The Value of Thoracoplasty in Pulmonary Tuberculosis

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THE VALUE OF THORACOPLASTY IN PULMONARY TUBERCULOSIS. P r e s e n t i n g a R evie w o f XOO C on secu tiv e Cases W ith S p e c i a l R e f e r e n c e to t h e A dvanced C a s e . By Harvey J„ B e a r d M. B. , tacacsiq»aoi0 QiStetaueaQn

F.R.C.S. E d . . ma o

ProQuest N um ber: 13916045

All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is d e p e n d e n t upon the quality of the copy subm itted. In the unlikely e v e n t that the a u thor did not send a c o m p le te m anuscript and there are missing pages, these will be noted. Also, if m aterial had to be rem oved, a n o te will ind ica te the deletion.

uest ProQuest 13916045 Published by ProQuest LLC(2019). C opyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C o d e M icroform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 4 8 1 0 6 - 1346

J '43 * S o c j ^ 0>

INTRODUCTION, acaOmcaociiO e *wc t

si

Pulmonary T u b e r c u l o s i s has had a s t e a d i l y rise

d ec lin in g death ra te

f o r many y e a r s

ex cep t f o r a temporary

i n t h e e a r l y y e a r s o f t h e w a r , T h i s f a l l h a d commenced

b e f o r e c o l l a p s e t h e r a p y was a s w i d e l y u s e d a s a t p r e s e n t 0 It

is therefore d if f ic u lt

to p r o v e t h a t

this

treatm ent

h a s h ad any i n f l u e n c e on t h e d e a t h r a t e b u t i n t h e individual

case th e re

i s no q u e s t i o n o f i t s

proof o f the value o f c o lla p s e therapy l i e s

e f f i c a c y , The in i t s

steadily

i n c r e a s i n g use* D espite the f a l l incidence o f tu b e rc u lo sis b e i n g p r o b a b l y d u e to conscious

is

in m o rta lity

increasing,

the public

figures

muc h o f t h i s

a s a w h o l e b e i n g more

o f t h e d i s e a s e and t h e d i a g n o s i s

consequently

mo r e common0 Ma ss R a d i o g r a p h y h a s h e l p e d t h i s many s c h e m e s to a s s i s t p a t i e n t s mo r e w i l l i n g

to

subm it to

the

and w i t h t h e

econom ically they are

t r e a t m e n t a t an e a r l i e r

The a d m i s s i o n o f h o p e l e s s c a s e s to t h i s

stage.

sanatorium are

f e w e r t h a n some y e a r s a g o . T h i s d o e s n o t mean t h a t t h e m ajority o f cases are in a pathological are not,

sense ea rly ,

t h e d i s e a s e commonly h a s a f i r m h o l d i n b o t h

l u n g s and i s o f t e n t o o w i d e s p r e a d pneumothorax a lth o u g h s u i t a b l e

f o r an a r t i f i c i a l

for th oracoplasty.

The i n t r o d u c t i o n o f t h o r a c o p l a s t y r e p r e s e n te d a g r e a t advance in the tre a tm e n t o f t h i s c h r o n i c i n v a l i d i n g d i s e a s e and w i t h i m p r o v e d m o d e r n

they

technique

r e s u l t s a r e now a c h i e v e d t h a t f i f t e e n y e a r s

ago w o u l d h a v e

been c o n s i d e r e d i m p o s s i b l e .

For the

e a r l i e r d i a g n o s e d c a s e s m e n t i o n e d abov e tho r a c o p l a s t y b e i n g u s e d mo r e a n d m o r e . B e i n g a m u l t i p l e it

is

yearly

is

stage operation

t i m e consumin g and a l t h o u g h t h e number p e r f o r m e d is

continually

increasing the l i s t of p a tie n ts

w aitin g s te a d ily le n g th e n s. Thoracoplasty

is

also meeting

w i t h m o r e f a v o u r a m o n g s t t h e p a t i e n t s who v i e w i t en d t o t h e i r d i s e a s e . T h e r e a r e g r o u n d s f o r t h o s e t h o r a c o p l a s t i e s who r e t u r n

for further

as an

t h i s view f o r treatm ent

a r e very few. The l o n g w a i t i n g l i s t s t o o p e r a t e o n good c a s e s

l e n d an i n c l i n a t i o n

r e q u ir in g only

two

s t a g e s and who

can b e q u i c k l y

transferred

to t h e c o n v a l e s c e n t

of a hospital.

I n t h i s way t h e c a s e w i t h a d v a n c e d d i s e a s e

t e n d s to be p u t on o n e s i d e , good r e c o v e r y thesis

y e t many o f t h e s e w i l l make a

follow ing o p eratio n .

It

is proposed in t h i s

t o make p a r t i c u l a r r e f e r e n c e .to t h i s

a nd a l s o

bring out features

type o f case

c o n s i d e r e d to b e o f i m p o r t a n c e

i n t h e p r e ° a n d po s t - o p e r a t i v e m a n a g e m e n t o f These one hundred c o n s e c u t i v e cases cover th e years

sections

1946 to 1949,

thoracoplasties. thoracoplasty

a p p r o x i m a t e l y one

t h i r d o f t h e o p e r a t i o n s b e i n g p e r f o r m e d by t h e w r i t e r ^^rho i n h i s a p p o i n t m e n t o f S e n i o r A s s i s t a n t M e d i c a l O f f i c e r to K e l 1i n g S a n a t o r i u m s u p e r v i s e s o f the h o s p i t a l .

all

t h e s u r g i c a l work

R e s i d e n c e i n s u c h an i n s t i t u t i o n

provides

an u n r i v a l l e d o p p o r tu n ity

for studying p a tie n ts over a

l o n g p e r i o d a n d i t was t h i s

that

stim ulated

s u b m i t t i n g t h e more a d v a n c e d c a s e s w hich were o f t e n

interest

to o p e r a t i o n , ,

in

cases

c o n s i d e r e d to h a v e a, h o p e l e s s p r o g n o s i s *

AN H I S T O R IC A L era (T>

pi

SUFVFY .

en a » *££» ca fft «** «£» *i» e» #^¥ cs *:* «=• **d» «

*™

The o p e r a t i o n o f t h o r a c o p l a s t y h a s s i n c e its

i n c e p t i o n been a s u b j e c t o f c o n t e n t i o n and t h e r e i s

still

disag reem e n t o v er i t s u se , N e v e rth e le s s 9 major

thoracic has

surgery

in t h e t r e a tm e n t o f pulmonary t u b e r c u l o s i s

reached such p r o p o r t i o n s t h a t i t s

u s e f u l n e s s m u s t now

be acknowledged, M o rristo n Davies

( XS 37 ) h a s s a i d t h a t t h e

t e c h n i q u e o f an o p e r a t i o n c a n n o t be r e g a r d e d unless the r e s u lts

are su ccessfu l

t h e c a s e s 9 and t h a t . t h i s for thoracoplasty

as s a t i s f a c t o r y

in a la rg e m ajority of

claim cannot j u s t i f i a b l y

as th e p r o p o r t i o n o f

cases

b e made

in which a

c a v i t y has not been com pletely o b l i t e r a t e d o r th e i n f e c t i o n eradicated it

is

too h i g h . W h i l s t a c c e p t i n g t h i s

is necessary

tuberculosis

to r e a l i s e

peak o f the

t h a t t h e t r e a t m e n t o f pulmonary

by m a j o r o p e r a t i o n i s

I n many d i s e a s e s t h e

statem ent

a unique

surgical operation

s u r g i c a l problem*

represents

t r e a t m e n t w i t h hope o f a r a p i d c u r e to

w h erea s to t h e p h t h i s i o l o g i s t

tho r a c o p l a s t y

viewed a s a mere i n c i d e n t in a l o n g p la n o f

has

the follow ,

to be

campaign

a g a i n s t t h e d i s e a s e . The t r e a t m e n t o f p e p t i c u l c e r by g a s t r o - e n t e r o storny b e a r s but w h ilst

some s i m i l a r i t y

t h i s o p e r a t i o n has f a l l e n

into

to

th e problem

disrepute

t h o r a c o p l a s t y as a m easu re o f t r e a t m e n t i n pulmonary tuberculosis surgery

is

continues

called

i n to

to

advance. In most d i s e a s e s

e x c i s e t h e d i s e a s e d a r e a o r to

c o r r e c t a b n o r m a l i t i e s . R e s e c t i o n may u l t i m a t e l y ideal

become t h e

in pulmonary t u b e r c u l o s i s b u t meanwhile t h o r a c o p l a s t y

c o n t i n u e s to history

spread

r a p i d l y a n d a p a u s e to

review i t s

i s a d v i s a b l e , , O n l y i n t h i s way c a n we a p p r e c i a t e

a nd w i s e l y u s e t h e m o d e r n o p e r a t i o n w h i c h h a s b e e n so painstakingly

evolved. The i n f e c t i v i t y o f t u b e r c u l o u s m a t e r i a l

h a d b e e n p r o v e d by v i l l e m i n i n 1865s

b u t i n 1882 t h e w hole

o u t l o o k o n t h e d i s e a s e was c h a n g e d by K o c h ’ s d i s c o v e r y o f the

tubercle b a c illu s, P h i l l i p Ellman in h i a p r e s i d e n t i a l Address

to t h e L i s t e r i a n S o c i e t y , a nd M o d e r n , artificial

states

that

Pulmonary T u b e r c u l o s i s A n c ie n t

for the

first

crude o u tli n e of

p n e u m o t h o r a x we mu st h a r k b a c k t o H i p p o c r a t e s

who s u g g e s t e d t h a t w h e r e t h e r e was a c h e s t wound o r a n o p e r a t i o n f o r empyema i t was p o s s i b l e w ith a ir ,

compress i t P rior

Liverpool

to

and f o r c e t h e a i r

fill into

a bladder the ch e st.

to K o c h ’ s d i s c o v e r y J a m e s C a r s o n o f

i n 1 822 f i r s t u r g e d t h e u s e o f a r t i f i c i a l

p n e u m o t h o r a x , H'e p o i n t e d o u t how g r e a t a b a r t o h e a l i n g were the e l a s t i c i t y ,

c o n d i t i o n o f e x t e n s i o n and c o n s t a n t

movement o f t h e l u n g s . ’’t h e

I n a b s c e s s o f t h e l u n g he remarked

sides are prevented

from f a l l i n g

into

a salutary

c o n t a c t n o t by t h e m a t t e r w h i c h l o d g e s b e t w e e n t h e m , by t h e p o w e r f u l

elasticity

but

and r e t r a c t i o n o f th e

s u r r o u n d i n g s u b s t a n c e " . He s t a t e d

t h a t by c o l l a p s e o f t h e

l u n g t h e d i s e a s e d p a r t would be p l a c e d i n a q u i e s c e n t

state,

receive

little

o r no d i s t u r b a n c e f r o m t h e m o v e m e n t s

o f r e s p i r a t i o n and t h e d i v i d e d i n to

close

s u r f a c e s wrould h e b r o u g h t

c o n t a c t by t h e same r e s i l i e n t

power which

b e f o r e h a d k e p t t h e m a s u n d e r . He a d v o c a t e d i t s t r e a t m e n t o f p h t h i s i s and r e a l i s e d be g r a d u a l .

In th e l i g h t o f a l l

t h e s e words

ofhis

my o p i n i o n t h a t cured,

and i t

the c o lla p se

should

t h a t has happened

are worth quoting,

if

use in th e

since

" I t has long been

ever th is disease p h th is is

i s to be

i s a n e v e n t o f w h i c h I am by no m e a n s d i s p o s e d

to d e s p a i r ,

i t m u s t b e a c c o m p l i s h e d by m e c h a n i c a l

or in o th e r

w o r d s by a s u r g i c a l o p e r a t i o n " 0

means,

A l t h o u g h C a r s o n ’ s i d e a s now s e e m t o u s to have been o f th e g r e a t e s t

importance b is contem poraries

c o u l d n o t h a v e t h o u g h t so f o r i t was n o t u n t i l F o rla n in i of P av ia also

proposed a r t i f i c i a l

and l a t e r h e was t h e f i r s t idea,

pneumothorax

to p r a c t i c e a n d d e v e l o p t h e

t h o u g h he d i d n o t u s e a manometer* Looking back i t

beginnings

i t was a n a t u r a l

s h o u l d be r e s e c t e d Three y e a r s first

1832 t h a t

later

resected

s e e ms t h a t

s t e p to

from t h e s e

suggest

th at ribs

to p r o d u c e a c o l l a p s e o f t h e l u n g . i n l 385 E d o u a r d de C & r e n v i l l e o f L a u s a n n e

ribs

i n o r d e r to

re la x the u n derlying tu b e r ­

c u l o u s l u n g . He b a s e d h i s w o r k o n t h e empyema s t u d i e s o f E s t l a n d e r * From t h i s

time onwards t h e o p e r a t i o n o f

t h o r a c o p l a s t y was s t e a d i l y d e v e l o p e d , procedures being t r i e d e ffic ie n t operation.

many d i f f e r e n t

by s u r g e o n s l o o k i n g

f o r a more

T his development o f t h o r a c o p l a s t y

c o u l d h a r d l y h a v e come e a r l i e r f o r s u c h a n o p e r a t i o n d e ma n d e d s u r g i c a l

cleanliness,

i n 1365

a n d i t was o n l y

t h a t L i s t e r had p u b lis h e d h i s o r i g i n a l p a p e r , de C e r e n v i l l e h ad r e s e c t e d of the rib s a n te rio rly ,

t h e n umbe r v a r y i n g w i t h t h e s i z e

o f t h e c a v i t y w h ich he w is h e d to a f f e c t , 1890 u s i n g a p e r i s c a p u l a r i n c i s i o n , of ribs

fo r cases with a p le u ra l

operation "ex tra-p leu ral

sm all p o rtio n s

C a rl SPengler in

resected

g reater lengths

e f f u s i o n and c a l l e d th e

thoracoplasty",

w h i c h name s t i l l

stands„ Brauer studying the o p eratio n of th o raco p lasty realised

g r e a t e r l e n g t h s o f r i b m u s t be r e s e c t e d

to a p p r o a c h mo r e n e a r l y

t h e c o l l a p s e o f an a r t i f i c i a l

p n e u m o t h o r a x . He p r o p o s e d t h e r e m o v a l o f e n t i r e o f the

in o r d e r

r i b s two t o n i n e and s u c h an o p e r a t i o n

was u n d e r t a k e n by F r e i d r i c h

lengths

in one s t a g e

i n 1907 * t h e p a t i e n t

surviving*

A S c h e d e i n c i s i o n was u s e d a nd t h e r i b s a l o n g w i t h t h e i r p e r i o s t e u m and i n t e r c o s t a l m uscles r e s e c t e d . T h i s o p e r a t i o n was s o o n a b a n d o n e d a s b o t h B r a u e r a n d F r e i d r i c h r e a l i s e d w a s too s h o c k i n g , final

chest w all

paradoxical

s e v e r e and t h e

c o l l a p s e n o t a s good a s was e x p e c t e d .

D epression o f the f i r s t for,

respiration

r i b was n o t a s e x t e n s i v e

as hoped

so s e p a r a t i o n o f t h e a p e x o f t h e l u n g f r o m t h i s

was t r i e d ,

it

b u t i n t i m e i t was r e a l i s e d

i t s e l f m ust be removed. D e s p i t e

these

t h a t the

first

rib rib

fa u lts Brauer re a lis e d

t h e p r i n c i p l e o f h i s o p e r a t i o n was c o r r e c t 0 Wi lms a nd S a u e r b r u c h e a c h d e v e l o p e d t h i s

operation,

perform ing a p a ra v e rte b ra l

G o u r d e t i n 1 8 9 ? h a d "been t h e f i r s t collapse

r e s e c t i o n which.

to r e a l i s e

than r e s e c tio n o f long l a t e r a l

gave a b e t t e r

portions of r i b 0

(Fig* l o )

r

L ateral

Paravertebral resection 0

resection, Fig, X

Wi lms a l w a y s r e m o v e d t h e f i r s t a pneum olysisp f i l l i n g w ith

r ib or did

the rem aining e x t r a - p l e u r a l

f a t o r b o n e c h i p p i n g s 0 Pie named h i s o p e r a t i o n ” 0 0 l u m n a r

r e s e c tio n ” , A dditional p a ra -s te rn a l t i m e s made to

r e s e c t i o n s w e r e s o me ­

increase collapse, Sauerbruch paid s p e c ia l a t t e n t i o n

first said

space

rib

removing i t

from below and b e h in d and,

i t m ust always be removed, B e r a r d

to t h e i n XQ24 ,

i n 1 923 h a d c a l l e d

the

first

r i b t h e hey to

diagram m atically

F irst

t h e t h d r a c i c dome a n d A l e x a n d e r

represents th is,

(Fig,

2 0)

F irst

r i b n o t removed

r i b removed.

Fig. 2

The r e a s o n f o r l e a v i n g t h e f i r s t operations

appears

rib

in these

to h a v e b e e n i n o r d e r to

t i m e to t h e mi ni mum. S h o c k was a v e r y r e a l lessen

this

speed o f o p e r a t i o n

considered

earlier

reduce o p e ra tin g f e a r and to

essential.

B o t h Wi l ms an d S a u e r b r u c h u s e d two s t a g e o p e r a t i o n s a s p r o p o s e d by B r a u e r a f t e r h i s experiences.

These s u r g e o n s were g r e a t l y

earlier

e x e r c i s e d by t h e

c o m p l i c a t i o n o f p n e u m o n i a c a u s e d by t h e a s p i r a t i o n o f infected secretions

into

the u n co llap sed lower lung a f t e r

th e upper lu n g had been c o lla p s e d *

To a v o i d a s p i r a t i o n

10 pneumonia S a u e rb ru c h l a t e r low er lung f i r s t ,

i n s i s t e d on c o m p re s s in g t h e

taking rib s

s i x to

eleven in c lu siv e ,

b u t t h e m e t h o d was n o t a l w a y s s u c c e s s f u l 0 I t was r e a l i s e d t h a t i m p a i r m e n t o f c o u g h by p o s t o p e r a t i v e p a i n p r e v e n t e d expulsion o f the in fec ted

secretions

from t h e low erlung,

and t h a t t h e l o n g e r t h e s e

secretions

remained t h e r e th e

more l i k e l y would th e y be

to c a u s e p n e u m o n i a * E v e r y

w a s made to

p a t i e n t to co.ugh w h i l s t

encourage th e

same t i m e g i v i n g manua,! s u p p o r t to t h e

soft

at

effort the

chest w all,

Brauer also modified h is o r i g i n a l o p e ra tio n , r e s e c tin g g r e a t e r le n g th s o f the upper rib s

t h a n d i d Wilms

a n d S a u e r b r u c h * I n o r d e r t o do t h i s h e u s e d i n a d d i t i o n to

the p a ra v e rte b ra l

i n c i s i o n an h o r i z o n t a l

incision

th e a x i l l a , th ro u g h which he d iv id e d t h e a n t e r i o r r i b

in ends*

A d e v e l o p m e n t a l t r e e o f t h e o p e r a t i o n may th e n be p r e s e n t e d t h u s , -

II

de C e r e n v i l l e I 8 6 5 Small a n t e r i o r rib resection.

G o u r d e t X895 P aravertebral

B r a u e r a n d P r e i d r i o h I 907 Long l a t e r a l

resection.

resection„

i l m s I 911

S a u e r b r u c h I 909

Wi1ms - Sa u e r b r u ch P a ra v e rte b ra l T horacoplasty.

B rauer IQII Subscapular p ara v e rte b ra l tho r a c o p l a s t y .

With i n d i v i d u a l

s u r g e o n s own m o d i f i c a t i o n s

t h e W ilm s - S a u e r b ru c h and B r a u e r o p e r a t i o n s w ere th e standard procedures for thoracoplasty u n til h is operation

in 193$. In t h is

c o u n t r y M o r r i s t o n D a v i e s was t h e

p i o n e e r i n t h i s work p e r f o r m i n g i n 1912 t h e thoracoplasty operations Pearson

f o r pulmonary tu h e ro u lo s i s 0 T h o r a c o p la s ty

factor

in

i n 1901 .

Mo r r i s t o n D a v i e s in th e se e a rly

was t h e " b u c k e t h a n d l e "

cartilages

S„V0

remembers a s s i s t i n g a t such an o p e r a t i o n

t h e B romp t o n H o s p i t a l

the ribs*

first

f o r empyema h a d b e e n p e r f o r m e d l o n g b e f o r e *

(19^6)

essential

Semb i n t r o d u c e d

(1937 ) h a s shown t h a t t h e tuberculous

thoracoplasties

r o ta tio n o f the rem aining p a rts of

Torsion o f the rib s takes p lace a t the c o s ta l a n d t h e downward r o t a t i o n

greatly

reduces th e

s i z e o f t h e c a v i t y o f t h e c h e s t on t h e a f f e c t e d

side.

To

produce th e n ecessary leverag e a long le n g th o f r ib is necessary

a n d t h i s me a n s t h e p o r t i o n o f t h e

rib

p a r a v e r t e b r a l l y m u s t n o t be o v e r l o n g * He f i n d s

resected this

ideal

l e n g t h to b e 1 0 - I 2 cm*0 I n summary, lengths of rib a n te rio rly

de C l r e n v i l l e (he a ls o

r e s e c te d small

drained c a v itie s ) ,

B r a u e r a n d F r e i d r i c h i n s i s t e d on l o n g l e n g t h s o f r i b b e i n g re s e c te d but t h i s brought high m o rta lity

and g rave

c o m p l i c a t i o n s „ Wi lms a n d S a u e r b r u c h w o r k i n g i n d e p e n d e n t l y a d o p t e d a mo r e m o d e r a t e b u t p a r a v e r t e b r a l B r a u e r made s i m i l a r m o d i f i c a t i o n s *

resection,

and

13 A ttention

g r a d u a l l y moved t o w a r d s i m p r o v i n g

th e c o l l a p s e o v e r th e u p p er lu n g and th e u se o f m u l t i p l e s t a g e o p e r a t i o n s „ The W i l m s - S a u e r b r u c h p a r a v e r t e b r a l thoracoplasty

c o n t i n u e d a l m o s t unchanged b u t from th e

B r a u e r s u b s c a p u l a r p a r a v e r t e b r a l o p e r a t i o n t h e mo d e r n u p p er s ta g e t h o r a c o p l a s t y slowly realised

t h a t t h e u p p e r l u n g c o l l a p s e was s t i l l

s u f f i c i e n t and y e t i t

operation

not

was i n t h e u p p e r l u n g w h e r e

t u b e r c u l o s i s was u s u a l l y

w ith h is

evolved* Surgeons

f ou n d * B r a u e r i n s i s t e d

that h is

s h o u l d be p e r f o r m e d i n o n e s t a g e a n d t h i s a l o n g re s e c tio n of g re a te r lengths o f the upper rib s

did give a b e t t e r c o l l a p s e w ith a b e t t e r chance o f c a v i t y closure.

