Esophageal Surgery in Greece during the 19th Century

Abstract

Background

The purpose of this manuscript is to highlight the endeavors of the Greek surgeons during the 19 th century to perform various types of operation on esophagus.

Methods

Research has been conducted in the archives of National Greek Library and the medical archives of the major Greek hospitals during the 19 th century.

Results

The research found that the surgery of esophagus during the 19 th century in Greece was limited to esophagostomy, removal of foreign objects, dilation and suturing.

Conclusion

Greek surgeons of the 19 th century faced similar problems as their colleagues in Europe in the surgical approach of the esophagus.

Keywords: esophagus, Ioannis Olympios, Theodoros Aretaios, Spyridon Magginas, Greek surgery.

INTRODUCTION

Esophageal surgery in modern Greek surgery would take a central place in the 1960s with the work of Professor Panagiotis Chrysospathis (1915-2015), who distinguished himself in this field and gained international recognition with his work both in Europe and America (1-5).

Nevertheless, the first steps in esophageal surgery in Greece will be sought a century earlier in the work of pioneering Greek surgeons and especially that of Professor Theodoros Aretaios (1829-1893), who is recognized as the greatest Greek surgeon of the 19 th century (6-7).

Esophageal surgery presented a significant challenge for surgeons in the 19 th century, not only in Greece but also internationally. The difficulty in surgically accessing the organ led to limiting surgical procedures to esophagostomy at the level of the cervical esophagus. This was primarily done in an attempt to feed patients who exhibited dysphagia, regardless of its cause, which was mainly addressed by placing catheters to provide liquids. Additionally, trauma management and the removal of foreign bodies, primarily lodged in the proximal part, mainly upper third of the esophagus, was another area of surgical intervention for this organ (8).

In the European theater of surgical operations, attempts were made at suturing, dilating, or capturing and removing foreign objects. Removal was limited in the reach of various forceps, while lower position was confronted with a push-downwards method, with the hope that objects shall fall and be digested in the stomach or move forward towards the rectum. Tools, water, drugs were used for the purpose. Tumors were considered fatal. In cases of obstruction, esophagotomy was considered. Although at the beginning of the 19 th century surgeons had some reservations on operating the esophagus, it was Tarenget who performed an esophagotomy for stricture in 1786 and paved the way for future surgical procedures in the area (9-10). This historical narrative review surveys Hellenic esophageal surgery during its origins in the 19 th century.

Materials

Modern Greek surgery would be inextricably linked to the founding of the University of Athens in 1837 and the simultaneous opening of its Medical School. The first Professor of Surgery, Ioannis Olympios (1802-1869), published the inaugural textbook of surgery in Greek, which was the translation of the work of Professor Maximilian Joseph von Chelius (1794-1876). In this work, the surgical knowledge of the German Professor was presented in Greek. However, the successor of Ioannis Olympios, Professor Theodoros Aretaios, wrote the first Greek surgical textbook written by a Greek and in his native language, which was not a synthesis of the views of European surgeons, as expressed in their own writings, but a creative critical analysis complemented by the experiences of Theodore Aretaios. Thus, Theodoros Aretaios began his writing work in 1864 and, after 13 years, he concluded through his notes to write two basic textbooks of surgery, Surgical Pathology and On Operations, in which he described the techniques of various surgical operations accompanied by elements of surgical pathology (11-12).

In his work on surgical techniques, he devoted three chapters to dealing with surgical operations of the esophagus. The first one concerned esophagotomy (Figure 1) (13), the second one the catheterization of the esophagus (Figure 2) (14) and the third one the removal of foreign objects from the organ (Figure 3) (15). However, in the first lines, Theodoros Aretaios stated that operations of the esophagus belonged to the rarest operations because only a few cases in living patients were known, a fact that indicated the difficulty in the surgical approach of the organ.

The chapter of esophagotomy concerned the performance of esophagotomy in the cervical portion of the organ. Initially, the topographic and surgical anatomy of the area of surgery is mentioned, followed by a brief historical review from ancient times regarding esophagotomy attempts to remove mainly foreign objects. In addition, the tools to be used were described, as well as the steps of the operation. He emphasized that the difficulties in this operation are access to the organ of the esophagus and the risk of injury to the vessels of the area, thyroid and larynx, while this operation aimed to remove foreign objects and place an esophageal feeding catheter.

