandro Posadas' death, the eminent von Mikulicz, professor in Breslau, Germany used to tell Sauerbruch, who was beginning to work experimentally there with his pneumatic chamber: "Hundreds of thousands of people die from tuberculosis just because we don't know how to operate on the thorax" [33].
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Technique used by Posadas
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Thoracotomy
"Partial and Temporary Thoracoplasty" is the title of Posadas' professorial thesis published in 1898 [34]. In it, he proposed a modification of an incision first described by Delorme to treat infected pleural effusions [35]. He recommended superficial general anesthesia with face mask in order to maintain the cough reflex and to avoid bronchopulmonary aspiration of hydatid fluid. A U-shaped flap composed of the whole thickness of the extrapleural thoracic wall was then tailored. The parietal pleura was kept intact. At the end of the operation, the flap was reapplied in order to reconstruct the thoracic wall, closing the chest with a "complete suture in the nonseptic lesions (hydatid cysts, tumors)" [34].
Posadas closed the thorax in layers with no drainage. He realized that pneumothorax and subcutaneous emphysema would be resolved spontaneously [36].
Pulmonary anchorage
To avoid pulmonary collapse, Posadas anchored the lung to the parietal pleura with two broad stitches including the parietal pleura and the underlying lung "... using a Haguedorn needle with soft and strong catgut (number 4); horsehair, silk and metallic sutures tear the lung" [34]. He had previously used the technique experimentally on dogs.
Cyst treatment without drainage
Posadas wrote: "In hydatid cysts, by incising the lung with a scalpel, I extract the fertile membrane, I carefully dry the fluid that fell into the peri-cystic pouch, I suture the pulmonary incision and leave the lung in the thoracic cavity. Here, in a few words, the procedure that I use in all the nonsuppurative cysts: complete occlusion without drainage of the peri-cystic pouch" [34]. This technique "... has been employed eighty-two times with excellent results. The cysts were from the brain, lung, pleura, liver, spleen, kidney and peritoneum, the glands, muscles and lymphatic nodes" [36].
This type of parto hidático (hydatid delivery, ie, enucleation of the intact cyst) was popularized 50 years later in the Río de la Plata by the Uruguayan surgeon Armand Ugon. It is also known as Barret's technique [37]. A thesis by one of his students discussing, among others, 23 cases of hydatid cysts from the liver operated on by Posadas, confirms his priority in using the technique: "The hepatic tissue that covers the cyst and the pericystic membrane are incised with the knife and held up with forceps. The fertile membrane then appears herniated due to the great intracystic tension; it is convenient to avoid its rupture in order to extract it entirely ..." [38] (Fig 2).
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Fig 2. Posadas technique: (A) Partial and temporary thoracoplasty. (B) Pulmonary anchorage. (C) Cyst treatment without drainage. (D) Wound closure without drainage.
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Results
In this thesis, Posadas included 8 cases of noncomplicated pulmonary hydatic cysts with free pleura. There were 7 favorable evolutions and 1 death due to pulmonary gangrene [34]. Years later Arce, one of his fellows, stated that by the end of his life, Posadas had performed 14 cases with 1 death (7.1% mortality rate) [5].
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Background of employed techniques
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The use of modified thoracoplasty allowing a good surgical field without thoracic deformation [34] (Fig 2) was unusual in the years when thoracic retractors were not popular. In fact, the common approach was to perform a thoracotomy with costal resection [17], giving very poor cosmetic results.
In Europe, pulmonary anchorage was attributed to Roux, who worked in Lausanne. Similar to Alexis Carrel for his first vascular suture, Roux applied the learned techniques for sewing in his region: "... I have done what women call a back reinforced suture" [39]. However, a description of the suture between the parietal pleura and the parasite had already been published in Davies Thomas' book [17].
A less well-known aspect of Posadas' technique was his way of treating the parasites, and closing the pneumotomy and then the thorax without a drain either in the cystectomy or in the pleural cavity. The articles we could find suggested marsupialization or drainage of the parasitic cavity. Davies Thomas described the marsupialization: "The wound in the sac is securely stitched to the lips of the external wound ..." [17]. For this reason, to call the technique employed by Posadas "the Australian method" is incorrect [40]. He would only use marsupialization in suppurative cysts [36].
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Comment
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According to his disciple Arce, Posadas surgically treated the first pulmonary hydatid cyst ever operated on in Argentina in 1896, in the Hospital de Clínicas de Buenos Aires [5]. He did not improvise while standardizing the technique and formulated a surgical alternative to treat a frequent disease in Argentina that had already had bad results with conservative observation or puncture. A mortality rate of 54% while awaiting spontaneous resolution corresponded to 27% with drainage by puncture. However, the pneumonotomy and cyst resection reduced this to 16% [18]. Posadas improved the surgical outcome.
Furthermore, he had his own experimental and clinical series strictly discussed [34, 36], when most of the published material referred to isolated cases [19] or had been gathered from international communications where each surgeon's experience was small [14, 20] (Table 1).