To o b t a i n s t i l l

notably A lexander,

mor e c o l l a p s e

re s e c te d also

and t h e u n d e r l y i n g r i b ,

the

some s u r g e o n e s

transverse processes

so r e d u c i n g t h e s i z e o f t h e

" g u t t e r " * The s h o r t a n t e r i o r a n d a n t e i o - l a t e r a l rib

rem ained ana i t

to keep t h e

stumps o f

was t h e s t i f f n e s s o f t h e s e w h i c h t e n d e d

c u p o l a o f t h e t h o r a x mo r e o r l e s s

I m p r o v e d c o l l a p s e was a c h i e v e d bv r e s e c t i n g stumps th r o u g h an a n t e r i o r

expanded*

th ese remaining

i n c i s i o n w h i c h was u s u a l l y

perform ed as a s e p a r a te o p e r a t io n a lth o u g h G raf performed b o t h a n t e r i o r a n d p o s t e r i o r o p e r a t i o n s a t t h e same t i m e * By t h e s e o p e r a t i o n s

th e whole o f th e f i r s t

r i b s w e r e r e m o v e d a nd m o s t o f t h e t h i r d much o f t h e r i b s b e l o w t h i s

level

as

and s e cond

t o g e t h e r w ith as

was t h o u g h t

necess©,ry * The d i v i s i o n o f t h e t h o r a c o p l a s t y o p e r a t i o n

into

s t a g e s a l t h o u g h n o t a new i d e a was f i r s t p u t i n t o

r e g u l a r u s e by C . A . H e d b l o m d u r i n g t h e y e a r s 1922^26 f o r bronchiectasis,

c h r o n i c n o n - t u b e r c u l o u s and tiAberculous

empyema a n d f i n a l l y

f o r pulmonary t u b e r c u l o s i s * H edblonhs

i n s i s t e n c e on t h e m u l t i p l e s t a g e t h o r a c o p l a s t y met w i t h c o n s i d e r a b l e o p p o s i t i o n b u t e v e n t u a l l y h i s w i s e l e a d was f o l l o w e d by m o s t t h o r a c i c a l i m i t e d n u mb e r o f r i b s considerably

the

s u r g e o n s p The r e s e c t i o n o f o n l y a t any o n e o p e r a t i o n l e s s e n e d

risk s o f paradoxical re s p ira tio h ,

y e t the

t o t a l a m o u n t s o f r i b r e s e c t e d w e r e i n c r e a s e d * A mo r e c o m p l e t e upper th o racic patient*

c o l l a p s e was a c h i e v e d w i t h l e s s

Sauerbruch*s o r ig in a l

r i b s must be r e s e c t e d was l a r g e l y technique

first

r i s k to

the

teaching, t h a t th e lower

to a v o i d a s p i r a t i o n p n e u m o n i a

abandoned because w ith th e m u l t i p l e

stage

t h i s c o m p l i c a t i o n was n o t so f r e q u e n t l y

S auerb ru ch* s method meant t h a t h e a l t h y

seen*

low er lo b e s were

f r e q u e n t l y p u t o u t o f a c t i o n w hereas w i t h t h e newer technique these healthy

a r e a s o f lu n g had t h e i r

respiratory

f u n c t i o n p r e s e r v e d * The i m p o r t a n c e o f H e d b l o m ’ s d i c t u m can h a r d l y be o v e r em phasised* I n 1 92 8 A l e x a n d e r f o u n d t h a t by s e p a r a t i n g th e attac h m en t o f th e s e r r a t u s a n t e r i o r muscle u p p e r f i v e o r s i x r i b s h e c o u l d r e mo ve t h e r i b s r o u n d to a n d i n c l u d i n g t h e i r a n t e r o - l a t e r a l U ntil

this

time d e s p i t e

from t h e right

portions*

the varying in c is io n s the a c tu a l

e x p o s u r e o f t h e r i b s o b t a i n e d had n o t been improved* G r a v e s e n w r o t e i n 19^5 t h a t t h e d e e p p o s i t i o n o f t h e u p p e r

I? r i b s made i t

d i f f i c u l t to r e s e c t

a s u f f ic ie n t length o f

t h e m t o p r o d u c e t h e c o m p l e t e c o l l a p s e r e q u i r e d and e v e n w i t h t h e m o s t r a d i c a l me a n s o b t a i n a b l e t h e o p e r a t i o n was found to

l e a v e an a p i c a l

c a v i t y o p e n a l t h o u g h c o n s i d e r ably-

reduced in size* An i m p o r t a n t c o n t r i b u t i o n

tow ards im proving

t h e e x p o s u r e o f t h e r i b s was made by E ol o 0 fB r i e n i n May

1933 w h e n a t t h e A n n u a l M e e t i n g o f t h e A m e r i c a n A ssociation

f o r T h o racic Surgery he f i r s t

described h is

a.pproach f o r t h e removal t h r o u g h a s i n g l e p o s t e r i o r i n c i s i o n o f t h e whole o f t h e f i r s t , ribs

including th e ir c o s ta l

paravertebral

in p o s itio n ,

second,

cartilages*

and t h i r d

This i n c i s i o n ,

commenced n e a r t h e u p p e r e d g e

o f t h e t r a p e z i u s m u s c l e b u t a t t h e l o w e r e n d was c a r r i e d round t h e a n g l e o f t h e s c a p u l a to t h e a x i l l a r y A fte r sep aratio n of the O ’B r i e n ' s

s e r r a t u s a n t e r i o r from t h e r i b s

e x t e n d e d i n c i s i o n to t h e a x i l l a r y

a fre e r e t r a c t i o n of the

line*

l i n e allowed

s c a p u l a w h ich gave a wide ex p o s u re

o f th e ribs* By IQ33 t h e c l a s s i c a l w hich had s t a r t e d

th o rac o p lasty period

a b o u t 1 9 1 2 was e n d e d a n d many v a r i a t i o n s

o f t e c h n i q u e t h e n e x i s t e d s h o w i n g a s O ’B r i e n

said,

that

no o n e p r o c e d u r e hact p r o v e d s a t i s f a c t o r y *

P 0H 0C o r y ! X o s a t

the

serratus anterior

same t i m e d e s c r i b e d

se p a ra tio n o f the

b u t g a v e &• m o r e d e t a i l e d a c c o u n t o f r e s e c t i o n o f t h e

first

r i b * He d i v i d e d t h e p o s t e r i o r end o f t h e r i b a f t e r w h i c h severance of the

scalen u s a n tic u s muscle a t i t s

insertion

was made e a s i e r *

I n t w e n t y e i g h t c a s e s when p e r f o r m i n g

p h r e n ic e c to m y he had a t

t h e same t i m e d o n e a p r e l i m i n a r y

scalenotom y which at th e resectio n o f the f i r s t m ention i t , help

the

s u b s e q u e n t t h o r a c o p l a s t y made

rib

e a s i e r * A lth o u g h he does n o t

s e c t i o n o f t h e s c a l e n e m u sc le would a l s o

the v e r t i c a l

r e l a x a t i o n o f t h e a.p.ex*

At t h i s p o i n t i n t h e h i s t o r y th e American t h o r a c i c

surgeons l a i d

o f the upper three rib s

o f thoracoplasty

em phasis on r e s e c t i o n

in t h e i r e n t i r e t y

p ro d u c in g what

C oryllos c a lle d a p h y sio lo g ic am putation o f th e upper h a l f o f t h e u p p er lobe* M o rristo n Davies stage o p eratio n -w ith r ib but s t a t e s

its

that h is

( 1948 ) a d o p t e d t h e m u l t i p l e

resectio n of g re a te r lengths of r e s u l t s w e r e so i n d i f f e r e n t i n t h e

y e a r s 1931 t o XS35 t h a t h e r e v e r t e d

t o a m o d i f i e d Wilms

o p e r a t i o n w h i c h gave a good " b u c k e t h a n d l e "

drop o f th e

ribs „ In the o p in io n o f th e Norwegian school t h e s e o p e r a t i o n s did n o t give a s u f f i c i e n t l y closure*

They c o n c e n t r a t e d

satisfactory

cavity

t h e i r a t t e n t i o n on im p r o v in g

t h e r e l a x a t i o n o f t h e l u n g and w ere s e a c h i n g f o r a m eth o d o f m o b i l i s i n g t h e a p e x * P 0H 0B u l l o f O s l o h a d a l r e a d y d e s c r i b e d 8. m e t h o d o f a p i c o l y s i s of the

fourth or th ird

endo-thor& cic

r i b he d i v i d e d

f a s c i a and th r o u g h t h i s

an e x t r a - p l e u r a l l u n g was f r e e d

i n 1920* A f t e r r e s e c t i o n

dissection

t h e p e r i o s t e u m and I n c is io n c a rr ie d out

in the p r o c e s s o f which th e

from t h e second and f i r s t

r i b s * B u l l makes

it

q u i t e c l e a r t h a t h i s p rim ary aim i n p e r f o r m i n g th e

a p i c o l y s i s wa s to make i t second and f i r s t

e a s i e r and s a f e r to

resect the

rib© b u t s t a t e s t h a t t h e a p i c o l y s i s h e l p s

t h e G o l l a p s e o f t h e lung* A p a r t from t h e a p i c o l y s i s h i s o p e r a t i o n wa s s i m i l a r t o B r a u e r ' s In the

early

apicolysis

aubscapuls-r th o ra c o p la s ty *

1930 s t h e N o r we gi an © demand w a s f o r a b e t t e r

than th is*

thoracoplasty

T h e i r v ie w was t h a t t h e c l a s s i c a l

gave l a t e r a l

stretched vertically*

collapse but l e f t

the cavity

The d i v i s i o n o f t h e s c a l e n e m u s c l e s

p l u s t h e r e m o v a l o f t h e u p p e r two r i b s g a v e some relaxation

c o m p a r a b l e to a p h r e n i c e c t o m y e f f e c t

from below

b u t was n o t e n o ug h * F o i s t an d F r i m a n n - D a h l w o r k i n g together trie d

extensive ex tra -p le u ra l

a p ic o ly s is plus

s e c t i o n o f x5 e r i ^ ^ t e u m a n d i n t e r c o s t a l m u s c u l a t u r e o f t h e resected

r i b s and p a c k i n g w i t h ga u z e o v e r t h e p e r i o s t e a l

muscle- f l a p t h u s

f o r me d* The c h i e f o b j e c t i o n t o t h i s was

d e l a y e d wound h e a l i n g *

They w e r e ,

however,

r e l a x a t i o n o f t h e apex from above, phrenicectom y, o ffe re d At t h i s

convinced t h a t

an d n o t f r o m b e l o w by

th e only s o l u t i o n to

t h e i r problem*

p o i n t t h e t e c h n i c a l d i f f i c u l t y was s o l v e d by

C a r l Semb„ C a r l Semb u s i n g a s i n g l e p o s t e r i o r i n c i s i o n suggested th a t

i n s t e a d o f an e x t r a - p l e u r a l

an e x t r a - f a s c i a l

e - p i c o l y s i s w i t h o u t p a c k i n g s h o u l d b e u s e d * He f i r s t described h is o p eratio n

i n 1933 o T h i s a n a t o m i c a l d i s s e c t i o n

u n d e r d i r e c t v i s i o n c o m b i n e d w i t h a w i d e e x p o s u r e an d r e s e c t i o n o f t h e whole o f th e f i r s t

and s e c o n d r i b s a n d

m

most o f t h e t h i r d

f o r m s t h e “b a s i s o f a l l m o d e r n r e l a x a t i o n

t h o r a c o p l a s t y o p e r a t i o n s 0 The t e c h n i q u e o f t h i s o p e r a t i o n w i l l be discus'sed in g r e a t e r d e t a i l l a t e r i n t h e t h e s i s ,, T heoretically

the r e la x a tio n

a p p e a r s to be t h e i d e a l o p e r a t i o n , is e ff ic ie n tly s i m i l a r to

performed the r e s u l t i n g c o l la p s e is very

still

satisfactory com pletely

pneumothorax where

free of p le u ra l adhesions0 N evertheless,

p a r a v e r t e b r a l o p e r a tio n in modified apicolysis

f o r when t h e d i s s e c t i o n

t h a t g i v e n by a n a r t i f i c i a l

the lu n g .is

thoracoplasty

has i t s

resu lts,It

the

form and w i t h o u t

a d h e r e n t s who u n d o u b t e d l y g e t is

satisfactory,

c e r t a i n t h a t no ome m e t h o d i s

though th e w r i t e r fav o u rs th e

re la x a tio n thoracoplasty* The i n t r o d u c t i o n o f t h e Semb e x t r a - f a s c i a l apicols^sis into

surgery

f o r pulmonary t u b e r c u l o s i s has

been the s u b je c t o f n e a rly of thoracoplasty

itself.

a s much c o n t e n t i o n a s t h a t

19

PHYSIOLOGICAL AND ANATOMICAL CONSIDERATIONS OF THE LUNG IN RELATION TO THORACOPLASTY.

The l u n g h a s an i n h e r e n t to

its

sm allest possible

te n d e n c y to

retraction

amount o f e l a s t i c fibres

te n d e n c y to

s iz e around the hilum ,

in t h e lung i s due to

fibre

t i s s u e which i t

run l o n g i t u d i n a l l y

retract

This

the la rg e

c o n t a i n s , , The

along the b ro n c h if enveloping

a ny b r a n c h b r o n c h u s i n t h e m a n n e r shown i n t h e accompanying diagram,

(Fig,

3)P

Fig,

but

in the t i s s u e s

an d t h e a l v e o l i M iller

(194-7)

3o

surrounding the a t r i a ,

the e l a s t i c

states

fibres

sacculi

alveolares,

form a c o m p l e t e network,,

t h a t we ma 3r c o n s i d e r t h e s e

structures

a s d i s t e n s i b l e a i r b l a d d e r s e n c l o s e d by a n e l a s t i c

network

a n d t h a t when t h e y a r e d i s t e n d e d w i t h a i r a l l t h e e l a s t i c f i b r e s a r e p u t on t h e s t r e t c h , surrounding the a t r ia , longitudinally

air

in a l l

directions

s a c s and a l v e o l i b u t

a l o n g t h e b r o n c h u s . The t o t a l

tension of

20

a l l these to

fibres

is very

c o n s i d e r a b l e so t h a t

r e a l i s e how t h e l u n g w i l l c o n t r a c t

if

it

is

given the

opportunity 0

The P r i m a r y L o b u l e o f t h e L u n g ( a f t e r M i l l e r ) „ Be

R espiratory bronchiole.

Do

D uctulus a l v e o la r ie

A0

Atrium,

So

Saceulue a l v e o l a r i e

A!o A l v e o l u s , Fig, 4 o

(V estibule)„

(Air s a c ) 0

easy

dl The v i s c e r a l a n d p a r i e t a l i n c l o s e a p p o s i t i o n "by t h e n e g a t i v e

p le u ra are kept

intra-pleural

pressure

w h ic h means, ( 1) a s l o n g a s t h e c h e s t w a l l a n d i t s framework a r e

bo n y

i n t a c t t h e l u n g i s u n a b l e to c o n t r a c t a r o u n d

th e hilum and, ( 2 ) a t a n y g i v e n moment t h e l u n g mo v e me n t s are controlled

by t h e c h e s t w a l l ,

d i a p h r a g m a t i c and

m e d i a s t i n a l m o v e me n t s * D u r i n g i n s p i r a t i o n t h e p u l l on t h e lu n g o f the negative

in tra-p le u ra l pressure

o p p o sitely a c tin g pull of the e la s tic therefore,

is

g r e a te r than the

f i b r e s o f th e lun&p

t h e l u n g m u s t f o l l o w t h e c h e s t w a l l mo v e me nt s

( F i g * !?)„

I,

Chest w all p u ll,

20 R etractile pull o f lung „

Fig* ? 0

The mo r e t h e l u n g s a r e

stretched

the g re a te r

is th e ir

te n d e n c y to

retract,

consequently the deeper the

inspiration

t h e mo r e n e g a t i v e d o e s t h e i n t r a - p l e u r a l

p r e s s u r e be c o me 0 T h e s e i n s p i r a t o r y mo v e m e n t s i n c r e a s e t h e volume o f t h e t h o r a x and s i m i l a r l y t h e v olum e o f t h e lu n g * The p u l l o f t h e c h e s t w a l l o n b o t h s i d e s o n t h e u n d e r l y i n g lungs keeps th e m ediastinum in b a lan ce but c h e s t w a l l b e i n an y way d a m a g e d ,

s h o u l d one

e pg , by r e m o v a l o f r i b s ,

t h e n t h i s b a l a n c e i s u p s e t and t h e m e d i a s t i n u m i t s e l f w i l l e x e r t a n e f f e c t o n l u n g vol ume* The i n t r e d u c t i o n o f a l i m i t e d a m o u n t o f a i r into

a p le u ra l cavity

retract

tow ards the hilum* This i s t h e p r i n c i p l e o f

artificial that

f r e e o f a d h e s i o n s a l l o w s t h e l u n g to

pneumothorax b u t i t

the p a r t l y

is

e s s e n t i a l to

c o lla p s e d lung is not a t

The p l e u r a l c a v i t y

is a closed space,

realise

complete r e s t*

there

is

still

a

n e g a t i v e i n t r a - p l e u r a l p r e s s u r e a n d t h e lung: w i l l t h e r e ­ fore s t i l l

f o l l o w e v e r y c h e s t w a l l movement * S u c h l u n g

r e s p i r a t o r y movement i s

easily

s e e n on t h e X-Ray s c r e e n

when a p a t i e n t w i t h a n a r t i f i c i a l to b r e a t h e

pneumothorax i s asked

i n a n d o u t mo r e f o r c i b l y t h a n n o r m a l * S h o u l d

t h e m e d ia s t in u m be f l e x i b l e t h e n i t

too w i l l

move ment o f t h e

assuming th e absence

o f extensive less

co llap se d lung but,

fibrosis

follow th e

i n t h e l u n g e i t s movements w i l l be

t h a n t h a t o f t h e l u n g * Once t h e i n t r a - p l e u r a l p r e s s u r e

becomes h i g h enough to be p o s i t i v e

( i * e 0 g r e a te r than

23 atm ospheric)

in hoth

l u n g movements w i l l still

i n s p i r a t i o n and e x p i r a t i o n th e n t h e a p p e a r to c e a s e h u t t h e

d i a p h r a g m may

c a u s e some r e s p i r a t o r y m o v e m e n t 0 I n a f a v o u r a b l e c a s e a. t u b e r c u l o u s

in th e lung w i l l tend

to h e a l by f i b r o s i s

and t h i s

focus shoula

cause g r e a t e r c o n t r a c tio n o f th e d ise a se d a r e a o f lung than th e n a tu ra l

elasticity

of the healthy

forms t h e b a s i s o f s e l e c t i v e c o l l a p s e ,

a r e a s # This

t h e d i s e a s e d and

f i b r o s e d a r e a s h r i n k i n g mo r e t h a n t h e h s a l t h y i s a b l e to m a i n t a i n c o n s i d e r a b l e r e s p i r a t o r y

a r e a which function.

In

a l u n g c o l l a p s e d by a r t i f i c i a l p n e u m o t h o r a x t h e s e s h r u n k e n d i s e a s e d a r e a s w i l l be s e e n to rem ain unexpanded d u r i n g in s p i r a tio n w hile the h ea lth y

lung around i s

N e v e rth e le s s th e expanding h e a lth y

lung w ill

expanding. exercise

some p u l l o n t h e d i s e a s e d a r e a d u r i n g r e s p i r a t i o n . r e s p i r a t o r y mov e men t t h e l e s s w i l l subjected

th e d i s e a s e d a r e a be

to m o v e m e n t . To g i v e maximum r e s t

an a r t i f i c i a l

The l e s s

to t h e l e s i o n

p n e u m o t h o r a x m u s t b e b a c k e d up by a d e q u a t e

bed. r e s t which, i s t h e o n l y s a t i s f a c t o r y

way o f d e c r e a s i n g

r e s p i r a t o r y m o v e m e n t . When a p a t i e n t

r e s t i n g in bed h i s

m etabolic

rate

ventilation

is

is

c o n t i n u o u s l y low,

is thus

t h e pulmonary

a t a minimum and r e s p i r a t o r y

movement

lessened 0 The e nd r e s u l t s o f t h o r a c o p l a s t y permanency to

the favourable e ffe c ts of c o lla p se .an d r e s t

but w h ilst the p a tie n t all

give

i s b e i n g s u b j e c t e d to

t h e above f a c t o r s o f pneumothorax,

the o p e ra tio n

intra-pleural

24 pressure,

c h e s t w a l l and m e d i a s t i n a l movements must he

considered

if

s e r i o u s c o m p l i c a t i o n s a r e to

oe a v o i d e d *

D u r i n g and im m e d ia te ly a f t e r

thoracoplasty

o p e r a t io n th e n e g a tiv e i n t r a - p l e u r a l p r e s s u r e o f the contralateral

side

still

causes

its

l u n g to

follow the

movements o f t h e c h e s t w a l l b u t on t h e o p e r a t i o n c o n d i t i o n s a r e now r e v e r s e d and t h e n e g a t i v e

side

intra-pleural

p r e s s u r e h e r e c a u s e s th e c h e s t w a ll denuded o f r i b s

to

f o l l o w t h e m o v e m e n t s o f t h e l u n g 0 The f l a c c i d c h e s t w a l l i s s e e n to b e s u c k e d i n d u r i n g i n s p i r a t i o n a n d t o b u l g e outw ards d u rin g e x p i r a tio n .

S im ilarly the u nderlying lung

ex p an d s d u r i n g e x p i r a t i o n and c o n t r a c t s which r e v e r s a l o f th e normal r e s p i r a t o r y c alle d paradoxical

respiration,

during in s p ira tio n movements i s

a i r being in sp ire d during

t h e e x p i r a t o r y p h a s e an d e x p i r e d d u r i n g t h e p h a s e (Fig*

6) „

Paradoxically moving a r e a o f lung

F ig ,

6„

inspiratory

The i m p o r t a n c e o f t h i s i s t h a t i n p a r a d o x i c a l b r e a t h i n g respired

air

from t h e

c o l la p s e d lu n g mixes w ith th e a i r

inspired

f r o m o u t s i d e t h e b o d y a nd e n t e r s t h e n o r m a l l y

r e s p i r i n g p a r t s o f t h e same lung* a n d n o r m a l l y r e s p i r i n g contralateral

l u n g . A i r i s t h e n b e i n g sucked to

and from

t h e p a r a d o x i c a l l y m o v i n g a n d n o r m a l l y m o v i n g l u n g 0 The g r e a te r the percentage o f th is

respired

a i r in the

inspired

a i r t h e g r e a t e r t h e p e r c e n t a g e o f c a r b o n d i o x i d e and t h e le s s th e p erce n tag e o f oxygen. In severe p a ra d o x ic a l breathing,

i 0a , when a l a r g e a r e a o f l u n g i s m o v i n g

paradoxically,

the r e s u l t

c y a n o s i s and i n e x tre m e life

i s anoxaemia,

conditions

is

d y s p n o e a and

incom patible with

,

A f l e x i b l e o r s la c k m ediastinum w ill f o l l o w t h e m o v e m e n t s o f t h e p a r a d o x i c a l l y m o v i n g l u n g and so make m a t t e r s w o r s e . P arad o x ical b re a th in g as d escrib ed is a p a t h o l o g i c a l p r o c e s s b u t in normal h e a l t h y

lungs th e re

is

p r o b a b l y a l w a y s some f l o w o f a i r b e t w e e n d i f f e r e n t a r e a s o f l u n g and a t t h e b e g i n n i n g o f a q u i c k d e e p i n s p i r a t i o n t h e a p i c e s o f th e lu n g s w i l l be seen to

fall

in momentarily

w hile th e bases a re expanding. These p h y s io lo g ic a l

p r i n c i p l e s must alw ays

b e b o r n e i n m i n d when p l a n n i n g a t h o r a c o p l a s t y in d iv id u al case, w ill

for the fa c to rs

governing th e se p r in c ip le s

vary g re a tly w ith the varying p a th o lo g ic a l

present

in each c a s e .

f o r an

conditions

THE PATHOLOGICAL COHSILERATIOHS OF THORACOPLASTY• JC5J

ua ua

«ea ly a n d movement

o f th e c o lla p se d lung r e s u l t s

in le s s

to x in s reaching the

system ic c i r c u l a t i o n . The BRONCHI i n t h e d i s e a s e d a r e a o f a c o l l a p s e d l u n g s u f f e r d i s t o r t i o n and i f

tuberculosis of

t h e b r o n c h i a l w a l l be p r e s e n t t h e s w o l l e n m u c o s a may c a u s e o c c l u s i o n o f t h e lum en, A uerb ach found t u b e r c u l o u s i n v o l v e m e n t o f t h e b r o n c h i was l i m i t e d to t h e b r o n c h o - c a v i t a r y

In t h i s

cases

r e g i o n . The w r i t e r i n o n e p o s t ­

mortem f o l l o w i n g t h o r a c o p l a s t y disease.

in n ea rly a l l

f o u n d e x t e n s i v e e n d o “b r o n c h i a l

case th e p a t i e n t had had an a c u te e x u d a tiv e

l e s i o n o f t h e l u n g t r e a t e d by a r t i f i c i a l . p n e u m o t h o r a x and a s p o n t a n e o u s c a v i t y r u p t u r e f o l l o w e d r e s u l t i n g i n tuberculous

empyema. T h e l u n g h a d b e e n c o l l a p s e d

for

e i g h t e e n m o n t h s . S h o u l d a ny b r o n c h u s h a v e b e e n t h e s i t e o f t u b e r c u l o u s d i s e a s e i t w o u l d seem I m p o s s i b l e t h a t i t s m u c o u s me mbr a n e c o u l d h e a l retain

its

normal f u n c t i o n .

and t h e c i l i a t e d

epithelium

I n a r e c e n t a r t i c l e Negus

( 1 9 4 9 ) h a s shown u s how t h e c i l i a t e d

e p i t h e l i u m may be

34 e a s i l y a n d p e r m a n e n t l y damaged,, A u e r b a c h saw m e t a p l a s i a o f t h e b r o n c h i a l mucosa to states

t h a t in a l l

s q u a mo u s e p i t h e l i u m a n d M i l l e r

the instances

i n w h i c h h e saw s u c h

m e t a p l a s i a th e lungs were t u b e r c u l o u s 0 B ronchiectasis re su lt of phthisis

i s w e l l known a s a l a t e

a n d was o b s e r v e d by A u e r b a c h i n t w e n t y

seven per cent o f h is th o r a c o p la s ty a u to p s ie s * R ecurrent h a e m o p t y s i s i n a n o l d c a s e may b e d u e t o b r o n c h i e c t a s i s but i t

is

e s s e n t i a l to r e a l i s e

t h a t th e s e haemoptysee

may b e a s i g n o f m i l d f l a r e up o f t h e

tuberculosis

in

s m a l l u n c l o s e d c a v i t i e s 0 A l t h o u g h A u e r b a c h f o u n d no e v i d e n c e o f secondary i n f e c t i o n in the b r o n c h ie c ta tic seems r e a s o n a b l e

to a s s u m e t h a t i t

areas i t

i s p o s s i b l e and c o u l d

be t h e c a u a e o f - t h e h a e m o r r h a g e s 0 T u b e r c u l o s i s b e i n g m o r e common i n t h e u p p e r l o b e t h a t a l s o s i t e o f t h e b r o n c h i e c t a s i s which r e s u l t s involvement in the

t u b e r c u l o s i s and n o t

i s t h e common from b r o n c h ia l from t h e f i b r o s i s

o r t h o r a c o p l a s t y c o l l a p s e , , I t w o u l d s e em t h a t t h e b r o n c h u s i t s e l f must hav e been in v o lv e d in th e t u o e r c u i o u s

infection,

t h e b r o n c h i a l w a l l b e i n g damaged a n d t u b e r c u l o u s p r o d u c t s being re ta in e d because tuberculous g ra n u la tio n s o f the b r o n c h i a l w a l l p r e v e n t e d t h e i r d r a i n i n g ; away 0 I t

cannot

be co n c eiv e d t h a t a h e a l t h y bronchus in a colle-psed lung, no m a t t e r how d i s t o r t e d the

by f i b r o u s

tissue,

c o u l d become

s i t e o f b ro n c h ie c ta s is w ithout a previous in f e c tio n

of its

w alls

t a k i n g p l a c e , Tj'rwin ( 1 9 3 9 ) p o i n t e d o u t t h a t i n

cases o f tu b ercu lo sis

in which u n m is ta k a b le f i b r o s i s

is

present oil

t h e ' b r o n c h i i n t h a t a r e a w h en o u t l i n e d by i o d i s e d

reveal

that

distortion

fibrosis

(1943)

r a t h e r than d i l a t a t i o n ,

thus proving

a lo n e d id n o t c a u s e b r o n c h i e c t a s i s , Aufses*

f i n d i n g s were s i m i l a r , G a r d n e r and A uerb ac h o b s e r v e d t h a t

bronohiectasis collapse has

i s mo r e coramon i n p a t i e n t s who h a v e h a d

therapy. Is

i t n o t p r o b a b l e t h a t a p a t i e n t who

e x t e n s i v e d i s e a s e a n d no c o l l a p s e t h e r a p y

t o d i e b e f o r e t h e b r o n c h i e c t a s i s makes i t s e l f if

is likely e v i d e n t ? Or,

th e d i s e a s e remains sm ouldering then th e b r o n c h i e c t a s i s

i s m a s k e d by t h e and as h e a l i n g collapse

ever p rese n t a c tiv e

i s mor e l i k e l y

therapy,

bronchiectasis

especially

i s more l i k e l y

tuberculous le sio n s

i n p a t i e n t s who h a v e h a d t ho r a c o p l a s t y , so to b e f o u n d i n t h e s e p a t i e n t s .

