Ann Thorac Surg 2008;85:1497-1499. doi:10.1016/j.athoracsur.2007.10.106
© 2008 The Society of Thoracic Surgeons
Our Surgical Heritage
Franz John A. Torek
Attila Dubecz, MD*,
Seymour I. Schwartz, MD
Department of Surgery, University of Rochester, School of Medicine and Dentistry, Rochester, New York
* Address correspondence to Dr Dubecz, Department of Surgery, University of Rochester, 601 Elmwood Ave, Rochester, NY 14642 (Email: dubeczattila{at}gmail.com).
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Abstract
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Franz John A. Torek (1861 to 1938) is one of the pioneering surgeons in thoracic surgery. The son of German immigrants, he worked in the German (now Lenox Hill) Hospital in New York City. In 1913 he performed the first thoracic esophagectomy for cancer, and the patient survived for 12 years. We describe the surgical work and private life of Torek and recall the details of the groundbreaking operation.
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Introduction
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A lthough highly regarded by his colleagues, Franz John A. Torek (Fig 1), the pioneering surgeon who performed the first thoracic esophagectomy for cancer, has never been the subject of a published biography, and there is no Wikipedia entry for his name. In fact, there is only one recent brief historical article about him [1]. He is perhaps better known for a procedure that corrected undescended testicles [2].
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Biography
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Franz John A. Torek was born on April 14, 1861, in Breslau, Germany (now Wroclaw, Poland), where both Jan Mikulicz-Radeczki and Ferdinand Sauerbruch worked. His family immigrated to New York City as part of a wave of Germans who fled the rule of Bismarck after the German Unification in 1871. Young Torek graduated from the College of the City of New York in 1880, spent 3 years teaching English, and eventually graduated with his medical degree from Columbia University’s College of Physicians and Surgeons in 1887. He joined the staff of the German Hospital (now the Lenox Hill Hospital) in New York City, where he remained for his entire professional life. He was also a member of the attending staff of the New York Post Graduate Hospital from 1890 to 1915, at St. Mark’s Hospital from 1891 to 1905, and the New York Skin and Cancer Hospital from 1890 to 1935.
Torek was a versatile general surgeon who is to be credited with much more than his famous esophageal resection. In 1913 he described a case of breast cancer that disappeared after bilateral ovariectomy [3], and he was the first to publish a case of resection of an intrathoracic metastatic uterine adenocarcinoma after hysterectomy [4]. He published an article in 1919 describing a series of 600 inguinal hernia repairs with a 0.33% recurrence rate. In that article, he ascribed his success as being mainly related to separation of the vas deferens and the accompanying blood vessels from each other and closing the internal ring between them [5]. In another report, he described an operation for undescended testicles [2].
He was a member American Surgical Association, the New York Surgical Society, and was honored with the presidency of the New York Society for Thoracic Surgery, the American Association for Thoracic Surgery, and the German Medical Society. Torek was soft-spoken, well dressed, and an excellent musician who played the violin and piano. He married Minnie Volkening, and they had 2 children, Margaret and Paul. He died of bronchopneumonia related to a cardiac condition on September 19, 1938, in Vienna, Austria while on vacation.
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The First Successful Transthoracic Resection for Carcinoma of the Esophagus
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Esophageal surgery remains one of the most difficult operations. In the first part of the 20th century the challenge was enormous. In 1877, before the introduction of blood transfusion, antibiotics, and intensive care, the first resection of the cervical esophagus was performed by Johann Nepomuk Czerny. In Torek’s original article, he specifically indicated that Sauerbruch still advised against operations on the thoracic esophagus [6].
Torek’s successful transthoracic esophagectomy was performed on a 67-year-old woman who presented with progressive dysphagia and weight loss. A preoperative bismuth swallow demonstrated the typical signs of a malignant stricture.
Before proceeding with the esophagectomy, Torek performed a preliminary gastrostomy for feeding purposes. The transthoracic esophagectomy took place on March 14, 1913, at the German Hospital [6]. Anesthesia was accomplished with a combination of chloroform, ether, and ethyl chloride. An 18F intubation catheter was sutured to the patient’s upper lip because she had no teeth to which it could be tied. General anesthesia was performed by tracheal insufflation with a Meltzer-Auer apparatus, which had been introduced in 1909 [7] (Fig 2
[8]).
The lesion was exposed through an incision along the entire length across the seventh intercostal space on the left side (Fig 3) [9], and the proximal ends of fourth, fifth, sixth, and seventh ribs were transected near their tubercles. After the intrapleural adhesions were divided, the tumor was found fixed under the aortic arch. The adhesions, possibly caused by previous tuberculosis, likely allowed adequate spontaneous ventilation while the chest was open [10]. In the course of freeing the lesion, the esophageal branches of the vagi were interrupted. No consequent bradycardia resulted.