Both the 1895 Ninth French Congress for Surgery [16] and the 1897 12th International Congress for Medicine in Moscow [13] demonstrated the increasing importance of thoracic surgery by dedicating their meetings to the specialty. The discussions centered around how to prevent opening a thoracic cavity without adhesions. Some surgeons attempted to avoid its contamination and the consequent purulent pleurisy [25]. Others [27], like Posadas [34], began to emphasize the physiopathologic consequences of pulmonary collapse, respiratory insufficiency, and risk of life.
The trend for the treatment of intrapulmonary collections (ie, abscess and bronchiectasis) in two stages with variable intervals was then strong. Quincke [26], one of the main proponents, insisted that the suture between the pleurae was no guarantee of sealing. Nevertheless, among those who preferred a two-stage procedure, some admitted that anchorage was indicated for urgent cases [19]. Creation of adhesions began to disappear with the beginning of anesthesia with positive pressure, but its remnants continued during the first half of the 20th century.
Clearly sparing the concept of suppurative and nonsuppurative lesions, Posadas preferred direct access without artificial pleurodesis for the latter. He was sure that some degree of pneumothorax was inevitable, but nevertheless he trusted that "anchorage of the lung before opening the pleura avoids asphyxia, preventing the total collapse of the lung... , it takes no more than holding the retracted lung towards the incision to observe that respiration becomes normal..." [34].
Partial temporary thoracoplasty had been proposed by Delorme to treat empyema. Incidentally, the author also suggested pleural "toilette" (ie, early decortication) [35]. Posadas' uniqueness was to adapt the incision to pulmonary lesions with a free pleura.
Posadas did not claim originality in not draining aseptic cysts. He said: "It seems that the first to propose its use was the English surgeon Bond in 1891" [36]. But he also pointed out that the method did not become generally accepted due to "an insufficient number of practical cases to prove its value." He offered, instead, a series of 53 cysts in different locations, operated on with only 1 death [36]. This contribution became internationally known [38].
His results were excellent (Table 1). Actually, his patients were children or young people, averaging 22 years of age (range, 7 to 38) [34].
At that time, it was usual to hear in academic discussions among doctors vague expressions like "... perhaps I used it other times, however I do not remember right now either when or which the special cases were" [36], or "... I have seen a cure with this method in some pleural cysts and others in the lung" [40], or "... the suture I placed last Thursday, 6 days ago, has kept well" [39]. In comparison, Posadas' precise way of showing facts [3, 4, 34, 36] must be emphasized.
With the turn of the century, thoracic surgery began a period of growth worldwide. Tuffier [41] recognized the importance of radiology to localize chest lesions. In fact, Posadas himself had initiated in Argentina the use of radiology, as well as making the first scientific movie. Simultaneously, Doyen [42] presented postoperative aspiration of the thoracic cavity and also endotracheal intubation, that was developed 10 years later by Meltzer and Auer. Fabrikant [13] advised against thoracic surgery in two stages, which until then his German compatriots recommended.
However, as late as 1906, Delagenière [29] still stated that, faced with lung lesions with free pleurae, there were two alternatives: the "physiologic method" of Tuffier and Sauerbruch, who sought compensation of the negative interpleural pressure; and the "surgical method," consisting in reducing total intraoperative pneumothorax into a partial pneumothorax by suturing the lung to the chest wall, the method employed by Posadas 10 years before.
During his short career as a professor of surgery, Posadas had three main fellows: Pedro Chutro, Enrique Finochietto, and José Arce. Each one of them became a founder of one of the principal branches of the Argentinian school of surgery. In particular, José Arce followed his teacher at the Hospital de Clínicas of the University of Buenos Aires, introducing therapeutic preoperative pneumothorax as a way to prepare patients for thoracic operations. He was followed by Oscar Ivanissevich, who added to his outstanding academic career by serving as Argentine ambassador to the United States. Mario Brea, his successor, introduced cardiac surgery with extracorporeal circulation in Argentina. After him, Andrés Santas was an outstanding international personality in medical education. In 1992, the first lung transplantation ever done in a public hospital in Argentina was performed at the Hospital de Clínicas.
As a testimony of the persistent memory of his talent, the main auditorium of the Hospital de Clínicas was named after Alejandro Posadas at the Centennial of his death.
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Conclusion
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Alejando Posadas systematized techniques and ideas of his time to treat hydatid cysts when pleurae were free from adhesions. He never claimed to be an inventor, but honestly recognized the influence of medical publications on his solitary work [36]. He can be considered as being the first surgeon in Argentina capable of collecting a series of uniformly treated patients, based on experimental research on animals and corpses, and presenting his results in written detail with supporting illustrations, photographs, and movies.
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Acknowledgments
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Acknowledgment to Prof Christian Baille, Director of the Patrimoine Historique; Annick Zwicz de Aliaga, Director of the Library of the University of the Méditerranée School of Medicine, Marseille, France; Lic Teresa D'Vietro, Director of the Library of the University of Buenos Aires School of Medicine; and María Rosa Saracino.
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References
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Introduction
Biographic notes