The m a j o r i t y o f p a t i e n t s who r e c o v e r w i t h o u t c o l l a p s e t h e r a p y h a v e a s m a l l amount o f d i s e a s e , infection unlikely

b ro n c h ia l w all

i s o f minimum e x t e n t an d b r o n c h i e c t a s i s an sequel. I n an o l d

standing a t e l e c t a t i c

lung severe

d i s t o r t i o n a n d s a c c u l a r d i l a t a t i o n o f a b r o n c h u s may o c c u r and g i v e r i s e cavity

t o c o n f u s i o n when r e s e m b l i n g a t u b e r c u l o u s

i n a n X-F.ay f i l m . B e i n g u s u a l l y

the b ro n e h ie c ta tic sy mpt o ms a r e

in the upper lobe

a r e a s d r a i n w e l l and t r o u b l e s o m e

by no m e a n s t h e r u l e . C l o s u r e o f a b r o n c h u s may r e s u l t i n

a t e l e c t a s i s o f an a r e a o f l u n g and a t e l e c t a s i s seen during th o raco p lasty

though i t

is

is

frequently

not always o f s e rio u s

.

3b

'

impo r t a r i G o , C l o s u r e o f a s m a l l b r o n c h u s a o e s n o t n e c e s s ­ arily

result-,in a te le c ta s is

and t h o r a c i c

surgeons have long

h e l d t h e view t h a t c o l l a t e r a l v e n t i l a t i o n

through pores in

th e a l v e o l i has been th e reason f o r t h i s .

If

p r e s e n t o r no t normally i s

these pores are

a su b je ct o f disagreem ent

between a n a to m is ts . M i l l e r b e lie v e s

they

e x is t only as a

r e s u l t o f p a t h o l o g i c a l p r o c e s s e s . The c o l l a t e r a l m aintains the a lv e o li d i s t a l of inflation. functions

air d rift

to t h e bloclc i n a c o n d i t i o n

Such a l v e o l i a r e d e v o i d o f r e s p i r a t o r y

as th e a i r which re a c h e s

them faaso.already p a s s e d

t h r o u g h o t h e r a l v e o l i and r e a c h e d e q u i l i b r i u m w i t h t h e capillary

blood

( C h u r c h i l l ) , Baarsma e t a l

s hown t h a t c o l l a t e r a l by s h a l l o w

stom ata opening.

r e l i e f o f p o s t - o p e r a t i v e p a i n and

Areas o f a t e l e c t a s i s

thoracoplasty is

inflam m ation

i n b r e a t h i n g may h e l p to p r o m o t e c o l l a t e r a l

ventilation.

it

and to

b o th o f which p r e v e n t th e

In th o ra c o p la s ty training

v e n t i l a t i o n may b e i n t e r f e r e d ' w i t h

b r e a t h i n g d u e to p a i n ,

in th e a l v e o l i ,

(1948) have

possible

so o f t e n

seen in

p o s t - o p e r a t i v e X-Rays f r e q u e n t l y that c o llatera l ventilation

is

c l e a r and responsible

f o r some o f t h e r e - i n f l a t i o n o f t h e c o l l a p s e d a r e a s 0 Once th is occurs the negative pressure to

the o b s t r u c t i o n

is

in the bronchus d i s t a l

r e l i e v e d which in i t s

e x p e c to r a t i o n and h e l p s

to

turn aids

r e l a x an y b r o n c h i a l

spasm, A i r

w i l l now b e a b l e t o p a s s a l o n g t h e b r o n c h u s a g a i n and so r e - e x p a n d a ny r e m a i n i n g a t e l e c t a t i c itself

is unlikely

area. A telectasis

to b e a c c o m p a n i e d by s e r i o u s

sympt oms

unless

in th e a t e l e c t a t i c

o f infection,

area o f lung th e re

tuberculous infected

is

a source

sputum f o r example,

w h i c h may c a u s e a s p r e a d o f t u b e r c u l o s i s . It

is

b r o n c h u s l e a d i n g to

still

the area o f a t e l e c t a s i s

T h a t t h i s may b e d u e t o s p u t u m o r to

a m a t t e r f o r d e b a t e how t h e becomes c l o s e d .

an i n h a l e d p l u g o f t e n a c i o u s

in h a le d blood fo llo w in g haem optysis i s

certain

b u t by no m e a n s a l w a y s t h e c a u s e . T h e i n h a l e d s p u t u m t e n d s to b e drawn f u r t h e r i n t o

t h e b r o n c h i by i n s p i r a t o r y

e f f o r t s a n d by t h e n e g a t i v e p r e s s u r e d e v e l o p i n g i n t h e bronchus as a r e s u l t o f the a t e l e c t a s i s . possibility

is

The o t h e r

a n e u ro -m u s c u la r mechanism in th e b r o n c h ia l

w a ll which p ro d u c e s spasm o f th e b r o n c h i a l m u s c u la tu re and a n a r r o w i n g o f t h e lumen, spasm b e i n g a l o c a l i r r i t a t i o n tuberculous b r o n c h itis .

the e x c itin g cause o f the such as a p a tc h o f

The m u c o s a l o ed e m a o r

tuberculous

g r a n u l a t i o n s which accompany t h e e n d o - b r o n c h i a l d i s e a s e c o u l d w i t h t h e n a r r o w e d l u me n c a u s e c o m p l e t e c l o s u r e o f the bronchus. I f

t u b e r c u l o u s i n f e c t e d sputum i s

trapped

in th e b ro n c h i in th e c o l la p s e d a r e a o f lu n g o r i f a c t i v e f o c i o f d i s e a s e a r e a l r e a d y p r e s e n t a t u b e r c u l o u s pneumonia w h i c h may p r o c e e d t o

c a s e a t i o n a n d c a v i t a t i o n may r e s u l t .

T h i s s e r i e s o f e v e n t s i s mo r e l i k e l y sudden o n s e t as found a f t e r The a t e l e c t a t i c than h e a lth y

in a t e l e c t a s i s of

thoracoplasty o p eratio n s.

a r e a s a p p e a r to b e m o r e p r o n e t o

infection

areas, X a la b a rd e r has fo r s e v e r a l y e a r s been o f the

38 opinion th a t a t e l e c t a s i s and i n h i s

results

from a r e f l e x a c t i o n

re c e n t p a p e r (1 9 4 9 ) has given a d e t a i l e d

e x p l a n a t i o n , He m a i n t a i n s muscle in th e

that i t

is

c o n t r a c t i o n o f smooth

lung parenchyma which produces th e s h r in k in g

i n s i z e o f an a t e l e c t a t i c

area,

this

s h r i n k i n g b e i n g much

g r e a t e r t h a n c o u l d h e a c c o u n t e d f o r by t h e e l a s t i c i t y o f t h e o r g a n . Whereas M i l l e r b e l i e v e s ends a t it

the ductulus a lv e o la r is ,

i s found

in the

this

a normal p h y s io l o g ic a l to n e ,

local

irritan t

X alabarder m aintains

form o f a n etw o rk a r o u n d t h e a l v e o l i .

The a o n o r m a l c o n t r a c t i o n o f

from a m e c h a n i c a l

t h e smooth m u scle

irritan t

f a c t o r in

smooth m u s c le ,

which h as

is a re fle x action re su ltin g

in t h e main b r o n c h u s ,

the lung,

or a

o r from a c h e m ic a l

r e a c t i o n c a u s e d ' - b y t h e p r e s e n c e o f a c e t y l c h o l i n e , By e x p e r i m e n t i n p a t i e n t s h e h a s shown t h e two l a t t e r w ill produce lo c a l

factors

atelectasis,

THE EFFECT OF COLLAPSE OH CAVITIES. The

q u e s t i o n o f how c a v i t i e s f o r m ,

h e a l a n d how t h i s h e a l i n g i s a i d e d

by c o l l a p s e t h e r a p y

h a s b e e n a s u b j e c t o f d i s c u s s i o n f o r many y e a r s . early years of thoracoplasty largely

how t h e y

In the

th e term "compression"

figured

f o r by t h i s m e a n s t h e c a v i t y w a l l s w e r e h o p e d

to be b r o u g h t

into

a p p o s i t i o n and h e a l by g r a n u l a t i o n

t i s s u e . L a t e r y e a r s have in tro d u c e d th e term " r e l a x a t i o n th o r a c o p l a s t y " which h as

figured prom inently

d r a i n i n g b r o n c h u s h a s b e e n found to

since the

p l a y an i m p o r t a n t

39 part

in c a v ity

cavities

closure,

It

is

essential

t o c o n s i d e r how

form and c l o s e b e f o r e s t u d y i n g t h e e f f e c t s o f

c o l l a p s e t h e r a p y upon them , B erck (1934) i n t h r e e ways,

c o n s i d e r s c a v i t i e s may a r i s e

by (a,) L i q u e f a c t i o n a n d s e q u e s t r a t i o n i n c a s e o u s b r o nc ho pneumo n i c a r e a s , (b) E n d o b ro n c h ia l and p e r i b r o n c h i a l c a s e a t i o n and d i s i n t e g r a t i o n , (c) T u b e rc u lo u s u l c e r a t i v e b r o n c h i e c t a s i s .

I f the cav ity a ris e s it

is

from a bronchopneumonic

s m a ll and u s u a l l y

focus then

situ a te d p e rip h e ra lly but i f

from

a c a s e o u s pneumonic a r e a o f l o b u l a r o r l o b a r d im e n sio n s t h e n m u l t i p l e l i q u e f y i n g f o c i a r e p r e s e n t w h i c h by c o n ­ fluence

form a l a r g e

c a v i t y . T he c o n t i n u a l

the c a v i t i e s o f tu b ercu lo u s m a te ria l l a r g e r b r o n c h i to

tuberculous

m u ltilo b a r in extent,

d i s c h a r g e from

exposes th e contiguous

infection,

Giant c a v i t i e s ,

o f t e n communicate t h r o u g h l a r g e h o l e s

in th e i n t e r l o b a r f i s s u r e s . Why, when a t u b e r c u l o u s c a v i t y h a s f o r m e d and d i s c h a r g e d i t s factors

c o n t e n t s does i t

are e s se n tia l

no m a t t e r w h e r e , i t

is

n o t c l o s e ? Two

f o r t h e h e a l i n g o f an a b s c e s s c a v i t y situated,

(1) E f f i c i e n t d r a i n a g e (2) A p p o s i t i o n o f t h e c a v i t y w a l l s . Any s i m p l e a c u t e a b s c e s s way ,

in so ft t i s s u e s h e a ls

ap p o sitio n of the cav ity w alls

resulting

in th is from t h e

natural

retractile

property o f the tis s u e s a f t e r the

a b s c e s s c o n t e n t s h a v e d r a i n e d away, B r i c e Thomas ( 1 9 4 2 ) h a s d i s c u s s e d t h e s e factors

i n r e l a t i o n to pulmonary c a v i t i e s , A number o f

lung abscesses w ill close bronchial

spontaneously

if

efficient

d r a i n a g e i s p r o v i d e d . The e f f e c t o f t h e p u l l

o f t h e c h e s t w a l l on t h e l u n g h a s b e e n r e f e r r e d to

in

p h y s i o l o g i c a l c o n s i d e r a t i o n s „ P r i c e Thomas c o n s i d e r s how t h i s p u l l may b e e l i m i n a t e d " in i t s its

early

natural

s t a g e s a r e s o f t a nd a l l o w t h e l u n g t o r e t r a c t i l e power

contents, A local fills

exercise

a f te r discharge of the absces

c o m p e n s a t o r y emphysema i s p r o d u c e d w h i c h

t h e s p a c e o r i g i n a l l y o c c u p i e d by t h e a b s c e s s c a v i t y .

If this to

the w a lls o f a lung absces

local

emphysema d i d n o t o c c u r i t

is

d ifficult

s e e how t h e r e t r a c t i l e p r o p e r t y o f t h e l u n g c o u l d e v e r

overcome th e c h e s t w a ll p u l l . efficiently

I f th e lung abscess

d r a i n e d i t s w a l l s bec o me t h i c k e n e d ,

surrounding tis su e s

is not

the

f i b r o s e d and t h e l u n g a d h e r e n t to

c h e s t w a ll o v e r a wide a r e a ,

the

a se rie s of pathological

c h a n g e s w h i c h w o u l d e f f e c t i v e l y p r e v e n t a n y l o c a l emphysema o c c u r r i n g and c l o s i n g t h e c a v i t y . S m all t u b e r c u l o u s cavities into

resulting

from t h e r u p t u r e o f t u b e r c u l o u s f o c i

a b r o n c h u s may w e l l c l o s e i n t h e way d e s c r i b e d a b o v e .

An e x a m p l e o f t h i s

is,

1 believe,

the case o f the p a tie n t

w i t h l i m i t e d d i s e a s e who ha,s s p u t u m f o r a s h o r t t i m e , f r e q u e n t l y o n l y o n c e p o s i t i v e a n d t h e n no f u r t h e r a n d no r a d i o l o g i c a l

evidence o f c a v ity .

sympt oms

The m a j o r i t y o f t u b e r c u l o u s c a v i t i e s o p e n a n d no m a t t e r how t h e y may a r i s e o n e o r mor e b r o n c h i . c a v i t i e s o u g h t to many c a v i t i e s

If

close spontaneouslyt

surrounding tis s u e s

drain into

f r e e d r a i n a g e o c c u r r e d many mo r e

are seen w ith f a r l e s s

the o ld er cav ity

they a l l

remain

than is

for radiologically

r e a c t i o n In th e

seen w ith lung a b s c e s s . In

i t s w alls are almost in v a ria b ly

adherent

o v e r a w id e a r e a to t h e c h e s t w a l l , o r t h i c k b an d s o f fibrous w all.

tissue

run outw ards

from t h e c a v i t y

to th e c h e s t

In th ese cases the ch est w all is probably a f a c to r

in keeping the c a v ity open, A p a t i e n t w ith poor r e s is ta n c e and l i t t l e steadily

tendency to

f i b r o s i s may h a v e a c a v i t y w h i c h

e n l a r g e s by p r o g r e s s i v e e x c a v a t i o n ,

p a t i e n t who h a s

seen in th e

repeated f e b r ile a tta c k s w ith in creased

s p u t u m a n d a f t e r e a c h a t t a c k an X-Ray f i l m shows t h e c a v i t y a little

l a r g e r . There s t i l l

r e m a i n t h e p a t i e n t s who h a v e

a c a v i t y w h i c h i s n e i t h e r o l d n o r p r o g r e s s i n g by e x c a v a t i o n , a cavity in s iz e

frequently o f.s p h e ric a l

shape and o f t e n v a r y i n g

from t i m e to t i m e , Even a f t e r an a r t i f i c i a l

pneumothorax o r t h o r a c o p l a s t y t h i s sometimes n o t o nly f a i l a n d i n an a r t i f i c i a l into

the p le u ra l

t o c l o s e b u t may i n c r e a s e

in s iz e

pneumothorax be seen to b a l l o o n o u t

space, Coryllos

th e conception th a t

type o f c a v ity w ill

i n 193 3 f i r s t

in th e s e c a v i t i e s

failure

p u t forward to c l o s e

was due to n a r r o w i n g o f t h e d r a i n i n g b r o n c h i w h i c h a l l o w e d air

to

e n t e r b u t n o t to

leave the c a v ity .

To t h e s e was

g i v e n t h e name " T e n s i o n c a v i t i e s " „ P e a r s o n i n 1.930 was b\-TY o f fVU\iV0

probably

the f i r s t

to

introduce a needle into

and f i n d a p o s i t i v e p r e s s u r e „ B ru n n e t a l

a cavity

(ig4l)

d e m o n s t r a t e d t h a t oedema, i n t h e " b r o n c h i a l s u b m u c o s a c a u s e d n a r r o w i n g o f t h e lumen to

s u c h a n e x t e n t t h a t i t was

c l o s e d e x c e p t d u r i n g i n s p i r a t i o n when a i r w o u l d e n t e r t h e c a v i t y a By s t u d y i n g t h e p r e s s u r e s

in th e

t r a n s p l e u r a l d r a i n a g e t h e y came t o entered the cav ity inspiration. inspiration

at

cav ity during

the conclusion th a t a i r

i n t e r v a l s o n ly and n o t w i t h ev e ry

The n o rm al w i d e n i n g o f a b r o n c h u s d u r i n g is

regularly

s e e n wh e n p e r f o r m i n g a

b r o n c h o sco py „ Coryllos or

bronchi o f g ia n t

into

(X93S) s a i d t h e d r a i n i n g b r o n c h u s

c a v i t i e s were f r e q u e n t l y

th e lower w all o f th e c a v ity

found opening

i n an o b l i q u e manner

(Fig. 7 ).

P u ll o f the negative i n t r a ^ p l e u r a l jjreseiare.

'Positive Valve l i k e opening o f bronchus into

cavity.

B r o n c h i a l wall® o edematous„

Pigo 7 o

43 The p o s i t i v e p r e s s u r e i n s i d e keeps th e v alv e clo sed d u rin g e x p i r a tio n , t h e "b r on ch us o w i n g to

the cavity

and i n a d d i t i o n

i t s oedema i s n a r r o w e d o r d o s e d

d u r i n g exp i r a t io n „ The p u l l o f t h e n e g a t i v e

intra-pleural

p r e s s u r e o p e n s t h e v a l v e a n d "br onchus d u r i n g i n s p i r a t i o n if the p o sitiv e pressure

i s not too h ig h .

A c c o r d i n g t o P r i c e Th o ma s , when t h e po s i t l v e p ressu re in the cav ity i s to o p e n t h e p o s s i b i l i t y

t o o h i g h to a l l o w t h e b r o n c h u s

o f a two way b y - p a s s m u s t b e

a d m i t t e d a n d t h a t when t h e i n t r a c a v i t a r y p r e s s u r e i s high a i r w ill

flow i n and o u t o f t h e c a v i t y 0 There i s ,

I believe,

an a l t e r n a t i v e

e x p l a n a t i o n . When t h e i n t r a c a v i t a r y p r e s s u r e t h e b r o n c h u s r e m a i n s c l o s e d . The a i r

low e n o u g h t o

slowly

reduces

a l l o w t h e b ro n ch u s to o p e n d u r i n g

i n s p i r a t i o n a n d a d m i t mo r e a i r , starts

i s too h i g h

enclosed in th e o av ity

i s now s l o w l y a b s o r b e d a n d t h e p r e s s u r e u ntil

when t h e c y c l e o f e v e n t s

a g a i n . T h i s w o u l d e x p l a i n why B r u n n e t a l

above found a i r o n l y when t h e

too

e n tered the ca v ity only a t

intracavitary

closed.

i n t e r v a l s and

p r e s s u r e wa s n e g a t i v e .

I t has been s ta te d t h a t a i r when t h e b r o n c h u s i s

quoted

i s absorbed

T h i s was t h e v i e w o f C o r y l l o s ,

He m a i n t a i n e d t h a t o n c e t h e b r o n c h u s was c l o s e d t h e a i r must be a b s o r b e d , gical

as i t

i s by any t i s s u e

i n t h e body

emphysema i s a n e x a m p l e ) . As t h e a i r

(sur­

is absorbed

and t h e b ro n c h u s rem ains c l o s e d a v ery n e g a t i v e p r e s s u r e (C oryllos quotes

cm, o f Hg) d e v e l o p s a s a r e s u l t o f

44 which t h e c a v i t y w a l l s

concentrically

c l o s e and t h e l o c a l

c o m p e n s a t o r y emphysema d e s c r i b e d by P r i c e Thomas f i l l s space where th e c a v i t y p r e v io u s ly

existed.

Bronchus open

Tension c a v i t y e

/A Bronchus closed

Fig, 8 0 (A fter C o ry lle e )0

the

This

is

a s i m p l e e x p l a n a t i o n o f how a c a v i t y

c l o s e s and p ro c e e d s to h e a l i n g i f permanently

closed.

th e bronchus

S t r i k i n g evidence in su p p o rt o f t h i s

theory are the p a th o lo g ic a l

findings of healed c a v itie s .

I f c a v i t i e s h e a l e d by a p r o c e s s o f f i b r o s i s cavity

gradual

extensive

is

around the

s h r i n k i n g i n s i z e w o u l d b e s e e n a n d an

fibrotie

s c a r would rem ain which i s n o t

F u r t h e r m o r e any c a v i t y

c l o s i n g by f i b r o s i s

the ca se .

should never

r e o p e n . When a n e x t e n s i v e s c a r d o e s r e m a i n i t

i s as a

r o u g h l y s p h e r i c a l ma s s a n d c o n s i s t s o f t h e i n s p i s s a t e d c o n t e n ts o f t h e c a v ity which were not re a b so rb e d a f t e r b r o n c h u s c l o s e d . P a g e l a n d Simmonds ( 1 9 ^ ) conversion o f the ca v ity

into

a solid

the

suggest th a t

focus i s

probably

th e most f r e q u e n t b a s i s o f c a v i t y h e a l i n g . T h is explanation o f cavity Pinner to

closure

is not u n iv e rs a lly

(A lex an d er’s C ollapse Therapy) did not s u b sc rib e

this

v i e w a nd h e l d t h a t c l o s u r e o f t h e b r o n c h u s was a

s e r i o u s c o m p lic a tio n as th e r e s u l t i n g i n t h e c a v i t y m ig h t l e a d to believed

c o m p l i c a t i o n s . He

i n f e c t i o n which alth o u g h not always p e n e t r a t i n g

t h e c a v i t y w a l l was p r e s e n t effectively

accept th is

frequently

in i t s

s e c r e t i o n s . Go r y l i o s

d i s p r o v e d t h i s , a nd P i n n e r l a t e r

how s e c r e t i o n s

cavity

perilous

s ta s is of secretions

t h a t alm ost i n v a r i a b l y c a v i t i e s were th e s i t e o f

secondary

came t o

accepted.

t h e o r y on c a v i t i e s .

are retained

It

is

(1940)„ easy to

see

in the t e n s i o n c a v i t y „

s e e n as t h e f l u i d l e v e l

i n t h e radioXo gic&l

shadow s b u t t h e p a t i e n t i s nob a l w a y s i l l .

Go r y l l o s

w ith s t r i c t

aseptic

t e c h n i q u e removed s p e c i m e n s o f f l u i d

from t e n s i o n c a v i t i e s and found i n a l l c a s e s

t h a t the

only

He g o e s o n

to

b a c t e r i a p r e s e n t were t u b e r c l e b a c i l l i .

say t h a t as th e oxygen in t h e a i r

cavity to

the tu b e rc le b a c i l l i being s t r i c t l y

grow, i t

bacilli

c e a s e d to

g r o w . He c o u l d n o t h a v e m e a n t t h e y d i e i n an e n c a p s u l a t e d ,

where d ep riv e d o f t h e i r oxygen,

but liv in g

aerobic cease

should be n oted t h a t C o r y llo s s a i d th e t u b e r c l e

for tub ercle b a c i l l i focus,

i s a b s o rb e d from th e

avascular,

caseous

remain dormant

for years. The c o n t r a r y v ie w h e l d o n t h e c l o s u r e o f

cavities

is

t h a t t h e y w i l l o n l y c l o s e a n d h e a l when t h e

d r a in in g bronchus i s open. That t h i s w i l l o c c u r P r i c e Thomas h a s sh own , b u t c o n d i t i o n s m u s t b e s u i t a b l e local

c o m p e n s a t o r y emphysema t o

for

f o r m a n d i n t h e mor e

ad van ced c a s e c o n d i t i o n s a r e n o t s u i t a b l e due to

extensive

s u r r o u n d i n g f i b r o s i s a n d ^e x t e n s i v e a d h e r e n c e t o c h e s t w all,

in

fact

in th e w r i t e r ' s

c lo se as a s u f f i c i e n t

view such a c a v i t y c a n n o t

negative

intracavitary

c a n n o t o c c u r to b r i n g a b o u t t h e se q u en ce o f

pressure events

d e s c r ib e d above. F u rth erm o re Brunn e t a l s t a t e d t h a t i n (EOG a u t o p s i e s

they found every c a v i t y

n u m b e rin g anywhere from one to closed bronchi 134 a u t o p s i e s

six.