The chapter of esophageal catheterization mainly described the anatomy of the pharynx completing the anatomy of the earlier mentioned area, which was principally concerning the swallowing organs. It is considered that the purpose of esophageal catheterization was to try to open the strictures in the esophagus and feed the patient in cases of stenosis or inability to swallow due to paralysis. In fact, it is emphasized that there were two catheterization entrances from the nose and mouth, with the mouth being preferable as it was more acceptable to the patient. It was indicated that the patient should be in a sitting position and the surgeon should stand in front of him. It is also reported that catheterization was performed with surgical candles and elastic tubes of various diameters depending on patency, but always 10 to 12 cm longer than the length of the esophagus.

In the third chapter, which describes the methods of removing foreign objects from the esophagus, it is stated that fish spines, needles, bone fringes, coins and knobs are usually wedged into the esophagus. He distinguished two methods for managing these bodies. One of them was to promote them in the stomach by swallowing a large amount of water or oil or a large portion of bread or other food. The other one is to remove them through the oral cavity. This could be achieved either by inducing vomiting, or by leveraging with the fingers for bodies wedged in the pharynx or scaphoid fossa, or by using forceps or hooks with long and convex strands. In addition to these methods, he pointed out that sometimes the technique applied by the Byzantine physician Paul of Aegina (the seventh century AD), in which the patient swallowed a wedge-shaped piece of sponge extracted by the surgeon from the strong suture on which it was suspended, can sometimes prove useful.

Apart from the textbooks, the records of such specific cases are extremely limited in the material that has survived to date. The difficulty in surgically treating esophageal conditions is clearly illustrated by the case of a 35-year-old patient with dysphagia, as recorded in the report of the surgical attending Konstantinos Lambros of Theodoros Aretaios’ Clinic during the Academic Year 1889-1890 (16). The patient initially presented in the Clinic, in 1890, in a state of absolute physical exhaustion and malnutrition due to his inability to ingest because of dysphagia. The patient's history revealed an eight-day period of complete anorexia and oral intake cessation, indicative of severe dysphagia and nutritional compromise. It was clinically diagnosed that he had an esophageal stricture which was completely impassable by contemporary surgical instruments. Therefore, any surgical attempt was deemed futile, and the patient was treated with nutritional enemas, as reported. Unfortunately, the patient died after 48 hours. During the autopsy, extensive cancerous infiltration was found, extending from the entrance of the esophagus and occupying most of the thoracic portion of the organ. This case should be recognized as the first confirmed case of esophageal cancer in modern Greek surgery. The report does not provide further details about the type of cancer or its morphological state (16).

Another case, which was recorded in Lambros' report in 1890, particularly intrigued the surgeon's interest. It involved a 55-year-old female patient who had been experiencing episodes of dysphagia for 15 years. The dysphagia progressively worsened, resulting in the patient only being able to ingest food in liquid form only in small quantities and with extreme difficulty during the last trimester. It is emphasized that the patient's voice remained unaltered. However, it was observed that the larynx appeared more voluminous and protruding, although it remained mobile during swallowing. Examination with the laryngoscope did not reveal any pathology. Attempts to catheterize the esophagus, even with the finest catheters, proved futile. Eventually, a thin catheter of size 18 (according to the French scale, as mentioned) was successfully passed. This was achieved through a specific maneuver: the catheter could only pass when directed left and backwards, allowing it to traverse the stricture at the beginning of the esophagus. This action was facilitated by pulling the larynx ventrally. Upon removal of the catheter, the dysphagia remained unaltered, with inability to ingest liquids.

In addition, the patient experienced intense pain during catheterization attempts. She was subsequently discharged from the clinic after 12 hours in a stable condition. Nevertheless, due to the ease of catheterization when pulling the larynx forward, as well as the morphological alteration of the larynx, a diagnosis of esophageal stenosis due to compression from an ossified larynx was made. It is emphasized that this pathology was generally rarely documented in the international literature of the time. It is indicated that palpation with the index finger helps in diagnosis, allowing for the detection of hardness and flattening of the ossified cricoid cartilage. Pulling the larynx is noted as a significant maneuver that would release the stricture (16).