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Fig 3. The incision was marked with silver nitrate the day before the operation. (Reprinted from Torek F. Carcinoma of the thoracic portion of the esophagus. Arch Surg 1925;10:353–60, with permission. Copyright 1925, American Medical Association. All rights reserved.)
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During the dissection, the thoracic branches between the aorta and esophagus were ligated and divided. The left main bronchus was inadvertently incised and was repaired with silk sutures. After transaction of the esophagus proximally, the proximal stump of the esophagus was brought out at the anterior border of the left sternocleidal mastoid muscle. The lower esophageal stump was invaginated with 2 purse-string sutures after it had been crushed with a Payr duodenal clamp. After the intrathoracic esophagus was removed, the thorax was closed with silk and chromicized catgut sutures. No drainage was used.
At the end of thoracic procedure, under local anesthesia, the proximal esophagus was tunneled subcutaneously and brought out through a separate incision onto the anterior chest wall. At the end of the operation, a hot coffee enema with whiskey and strychnine was applied. The entire operation lasted for 2 hours and 43 minutes. Histology confirmed squamous cell carcinoma of the esophagus, and the report describes an anthracotic lymph node.
The patient was fed through the gastrostomy tube for the first 8 postoperative days and later received nutrition orally. The meal passed from the proximal esophageal stoma through an external tube to the gastrostomy (Fig 4) [6]. The patient survived for 12 years, ultimately dying of pneumonia.
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Fig 4. Torek’s esophagectomy patient on the 12th postoperative day. The gastrostomy tube was introduced into the esophagus whenever the patient desired to swallow. (This article was published in Surg Gynecol Obstet, 16, Torek F, The first successful case of resection of the thoracic portion of the oesophagus for carcinoma, 614-17, Copyright Elsevier [1913].)
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Epilogue
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Torek revisited esophageal surgery in two subsequent publications. He recounted his original procedure in 1925 [9] and indicated that an additional 25 cases were performed at his hospital, with two recoveries. At that time of the report, two other thoracic esophagectomies had been performed, one extrapleurally by Howard Lilienthal [11] and the other, transthoracically, by Carl Eggers.
In 1929 Torek published another article [12] on the subject, a review in which he emphasized the factors that contributed to a high morbidity and mortality. The postoperative mortality rate was reported to be 91%, but Torek indicated that he believed that more favorable results could be obtained.
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Legacy
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Torek’s operation was a major surgical breakthrough, proving that thoracic esophagectomy was feasible and that esophageal cancer could be cured surgically. As his friend and colleague Carl Eggers wrote in the obituary: "Because of his personality, his sterling character, his work and his contributions, Doctor Torek will long be remembered and be an inspiration to those who follow after. He was one of America’s great surgeons" [13].
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Acknowledgments
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We thank Christopher Hoolihan of Edward G. Miner Library and Gianna Nixon for their invaluable help.
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References
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- Scannell JG. Franz JA Torek (1861–1938) J Thor Cardiovasc Surg 1997;114:690-691.[Free Full Text]
- Torek F. Orchiopexy for undescended testicle Ann Surg 1931;94:97-110.[Medline]
- Torek F. Disappearance of recurrent mammary carcinoma after removal of the ovaries Ann Surg 1914;60:476-477.[Medline]
- Torek F. Removal of metastatic carcinoma of the lung and mediastinum Arch Surg 1930;21:1416-1424.[Abstract/Free Full Text]
- Torek F. Inguinal hernia: an operative method by which close to 100 per cent cures have been obtained Ann Surg 1919;70:65-80.[Medline]
- Torek F. The first successful case of resection of the thoracic portion of the oesophagus for carcinoma Surg Gynecol Obstet 1913;16:614-617.
- Meltzer SJ, Auer J. Continuous respiration without respiratory movements J Exp Med 1909;11:622-625.[Medline]
- Founders Contributions—Anesthesiahttp://www.aats.org/annualmeeting/Program-Books/50th-Anniversary-Book/Founders-Countributions-Anesthesia.html 1909Accessed: August 16, 2007.
- Torek F. Carcinoma of the thoracic portion of the esophagus Arch Surg 1925;10:353-360.[Abstract/Free Full Text]
- Klingman RR, DeMeester TR. Surgery for carcinoma of the thoracic esophagus: Adams and Phemister in perspective Ann Thorac Surg 1988;46:699-702.[Abstract/Free Full Text]
- Lilienthal H. Carcinoma of thoracic oesophagus extrapleural resection and plastic description of an original method with a successful case without gastrostomy Ann Surg 1921;74:259-279.[Medline]
- Torek F. The causes of failure in the operative treatment of carcinoma of the esophagus Ann Surg 1929;90:496-506.[Medline]
- Eggers C. Franz JA Torek 1861–1938 Ann Surg 1939;110:797-799.[Medline]
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Abstract
Introduction