I n no i n s t a n c e w e r e

found. Auerbach ( ig 4 l) found c a v i t i e s

s ho wed o p e n o r o n c h i ,

in h is

i n 117 c a s e s

th e d r a i n i n g b ro n c h i were open but h e a l i n g had o c c u r r e d and in a l l

series of

i n a l l o f which

in I 7 c a se s c a v ity

instances the draining

47 b r o n c h u s was c l o s e d and

ended b l i n d l y i n t h e c a v i t y SGar

o r th e in s p i s s a t e d caseous cavity c o n te n ts . In t h e i r s e r i e s o f s i x c a s e s P a g e l and Simmonds ( 1 9 4 2 ) f i n d i n g s wer e t h e same and gave a s t h e i r o p i n i o n t h a t f o u r weeks was t h e minimum t i me r e q u i r e d f o r h e a l i n g . P r i c e Thomas g o e s much f u r t h e r t h a n C o r y l l o s and p u t s

f o rw a r d t h e view t h a t t h e r e a s o n more c a v i t i e s

do n o t h e a l

spontaneously

tension c a v itie s

f ro m t h e s t a r t ,

involvem ent which i s cavitary

is because th e m a jo rity

junction

the bronchial

are

tuberculous

so commonly f o u n d a t t h e broncho**

i n t e r f e r i n g w ith e f f i c i e n t d rain a g e.

He i s o f t h e o p i n i o n t h a t t h e p r e s s u r e o n t h e s u r r o u n d i n g lung t i s s u e s atelectasis

c a u s e d by t h e t e n s i o n c a v i t y p r o d u c e s l o c a l and e m b a r r a s s e s t h e b lo o d sup p ly on w hich

depends th e mechanism o f d e f e n c e . T hat r e d u c t i o n o f intracavitary

p r e s s u r e c l e a n s up c a v i t y w a l l s and i n c r e a s e s

t h e number o f c a p i l l a r y

vessels

is seen in e x te rn a l

d r a i n a g e o f c a v i t i e s when t h e p r o c e s s c a n b e v i e w e d t h r o u g h a cavernoscope, the w r i t e r has him self seen these changes. W h a t e v e r mas? b e t h e r e a l p a t h o l o g i c a l physiology o f c a v ity clo su re th e re is

no d o u b t t h e a b o v e

e x p l a n a t i o n p r o v i d e s an e x c e l l e n t w o r k i n g h y p o t h e s i s and it

is

essential

to h a v e i n mi nd some c l e a r h y p o t h e s i s

when c a r r y i n g o u t c o l l a p s e t h e r a p y . The t h e o r y h a v i n g b e e n a c c e p t e d t h a t c a v i t y closure r e s u lts bronchi i t

from c l o s u r e o f t h e d r a i n i n g b r o n c h u s o r

r e m a i n s to

s e e how t h i s c a n b e a i d e d by

43

co 11 ap s e t h e rapy 0 An a r t i f i c i a l p ne um ot h or ax f r e e from p l e u r a l a d h e s i o n s pro T i d e s t h e b e s t r e s u l t f o r t h e l u n g can t h e n e x e r c i s e i t s power to r e t r a c t a r o u n d t h e h i l u m

(Pis. 9).

Pi g. 9. T h i s r e t r a c t i o n a r o u nd t h e h i l um r e d u c e s t h e e f f e c t o f t h e i n t r a - p l e u r a l n e g a t i v e p r e s s u r e and i n s p i r a t o r y p u l l on b o t h l u n g and b r o n c h i . The c a v i t y d r a i n i n g bronchus i f closed, by o edematous mucosa may now no t open a t a l l d u r i n g i n s p i r a t i o n and s h o u l d i t remain c l o s e d l o n g enough t h e c a v i t y a l s o w i l l c l o s e and h e a l . P e r m a n e n t c l o s u r e o f t h e b r o n c h u s i s e f f e c t e d by f i b r o s i s o f t h e g r a n u l a t i n g mu co sal s u r f a c e o r a f i t r o t i c

stenosis.

Two o b j e c t i o n s must be met ,

first,

that

th e widening o f th e bronchus d u rin g i n s p i r a t i o n i s a n e u r o - m u s c u l a r mechanism g ov er n ed by t h e v a g o - s y m p a t h e t i c

49 n e r v e su p p ly and n o t e n t i r e l y

a re su lt of inspiratory

p u l l , E v e n so i t may 'be a s s u m e d t h a t collapsed

state

as w idely as the

-vith t h e l u n g i n a

t h i s mechanism does n o t open t h e

in the f u lly

expanded s t a t e .

bronchus

Secondly,

as

i n t r a c a v i t a r y p r e s s u r e bec mo ee mo r e a n d mo r e n e g a t i v e

w ill

i t n o t e v e n t u a l l y overcome t h e b r o n c h i a l b lock?

Brunn

(1941) on i n t r o d u c i n g a i r in to

ra is in g the pressure u n til

t h e c a v i t y and

i t was w e l l p o s i t i v e

found

a 100^ e f f i c i e n c y o f t h e b r o n o h o ^ c a v i t a r y v a l v e , bronchus i s

effectively

complete e f f i c i e n c y

closed during

i n s p i r a t i o n t h e same

c a n be e x p e c t e d .

The o p e r a t i o n o f t h o r a c o p l a s t y successful bronchus

Xf t h e

to be

in b rin g in g about clo su re o f the d rain in g

should as n e a r l y as p o s s i b l e resem b le t h e

c o l l a p s e a c h i e v e d by a f r e e a r t i f i c i a l

p n e u m o th o ra x and

the o p eratio n

extra«fascial

apicolysis

d e v i s e d by Semb w i t h i t s

i s t h e n e a r e s t a p p r o a c h to

this.

The

m o b ilis a tio n o f the lung c a rrie d out during t h i s o p e ra tio n allow s

t h e apex to

re tra c t concentrically

towards the

h i l u m t h u s p r o v i d i n g r e l a x a t i o n w h i c h i s h o p e d t o be s u f f i c i e n t to not close relaxation

c l o s e t h e b r o n c h u s . When t h e c a v i t y

follow ing o p eratio n is not

sufficient,

it

is possible

possibly

does

t h a t the

in one d i r e c t i o n

o n l y „ to a l l o w t h e b r o n c h u s to r e m a i n c l o s e d d u r i n g in s p ira tio n or i f the cavity extensive tis s u e

l a r g e as a r e s u l t o f

d e s tru c tio n then i t s

is probably o f la rg e operation,

is

d r a i n i n g bronchus

c a l i b r e and n o t e a s i l y

c l o s e d by

INDICATIONS FOP. THORACOPLASTY.

The r e s e a r c h and i m p r o v e m e n t i n t e c h n i q u e of thoracoplasty since i t s

t h a t has taken p la c e o ver th e y e a rs

i n t r o d u c t i o n h a v e c h a n g ed a g r a v e and

dangerous o p e r a tio n the

early o p eratio n s

ribs

into

co n sistin g of the

at a sin g le stage,

ha.s g r a d u a l l y w ith i t s

a com paratively

safe one.

From

rem oval o f numerous

a procedure fra u g h t w ith danger,

e v o l v e d t h e m o d e rn m u l t i - s t a g e

e m p h a s i s on l u n g r e l a x a t i o n r a t h e r

d e c o s t a l i s e d c h e s t w a l l . With t h e s e

thoracoplasty t h a n on

technical

h a s come a w i d e n i n g o f t h e i n d i c a t i o n s

improvements

for thoracoplasty.

The s e v e r e o n e s t a g e o p e r a t i o n d emanded t h a t t h e p a t i e n t b e n o n -tox.*ie, h i s good,

and t h e l a r g e n u m b e r o f r i b s

dangers o f p aradoxical a nd p r e d o m i n a n t l y considered

removed,

respiration,

fibrotic

but where a s a t i s f a c t o r y

condition bringing

d e ma n d e d u n i l a t e r a l

d i s e a s e . P a t i e n t s were

s u i t a b l e who f u l f i l l e d

a n d f o r whom a n a r t i f i c i a l

general

these requirem ents

p n e u m o t h o r a x was i n d i c a t e d

c o l l a p s e c o u l d n o t be o b t a i n e d .

These p a t i e n t s w ith t h e i r

fibrotic

d i s e a s e and f i x e d

m e d i a s t i n u m r e s p o n d e d w e l l to o p e r a t i o n an d t h e y s t i l l figure

i n t h e l o n g t e r m r e s u l t s o f s u r g e o n s who h a v e

practised

thoracoplasty

f o r many y e a r s .

The g r a d u a l w i d e n i n g o f i n d i c a t i o n s brought

in p a t i e n t s w ith healed d is e a s e

l a t e r a l lung,

in the c o n tra ­

then w ith c o n t r a - l a t e r a l pneumothorax.

yx,

L a t e r t h e more t o x i c

p a t i e n t w ith moderate e x u d a tiv e

d i s e a s e wa s a d m i t t e d , , T h e i n t r o d u c t i o n o f s t r e p t o m y c i n "b r ou g h t a c h e m o t h e r a p e u t i c me t h o d t o t h e r a p y and i t

w i l l h e shown l a t e r

h a s a&ain w ia e n e a t h e the

indications

th e aid o f c o lla p s e

that this

i n d i c a t i o n s , , As i n a l l

combination forms o f s u r g e r y

f o r o p e r a t i o n v a r y w i t h t h e s u r g e o n an d

w i t h t h e amount o f a t t e n t i o n he f o c u s e s on h i s m o r t a l i t y f i g u r e s „ Speaking o^ surgery O g ilv ie has re c e n tly

in g e n e r a l S i r Heneage

s a i d t h a t t h e s u r g e o n who n e v e r d o e s

a severe o p e ra tio n has the fewest deaths, the fewest l i v e s . Tudor Edwards

but he saves

Speaking o f th o r a c o p la s ty

(1935) w r o te t h a t i f t h e

kept w ith in narrow l i m i t s ,

in p a r tic u la r ,

in d ic a tio n s are

the proportion o f apparent

c u r e s w i l l b e much h i g h e r t h a n i n o p e r a t i o n s p e r f o r m e d because i t patient,

is

th e o n ly hope o f a m e l i o r a t i o n

O ’B r i e n

(1933)

considered

s h o u l d b e p e r f o r m e d 'when i n d i c a t e d

fo r the

th at a thoracoplasty i n any p a t i e n t

in

whom i t a p p e a r s t h a t t h e r e i s a c h a n c e o f s u c c e s s w h eth e r th e d i s e a s e be e x u d a tiv e ,

mixed o r p r o d u c t i v e ,

X believ e th a t d esp ite the increased

risk

the undertaking

o f t h o r a c o p l a s t y on t h e p a t i e n t w i t h a d v a n c e d d i s e a s e i s w e l l w o r t h w h i l e and i t

i s my. w i s h t o p r e s e n t c a s e s

in support o f t h i s c o n te n tio n , THE; OBJECT OF COLLAPSE THERAPY i s

to r e s t

th e lung an d , (l) A rre s t the spread o f th e

tuberculous

disease

and a l l a y

toxaemia,

(2) H eal t h e d i s e a s e d t i s s u e

a n d any c a v i t y

w h i c h may h e p r e s e n t , ( 3) R e s t o r e t h e p a t i e n t

t o h e 6 , 1 t h and

r e n d e r him sputum n e g a t i v e . A ttention is usually which i f

successful

f o c u s e d on t h e seco nd o b j e c t i v e results

in the o th e r o b je c ti v e s

ceing

a c h i e v e d . How c o l l a p s e t h e r a p y a i d s h e a l i n g a n d c a v i t y c lo s u r e has been d isc u sse d . t h e i m p o r t a n t aim, infiltrativ e

ana i f

Cavity c lo s u re

this

is

su ccessfu l the

l e s i o n s h o u l d h e a l . An o p e n c a v i t y

always th e s i t e o f f l o u r i s h i n g

to h i m s e l f , L i v i n g math a c a v i t y edge o f a v o lc a n o o f quiescence,

is lik e

f o r a t any t i m e ,

is

and a p a r t

a danger

l i v i n g on t h e

e v e n a f t e r many y e a r s

t h e d i s e a s e may s u d d e n l y

f l a r e up w i t h

r e s u l t s , A few f o r t u n a t e p a t i e n t s may l i v e

w i t h an o p e n c a v i t y Reid

is nearly

tubercle b a c ill i

from, b e i n g a d a n g e r t o o t h e r s t h e p a t i e n t

disastrous

is usually

f o r many y e a r s b u t t h e y a r e v e r y

few,

( 1 9 4 6 ) f o u n d t h a t 8 0 ^ o f p a t i e n t s who h a v e a c a v i t y

w h i c h i s h e l d o u t by a d h e s i o n s r e s u l t i n g ineffective a r tif ic ia l

f r o m an

pneumothorax d ie w i t h i n

four y e a rs ,

THE RELATION OF THORACOPLASTY TO ARTIFICIAL PNEUMOTHORAX AND OTHER COLLAPSE METHODS* The i a e a l c o l l a p s e

treatm ent

a r t i f i c i a l pneumothorax f r e e o f p l e u r a l a l l o w s t h e l u n g to u s e to retractile

the f u l l

i s by a n

a d h e s io n s which

its natural

p o w e r s . The mo r e e x t e n s i v e t h e d i s e a s e

in the

53 lung the le s s

likely

is

this

i d e e l aim to he r e a c h e d ,

The i n e f f e c t i v e p n e u m o t h o r a x

i s dangerous

a n d s h o u l d be a b a n d o n e d a s s o o n a s p o s s i b l e . all

artificial

I n my o p i n i o n

p n e u m o t h o r a c e s s h o u l d he s u b j e c t e d to

thoracoscopy u n le ss th e re is

some d e f i n i t e

contraindication0

O n l y by t h i s means c a n t h e s u i t a b i l i t y o r o t h e r w i s e o f t h e pneumothorax: be a s s e s s e d . Hot o n l y a r e t h e e x t e n t o f t h e a d h e s i o n s seen h u t t h e s t a t e o f t h e p l e u r a can be ascertained,

i n r e g a r d to

m yself doing l e s s ago.

the

e x t e n s i v e o p e r a t i o n s t h a n a few y e a r s ^

The s e c t i o n o r e n d o t h o r a c i c e n u c l e a t i o n o f l a r g e

adhesions is

se c tio n o f adhesions I find

too

c a r r y i n g th e b lo o d supply to

frequently

ineffective

f o l l o w e d by t i s s u e n e c r o s i s a n d , l i k e

artificial

empyema. B r o n c h o “ p l e u r a l and a perm an en t The p a t i e n t

the cav ity area

pneumothorax*

fistula,

intercostsJ

by t u b e r c u l o u s

secondary

infection

d r a i n a g e t u b e may f o l l o w .

i s by t h e n s u f f e r i n g

from c h r o n i c

i s a p h y s i c a l w r e c k a n d i n no c o n d i t i o n to

toxaemia,

etana the

m a jo r t h o r a c i c o p e r a t i o n which r e p r e s e n t s h i s o n ly hope o f recovery. A ll th is to

start

f o l l o w s from i t

and m a i n t a i n an i n e f f i c i e n t

pneumothorax which in i t s

first

b e i n g too

easy

artificial

few w e e k s o f t e n

gives

a t e m p o r a r y and g r a v e l y m i s l e a d i n g im provem ent i n g e n e r a l health.

It

i s much s a f e r to s u b j e c t t h e p a t i e n t to

thoracoplasty,

aespite

o f events takes p la c e .

its

risks,

before th is

grim s e r i e s

54 THY: SITE OP THE LESION i n f l u e n c e ® t h e type o f c o lla p s e therapy

chosen. Both a r t i f i c i a l

pneum othorax and t h o r a c o p l a s t y give t h e i r t e s t

results

i n u p p e r lo b e l e s i o n s p M iddle lo b e and l i n g u l a l e s i o n s , particularly

cavities,

a r e l e s s common a n d r e s p o n d l e s s

s a t i s f a c t o r i l y . L o w e r l o b e l e s i o n s a l o n e do n o t u s u a l l y call

f o r t h o r a c o p 1 &s t y h u t f o r r e s e c t i o n o r a c o m b i n a t i o n

o f pneumo-peritoneum,

phrenic crush o p e ra tio n s,

probably pneumothorax. lobe o r d o r s a l lobe

and

C a v ita tio n o f t h e apex o h th e lower

( n o m e n c l a t u r e o f t h e b r o n c h i and

p u l m o n a r y s e g m e n t s i s a f t e r F o s t e r - C a r t e r 1 9 4 2) d i f f i c u l t to

treat, UPPEP LOBE d i s e a s e w i t h a p i c a l

r e s p o n d s w e l l to t h o r a c o p l a s t y . out also

in th e pathology, are the ap ic a l

may b e d e c e p t i v e l y

In

cavitation

this area,

i f the d ise a se is

as p o in te d

ex ten siv e then

adhesions e x te n siv e . A r t i f i c i a l

pneumothorax i s o f t e n

w ill

I s mo r e

easily

successful

induced and r a d i o l o g i c a l l y (Fig,

10) , Only t h o r a c o s c o p y

show o v e r how w i d e a n a r e a t h e l u n g i e

a n d make t h e o p e r a t o r r e a l i s e w h a t l i t t l e

adherent

chance th e re

is

o f th e c a v ity c lo s in g because the lung cannot r e t r a c t concentrically

around th e hilum .

F r e e i n g o f t h e l u n g by

t h e r m o - c a u t e r y c a n b e v e r y d i f f i c u l t ,0 commonly t h e l u n g is adherent j u s t over the apical

dome,

down t h e m e d i a s t i n u m ,

it

anteriorly

posteriorly

is often

A d h e s i o n s o v e r t h e apex a r e a p t to be s h o r t m a rg in between lu n g and c h e s t w a l l

and

free. a nd t h e

( o r may b e s u b c l a v i a n

55 vessels) is

s m a l l 0 I f troublesom e haemorrhage o cc u rs diathermy

necessary

necrosis

to a r r e s t

it

a n d t h i s may c a u s e d e e p t i s s u e

in v o lv in g lung in short adhesions w ith the r i s k

o f s u b s e q u e n t empy e m a „

Fig, 1 0 o

U n l e s s t h e l u n g a p e x can be w i d e l y and s a f e l y section

freed adhesion

s h o u l d n o t be* a t t e m p t e d b u t t h e p n e u m o t h o r a x

abandoned and,

o th er conditions o f the p a tie n t being

s a tis f a c to r y , thoracoplasty

s u b s t i t u t e d 0 The a d d i t i o n

to

t h e p n eum oth o rax o f a p h r e n i c c r u s h and p neum operitoneum is unlikely

to

cavity

is very

ideal

treatm ent

a good,

lasting

give s u f f i c i e n t

re la x a tio n u n less the

sm a ll„ T horacoplasty w ith o u t doubt i s th e fo r th e type o f le s io n d e s crib ed ,

giving

resu lt0 DOB SAL L0BT3 ( A p i c a l s e g m e n t o f t h e l o w e r

"JV-

------------------------------lobe)

cav itatio n presents

cavitation

special

p r o b l e m s . D i s e a s e and

i n t h i s a r e a i s n e a r t h e l u n g s u r f a c e and a s

in th e u p p er lo b e apex e a s i l y

gives r i s e

a d h e s i o n s . The a d h e r e n t d o r s a l l o b e l i e s tebral

g u tte r w ith i t s

the v e rte b ra l the

- -•

medial s u r fa c e

c o l u m n . To r e l a x t h i s

c o n d itio n s o f lung r e t r a c t i o n

s e c t i o n on p a t h o l o g y o f c a v i t i e s f r e e i n g o f t h i s a r e a by c a u t e r y

to

pleural

in th e p a ra v e r­

in c o n ta c t w ith

segment and f u l f i l

a s l a i d down i n t h e is not

e a s y . The

i n an a r t i f i c i a l

pneumothorax i s very d i f f i c u l t p a r t i c u l a r l y

on t h e r i g h t

s id e where th e azygos v e in p r e s e n t s a h a z a r d , p h re n ic c r u s h and pneum operitoneum a r e o f t e n measures a re w orth tr y in g but i f

ineffective.

i n e f f e c t i v e a re time

c o n s u m i n g a n d d i s a p p o i n t i n g to t h e p a t i e n t . thoracoplasty

is

I f they

fail

i n d i c a t e d . The u s e o f a l o c a l i s e d ,

low er o p e ra tio n over the cavity

s i t e w ith a p a ra v e rte b ra l

p n e u m o l y s i s may b e s u f f i c i e n t b u t mor e s u c c e s s f u l subtotal

A ll these

is a

th o ra c o p la sty w ith m o b ilis a tio n o f the lung

from above,

t h o u g h t h i s may e n t a i l m o b i l i s a t i o n down a.s

f a r as th e e i g h t h i n t e r c o s t a l b u n d le to p r o d u c e t h e required re la x a tio n . A dditional re la x a tio n

from below

can be o b t a i n e d w i t h a s u b s e q u e n t p h r e n i c n e r v e c r u s h . A c o m b i n a t i o n o f u p p e r l o b e and d o r s a l l o b e c a v i t a t i o n is

q u i t e common. T h i s m u l t i p l e l o b e c a v i t a t i o n

a r e s u l t o f e x t e n s i v e d i s e a s e and i s a s t r o n g

is usually indication

for thoracoplasty. The u s e o f PPTMAPY TFORACOPLARTY, t h a t

is w ithout a previous accepted.

It

lung c a l l s

is

my

pneumothorax b e in g t r i e d ,

o p i n i o n t h a t an e x t e n s i v e l y

i s now diseased

f o r a p e r m a n e n t c o l l a p s e a s g i v e n by t h o r a c -

p l a s t y , f o r i n such a l u n g t h e r e a r e numerous a r e a s which t u b e r c l e b a c i l l i

lie

dormant and r ead y

in

to c a u se

r e a c t i v a t i o n o f disease,, A r t i f i c i a l pneumothorax i s h ^re dangerous even i f t h e

collapse is

adequate?

r i s k s o f l o b a r a t e l e c t as i s a n d t u b e r c u l o u s lung d iseased

to

this

th e re are the empy e m a , A

exten t never re-expands but

f i b r o s e s and i n t h e p r o c e s s o f o b l i t e r a t i n g

the p le u r a l

c a y i t y merely d rag s th e m ediastinum w ith i t .

This type

o f l u n g when c o l l a p s e d u n d e r n e a t h a t h o r a c o p l a s t y likely

to be c o me a c t i v e

for i t

is

subjected

strain

t h a n i n t h e p r e s e n c e o f p n e u m o t h o r a x . . The

is

less

to much l e s s

d i s a d v a n t a g e o f c o l l a p s i n g some h e a l t h y a r e a s o f l u n g in th e course o f th e o p e r a t i o n increased

is

f a r o u t w e i g h e d by t h e

chances o f rem aining f re e

o f d i s e a s e 0 T\„HQO v e r h o l t

(1941)

from f u r t h e r a t t a c k s

e xx > r es s e d t h e vv i e w t h a t

p a t i e n t s w i t h e x t e n s i v e d i s e a s e who h a v e h a a a t h o r u c o p l a s t y a r e a b l e to

stand ordinary a c t i v i t i e s o f l i f e b e t t e r

t h a n t h o s e who a p p a r e n t l y

a r r e s t , t h e d i s e a s e w i t h some

t empo r a r y f o rm o f c o l 1 a p o e 0 Xn t h e s e c a s e s t h e m e d i a s t i n u m i s u s u a l l y a l r e a d y f i x e d by f i b r o s i s .

The d a n g e r o f t o r n p l e u r a a t

o p e r a t i o n i s no g r e a t e r t h a n w h e r e a n a r t i f i c i a l pneumothorax h as been t r i e d , by a d h e s i o n s

fQT t h e a c t u a l

a re a covered

i n a n i n e f f e c t i v e p n e u m o t h o r a x , may b e v e r y

sm all

compared to

the rem ainder o f the p le u r a l

w h i c h may h e a d h e s i o n f r e e . torn pleura

it

is usually

cavity

Should th e lu n g s u f f e r a

noticed th a t the adhesions

o v e r t h e d i s e a s e d a r e a a r e so e x t e n s i v e

t h a t no a d h e s i o n

s e c t i o n would h a v e been p o s s i b l e . The p a t i e n t o v e r f o r t y p r e s e n t i n g h i m s e l f for treatm ent is

suitable,

fo r the

f i r s t time sh o u ld ,

be c o n s id e re d for prim ary

if

the le sio n

thoracoplasty.