Furthermore, it is pointed out in relevance to the aforementioned case that the long course of the disease excludes malignancy, mechanical or chemical injury to the esophagus from the differential diagnosis. The report of this case demonstrates the meticulous observation and deductive reasoning employed by physicians of the era in diagnosing complex conditions with limited technological resources.

In the same report of proceedings there was a description of three cases of outpatients whose foreign bodies lodged at the beginning of the esophagus were removed. The surgeons accessed these through the mouth and extracted them using forceps. No further information is provided beyond this relatively simple report of the cases (16). The first case involved the removal of a flattened fish bone wedged at the entrance of the esophagus, which was extracted using a large, curved polypus forceps. The second case concerned a piece of lamb cartilage lodged in the esophagus at the level corresponding to the beginning of the trachea in a 63-year-old man. This clearly refers to approximately the end of the cervical portion of the esophagus, and the piece was pushed into the stomach. The third case involved a piece of lamb bone wedged in the upper part of the esophagus of a 45-year-old man. This piece was of particular interest as its design was recorded in the report in the form of a woodcut (Figure 4) (16). It was removed using Gräfe's forceps named coin catcher.

From within the corresponding report for the Academic Year 1892-1893 recorded by Demetrios Sp. Balanos (1862-1907) in the same clinic, but now under the direction of Spyridon Magginas (1839-1920), a case of esophageal stenosis is recorded. It involved a sailor, for whom no further demographic details were provided, who had been experiencing difficulty swallowing for a year without any identifiable preceding cause. For eight months, the episodes of dysphagia recurred, until finally the patient was unable to ingest solid food and started having difficulty with liquids too. No other symptoms were observed. It is reported that the esophagus was catheterized with many sizes of catheters, until finally he began to take solid food again. It was understood that the repetitive use of esophageal catheters probably dilated a possible stricture, which was not further described. After more than a month of hospitalization, the patient returned to his hometown, Nafpaktos, after having been provided with catheters for self-catheterization (17).

From this last report, we also mention one more case of a 28-year-old fruit vendor who, during Carnival celebrations, was performing outdoor shows impersonating a magician by inserting elongated pieces of tin from his mouth to his esophagus as if they were swords. During one performance, while attempting to insert the fifth piece, he bled profusely. He was transferred to Magginas' Clinic and was treated conservatively with ice. It was found that he had injured the upper part of the esophagus, while simultaneously a diagnosis of bronchitis was made. According to current understanding, this was a result of aspiration. The patient accepted only the treatment for the injury and the longer-term treatment for bronchitis, because he wanted to continue his outdoor performances (17).

CONCLUSIONS

This historical account elucidates several significant aspects of late 19 th -century esophageal surgery and medical practice. It provides insight into the spectrum of foreign bodies commonly encountered in the esophagus during this era. This scientific text outlines the utilization of specialized surgical instruments, such as polypus and Gräfe's forceps, used for foreign body extraction. Furthermore, it is underlined the wide employment of esophageal dilation using catheters for the management of esophageal stenosis. An early recognition of aspiration as a sequela of esophageal injury is mentioned, albeit not explicitly referring to the causality of the two. Finally, the documentation methods employed during this period are also depicted, offering valuable insight into historical medical record-keeping practices.

It is almost unknown the Greek esophageal surgery during the 19 th century.

Greek surgeons’ teaching texts and surgical approaches on esophageal diseases during the 19 th century come to light for the first time.

FIGURE 1.

Aretaios’ manuscript on esophagotomy

FIGURE 2.

Aretaios’ manuscript on esophagial catheteriazation (National Library of Greece)

FIGURE 3.

Design of a lamb’s bone piece wedged in the upper part of a 45-year-old man’s esophagus in 1890

FIGURE 4.

Design of a lamb’s bone piece wedged in the upper part of a 45-year-old man’s esophagus in 1890

Conflicts of Interest

None declared.

Financial Support

None declared.