The n e w l y d i a g n o s e d l e s i o n a t t h i s a g e i s u s u a l l y r e a c tiv a tio n o f o ld d ise ase the

p re s e n c e o f which has

probably never been s u s p e c t e d a unsuitable afford It

is

who 1 e s u c h c a s e s a r e

f o r pneumothorax tr e a tm e n t and they cannot

t o w a i t a few y e a r s t o too,

a

give t h i s

s u r p r i s i n g how q u i c k l y y e a r s

a trial slip

first.

by when

t r e a ti n g a case o f p h th is is . P le u ra l com plications at t h i s a g e l e a v e t h e p a t i e n t w i t h g e n e r a l h e a l t h a nd c a r d i o “V ascu lar system s e r io u s ly

i m p a i r e d so m a k i n g h i m

a bad o p e r a t i o n r i s k . ' I should l i k e tho r a c o p l a s t y

to e m p h a s i z e a g a i n t h a t

fo r th e ex ten siv e ly diseased lung is

d a n g e r o u s to l i f e

less

than are the com plications r e s u lt in g

f rom an i n e f f e c t i v e pn eumo t h o r a x „ The s t a t e o f ACTIVITY OP THE DISEASE i n t h e lu n g to be s u b j e c t e d to c o l l a p s e t h e r a p y No c o l l a p s e lung is

is

im portant.

s h o u ld be u n d e r t a k e n where a l a r g e a r e a o f

the s i t e o f acu te exudative le s io n s .

In the

subacute types o f le s io n o p e r a tio n i s j u s t i f i a b l e to

save l i f e ;

small m u ltip le

stages is

which in th e s e c a s e s i s cavity

r i s k y b u t may b e

even h e r e t h o r a c o p l a s t y preferable

frequently

to

in

pneumothorax

f o l l o w e d by s p o n t a n e o u s

r u p t u r e a n d empyema. I d e a l l y

there

should have

b e e n no a c t i v e d i s e a s e i n e i t h e r l u n g f o r a t l e a s t

six

months , When a p n e u m o t h o r a x i s u p t h o r a c o p l a s t y may b e n e e d e d t o

eventually

complete tr e a tm e n t .

h e a l i n g h a s b e e n a c c o m p a n i e d by much f i b r o s i s m ediastinal

If

the

c o n t e n t s w i l l be d rag g ed to w ard s t h e f i b r o s e d

l u n g . The t r a c h e a may b e s e e n t o and w i d e n i n g , fibrosed

given

and t h e h e a r t

s u f f e r marked d i s t o r t i o n

seems t o d i s a p p e a r i n t o

the

t i s s u e s . The p a t i e n t i s l e f t w i t h a t e n d e n c y

to b r o n c h i t i s ,

d y s p n o e a and c a r d i a c

the p a tie n t

s t i l l w ell th o raco p lasty

is

to b r i n g t h e d i s t o r t e d

i s w i s e l y done

s t r u c t u r e s ba o c c u r i f t h e p a t i e n t

is being strip p ed o f i t s

and t e a r s

In

easily.

s tra in s w hilst

periosteum ,

o r during the

la te r dissection. In one advanced case d u r i n g t h e

second

s t a g e d i s s e c t i o n a l u n g c a v i t y was o p e n e d 0 F u r t h e r m o b i l i s a t i o n was p e r f o r m e d t o w alls.

allow s u tu re o f the ca v ity

S t r e p t o m y c i n was n o t t h e n a v a i l a b l e

tuberculous

an d

i n f e c t i o n o f t h e wound f o l l o w e d w i t h

fatal

results 0 THF POST-OFTCRATIV® TRPATMWT 0 Omnopon i n s m a l l d o s e s o r t a b , co „ are

g i v e n to a l l a y

codeine

p a i n w h i c h makes c o u g h i n g

s u p p o r t e d by m a n u a l p r e s s u r e

easier,

P o st^ o p e ra tiv e vom iting is

rarely

op t r o u b l e s o m e a n d when I t h a s c e a s e d f r e q u e n t a r e g iv e n to

replace

small d rin k s

flu id loss.

During the f i r s t

forty

eight hours,

in

the absence o f com plications needing medical a t t e n t i o n , the p a tie n t position

is

essentially

i s m a in ta in ed as t h i s h e lp s r e a p ir a .tio n ,

o r a t i o n and a p i c a l to

a n u r s i n g p r o b l e m . The s i t t i n g

c o l l a p s e and t h e p a t i e n t

expect-

soon l e a r n s

p r e f e r s le e p in g in t h i s p o s i t i o n . A p p e tite u su a lly

recovers quickly, Physiotherapy

commences o n t h e

first

day

w i t h p a s s i v e a r m m o v e m e n t s w h i c h e x t e n d e a c h day u n t i l t h e p a t i e n t h a s a c t i v e and alm o st to

full

range w ith in ten

fo urteen days. B reath in g e x e rc ise s are continued

a n d f r o m t h e f i r s t o r s e c o n d day t h e p a t i e n t down on h i s n o n - o p e r a t e d o n c e to h e l p restricted

to

is

put

s i d e f o r a f ew m i n u t e s a t l e a s t

e x p e c t o r a t i o n . The u s e o f w e i g h t s

is

those c a se s with e x te n s iv e f i b r o t i c Patients

disease.

a r e X - R a y e d by t h e m o b i l e m a c h i n e

p o s t - o p e r a t i vely whenever i t

is

considered necessary.

The p a d s a r e r e mo ve d a n d t h e d r e s s i n g c h a n g e d on t h e t h i r d

day.

When t h e r e patients

i s a n o t h e r st&ge to

follow

a r e a l l o w e d up f o r . h a l f t o o ne h o u r d a i l y

the n in th

day a n d t h i s

considerably. next stage

is

found to

I f wound i n s p e c t i o n

improve t h e i r reveals

from

condition

s e p s is the

is postponed, P o st« o p erativ e treatm ent follow ing

the

s e c o n d and s u b s e q u e n t s t a g e s the

scapula is

is

sim ila r except th a t a f te r

embedded t h e arm i s k e p t a t r e s t

f o r seven

days. All

p a t i e n t s a r e k e p t im b e d f o r a t l e a s t

t h r e e months a f t e r t h e c o m p le tio n o f t h e i r o p e r a t i o n , b e i n g a l l o w e d up f o r t o i l e t does n o t e r a d i c a t e into

purposes only.

Thoracoplasty

the d ise a se but puts th e ch est w all

a p o s i t i o n where t h e lung b e n e a th i s

given a chance

t o h e a l by t h e n a t u r a l p r o c e d u r e o f f i b r o s i s when d i s c u s s i n g p a t h o l o g i c a l extensive lung,

the d isease,

as d e s c rib e d

c o n s i d e r a t i o n s „ The mor e

especially

in the c o n t r a la te r a l

th e l o n g e r must be th e p e r i o d o f bed r e s t . A f t e r ­

wards th e p a t i e n t p asses

through a r o u t i n e

course o f graduated ex e rc ise .

sanatorium

A REVIEW OF IOO CONSECUTIVE CASES OF THORACOPLASTY WITH SPECIAL REFERENCE TO THE ADVANCED CASE„ eg Q C 3 c a iitiiiu e a c a « i o

e* pa ca «

w

f a c?* c » Ct* r i H a o

ca c s C a O r^ te ftC a C d C jf e c ^ f ia jO F a



T h i s fstudy i s b a s e d u p o n 100 c o n s e c u t i v e c a s e s o f t h o r a c o p l a s t y o p e r a t e d o n f r o m A p r i l 1 946 to November 1 9 4 9 i n K e l l i n g S a n a t o r i u m , male p a t i e n t s .

a sanatorium for

Prom J u n e 1 9 4 7 f e m a l e p a t i e n t s w e r e

adm itted fo r th o raco p lasty o p e ra tio n s. The p o l i c y a d o p t e d t h r o u g h o u t h a s b e e n t o r e f u s e no p a t i e n t a t h o r a c o p l a s t y when i t h a s b e e n f e l t t h a t he would d e r i v e b e n e f i t from t h e o p e r a t i o n . A d o p tin g such a p o lic y

i n e v i t a b l y means t h a t many c a s e s a c c e p t e d

f o r o p e r a t i o n have l i t t l e I f these p a tie n ts

chance o f becoming sputum n e g a t i v e .

are su fficie n tly

improved in h e a l t h

w o r k t h e n a n o p e r a t i o n i© w o r t h w h i l e , A n f s e s

to

(1941) h e l d

t h e same o p i n i o n s a y i n g t h a t t h e r e t u r n o f t h e p a t i e n t to

induetiy is

r e a l l y o f g r e a t e r im portance than the

a c h ie v e m e n t o f a sputum co n v e rsio n ,0 too o f t e n p a t ie n t © h a v e t h e i r t u b e r c u l o s i s a r r e s t e d o n ly to

remain invalid©

and economic l i a b i l i t i e s , No s a t i s f a c t o r y m e t h o d o f c l a s s i f y i n g p ulm onary t u b e r c u l o s i s h a s y e t been e v o l v e d and to

take

a number o f p a t i e n t s and g r o u p them a s good o r bad c a s e s for a sp ecific

lin e o f treatm ent is

ev e n more d i f f i c u l t ,

d e p e n d i n g a s i t must on t h e i n d i v i d u a l a p p r o a c h to t h e p r o b l e m . When a d v a n c e d c a s e s a r e a c c e p t e d f o r o p e r a t i o n t h e i n t e r p r e t a t i o n o f t h e 11good c a s e 1' w i l l b e mo r e l i b e r a l .

88 In r e p o r tin g t h i s

s e r i e s t h r e e g r o u p s h a v e “b e e n a d o p t e d ,

I . THE GOOD CHRONIC „ in filtrativ e extensive, sized

lesions

in one o r b o th l u n g s a r e n o t

a r e q u i e s c e n t an d t h e a i m i s

cavity

X-Ray f i l m )

Wh e r e t h e

(not g r e a t e r than

4

to

c lo s e a moderate

cm, d i a m e t e r i n t h e

th e re being novevidence o f c a v i t a t i o n

contralateral i n good h e a l t h

lu n g . These p a t ie n t s w i l l u s u a lly

in th e

remain

f o r l o n g p e r i o d s when l i v i n g a t home w h e r e

t h e y can be a l l o w e d to

remain w h i l s t a w a itin g t h e i r t u r n

on t h e o p e r a t i n g l i s t , II.

THD POOR CHRONIC,

i s mo r e e x t e n s i v e ,

the cavity

i s g r e a t e r t h a n 4 cm, o r

t h e r e may b e two o r mo r e c a v i t i e s , contralateral

w hilst

or the le sio n

in th e

l u n g may b e e x t e n s i v e a n d c a v i t a t i o n p r e s e n t

even i f n o t s e e n in t h e frequently

Whe r e t h e d i s e a s e

film . P a tie n ts

r e m a i n s t a b l e and i n f a i r l y

in t h i s

group

good c o n d i t i o n

i n s a n a t o r i u m b u t when t h e y r e t u r n home a r e 1 i a b l e

to p e r i o d s o f i l l

health resulting

III.

in rapid d e te r io ra tio n ,

THT? DDT DR! ORATING CHRONIC.

In t h i s

g r o u p a r e t h e c a s e s w i t h e x t e n s i v e a n d mor e a c t i v e d i s e a s e and c a v i t a t i o n

in one o r b o th lu n g s ,

b e i n g c o n f i n e d to b e d ,

fre q u en tly w ith a continued

elev atio n o f tem perature, P atients

in th is

the p a t ie n t o fte n

p u l s e and s e d i m e n t a t i o n

rates.

group a r e n o t only bad r i s k s because

o f t h e i r lung d is e a s e b u t in a d d itio n are fre q u e n tly poor risks

fo r a m ajor o p e r a tio n . In grouping cases not only

is the extent

a nd q u a l i t y o f t h e p u l m o n a r y l e s i o n s patient*s

age,

general condition,

tuberculous h isto ry

are also

and l e n g t h o f t h e

taken into

Of t h e 100 c a s e s , thoracoplasties,

a s s e s s e d "but t h e

account.

2 wer e b i l a t e r a l

2 revision operations,

9 f ° r tuberculous

and mixed empyemata and i n a l l t h e r e wer e 2^9 o p e r a t i o n s t a g e s . Two p a t i e n t s h a v i n g to w a i t s e v e r a l months f o r t h e i r f i n a l s t a g e s were by a r r a n g e m e n t t r a n s f e r r e d to t h o r a c i c c e n t r e s n e a r t h e i r homes. T h e r e was one c a s e c o m p l i c a t e d by known d i a b e t e s c o n t r o l l e d by i n s u l i n u n i t s XXX t h r e e t i m e s d a i l y . The 9 empyema c a s e s a r e n o t the

follow ing ta b le s

g r o u p . Of t h e

b u t ^vill be r e f e r r e d

to

as a s e p a r a t e

r e m a i n i n g QI c a s e s 40 w e r e p r i m a r y

t h o r a c o p l a s t i e s ’ 35 h a d a n a r t i f i c i a l these

included in

pheumothorax t r i e d ,

i n c l u d e d t h o s e c a s e s w h e r e a p n e u m o t h o r a x was

in d u c ed b u t abandoned a f t e r th o ra c o sc o p y

In fav o u r of

t h o r a c o p l a s t y l 1 6 c a s e s had had a p r e v i o u s pneum othorax e x t e n d i n g f r o m a few m o n t h s t o

s e v e r a l y e a r s , A pneumo-

peritoneum preceded 8 o f th e thoraco p l a s t i e s 0 I t i n t e r e s t i n g to

is

note t h a t 8 o f the p a t i e n t s had been

d i s c o v e r e d by ma s s r a d i o g r a p h y and t h o r a c o p l a s t y represented

their in itia l

treatm ent.

At some t i m e f o l l o w i n g , t h e o p e r a t i o n 6 p a t i e n t s had a p h r e n i c c r u s h p erfo rm e d on t h e

same

s i d e w i t h i n 5 t h e a d d i t i o n o f a pneumoperitoneum..

TABUS I . AGS GROUPS. Age (years;

No. o f p a t i e n t s , * « 4 t e a t e t i W J * ‘. a « ; i i r 4 j e 3 « « E « r s i f t * f c i » c i* t = i * » C 3 t ! O c = a c 3 « s i « = 3 c a p ! ^ « F a « ^ * « i c » c ? 3

X5“ " 2 0 .

6.

21 “ “ 3 0 ,

46.

3 1 - "4o.

35 .

4 1 — 50.

4.

Q c j r a p a i S J c a i C T c s c i c s t f S t a t e a c a E j i a c i S c j C J a a c j O T O B S C j e a s a r a o e s r a M f i H r t t i i i s f i r a i s t o r s c a c s c a c i B S

Th e y o u n g e s t 1 8 , Males 8I * F e m a l e s 19« Patients districts

t h e o l d e s t 49•

came f r o m h o t h u r h a n a n d c o u n t r y

and p r i o r to t h e i n t r o d u c t i o n o f t h e n a t i o n a l

H e a l t h S e r v i c e were drawn,,from a wide a r e a , L incolnshire,

H orfolk,

London,

a n d Y o r k s h i r e 0 The o c c u p a t i o n s a s w o u l d h e

e x p e c t e d v a r i e d c o n s i d e r a b l y i n c l u d i n g m e mb e r s o f labouring,

clerical,

t e c h n i c a l and p r o f e s s i o n a l c l a s s e s « TABLE 1 1 o

THE SIDE OPERATED OH AHD THE HUMBER OF RIBS REMOVED„ Ribs r e s e c t e d . Ho o o f oases, Right L eft,

.

2

3

4

5

6

7

10

8

41

I

2

1 13

I

13

6

4

52

X

0

0 XI

3

24

8

5

Two w e r e b i l a t e r a l c a s e s .

TABLE I I I . THE RESULTS ACCORDING TO THE THREE GROUPS ADOPTED.

Sputum Deaths N e g a t i v e Sputum NOoOf I mmedC a v i t i e s P o s i t i v e ImproveCases i a t e L ate Closed Improved me n t 1 Good C hronic,

24

1

0

22

I

0

2 Poor C hronic,

54

1

2

35

15

I

3 D eterio rating Chronic,

13

3

2

3

4

T

The st& t© o f t h e sputu m i s t h a t on t h e d isch arg e o f the p a t ie n t

from s a n a t o r i u m and sputum

n e g a t i v e means t h e r e h a v e b e e n r e p e a t e d s p e c i m e n s exam in ed by b o t h d i r e c t s m e a r a n d c u l t u r e . The r e s u l t s 91 c a s e s

9 have

died,

a s a w h o l e show t h a t o f t h e

6 d e a t h s b e i n g a t t r i b u t a b l e to

o p e r a t i o n . T h e r e a r e 60 w i t h n e g a t i v e s p u tu m and i n whose X-Ray f i l m c a v i t i e s

a r e no l o n g e r v i s i b l e .

T h e r e a r e 20

r e m a i n i n g s p u t u m p o s i t i v e b u t i m p r o v e d a n d 2 show no improvement„ The f i g u r e o f 6 5 09% c o n v e r t e d t o

sputum

n e g a t i v e r e v e a l s t h e e f f e c t s o f o p e r a t i n g o n many P o o r and D e t e r i o r a t i n g

cases,

a. p r o c e d u r e c o n s i d e r e d f u l l y

j u s t i f i e d by t h e m a r k e d i m p r o v e m e n t w h i c h h a s e n s u e d . Deaths have been s e p a r a te d in to

immediate,

92 t a k i n g p l a c e w i t h i n t h r e e months o f o p e r a t i o n and l a t e , t a k i n g ple-ce a f t e r t h r e e m o n t h s . TABLE I V , CAUSE OH DEATH

DEATHS

TIME POST-OPERATIVE

10 2, 3, 4,

Sho o k , Shook, Paradoxical re sp ira tio n S p r e a d o f d i s e a s e and wound i n f e c t i o n , 5o P u l m o n a r y t u b e r c u l o s i s a n d wound i n f e c t i o n ,

IMMEDIATE,

(W ithin th re e months o f operation) 1 t i s wSm t£2t ‘

9 ca a

cs es

a . £» o

ces

«* bd a

ta ca R

b «£*) CS9

a

B

(Z3 C 3 C 3 i

3 months

6 months 8 months year I y©a,r 10 mo n t h s I

i c ^ n ^ i i ^ o e s o c i i

The f i r s t

two d e a t h s a t t r i b u t e d t o

o c c u r r e d i n a P o o r G r o up b i l a t e r a l th e second s ta g e ,

7 days

ca ca cs ra e,u cs cn cs ca «

6, C h r o n i c pulmonary t u b e r c u l o s i s and t u b e r c u l o u s wound i n f ectioni0 7o T u b e r c u l o u s b r o n c h o ­ pneumonia, 8 , C h ro n ic pulmonary tuberculo s i s , 9« T u b e r c u l o u s m e n i n g i t i s .

LATE ( o v e r 3 months after operation)

■f h o u r I'|- h o u r s 40 h o u r s

the f i r s t

thoracoplasty

shock after

s id e h a v i n g been o p e r a t e d on

f i v e months p r e v i o u s l y * and i n a t o x i c D e t e r i o r a t i n g c a s e a f t e r t h e t h i r d s t a g e , N e i t h e r r e c o v e r e d from th e a n a e s t h e t i c which c o n s i s t e d o f cy clo p ro p an e,

gas and

o x y g e n a n d s i n c e t h e n no s u c h t o x i c c a s e h a s b e e n g i v e n g e n e r a l a n a e s t h e s i a , The t h i r d d e a t h w a s t h e m o s t d i s t u r b i n g b e i n g a Good C h r o n i c Groux:> p a t i e n t ,

a female,

f o l l o w i n g a two r i b s e c o n d s t a g e . The c a u s e o f d e a t h i s not s a t i s f a c t o r i l y

e x p l a i n e d and p o s t - m o r t e m e x a m i n a t i o n

93 was r e f u s e d hy t h e r e l a t i v e s , , D e a t h s f o u r and. f i v e , a f t e r f o u r t h and second s t a g e s r e s p e c t i v e l y , wer e ho.th i n t o x i c c a s e s from t h e D e t e r i o r a t i n g Group and i t i s f e l t t h a t wound i n f e c t i o n was a c o n t r i h u t o r y c a u s e . Case s i x was r e f e r r e d to u n d e r O p e r a t i v e a c c i d e n t s c The t h r e e r e m a i n i n g d e a t h s , one D e t e r i o r a t i n g ' and two P oo r C h ro n ic Groups r e q u i r e no comment0

Tahle V concerns the c o n d i t i o n o f th e c o n t r a l a t e r a l l u n g where t h e r e was e i t h e r an a r t i f i c i a l p n e u m o t h o r a x p r e s e n t , o r where i t s l e s i o n was e x t e n s i v e , o r had shown a c t i v i t y w i t h i n t h e t h r e e months h e f o r e o p e r a t i o n . In a l l cases not included in t h i s t a h l e the c o n t r a l a t e r a l l u n g gave r i s e to no a n x i e t y t h o u gh i t may have c o n tain ed d i s e a s e .

TABLE Y* THE CONDITION OF THE CONTRALATERAL LUNG AS JUDGED BY CLINICAL AND X-PAY EXAMINATION*

No * o f cases

ACTIVE OR ^ extensively DISEASED

No c a v i t y detected

14

Cavity present

14

Sputum negative cavities clo sed i n "both lungs

8

S p u t um po s i t i v e improved

■CONTRA­ LATERAL ' A Pn . BKKSENT

10

Cavity present Included

£2

[T~*1»*"•»(£□*iOV3 *C3

8

I

0

I

3

0

in th e a c t i v e ,

the "b ilateral

o

3

I c3 < £ 9« £ 3 O 23C®C3 V 3 *154

0

group i s

result*

A l l t h e s e c a s e s w ere from P o o r o r

95

D e t e r i o r a t i n g G r o u p s , T a b l e V shows t h a t o f t h e 67 c a s e s c o m p r i s i n g t h e s e two g r o u p s

( T a b l e XIX ) i n 42 t h e

c o n t r a l a t e r a l l u n g h a d e i t h e r e x t e n s i v e d i s e a s e o r an artificial

pneumotho r a x p r i o r to o p e r a t i o n *

cases w ith a c o n tr a la te r a l no c a v i t y d e t e c t e d o n l y

artificial

37

p n e u m o t h o r a x and

5 c o u l d be s a i d

an x iety about th e o p e ra tiv e procedure.

Of t h e 10

to

g iv e r i s e to

no

In th e rem aining

cases the conai tion o f the c o n t r a l a t e r a l

o c c a s i o n f o r c o n c e r n . Such a s t a t e m e n t a l s o

lu n g gave im plies

that

t h e l u n g t o b e o p e r a t e d on was i n a g r a v e c o n d i t i o n , THE CONTRALATERAL LUNG„ ACTIVE OR EXTENSIVELY DISEASED GROUP. c o n s i s t s o f 2d c a s e s o f w h i c h 14 h a v e b e e n r e n d e r e d s p u t u m n e g a t i v e * O n l y o n t h r e e o c c a s i o n s h a s l i t b e e n c o n s i d e r e d n e c e s s a r y d'r? a d v i s a b l e to in d u c e a c o n t r a l a t e r a l operation*

pneumothorax f o l l o w i n g t h e

I n two o f t h e s e n e g a t i v e s p u t u m a n d h e a l i n g

h as been ac h iev e d but in th e t h i r d

case,

e x te n siv e adhesion s e c tio n the ca v ity enlarge?

although the th o raco p lasty

closed th is other

is

even a f t e r

c o n t i n u e d to

l u n g c a v i t y was

c o n s i d e r e d a c a s e o f no i m p r o v e m e n t 0 The

c a s e s r e m a i n i n g s p u t u m p o s i t i v e h a d so much

c o n t r a l a t e r a l •l u n g i n f i l t r a t i v e even i f

d is e a s e t h a t pneumothorax

i t w e r e p o s s i b l e was c o n s i d e r e d d a n g e r o u s ,

thoracoplasty

lung because of i t s

e x t e n s i v e d i s e a s e and

c a v i t a t i o n was n o t made s p u t u m n e g a t i v e . g ro up s a r e most o f t h e

or the

In th e se

gravest risk p a tie n ts

two

t h a t were

u n d e r t a k e n a n d d e a t h s 1 , 2 , 4 , 6 and 9 w e r e a m o n g s t t h em , The g r o u p CONTRALATERAL ARTIFICIAL PNEUMOTHORAX PPESENT i s

s h a r p l y d i v i d e d . Wh e re no c a v i t y

w a s p r e s e n t 8 o u t o f 10 b e c a m e s p u t u m n e g a t i v e w h e r e a s o n l y one i s cavity

s p u t u m n e g a t i v e o u t o f f o u r w i t h a known

in th e

contralateral

artificial

pneumothorax lu n g .

E x c e p t f o r t h e 5 c a s e s n o t e d above t h e d e c i s i o n w h e t h e r to o p e r a t e o r n o t o n p a t i e n t s

in t h i s

g r o u p was a d i f f i c u l t

o n e t o make* O n l y o n e c a s e h a d an a d h e s i o n f r e e p n e u m o t h o r a x . O t h e r c a s e s had had t h e l u n g f r e e d as f a r as p o s s i b le

in t h i s o r o t h e r i n s t i t u t i o n s , A l l had

extensive disease

and t h e m a j o r i t y h a d a t h i c k e n e d p l e u r a

w i t h p o o r l u n g e x p a n s io n on r e s p i r a t i o n . had w e l l marked a r e a s o f a t e l e c t a s i s

Six cases also

amounting a p p a re n tly

to a c o m p l e t e l o b e i n t h r e e . Two o t h e r s h a d p o o r pneumo t h o r a c e s o f s e v e r a l y e a r s d u r a t i o n w i t h n u m e r o u s adhesions,

thickened

p l e u r a and c o l l a p s e d a r e a s ; n e i t h e r

had had a t h o r a c o s c o p y p e r f o r m e d . S everal o f th e se cases b e a r o u t the s t a t e m e n t s made i n "The I n d i c a t i o n s

f o r Tho r a c e p l a s t y 11 „

T h e i r i n e f f e c t i v e p n eu m o th o ra ce s had l e d to

fluid

f o r m a t i o n and p l e u r a l t h i c k e n i n g and w i t h t h e p ulm onary le s io n never e ffe c tiv e ly

c o n t r o l l e d t h e d i s e a s e had

e v e n tu a lly produced e x te n siv e le s io n s w ith c a v i t a t i o n the o th e r lung. D espite t h e i r extensive b i l a t e r a l d i s e a s e t h e s e p a t i e n t s h a v e good r e s i s t a n c e

fo r they

in

97 r e p r e s e n t t h e s u r v i v o r s o f many who d i e f o l l o w i n g s i m i l a r c o m p l i c a t i o n s „ They were many o f them c a s e s t r e a t e d u n d e r t h e d i f f i c u l t i e s o f war t i m e o r g a n i s a t i o n . I nd e ed i n two c a s e s i t was n o t p o s s i b l e f o r t h e l o c a l a u t h o r i t y c o n c e r n e d to t r a c e t h e X-Ray f i l m s o f t h e p a t i e n t t a k e n b e f o r e t h e p n eu m ot h or ax was i n d u c e d . Had i t b ee n p o s s i b l e to a ba ndon e a r l y t h e i r i n e f f e c t i v e pneumothorax; and s u b s t i t u t e a t h o r a c o p l a s t y t h e y would n o t ,

I believe,

h a v e i l a t e r had a s p r e a d to t h e o t h e r l u n g 0 I n f i v e e a s e s w i t h b i l a t e r a l d i s e a s e i t was c o n s i d e r e d e s s e n t i a l to c o n t r o l t h e c o n t r a l a t e r a l l u n g w i t h a p neu mo th or ax b e f o r e p r o c e e d i n g w i t h t h e t h o r a c o p l a s t y . Four o f t h e s e were t o x i c c a s e s o f v e r y poor p r o g n o s i s ? one d i e d f o l l o w i n g t h o r a c o p l a s t y

( d e a t h no. 5 ) ,

t h e o t h e r s a r e a l l w e l l t h o u g h o n l y one i s sputum n e g a t i v e ? two a r e w o r k i n g . A l l c a s e s grouped i n T a b l e V, p a r t i c u l a r l y t h o s e w i t h a c o n t r a l a t e r a l pneumot horax, p r e s e n t t h e p r o b l e m o f d e c i d i n g how much t h o r a c o p l a s t y c o l l a p s e can be u n d e r t a k e n . The e x t e n t to which t h e c o n t r a l a t e r a l l u n g i s a f f e c t e d f r e q u e n t l y l i m i t s t h e o p e r a t i o n to a f i v e r i b r e s e c t i o n i n s t e a d o f s e v e n which may r e p r e s e n t t h e i d e a l . E x c e s s i v e t h o r a c o p l a s t y c o l l a p s e i n t h o s e c a s e s may l e a v e the p a tie n t a re sp ira to ry c rip p le.

SIX ADVANCED CASTS. A description

follow s o f six cases o f

advanced pulmonary tu b e rc u lo s i s

su b m itte d to

tho r a c o p l a ,s ty 0

T h e s e a r e e x a m p l e s o f many P o o r a n d D e t e r i o r a t i n g C h r o n i c s who h a v e "been a c c e p t e d f o r o p e r a t i o n 0 I n t h e s e six cases a negative

sputum h as been a c h i e v e d ,

Case 1 0

X - R a y s f i g s . 13 and 14 „

Class i f i c a t i o n , D eteriorating

chronic.

Previous a r t i f i c i a l

pneumothoraxa

C o n tr a la te r a l lung,

a c t i v e f no c a v i t y

H 0A oPo a g e

seen 0

c a rp e n te r. M arried w ith

c h i l d r e n . A d m i t t e d to t h e s u r g i c a l b l o c k o n 2 5 t h A p r i l 1 9 4 6 , D e v e l o p e d pulmona. ry t u b e r c u l o s i s m ilitary

s e r v i c e , Twice p r e v i o u s l y

artificial

i n lg 4 4 during;

in sanatorium .

Right

p n e u m o t h o r a x i n d u c e d J u l y 1944 s a d h e s i o n

c a u t e r y a s f a r a s p o s s i b l e Ma r c h 1 9 4 5 . R i g h t a r t i f i c i a l p n e u m o t h o r a x a b a n d o n e d Nov embe r 1 945 a s d a n g e r o u s b e c a u s e o f numerous c a v i t i e s . D u rin g a l l had a t u b e r c u l o u s l a r y n g i t i s

this

tim e he

t r e a t e d by l o n g p e r i o d s

of silence. On a d m i s s i o n . w e i g h t Qst 6 l b s , , pulse ra te daily,

General c o n d i tio n poor,

t e m p e r a t u r e r a n g e 97

6 d ~ 7 2 0 B „ S 0R 0 2 0 / 2 0 0 1 s t h o u r .

p o s i t i v e . V i t a l c a p a c i t y 2,500

to 9

9

p 0m„,

S p u t u m 6 “ 10 0 2 s ,

c „c Be He was t o x i c

c o n f i n e d t o b e d and i n c l i n e d t o b e m o r o s e .

99 The p a t i e n t was o bv io u s l y the

right

increase

and t h e l e f t

c l e a r showed a l e s i o n w h i c h c o n t i n u e d t o

i n s i z e up to t h e t i m e o f o p e r a t i o n ,

being suspected cavities

go i n g d o w n h i 1 1 ,

lu n g c o n t a i n e d numerous c a v i t i e s

lung p re v io u sly



in t h i s

l e s i o n . The l a t e r a l

cavitation

f i l m showed

i n b o t h u p p e r and l o w e r l o b e s o f t h e r i g h t l u n g .

D e c i s i o n t o p r o c e e d w i t h t h e t h o r a c o p l a s t y was t a k e n . O peration„ 1st

stage

r i g h t tho raco p l a s t y

2 l s t August

194 6 , R e s e c t i o n o f r i b s 1 , 2 , 3 a n d p a r t o f 4 w i t h e x t r a f a s c i a l m o b i l i s a t i o n , Small p l e u r a l

tear

sutured.

2nd s t a g e 4 t h S e p t e m b e r 1 9 4 6 . R i b r e s e c t i o n 4,5,6,^nd 7 . Paradoxical

respiration

troublesom e post-

0peratively, 3rd s t a g e l 3 t h Septem ber 1946. Rio r e s e c t i o n 8,9,

and 1 0 0 4 t h s t a g e 2nd O c t o b e r 194 6. A n t e r i o r

supplementary o p e r a tio n .

R i b s and p a r t o f

costal

c a r t i 1 a g e 8 o f 3» 4, 5 a n d 6 r emo v ed s A naesthesia.

S tag e s 1 to

3 local,

s t a g e 4 P e n t o t h a l , gas

an d o x y g e n . A fte r the tem perature

r o s e to

a f t e r the subsequent where i t

first

101 i n t h e stages

it

and s e c o n d s t a g e s t h e evenings fo r gradually

t e n days b u t

fell

to 9b«8

r e m a i n e d f o r t h r e e m o n t h s when i t w as d e c i d e d

to p a r a l y s e t h e r i g h t d i a p h r a g m dome. 6 t h j a n u a r y X9 4 7 . R i gh t p h r e n i c c r u s h w i t h

xoo r e s u ltin g diaphragm atic p a ra ly s is .

From t h i s

tim e on t h e

t e m p e r a t u r e and p u l s e w e r e n o r m a l . T h i s p a t i e n t a l w a y s h a d a s l o w p u l s e and w h e n w e l l o f t e n sh owed a r a t e o f o n l y 52,

Six: m o n t h s a f t e r o p e r a t i o n s p u t u m wa s a t r a c e and

negative. to

S h o r t l y b e f o r e h i s d i s c h a r g e i t was d e c i d e d

re-crush his

r i g h t p h r e n i c n e r v e as a p r e c a u t i o n *

was s u c c e s s f u l l y p e r f o r m e d and h e l e f t

this

s a n a t o r i u m on 1 4 t h

O c to b e r 1 3 4 7 , Weight g e t 7 . B . S . R . 2 , F o l l o w i n g o p e r a t i o n he became a c h e e r f u l i n d i v i d u a l an d f o r e i g h t e e n m o n t h s h a s now b e e n w o r k i n g at his

former t r a d e .

101

C a e e I . H .A .P .

1 2 .7 .4 6

P r i o r to o p e r a t i o n . F ig . 13.

4 V MEDICAL'y

^ ^ I B RARV ^ #

#

*

Case I . H . A . P ,

2 3 * 5 * 4,9*

2 y e a r s 7 months a f t e r o p e r a t i o n . F ig . 14.

Case 2.

X-Rays f i g s . 1 5 and 1 6,

Class i f i c a t i o n ,

D eteriorating chronic „ P r e v i o u s a r t i f i c i a l p n eu mo th o r ax . C o n t r a l a t e r a l lung, J.F.W.

active,

a g e 32,

cavity p re sen t.

telephone

engineer. M arried.

A d m i t t e d to t h e s a n a t o r i u m November 1945* D e v e l o p e d pulmonary t u b e r c u l o s i s

i n J u n e 19 45 d u r i n g m i l i t a r y

service. Left a r t i f i c i a l

p n e u m o t h o r a x i n d u c e d O c t o b e r 19 4 5 ,

a b a n d o n e d N ov e mb e r I Q45 b e c a u s e o f b a l l o o n i n g c a v i t y . On a d m i s s i o n . w eight l i s t

5l h s .,

condition

fairly

t e m p e r a t u r e ran g e 9 7 *9 9 * p u l s e

7 6 - 8 8 , B . S . R . I ? . Sputum lo z . , in both lungs

General

continued

to

positive.

g ood,

rate

The- d i s e a s e

sp rea d and b e f o r e o p e r a t i o n

t h e t e m p e r a t u r e was 97 * 4 t o 9 9 »6 , p u l s e 8 4 - 1 0 0 , S . R . 35° Sputum r a t h e r more. V i t a l c a p a c i t y

3 *2 0 0 .

O peration. 1st stage l e f t Rib r e s e c t i o n 1 , 2 , 3 m obilisation. frothy

thoracoplasty

3r d July 1946.

and p a r t 4 w i t h e x t r a - f a s c i a l

Follow ing o p e r a tio n i n c r e a s i n g dyspnoea,

sputum and c o n t i n u e d h i g h p u l s e r a t e

shown t o b e d u e to a i r p r e s u m e d due t o

(1 2 0 ) were

in the l e f t p le u r a l ca v ity ,

an u n n o t i c e d

tear.

Symptoms s u b s i d e d

follow ing a s p ira tio n o f a i r , A p e r m a n e n t H o r n e r ’ s Syndrome r e s u l t e d from t h e o p e r a t i o n . 2nd s t a g e 1 9 t h J u l y 1 9 4 6 , R i b r e s e c t i o n

104 4 , 5 , 6,7

t

p l e u r a t d r n b u t r e s u t u r e d and a i r a s p i r a t e d .

A n a e e t h e s ia. bo t h s t a g e s , l o o a l , B l o o d s t a i n e d f l u i d was a s p i r a t e d the p le u ra l cavity

from

48 h o u r s a f t e r 1 t h e s e c o n d o p e r a t i o n .

R e c o v e r y was u n e v e n t f u l a n d w i t h i n t e n d a y s t h e t e m p e r a t u r e was n o r m a l . The c o n t r a l a t e r a l l u n g improved b u t a sm a ll c a v i t y

r e m a in e d u n c l o s e d and f i v e

months a f t e r o p e r a t i o n a r i g h t a r t i f i c i a l pneumothorax w a s e s t a b l i s h e d . The c a v i t y d i s a p p e a r e d a n d s p u t u m b ec ame n e g a t i v e , * t h o r a c o s c o p y was c o n s i d e r e d u n w i s e i n v i e w o f the

ex ten siv e d is e a s e . Following th o ra c o p la s ty

the

p a t i e n t had s i x months bed r e s t . He wa s d i s c h a r g e d 7 ^ h O c t o b e r I Q 4 7 * weight l i s t

I l l b s „ ,B„S 0R. 5»

was worl-cing a t h i s

sputum a t r a c e ,

f o r m e r employment

w ith in

negative,

and

eix months.

E i g h t e e n months a f t e r l e a v i n g s a n a t o r i u m t h e p l e u r a i n the c o n t r a l a t e r a l a r t i f i c i a l

pneum othorax b e g a n to

show

m a r k e d t h i c k e n i n g . The a r t i f i c i a l p n e u m o t h o r a x was abandoned and t h e l u n g s u c c e s s f u l l y p a t i e n t remains w e ll.

r e - e x p a n d e d 0 The

—-------------------xo 5

a

Case 2 . J .F .W .

30.6.46.

P r i o r to o p e r a t i o n . F ig . 15.

.

Caee 2 . J . F . W . 1 5 . 4 . 4 9 . 2 y e a r e 10 Oionthe a f t e r o p e r a t i o n . F ig . 16.

107 Case 3 e

X - B a y s f i g s * 17 and i d „

Class! f ic a tio n , Poor chronic* Art i f i c i a l

pneumotho r a x t r i e d „

C ontralateral

lung,

extensively diseased,

cavity

present„ C.1S0H„ a g e 32* C i v i l e n g i n e e r * M a r r i e d * A d m itte d to

the

s u r g i c a l b l o c k 2nd A p r i l 1 9 4 6 * S e v e n

y e a r s h i s t o r y o f pulmonary t u b e r c u l o s i s artificial an d l e f t

f o r which a r i g h t

pneu m o th orax had been t r i e d w i t h o u t s u c c e s s

artificial

previously,

pneumothorax induced f i v e y e a r s

t h o r a c o s c o p y h a d shown t h i s

f r e e * As a s m a l l c a v i t y p e r s i s t e d p a /b ie n t had a marked l a r y n g i t i s ,

to

in t h i s

be a d h e s i o n l u n g and t h e

endo ~ b r o n c h i a l

t u b e r c u l o s i s was p r e s u m e d p r e s e n t . The p a t i e n t was u n d e r o b s e r v a t i o n b e f o r e a d m i s s i o n and i n v i e w o f t h e a p p a r e n t extensive

fibrosis

the l e f t

artificial

p n e u m o t h o r a x was

abandoned t h r e e months p r i o r to o p e r a t i o n *

For over a

y e a r h e h a d b e e n h a v i n g r e p e a t e d s m a l l haemo p t y s e s a n d h a d n o t b e e n c a p a b l e o f w o r k f o r s e v e n y e a r s * D y s p n o e a was marked and t h e p a t i e n t l i a b l e

to

repeated

severe attack s

of bronchitis* On a d m i s s i o n * C o n d i t i o n o n l y to h i s

f a i r due

l o n g t u b e r c u l o u s h i s t o r y * W e i g h t 9 s t* 2 1 b s 0,

t e m p e r a t u r e Q7“ 99» p u l s e 7 6 - 9 2 * B * S eR 045* S p u t u m J to l o z . , p o s i t i v a . X - P a y showed e v i d e n c e o f much f i b r o s i s in both lungs* V i t a l c a p a c ity

I , 60 O «

103 Operation* 1st 1946„ R e s e c t i o n m obilisation,

s ta g e r i g h t tho raco p l a s t y ribs

o f

1 6th A p ril

1 , 2 and 3 w i t h e x t r a - f a s c i a l

t i s s u e s h a r d and d i s s e c t i o n d i f f i c u l t .

F o l l o w i n g t h e o p e r a t i o n t h e r e was f o r t e n d a y s a g r a d u a l l y r i s i n g t e m p e r a t u r e to l o J * A specimen o f f l u i d extra-fascial

apace

was r e p o r t e d s t e r i l e .

from t h e

On t h e

tenth

day t h e r e was a d i s c h a r g e o f p u s f r o m t h e u p p e r t h i r d o f t h e wound

w ith

r e l i e f o f s y m p t o m s . The wound was

r e - s u t u r e d , P e n i c i l l i n was g i v e n i n t r a - m u s c u l a r l y fifth

from

day p o s t - o p e r a t i v e l y „ 2nd s t a g e 22nd May 1 9 4 6 , R i b s r e s e c t e d

4 , 5 , 6 and 7 * A n a e s t h e s i a , 1 s t general

stage lo c a l,

( P e n t b t h a l , gas and oxygen)

2nd s t a g e

in view o f t h e

previous se p s is . The p o s t - o p e r a t i v e

c o u r s e was u n e v e n t f u l

a n d t h e p a t i e n t d i s c h a r g e d on 2 0 t h S e p t e m b e r I Q 4 6 , w e i g h t Qs t

Q lh s

. ,B eS 0R *2 0 S p u t u m a t r a c e ,

l a t e r he r e t u r n e d operation

negative.

t o worlc a s a o i v i l

S ix months

engineer.

Since

t h e p a t i e n t h a s h a d no f u r t h e r a t t a o x s o f

b r o n c h i t i s and dyspnoea i s o n ly s l i g h t .

1 log

Case 3. C . E . E . I4. 4 - . - d 6. t

P r i o r to o p e r a t i o n . F ig . 17.

Ce.ee 3. C . F . H . 3 yeare

^

24.12.4-9.

month6 a f t e r o p e r a t i o n . F i g . Itt.

Ill Case 4 .

X-F.ays . f i g s . 19 and 2o .

C lassif ication, D e te rio ra tin g chronic . Primary t h o r a c o p l a s t y . C o n tr a la te r a l lung,

extensively

diseased,

cavity

present 0 .RoGo a g e 2 j s i n g l e . to t h e s a n a t o r i u m

6t h

J u ly 1945.

Railway c l e r k . Admitted

Developed pulmonary

t u b e r c u l o s i s one y e a r p r e v io u s l y w h i l s t

in m ilita ry

service. On a d m i s s i o n . The p a t i e n t was v e r y weight o s t 5 l h s ., 84.

S pu t u m

tem perature

0 z . , po s i l i v e . He was

p u lse 7 6 - 92, B.S.R. in bed f o r o v e r a y e a r

w ith bouts o f acute exacerb atio n o f h is by a t t a c k s o f p l e u r i s y , o u n c e s and f i n a l l y

d i s e a s e accompanied

o c c a s io n a l haemoptysee o f s e v e r a l

developed a tu b e rc u lo u s l a r y n g i t i s .

G ra d u a lly he improved b u t t h e r e were s t i l l relapse.

I n M a r c h I 9 47 h i s

periods of

c o n d i t i o n b e i n g much b e t t e r

a p n e u m o p e r i t o n e u m was e s t a b l i s h e d , his

ill,

and d e s p i t e

this

and

e x t e n s i v e d i s e a s e h e was a b l e t o wallc b r i s k l y w i t h o u t

d y s p n o e a . A f t e r much h e s i t a t i o n .a l e f t

t h o r a c o p l a s t y was

d e c i d e d u p on. P r i o r to o p e r a t i o n t h e g e n e r a l was f a i r , vital

w e i g h t Qst 4 1 b s t e m p e r a t u r e

capacity

2 , 5 0 0 . X-Ray s t i l l

d ise a se but in the l a t e r a l

condition

97- 9 8 .8 , B .S.P.20,

showed v e r y a d v a n c e d

f i l m t h e low er l o b e s were

s e e n to b e o n l y m o d e r a t e l y a f f e c t e d and p r o b a b l y w i t h o u t cavitation.

T he p n e u m o p e r i t o n e u m r e f i l l s

were d is c o n tin u e d .

XX2 O peration. 1st

stage l e f t

X947. R e s e c t i o n o f r i h s

thoracoplasty

X lth June

1 , 2 , 3 an d e x t r a - f a s c i a l m o b i l i s a t i o n

p e r f o r m e d w i t h some d i f f i c u l t y . 2nd s t a g e 4 and 5 w i t h

26t h June 1 9 4 7 , Rib r e s e c t i o n

fu rth e r m o b ilisatio n . Pulse

rate

140 d u r i n g t h e o p e r a t i o n w h i c h was t h e r e f o r e 3rd s t a g e 9^

rose

to

term inated.

J u l y 1 9 47 „ R i b r e s e c t i o n

6 and 7 w i t h f u r t h e r m o b i l i s a t i o n . A naesthesia a ll

stages,

local.

T h e r e was no f u r t h e r d i s t u r b a n c e an d b e d r e s t was m a i n t a i n e d f o r contralateral

f i v e m o n t h s . The c a v i t y

in the

l u n g was no l o n g e r s e e n a n d b e c a u s e o f t h e

e x t e n s i v e d i s e a s e a p n e u m o t h o r a x a t t e m p t was c o n s i d e r e d inadvisable. The p a t i e n t was d i s c h a r g e d o n 2nd May I 3 4 d , w e i g h t 9 s t B i b s 0 , B . 3 0R 0 2 0 S p ut um t r a c e , t h r e e months t h e p a t i e n t first

part

negative.

retu rn ed td h is

tim e. A ro u tin e

In

fo rm e r work,

at

f i l m on 2 6 t h J a n u a r y I 9 4 9

s ho w e d a new s m a l l a r e a o f a t e l e c t a s i s

in the r ig h t lung.

He was r e - a d m i t t e d a t o n c e . 2nd F e b r u a r y IQ4Q b r o n c h o s c o p y r e v e a l e d evidence of tuberculous b ro n c h itis the

i n both, l u n g s ,

chiefly

right. S t r e p t o m y c i n g m s . 34 w e r e g i v e n and o n

l e t J u n e X9 4 9 b r o n c h o s c o p y showed a l l

visible

bronchial

m u c o s a a p p a r e n t l y h e a l t h y . At no t i m e d u r i n g t h i s

relapse

1X3 was a p o s i t i v e

sputum o b t a i n e d . The p a t i e n t was a g a i n d i s c h a r g e d 2 l a t

A u g u s t 1 9 4 9 . He i s

a p a t i e n t who d o e s n o t l i k e

being

u n o c c u p i e d a n d t h r e e month© l a t e r was a l l o w e d t o to w o r k .

return

114

Case 4 . R.G. 1 3 . 5 . 4 7 . P r i o r to o p e r a t i o n . F i g . 19.

xx5

C a s e 4 . R . G. 1 6 . 0 . 4 0 . 2 y e a r e I month a f t e r o p e r a t i o n . 5

Fig 20.

II6 Case

X- Ray s f i g s 0 21 and 2 2 ,

C lassification, Poor chronico P r im a r y tho r a c o p l a s t y 0 C o n t r a la t e r a l lung,

active,

no c a v i t y

detected.

BoA.So a g e 3 7 . M a r r i e d . A r c h i t e c t * A d m i t t e d t o t h e s a n a t o r i u m o n 4 t h D e c e m b e r X946 w i t h a s i x months h i a t o r y o f pulmonary t u b e r c u l o s i s 0 On a d m i s s i o n h i s

c o n d i t i o n wa s f a i r ,

8 s t 13 l b s . , t e m p e r a t u r e and p u l s e n o r m a l l i m i t s , Sputum 4 o z s . , p o s i t i v e *

The d i s e a s e

increased w ith c a v ita tio n

w eight

B oS oB ol 5 0

in both lu n g s slowly

in the l e f t

and p ro b a b ly

in

the r i g h t 0 A p r e l i m i n a r y pneumoperitoneum in January I947o A lthough t h e l e f t stationary

the right s t i l l

was s t a r t e d

l u n g d i s e a s e became

c o n t i n u e d to

in c re a se but

p n e u m o t h o r a x was w i t h h e l d u n t i l a f t e r o p e r a t i o n * P r i o r to o p e r a t i o n t h e g e n e r a l c o n d i t i o n was i m p r o v e d ,

w e i g h t 9 s t I 2 1 b e 0, t e m p e r a t u r e 9 7 06 t o 9 8 *8 ,

BoS*Ro35o S p u t u m r e d u c e d i n q u a n t i t y ,

vital

c a p a c i t y 3 e 2OOo

O peration* 1st stage l e f t

th o ra c o p la sty 8t h October

1 9 4 ? ° Bib r e s e c t i o n 1 * 2 , 3 d w ith e x t r a * f a s c i a l m o b i l i s a t i o n to t h e a o r t i c

arch* P o s t - o p e r a t i v e X- Ray r e v e a l e d a i r i n t h e

l e f t p l e u r a l c a v i t y * T h i s was a s p i r a t e d a n d a f t e r w a r d s t h e t e m p e r a t u r e r o s e d a i l y to r e a c h 1 0 2 * 6 on t h e f i f t h

day when i t

fell

q u i c k l y t o t h e r a n g e 9 8 ^ 9 9 ° X-E&y

s u g g e s t e d t h i s was d u e t o l o w e r l o b e a t e l e c t a s i s 0 D u r i n g the

se co n d week sputum r a p i d l y

tw elve ounces d a i ly , but the basal

increased

to

being almost e n t i r e l y

approxim ately f r o t h y mucous,

s ha dow s e e n i n t h e e a r l i e r f i l m c l e a r e d * The s e c o n d s t a g e w a s d e l a y e d f o r t h r e e

weeks to fell

a l l o w t h e c o n d i t i o n to i m p r o v e . V i t a l

by 1 , 0 0 0

e 0o . a f t e r

the f i r s t

capacity

stage*

2nd s t a g e 2 Q t h O c t o b e r 1 9 4 ? o E x t r a - f a s c i a l s p a c e found to resected,

c o n t a i n b l o o d o l o t i n e x c e s s a mo u n t * R i b a

4 a n d 5 wi t h, f u r t h e r e x t r a - f a s e i & l m o b i l i s a t i o n *

P o s t - o p e r a t i v e X-Rays showed normal a p p e a r a n c e s b u t a g a i n t h e r e was f r o t h y mucous e x p e c t o r a t e d ,

up to

fifteen

ounce © i n t w e n t y f o u r h o u r s f o r s e v e r a l d a y s . 3 r d s t a g e 1 3 t h l o v e m b e r 1947® R i b s - r e s e c t e d 6 and 7 w i t h m oderate m o b i l i s a t i o n *

General

condition

d u r i n g t h e p o s t - o p e r a t i v e p e r i o d was n o t g o o d b u t t h e t e m p e r a t u r e wa s n o r m a l , o n t h e s e v e n t h d a y t h e r e was a c o m p l e t e b r e a k d o w n o f t h e w h o l e w o u n d 9 t h e r e was no o b v i o t u s s e p s i s * O p e r a t i o n i n t e r v a l was f o u r w e e k s d u r i n g w h i c h t i m e t h e wound d i d n o t h e a l * 4 t h s t a g e I X t h D e c e m b e r J. 9 4 7 * E x o i s i o n o f wound m a r g i n s * R i b s r e s e c t e d 8 , 9 a n d 10 a D r a i n a g e by tube, o f e x t r a - f a s c i a l

space fo r fo rty

P e n i c i l l i n was g i v e n i n t r a - m u s c u l a r l y t h e wound h e a l e d by f i r s t

intention.

eight hours. f o r f o u r d a y s and F r o t h y mu c ous

c o n t i n u e d t o b e coughed up and g r a d u a l l y

subsided over

th e n e x t t h r e e months. A naesthesia,

s ta g e s I to

3 local,

stage 4 general,

cy clo pro pan e and oxygen. S i x m o n t h s p o s t - o p e r a t i v e b e d r e s t wa s enforced,

th e c o n t r a l a t e r a l lung s t e a d i l y

im p r o v e d and

pneum othorax did n o t a p p e a r to be i n d i c a t e d * The p a t i e n t was d i s c h a r g e d o n 2nd N o v e mb e r 1 9 4 8 , w e i g h t 9&$ 9 3*^s o0B o8 oH o2 o S p u t u m t r a c e , S i x months l a t e r he r e t u r n e d to w o rk .

[email protected]*

119

I*

Ca s e 5. S . A . S . 4 . 1 0 . 4 7 . P r i o r to o p e r a t i o n . F ig . 21.

120

Ca s e 5. S . A . S .

3-4.49.

I y e a r ^ months a f t e r o p e r a t i o n . F ig . 22.

Case 6 0

X-Rays f i g s .

23 a n d 2 4 .

G lass i f l o a t ion . Poor chronic. A r t i f i c i a l pneumothorax t r i e d . C o n t r a l a t e r a l lung*

a r t i f i c i a l pneumothorax,

cavity presento A .L .G . age 33- M a r r i e d .

Insurance c le rk .

A d m i t t e d t o t h e s u r g i c a l b l o c k 1 2 t h N o v e m b e r 1947 * D eveloped pulmonary t u b e r c u l o s i s during m ilita ry

service,

four y ears previously

h a v i n g ; t h e same y e a r a l e f t

a r t i f i c i a l pneumothorax t r i e d ,

right a r tif ic ia l

pneum othorax in d u c ed and a d h e s io n s e c t i o n . The p a t i e n t was i n s a n a t o r i u m o n s e v e r a l o c c a s i o n s and a l e f t p h r e n i c n e r v e p a r a l y s i s was p e r f o r m e d i n O c t o b e r 1 9 4 6 . D u r i n g t h e s e y e a r s mor e c a v i t a t i o n a p p e a r e d in both lungs,

t h e i n c r e a s e o f d i s e a s e and t h e c a v i t y

appearing in the collapsed rig h t lung being considered a s e r i o u s omen. On a d m i s s i o n , 6 l b s . 0t e m p e r a t u r e

two o u n c e s ,

97 . 6 t o

condition f a ir ,

weight 9 s t

99*2.. B o S o R . 2 3 . S p u t u m o n e t o

p o s i t i v e . Xs**Ray l a t e r a l

f i l m showed,

u p p e r l o b e c a v i t y i n t h e a n t e r o “l a t e r a l

segment,

th e p re se n c e o f a d o r s a l lobe c a v i t y . A 1.5cm.

the l e f t and a l s o

cavity

was s e e n i n t h e p o s t e r o ^ a n t e r i o r f i l m i n t h e r i g h t l u n g m i d z o n e . Y i t a l c a p a c i t y was 2 , 7 0 0 . O peration. 1 s t s t a g e l e f t t h o r a c o p l a s t y 4 t h December

1 9 4 7 o B i b r e s e c t i o n 1 , 2 and 3 . E x t r a ® f a s c i a l m o b i l i s a t i o n w ith d if f ic u lty ,

sym pathetic cord d e l i b e r a t e l y

during d is s e c tio n . P le u ra l te a r, a d h e r e n t to p l e u r a ,

tear

l u n g s e e n to be w id e l y

s u t u r e d . D i s s e c t i o n c a r r i e d down

to and p a r t l y o f f t h e a o r t a u n t i l P ostoperative and s e t t l i n g

divided

s o ft lung reached.

r e a c t i o n w i t h t e m p e r a t u r e r i s i n g t o 101

quickly a f t e r the t h i r d day. 2 n d s t a g e 1 7 t h D e c e m b e r 1 9 4 7 . Wound

u n h e a l t h y l o o k i n g . Bib© r e s e c t e d , was g i v e n i n t r a - m u s c u l a r l y

4 , 5 d 6 and 7 . p e n i c i l l i n

f o r fo u r days p o s t ^ o p e r a t i v e l y .

On t h e t e n t h d a y t h e r e w a s - a s e r o u s l o o k i n g d i s c h a r g e f r o m t h e u p p e r e n d o f t h e wound b u t no f u r t h e r t r o u b l e . Local a n a e sth e sia fo r both stag es. The c a v i t i e s c lo se . P a tie n t discharged

i n b o t h l u n g s a p p e a r e d to

S la t

5 l b s op B 08 «R 02 0 S p u t u m t r a c e ,

August 1948, w e ig h t 9 s t negative.

S i x months l a t e r

t h e p a t i e n t s t a r t e d work f o r a f i r m as a t r a v e l l i n g representative pneumothorax i s

d r i v i n g h i m s e l f by c a r . The c o n t r a l a t e r a l s t i l l , m aintained.

Ca s e 6 . A L.G. 3 0 . I I . 4 7 .



P r i o r to o p e r a t i o n . Fifc. 23.

V

___________

124

Case 6 . A . L . G . 2 6 . 4 . 4 9 . I y e a r 4 months a f t e r o p e r a t i o n . V

Fig.

24.

COMMENTARY„ T h e r e was c o n s i d e r a b l e d i s c u s s i o n o n a l l these

c a s e s b e f o r e a f i n a l d e c i s i o n was t a k e n to a c c e p t

them f o r o p e r a t i o n . The c h i e f f e a t u r e i n c a s e I w a s t h e t o x a e m i a and d e t e r i o r a t i o n

th e c o n t r a l a t e r a l lung although

sh o w in g a l e s i o n i n c r e a s i n g i n s i a e was n o t e x t e n s i v e l y d i s e a s e d Q C a s e 2 s o me wh a t s i m i l a r , h a d c o n s i d e r a b l y m o r e contralateral

d i s e a s e „ T h e s e two c a s e s w e r e b e d p a t i e n t s

a t t h e time o f o p eration,,

case 2 having a t o t a l of

e i g h t e e n m o n t h s c o n t i n u o u s b e d r e s t « C a s e 5 was s i m i l a r t o 2 b u t w a s - w e l l e n o u g h to be up f o r f i v e h o u r s a d a y b e f o r e o p e r a t i o n , , The r e m a i n i n g t h r e e c a s e s w e r e o f a more c h r o n i c n a t u r e a l l and s u f f e r i n g

up a n d a b o u t b u t i n p o o r h e a l t h

f re q u e n t r e l a p s e s 0 In each o f t h e s e t h r e e

eases the c o n tra la te ra l

l u n g was e x t e n s i v e l y d i s e a s e d „

Case 4 h ad t h e most d i s e a s e b u t t h e course o f th e

smoothest o p e r a tio n

s i x * The m o s t a n x i e t y d u r i n g I t h e t h o r a c o p l a s t y

wa s c a u s e d by c a s e 5 „ t h e c o n t i n u o u s f r o t h y

sputum b e i n g

c o n s i d e r e d a sympt om o f p u l m o n a r y o e d e m a « A f t e r c o n s u l t a t i o n w i t h t h e p h y s i c i a n i t w a s d e c i d e d t o go a h e a d w i t h t h e r e m a i n i n g s t a g e s a n d i t was f o u n d t h a t t h e p u l m o n a r y o e d e m a was made no w o r s e, , Ho c a r d i a c wa s s u s p e c t e d b e f o r e o p e r a t i o n , ,

deficiency

but th e poor reserve

p r e s e n t was p r e s u m a b l y t h e c h i e f f a c t o r i n c a u s i n g t h e wo un d t o o p e n a f t e r

the th ir d s ta g e .

Th e s i x c a s e s

re p o r te d have a l l had a

successful

result

serious risks

from t h e i r o p e r a t i o n

d e sp ite the

in v o lv ed . There are c e r t a i n

features

in

c o n n e c tio n w ith a l l t h e s e p a t i e n t s which X f e e l have contributed

to

the r e s u l t s . F i r s t l y p theia? m e n ta l a t t i t u d e .

all

e a g e r f o r t r e a t m e n t and a l l

equally

They w e r e

a n x i o u s to work,

n o n e o f t h e m wa s o f a l a & y n a t u r e an d a l l w e r e f u l l y c o “O p e r a t i v e . Secondly* early

a l l had been s u p e r v i s e d from

i n t h e i r t u b e r c u l o u s h i s t o r y b y me mb er s o f t h e

sanatorium m edical s t a f f . Thirdly*

t h e t h o r a c o p l a s t y wa s u n d e r t a k e n

i n t h e p a t i e n t 9© own s a n a t o r i u m . To a c h i e v e a s u c c e s s f u l result

t h e s e d e t e r i o r a t i n g and grav e r i s k

c a se s must be

o p e r a t e d on in th e sanatorium, where th e y a r e b e in g t r e a t e d . It

i s n o t o n l y a q u e s t i o n o f s u p e r v i s i o n b y s t a f f who

know t h e m b u t t h e t r a n s f e r t o a n o t h e r i n s t i t u t i o n b r i n g s on a f a t a l r e l a p s e . transferred

X have seen to x ic

frequently

cases

from a c o u n t r y s a n a t o r i u m to a c i t y h o s p i t a l

fo r o p e r a tio n die quickly* open s a n a to r iu m wards to

th e sudden change

from t h e

the c ity atmosphere being f a t a l .

F u r t h e r m o r e i n t h e i r own h o s p i t a l t h e s e p a t i e n t s c a n b© o p e r a t e d o n a t t h e o p p o r t u n e moment*

a point o f g reat

im p o rta n c e . M e itn e r (1939) re p o rtin g : th e r e s u l t s o f f i v e aGUte c a s e s s u b j e c t e d t o

thoracoplasty

sim ilarly

em phasises

t h e n e c e s s i t y o f o p e r a t i n g on su c h c a s e s w h e r e t h e y a r e and a t t h e r i g h t

tim e.

127 T h e r e was n o t h i n g t o l o s e on t h e above s i x o a s e s .

In

in o p eratin g

a l l t h e e a r l y p r o g n o s i s was

e i t h e r g r a v e o r i n t h o s e who w e r e c h r o n i c i n v a l i d s u l t i m a t e l y h o p e l e s s B The c a v i t i e s

p r e s e n t i n a l l now a p p e a r

t o b e c l o s e d a n d t h e p r o g n o s i s i n c a s e s 1 * 2 * 3 ®*nd 6 c a n b e c o n s i d e r e d good*

c a se 5 f a i r and in 4 d o u b t f u l .

TABLE VI . EMPYEMA CASES.

The empy ema

S tate o f lu n g le s i o n s G eneral co n d itio n .

A ctiv e.

Q u iescen t

F a irly good

0

4

Poor

4

Tube situ

in

0

0

ranged

of

in

the

1

the p a t ie n t s

f r o m ’2 q t o

em pyem a c o m p l i c a t e d in f ectio n .

Im p ro v ed tube s till present Bead

I

The a g e s w ere m a les

Lungs h ea led empyema ^ cured Ho and t u b e no t u b e

41,

tube

a ll

o f whom

a ll

had tu b ercu lo u s

cases

by s e c o n d a r y

3

C auses o f d e a t h i n empyema o a s e s .

1 . H a e m o p t y s i s . P a t i e n t a g e 33® o c c u r r i n g s i x months a f t e r t h e t h i r d s t a g e

(six ribs)*

further

o p e r a t io n h aving been postponed because o f poor c o n d itio n . 2. age

C o n tra la tera l

2 3 * two w e e k s

co n firm ed

after

the

a telecta sis.

th ird

stage

(eig h t

o p era tio n

c o n d itio n

co m p leted . P a t ie n t

g o o d and

empyema s p a c e

The p a t i e n t w as up a l l that

h e had b een

co n firm ed n o r was

rib s)g

b y p o s t “m o r t e m . 3o T u b e r c u l o u s m e n i n g i t i s

after

P a tien t

day

post-m ortem *

to

taken

excess.

no p u l m o n a r y

a b r o n c h o “p l e u r a l

20*

b ecom in g

and w hen

sun b a t h in g

age

six

fistu la .

m onths

general sm a ller. ill

confessed

D i a g n o s i s was

c a v itie s

were

found

THE GOMPLICATXQHS AND EFFECTS OF THORACOPLASTY EH COOTTERED.

W hereas

i t - was

a c c i d e n t s w e r e more l i k e l y

d u rin g th e

co m p lica tio n s

of

second

Even t h e m ost

stage.

w eather th e (1947) w ell

in

th o ra co p la sty

fir st

stage

as

th e

th r e e w eeks b e fo r e in ter v a l o f

th e

a r e more

serio u s

second

fir st

two w e e k s h o w e v e r d o e s

co m p lica tio n s

su r g ica l

w ere

it

is

not

an i n t e r v a l

of

The m ore u s u a l

not

seem to

make

o p era tio n as

but

due

to

it

may b e f s e e n

i® u n c o m m o n .

th is

Two

as

cause.

th is* ,

more

tem p eratu re

is th e

tense* a x illa

common a f t e r

and p u l s e

cla v icle

ex tr& ^ fa seia l

tend

g ra d u a lly

There

is

fills

a lso

and b e n e a th

to

th e

fir st

rise .

stage*

The c h e s t

outward®

b u lg in g th e

s p a c e . W ith haem orrhage

above

scap u la*

th e

th is

p leu ra b en eath

resista n tJ

lu n g

chest

where w a ll

haem orrhages

soft*

lifte d

the

w a ll

sig n

of

is

hard

r e su lts.

th e

below

cla v icle*

i© d e c o m p r e s s e d

and d ysp n oea

c a u s e more u p s e t o f

th e

and on p a l p a t i o n

b e i n g m ore m arked when t h e

th e

in

site s. X . The

the

after

deaths

P O S T “OPERATIVE HAEMORRHAGE may o c c u r

in to

as

m ore l i k e l y .

c la ssifie d

three

th e

seem to

say

SHOCK p o © t ^ o p e r a t i v e l y any

stage*

H ix o n and G o etz

stage

stage.

o p era tiv e

common a f t e r

cases

and a d v i s e

second

that fir st

su c c e ssfu lly .

a paper on th e

to le r a te d

rem arked

general

in to

b u lg in g and

more t h a n

B ig h t

sid e

co n d itio n

131 and m ore

rise

in p u lse

on t h e more y i e l d i n g fillin g

the

in to

th e

the

by n e e d l e

and

wa© o p e n e d ruptured were

It

em p tied

th rou gh

taken

co n d itio n

to

p o in t

in

good th e

In is

req u ired .

film

the

theatre*

was

when t h e wound

a c o n tin u ed

m ovem ents l i m i t e d been

in

at

the

th e n ext

o n two o f

opened

th e

n in th

two day*

clea n ed

to

in ju ry

n eed le o r

to

th e

of

the

excess

cases the

b lo o d

p a tien ts

and t h e i r

o cca sio n s.

no

Ho

in te r fe r e n c e

susp ected

th ey

ar© o n l y

next

stage.

f r o m X^R ay d ia g n o sed

Haems.toma o f t h e

the sig n © slig h t

and symptom© h a v e b e e n

ev en in g tem p eratu re

b ecau se o f p a in . of

rise

m u scle.

stru ctu re

Its

a n d arm alw ays

presence

a n d m ay m a k e

su tu rin g

d iffic u lt.

tra ck in g

vessel

by t h e

d ow n f r o m t h e

In

the

The haem atom a h a s

th e wound.

o f an i n t e r c o s t a l b lo o d

a ir

c o m p le te d . B lo o d

3 o X n t r a -p le u r a l haem orrhage* due

a ll

sev erity

In

these

may b e

at

norm al m u sc le stage

a shadow

v e r y m arked b u l g i n g

th o ra co p la sty

freq u en tly

th e upper th ir d

d istu rb s

shows

found.

but

is

pressure

and

a sp ira te

sm a lle r haem orrhages

has occurred

same*

to

th e

th eatre.

2. th is

w ith

th e wounds

T h eir p resen ce

appearances

film

com pressed

t h e w o u n d s On t h e

the

b ein g

X -R ay

One c a s e w i t h

tr a n s fu s io n s were g iv e n b leed in g

v a ries

may b e p o s s i b l e

sy rin g e.

and

lu n g

due to

neck t i s s u e s .

T reatm ent haem orrhage.

p resu m ab ly

rig h t h eart.

space w ith

pushed upwards

rate*

w h i c h may b e a n a esth etic

e x tr a -fa sc ia l

ca

space

through

c o lle c tio n th e is

a sm all u n n o ticed

of

b lood

is

shadow c a u s e d by seen on

its

t h e X-Ray

e x p lo r in g n eed le

la rg e

in

and t h e

the

tear.

dyspnoea i s

presence

film

proves

p leu ra l

If

a sym ptom b u t

th e

p leu ra l

in tro d u ctio n and t h e

d ia g n o sis

the

ca v ity

of

an

b lood

is

a sp ira ted 0 B lood eith er

d u rin g o p e r a tio n

haem orrhage too

but o n ly

much b l o o d *

The more t o x i c tu b e rcu lo u s after T h is

each

stage*

o ccu rrin g . betw een

for

h a em o g lo b in

the

the

p a tien t

by

has lev el

th e

and a s e v e r e its

is

the

iron

to

as p o s s ib le .

a ro u tin e

to

th e

have is

b lo o d

lo st

m ade.

lo n g er

lo ss

th e

made up

a n a e m i a may d e v e l o p .

done to

b e made

as

or the

in

restlessn ess

therapy

correct

dyspnoea and th is

but b efo re get

as

th e

and b e

sle e p le ssn e ss a n a em ia fir st

stage

n e a r a m axim um

Braverm an

(1942)

la y s

great

on t h i s .

itse lf

p o st-o g era tiv ely

lnA t h e

p leu ral

dyspnoea* co n fir m s

X-Ray

fe lt

p a tie n t

PLEURAL TEAR u n n o t i c e d

w ith

g iv en

estim a tio n

w ake an i n c r e a s e

can be

to

not

a p o st-o p era tiv e

© low er i s

some o f

L ittle

effort

stress

in

stages

if

after

the o ld e r

h isto ry

resp o n sib le

or

is

when a h a e m o g lo b in or

may b r i n g

every

tra n sfu sio n

and the

by a

irr ita tin g d ia g n o sis

th e b lo o d film

ca v ity *

a cco rd in g

n ea rly

sh o w in g a i r

o p era tio n

show s

the

amount o f

a ir

co n tin u ed h ig h

cough w ith

and

froth y

a sp ira tio n

alw ays in

to

at

present

th e p le u r a l

of

p u lse

rate*

sputu m . X-Ray

th e

relie v e s ca v ity

a ir the has

a lo n g sym ptom s. a lso

on o c c a s io n and

shown a se g m e n t o r l o b e w h ic h

a sp ira tio n

a p p a ren tly th ere has settled

been

a sp ira ted

rise

be

pressure to

a ctin g

be

drawn case

fo llo w e d w h ich had

before

ATELECTASIS i s

it so

fin a lly

can o n ly

rise

to

s y m p t o m s . Many p o s t “O p e r a t i v e X - R a y s

in

a

film

lo b u la r

rep eated

d isa p p ea red . in v o lv in g groups*

A part

sym ptom !ess

th e

two o r

la te r

o p e r a t i v e X-Ray

from t h e s e *

and

stages*

ta k in g

weeks*

be

several

is

in to

the in 'th e

be up.

when i t

g iv es

show t h e

la rg e

may h a v e

area© o f

can b e d i v i d e d

a telecta sis

in to

two

to x ic . These

a r e m o r e common

b ein g d is c lo s e d

of

but

th is

area

is

recovery o f

by t h e

p ost­

w h ole

lu n g to

slow *

freq u en tly

lu n g

fu n ctio n

be

seem s

co m p lete. (b)

above

la te r

f i l m w h i c h , may s h o w t h e clea rin g

on th e

a r e a s o f c o l l a p s e w h ich days

S ym p tom less.

’’ a i r l e s s ' 5 . T h e

to

three

f o r by th e

th o ra co p la sty

a co m p lica tio n

segm ental

on© o r m o r e l o b e s

(a) after

or

to

com mon a f t e r

it

of

for

ea rly

d ried

th at

presence

co n sid ere d

has

accounted

In one P oor C h ron ic

tim es

be

ca v ity

te m p e r a tu r e w h ich h a s

T h is w ould

effu sio n

several

in

sputum p r e s e n t

b ro n ch i.

a telecta tic

tem p o ra rily w orse

in tra p leu ra l

any

a p leu ra l

p leu ra l

a telecta sis

tr o u b le .

n e g a tiv e

m ore d i s t a l

from t h e

a sudden

and c a u s i n g

series

a ir

made t h e

w ith o u t

in crea sed lu n g

of

is

but

the

d ysp n oeic*

T o x ic.

The X-Ray

p a t i e n t ha© a h i g h freq u en tly

cyanosed

appearances

tem perature

are

as

and p u l s e

and c o m p la i n s o f

p a in

rate*

a k i n t o ” s t i t c h ” i n t h e a f f e c t e d s i d e . The o n s e t o f sy mpt oms i s . u s u a l l y

s u d d e n o c c u r r i n g commonly b e t w e e n

48 a n d 7 2 h g u r s p o s t - o p e r a t i v e l y 0 I f

th e c o n d i t i o n does

n o t c l e a r t u b e r c u l o u s c a v i t a t i o n a© d e s c r i b e d i n t h e pathological

s e c t i o n may e n s u e . At tim es

in

a d ifferen t

film s

more

A fter

seven

q u ick ly .

been heard

w ith

f o r m . Th© t e m p e r a t u r e

show t h e w h o le

dense.

a telecta sis

In

lu n g

to

fie ld

ten

days

rises

co n d itio n

r e s o l v i n ’g a t e l e c t a s i s

d ia p h ra g m d e s c e n d i n g b u t

slo w ly

and d a i l y

b e c o m in g more g r a d u a l l y the

and c o i n c i d e n t w i t h

s ym p t o m © p r e s e n t s

th is

clea rin g

breath

th e

of

reso lv es

film

the

sounds have has

lu n g

shown

th©

shadow h a s

com© l a t e r . T reatm ent o f stim u la tin g of

c o u g h in g and

v ib ra tio n

the

or

fo llo w in g

to

one

fa ilu re

to

had

th e

to x ic

a telecta sis

of

b ein g

in

be

in

of the

sid e . due to

to

C hronic*

a ll

when i t

form

W hether sputum

m ech an ism 1 b e l i e v e

the

b r o n c h o ©copy „ has

to

th ere

been

o p era tio n *

lo b es.

strep to m y cin

the cause o f

Empyema. B r o n c h o s c o p y

affected

lu n g w h ich p r io r

C o n tra la tera l se e n once*

the

are p r e fe r a b le

tu b e r c u lo sis The u s e

h elp

p h y sio th era p y

a D ete r io r a tin g

re-expand

co n sists

th o ra co p la sty

d escrib ed

case*

ex ten siv e

to

a n eu ro lo g ica l

sim p le m easures In o n ly

g iv in g

and p e r c u s s i o n

a tele cta sis

reten tio n

a telecta sis

sh ou ld

in

fu tu re

has

been

occurs.

lu n g a t e l e c t a s i s death*

perform ed

In

as

th is

recorded under case

fa ile d

to

a l l e v i a t e the c o n d itio n . Th© a s p i r a t i o n mu oh w o r r y in sta n ces

to

e a rlier

p rob ab ly

pn eum onia w h ic h

w riters

th is

on

to x ic

gave

so

was

in

th o ra co p la sty

form o f

many

a te le c ta sis.

INFECTION OF THE WOUND h a s b e e n a t r o u b l e s o m e p rob lem

in

th is

series.

g rea tly

ex ercised

and s u g g e s t i o n s

Many t h o r a c i c

over

to

sep sis

decrease

in

it

surgeons have been

t h o r a c o p l a s t y wounds

have been

Wu and P i a n e t t o

v a ried .

(1943) d e s c r i b e d a s p e c i a l

t e c h n iq u e o f p r o t e c t i n g th e wound w ith to w e ls * D ieffen b a ch

and G reece,

exposed

t h e wound

m in u tes

and Edw ards

p rep a ra tio n

edges

d esp ite

p a tie n ts

than o t h e r

th o ra co p la sty

wound

to

two h o u r s .

ly m p h a tic rem oved

v essels

is

D u rin g th e

and a l a r g e One o f

o r ig in a l

sk in

in

22$ o f

co m m u n ication

in fected .

in fectio n

a r e more

w ould

d ie

common a f t e r

o p era tio n s.

and o p e n

to

the

e x tr a -fa sc ia l

damaged*

q u a n tity the

three

s ta te d t h a t ap p roxim a tely

su r g ic a l

la rg e

m ust be

for

treatm en t.

in fe c tio n s

th o r a c o p la sty

lig h t

p ro lo n g ed

stages

a deep

prom pt and e f f i c i e n t Wound

one

(1537)

w ith

o p era tio n

fo u n d wound s e p s i s

10$ o f

quoted

end o f

te ch n iq u e.

( 1935) in h is

A lex a n d er a q u arter o f

the

ad vocated

(1941)

a n d Bemb

o p era tio n

at

u ltr a -v io le t

and a n o n - t o u c h

p a tie n ts

on h is

to

(1946)

F in n ey h is

(I§ 4 l)

of

ch ief

g la n d s

The a ir

for

d isse c tio n are o ften

serum c o l l e c t s . factors

is

u n d ou b ted ly

th©

r e - o p e n i n g o f t h e wound i n

ch ro n ic

tu b e r c u lo sis

b a cteria

im p la n ted

a sm a ll

poeket o f

rise

to

no

in to

th e

is

not

and by

at

th e

deep

tissu e s

tim e b etw een

t h e wound a r e a to

at to

be

o f unseen c a tg u t

oedem a

in crea ses

favour

th e

w ith

grow th o f

sta p h y lo co ccu s

the

deep

ward to

of

in v estig a tio n

a m enace

lu n g

to

co lla p se

each

does

not

fa ile d

life

to

are

d ela y

b lo o d

absorbed A ll

th ese

com m only

There in

rem a in in g

and t h e wound circu m sta n ces

th e

seem p o s s i b l e

known b e f o r e h a n d

three to

in

the

from u l c e r a t i o n

of

for

cross

su p er ficia l

th e

th eatre.

in fe c tio n

in fectio n * D u rin g

b a c te r io lo g ic a l

source

in fec tio n s

of

in fec tio n .

w h ile

subsequent

in su ffic ie n t d eform ity

u n lik ely

stage

to

to

and t h e

clo se

th e

and l i m i t e d

arm

caused. wound

in fectio n ©

be p e n i c i l l i n

from m ild

a

repeated

Increased

sim ila rly in

o rig in .

are ca rried

c ir c u la tio n

show any

may t h e n b e

m ovem ents

th ird

o p era tio n

g iv e

the

a n y th in g but

o p era tio n s

c a v ity .

two

p ro b a b ly

in fec tio n .

stage.

m ust o r i g i n a t e

pu lm on ary

ca rriers*

and c r e a t in g

a serio u s

are not

S u p e r fic ia l be

Any

r e - e s t a b l i s h e d *6 s m a l l

b a cteria *

cause

in fec tio n s

t h i .8 s e r i e s

for

by

aureus. It

in

w h ic h w ould

cause

fu lly

p ieces

stage

a sin g le

stages

d eb ilita ted

repeated o p e r a tio n s .

p rev io u s

in fec tio n

d istu rb a n ce

a p a tie n t

the

resista n t

ch rom ic m id d le th e hand o f

ear

cases

were

sta p h y lo co cca l d isea se

tu b e rcu lo u s

and

the

There w ere o ccu rrin g the

two

took

in

poor or

deaths

eig h teen

seven

d eterio ra tin g

recorded m onths

a ll

to

do

sep sis

by

th e use

sy stem ic& lly tim e

is

I

of

(l§48)

b eliev e*

sim ila r

sep sis

o p era tin g

th e

io d in e

TO% e t h y l

w ith

in

ill*

c la im e d marked

that

be d ip p ed

alco h o l?

p o ssib le

tem perature to

be

sure

e x tr a ~ fa sc ia l

space

is

its

red u ctio n

r o u t i n e us©

fo r w ith in

a fter

in to

th is

a short

con fron ted

w a s h i n g up

a 1% s o l u t i o n

appears

in fe c tio n

and p u l s e

that

to

for of

be m eetin g

if

th e

so ftB ° w ith

sep sis

by n e e d l e

and

sy rin g e

th e

n e cessa rily from t h e

reveal

pus

p a tien t

stea d ily

ch est w a ll

and

in

the

it

fir st

is

b elow

the

few d a y s

It

in v o lv es

ten se.

but organ ism s w i l l

soon

m ou n tin g.

n o ' co m p lica tio n s

sunken

the

c la v icle

E x p lo ra tio n does

be

not

cu ltu red

sp e cim en . If

the

pus

escapes

from t h e wound h e a l i n g

slo w . T reatm ent o f

R epeated effectiv e and

one c a se

success0

becom es

is

a lth o u g h

s u r g e o n who h a d b e e n

W ith a d eep

is

for

re sista n t.

suggested

fin g er s

Except

a m ista k e

th e o r g a n ism s becom e

a ll

p a tie n ts.

p en icillin *

A th o ra cic w ith

h ea led

in fe c tio n s

th is.

G y llen sv a rd of

serio u s

a sp ira tio n in one

d ra in a g e o f

and

case. the

th e

in fectio n

in stilla tio n A n o th e r was

e x tr a -fa sc ia l

of

v a ried .

p en icillin

treated space

has

w ith

praved

aureoraycin*

connected

to

a

138 c o n tin u o u s w ith in

su ctio n

three

th eatre*

m on th s.

the

space

c o m p lica tio n . sca p u la

apparatus* A th ir d

c a s e was

th o ro u g h ly

When s e v e n

em bedded

w h ich b ro u g h t

the

re-opened

clea n ed

rib s

and

have been

ex tra -fa sc ia l

about h e a lin g

clo se d

rem oved

space

in

is

the

w ith o u t and t h e

more q u i c k l y

o b litera ted . T u b e r c u lo u s wound been who

seen*

in

th e

t e n m onths

d ev elo p ed

in

led

th e

up

to

a fter

referred

su b sca p u la r g iv en

and h a s

to*

and

a th o ra co p la sty

t h e wound s c a r

strep to m y cin la te r

case

in fe c tio n s in

T h is

in tx^ am u scu larly

n ow b e e n h e a l e d

tw ice

a second

w ith o u t

a tu b e rcu lo u s

reg io n .

have

p a tie n t

in cid en t

s in u s w h ich

h ea led w ith

but

recurred

two m o n t h s

six

fo llo w in g

m onths m ore

strep to m y cin . G ale g lan d s

rem oved

and O atw ay

a t o p era tio n view

th at

it

(1938)

were

expressed

the

was

in fe c tio n

w as n o t more p r e v a l e n t .

found

tu b e rcu lo u s

su r p r isin g

RESPIRATORY c o m p l i c a t i o n s to

dyspnoea o f

a telecta sis*

w h ich

some c a u s e s

in tra p leu ra l

a ir

P a ra d o x ic© ! to

a slig h t

ca lled

exten t

for or

e x tra « (fa sc ia l lim its provoke

but

if

tem porary

serio u s

for

tig h te r

g iv e

has

a^ soft

symptoms*

been

ca rried

from h a e m o r r h a g e . alw ays

co n tin u a l

present

stra p p in g

beyond

lu n g p a r a d o x ic a l th e

rise

listed *

contx^ol by h a n d p r e s s u r e .

d isse c tio n

req u ired

is

of

and th e y

m o stly

have been

resp ir a tio n

th ird s

tu b e rcu lo u s

and p r e s s u r e

severe*

two

If

is the

the

m o v e m e n t may

pum ping a c t i o n

of

th e m o b ilised

tu b ercu lo u s lu n g

lu n g

to x in s

flo o d in g

the

and c o n t in u in g

and c h e s t w a l l

resp o n sib le

for

be

a f t e r X-R ay

lu n g has

dyspnoea.

appeared

o p era tio n .

o p era tiv e

sittin g

over h is

sid e

and w i t h o u t two

rib s

of

th e

lea n s

th e

than

co n tra la tera l

The p a t i e n t p u ts

the

slig h tly

in

the

after

excess

o p era tio n is

to

h is

the n e e d le

stage

w h ich c .c .

rise

as

after

rem oved by

the

to

presence

th e

fir st

no of

th e

v ita l

stage

has

norm al

in

h is

the p o s t­

pneum othorax

is

in tro d u ced

in

th e

ranged

the

d istu rb a n ces

the

fa ll

200

after

of

1*?00

to

5 0 Q e . c 00

stra ig h tfo rw a rd

a e o n ti'a la tera l

in crea sin g

from

Many o f

a

e x tr a -fa sc ia l d y s p n o e a *0

and

ca p a city

to

in

bed

and

300

sym ptom s

to

a sp ira tio n .

b ein g

average

p rio r

the

th o ra co p la sty

ca u sin g d isco m fo rt

shown by

on ly

a x illa .

Some d y s p n o e a i s each

both

pneum othorax

arm o f

Too m u c h a i r may r e m a i n space

u n til

for o cca sio n a lly

be m ore c o l l a p s e d

d iffic u lty in

so

p n e u m o t h o r a x may b e

exam in ation

p o sitio n

head

do

The p n e u m o th o r a x s h o u l d

no p r o b l e m s .

sid e

betw een

to

The r e f i l l

has p resen ted

to

stream w ith

harden.

A co n tra la tera l

r e fille d

b lo o d

pneum othorax

d escrib ed case

g iv e

but

in

the

d y sp n o ea w ou ld

r e su lt. The t r e a t m e n t o f th e were

cause.

Oxygen h as

tra in ed

in

ra rely

the u se

of

the

dyspnoea

b een used?

th e B .L .B .

at

is

fir st

to

rem ove

p a tien ts

m ask b u t when

offered

after

o p era ticn

it

was p r o m p tly

refu sed .

PULMONARY c o m p l i c a t i o n s , a te le c ta sis,

d istin c t

from

have been. (a)

two

as

o c ca s io n e ,

C o n tra la tera l p leu ra l

co n tra la tera l

on

s1i gh t,

bo t h (b)

effu sio n

R ecrudescence

lu n g h as

of

been noted

an o l d

lesio n

on th r e e

in

th e

o cca sio n s,

a ll

su b sid in g , ( e ) M a ssive co n tra la tera l but

se ttle d

lu n g was

fo llo w in g

s t a g e had to

th e to

observed

th o r a c o p la sty d ifferen tia te

of

in

for

spread lu n g

of

six

therapy.

of

to

occurs

co n tin u ed

h ig h

p u lse

com m onest c a u s e , elim in a ted

case

5 have

rate

before

la b ellin g

The

lo w er but

is

apart

giv en

fo llo w s

a p u lm on ary

the case,

second

zones

of

d ifficu lt

a te le c ta sis.

CARDIAC c o m p l i c a t i o n s pulm on ary oedem a i n

to

m onths.

d isea se

p rob ab ly

from a r e a s

d isea se

one D e te r io r a tin g

strep to m y cin

be p ostp on ed The

spread

th e

no

from th e

a n x iety ,

o p era tio n

c o m p lica tio n , th is

as

due

a

the

sh ou ld

to

If

be

ca rd ia c

in su ffic ie n c y 0 SKELETAL COMPLICATIONS may b e h e a d e d

as

fo llo w s, I. m ovement

due

to

Of th e

sep sis

has

s c a p u l a may

slip

Severe

can accom pany

p ain

and com e

been to

recorded.

rest

th is

arm a n d

o u tsid e

in cid en t

sca p u la .

The

embedded

the

eigh th

but

it

L im ita t

r ib 0

may o n l y

be

d isco v ered

days

it

la te r.

can be In

six

d issected in to

at

the

r o u tin e

rep la ced rib

S eap u lectom y

in n er

created

as

sc o lio sis

is

an X-Ray

film

of

avers

present may

a ll

sc o lio sis

u n co m p lica ted

in

(1947)

v a rieties?

that

order

to

O v erh o lt

degree o f but o n ly

over

sp in e

not however occu r

on ly*

and r o t a t i o n a l

sh ou ld

sid e

sc o lio sis

d efo rm ity

i© l a t e r a l

th e

of

p leu ro g en ic*

la te r a l

keep

spend

a soft stra ig h t.

in

an

case. Of th e

m u scles.

from t h e i r

and

[email protected] -atta.ch t h e m s e l v e s are

not

an atom ical

at

fir st

lik e ly

su b sid es* som etim es

cause o f

th ese

attach m en ts at

at

at

sudden o r

sudden a c u te

d u rin g

th e

T h e s e n ew

th ese

d ifferen t

are

d u rin g o p e r a tio

n ew s i t e s .

m u scle

th e

o ccu rrin g co m p la in

Many o f

s t r o n g and any

u n u s u a l m o v e m e n t may t e e , r t h e the

a

th e p a t ie n t

sep arated

attach m en ts

is

n on -op erated

sh ou ld

3.

p a tie n ts

r ib and

em bedded.

A m oderate

where th e r e

on h i s

co m p ressio n wedge

g ra d u a lly

seven th

( 1 9 3 8 ) h a s made a s t u d y

H© b e l i e v e d

tim e l y i n g

is

have been

th o r a c o p la stie s

empyema w h e r e t h e r e

d isto r tio n .

T h is

few

i t .

t h a t t h e r e a r e tw o

in

la te r

is

fir st

not u su a lly

tissu e s

the

by C o e l l o

after

reveal

and a t h o r a c o p l a s t i c

M arked

of

sca p u la

the s p in e .

B isga rd

much

the

suggested

2.

a risin g

su rface

the

but

the

(1939) h a s n o t b e e n p r a c t i s e d ,

and Tubbs

and

by m a n ip u l a t i o n

th o r a c o p la stie s

from t h e pocket

e x a m in a tio n . D u rin g

p o in ts. p ain *

site s

w h ich

o f w h ich

f i r s t - fe w m o n t h s

142 p o b t-o p era tiv ely , 4. no

reg en era tio n

had b een

taken

of

of to

bone

took

prevent

p la ce

it.

th e

rib s,

a lth o u g h

T h ree m onths

in

on© f i v e

rib

no m e a s u r e s after

o p era tio n

v

th is

p a tien t

(th ere w h ich

was

d ev elo p ed

a sim ila r

reso lv ed

that

th is

Soon

after

w ith

glan d

may h a v e

p a tien t

c a v ity

re-opened?

ca v ity

clo sed

The c h e s t w a l l

is

v ein

thre©

th ick en ed

H o lst

su b cla v ia n

v ein

tho r a c o p la s t y around

tender?

was m ore

p resu m ab ly

Tem porary

p ulm on ary

is

b ein g

and h a s

tem porary w ith in

tw ice

change

a few

w h i c h make©

in

up t h e

days, th e

it

is

thought fo rm a tio n .

a p ica l

in stitu ted * eig h teen

b ra ch ia l

arm w a s

th e

m onths.

th at

v e in has

sw o llen

su b sid ed

w ith in

due to

been

and th© thr© e w e e k s .

th ro m b o sis o f

sw ellin g

not

of

the

ea stra -fa so i& l

the

the

T h rom b osis

d isse c tio n

am

w ith o u t

elsew h ere

and

occurred.

been w id esp rea d . th e

is

bon©

SURGICAL EMPHYSEMA i n m o d e r a t e norm al

neck

b u n d le.

n o t uncommon.

em b olism h a v e

for

it

w ith

frequent, a f t e r

the n eu r o -v a sc u la r

th ro m b o sis

a ll

(1935) o b s e r v e d

a n d Sem b

so

the

t im e s when t h e and

the

fla c c id .

THROMBOSIS, o f d ia g n o sed

g ettin g

the:rapy w a s

rem ain ed

s till

in

by m outh and

in terfered

started

p ostural

and h as

glan d

e i g h t e e n m onths p r e v i o u s l y )

C a lcifero l

treatm en t th e

a tu b e rcu lo u s

v o ice

but

a ll

the p resen ce

p o st-o p e r a tiv e use

of

It

give©

degree rise

is to

a

symptom© d i s a p p e a r of

su r g ica l

em physem a

a steth oscop e

in

th

143 ex a m in a tio n

so

d iffic u lt. HORNER'S SYNDROME r e s u l t s

th e from

sym p a th etic the

lo ca l

the

second

The

d ro o p in g o f

the

absence o f

ch a in

at

the

a n a esth esia .

in ter co sta l th e

lid

sw ea tin g

fir st

stage

D iv isio n

sh o u ld

not

or the

ch a in

cause

eye

sig n s.

recovers

in

ar m h a s

w ith

had n o t h is

d isclo sed

sim ila r

m ental

o p era tio n

fa m ily

ho s p i t a l 0

ea rly

in

a p rev io u s h isto ry .

the sp e ll

He

is

series. in

b elow

tim e b u t

rem ain ed .

MENTAL DETERIORATION f o l l o w e d su ccessfu l

of

tem p o ra rily

of

p a rtly the

from d i v i s i o n

an o t h e r w i s e

The p a t i e n t

a m e n t a l home

s till

an

in m ate o f

or a

GENERAL CONSIDERATIONS OF RE SU LTS. O e a C 3C 3 C s & « a < »c *

To

assess

th o r a c o p la sty

is

m ust b e

taken

in to

even

cu ltu red

as

if

no

no

in te r p r e t

in

g en era lly

w ith

lesio n s

is

ju st

been of

a ctiv e as

r o u tin e ly

tryin g;

co lla p sed

to

lu n g

of

a c tiv ity

Through th e ca v ity and y e t th at on

may b e s till

t h e X-R ay w ith

in v isib le

It has

occurred

n o to rio u sly case

of

the

a sso cia ted

though u lt im a t e ly

com m only it

is

It

is

referred

the

ob ject

fib r o se d

rib s

produce

h ig h ly

d isea se

present

and

there

stage

d im in ish in g

be

lo st

are

p rob ab le

any

as o o n f u s in g

essen tia l to

film

exposure has

The

the

found.

t h e X-Ray

reg en era tin g

stages

d isea s

d iffic u lt

for

X-Ray

c a v itie s.

o p era tio n

e x ten siv e

th e se m usttbe

may b e

T o m o g r a p h © may b e

rem ain p a t e n t .

c a v itie s

in te r v a ls

series

sputum

arrested

sounds u s u a lly

resid u a l

traced

film *

of

a L ysholm g r i d w it h

c a v ita tio n .

as

are

g u id es

n e g a tiv e

s h a d o w s w h i c h , may r e s e m b l e

v a rio u s

ca v itie s

p a tie n t

a ll

or

and a number o f

lon g

th is

and o v e r l y i n g

a co n g lo m era tio n o f

a p a rtic u la r

in te r p r e ta tio n

In

throu gh

of

th o ra co p la sty

and

show up

at

rev ea ls

d iffic u lt.

-c» c ? c n c s G 3 G 3 d « a o * 5 >

criterio n

sig n s

the o ld

Ca CS o

A repeated

fin a l

p o sitiv e

steth oscop e

r e su lt

m atter

accou n t,

P h y sica l to

the

easy

is

an o c c a s i o n a l

t>3.e=*c=ad«nc=ic3«zi c s < r > 0

sig h t

of

to

rea lise

those

v isib le

that

in

any

a r e many s m a l l

for h e a lin g

to

be a ssu r e d

clo se d . is

o n ly

when w i t h

th e

p o ssib le passage

to

assum e

o f years

th at h ea lin g th e

p a tien t

rem ain s

in

good h e a lth *

sputum and X -R ay

a co m p le te

th e

lo n g

fig u r e s

term

series

r e su lts

and n e g a t i v e

and in

can

r e su lts.

(1937)

o p era tio n

known t o

in ter estin g

be

is

recent for

reference

that

a fter

ca v ity

H olm es

to

the clo su re

(194?)

S a ilo rs

as w ork in g

N ystrom

in v estig a tio n

too

ex p erien ce.

ab ou t 37$ had

a liv e.

d isea se.

from

states

recen tly

n e g a tiv e

Encouragem ent

lo n g

633 t h o r a c o p l a s t i e s

59% o f

cases

be o b t a i n e d

sp u tu m . M ore

5 l6 were an

o f 100

p r o d u c e d by a u t h o r s w i t h

p aravertebral

quoted

retro g ressin g

assessm ent o f

A lexan d er o ld

a p e r siste n tly

ev id en ce o f

T h is for

w ith

fu ll

tim e (1948)

and K irnm ann

reported

9?

th o r a c o p la stie s

d o n e b e t w e e n 1 9 1 4 a n d 1 9 2 9 o f whom 30

s till

and s e v e r a l

They

su rv iv ed * b rin g ou t

reported d ied

as

la ter

an i m p o r t a n t

cured of

at

the

p o in t

perform ed

sputum n e g a t i v e

and

after

In t h e ir

betw een th ey

o p era tio n .

th a t on ly

end o f two y e a r s

tu b e r c u lo sis.

th o r a c o p la stie s w ere

25 y e a r s

express

and I g 4 2 th e

(X 94I)

series

of

had th e

in clu d in g

h ig h

oases

w ith It

o p era tio n

of

rep u ta tio n o f o n ly

in

l 8l

is

th o r a c o p la stie s

rate

o f 79$

view

o n ly

in

th o ra co p la sty b ein g

d esperate

b ila tera l

recovered

a crip p lin g

cases.

th at

re su lts.

reported

recent years

has

65$

Mu ch o f

procedure its

these

le sio n s,

that

the

from i t s to

present

An

by M e l t z e r

sputum n e g a t iv e *

co n sid e r a b le

o f 80

groups

i m p r o v e d t e c h n i q u e h a s b r o u g h t m u ch b e t t e r ea rlier

cases

p o st-o p era tiv ely

la te r

X94I

two

be

ea rly

a p p lied

success

is

due

to

the

great

advance

in

a n a esth esia .

t e c h n i q u e o f m ore m e t i c u l o u s lo ca l

or

ep id u ra l

shock

even

d efo rm ity

in

a n a e sth e sia produces

th e m ost

th at

it

advanced c a s e

may p a s s

are

series

ex cellen t*

p resen ted

eq u a lly

of

tw enty

in

th is

perform ed rem ark ab ly

and

so

little

th o ra co p la sty

two o u t o f

th esis*

in

tw en ty

and t h e

t h e P o o r C h ron ic

more u n c e r t a i n

though

good a s

fir st

good

in

d ifferen t that t it

th e

p rob lem .

is

p a tie n ts

d esp ite

cla ssed

so m eth in g

is

sh ou ld

g iv en

be

success.

p ro g n o sis

in

p ro g n o sis

is

Group t h e

i n many o a s e s

d ifficu lt

it

is

fig u r e s

th e o p era tio n

o u tlo o k

fit

lists

so

th is

iro u p w i l l

th ose



they

th e ir

is

n eith er

in clu sio n

o p era tio n

the

It

is

a lrea d y

are op erated

A ll

two h a v e

in

liv e s. th e

b eliev e

some p r o s p e c t

p a tien ts

in to

a very

u n less

p resen ted

u aefu l

cases

fig u r e .

d e sir in g

th ere

oases

liv in g

th ese th at

to

m om ent. H owever*

sh ou ld

if

th irteen

are

d ie

and a p a t i e n t

chanoe

equal

effect

is

now a l m o s t

w orth w h ile ^ ’ I

the h ig h er m o r ta lity

in

Of the

to

adverse

Is

that

a lm o st

fa v o u ra b le the

th e

group.

attem p ted

and o t h e r s

w a itin g

risk

four

The D e t e r i o r a t i n g . Group p r e s e n t s

group

little

good. in

of

under

u n n o ticed .

The r e s u l t s cases

d isse c tio n

The modern

on

th is

at

fir st a d m itted ly

lo n g t h e m ost

d iffic u lty

has on

the

a

nor

percentage

be a d e te r r e n t. W h ilst

th e o p era tio n

sh ou ld

not

be

reserved

for

ca ses w ith

m ore u r g e n t and

advanced

for

they

d isea se

are

la tte r when b e d r id d e n

th e ir

m ore l i a b l e

nedd to

are a greater

is

p rob ab ly

in fect

oth ers

econ om ic

lia b ility .

• SUMMARY *

I o The h i s t o r y is

b r ie fly

of

Brauer

review ed

from t h e

and F r ie d r ic h

op era tio n

of

and d e v e lo p m e n t

to

ea rly

lu n g

fib r o sis

excess

prom otes

accep ted fir st is

ie

o p era tio n

rela x a tio n

Semb.

tu b e rcu lo u s

th is

th o ra co p la sty

stage

the m u lti-sta g ©

2 0 Th© p a t h o l o g i c a l

in

sin g le

of

sub jected of

th at

to

th a t where

and o p e r a t i v e

the

the

th o ra co p la sty

seen

firm h e a l i n g .

anatom y o f

in

u n eo lla p sed

The t h e o r y d ra in in g

procedures

ex h ib its

of

ca v ity

bronchus

m u s t be- s o

lu n gs?

is

clo su re clo sed

d ev ised

that

th is

a cco m p lish ed . 3o T h e

a r tific ia l p ra ctica b le

id ea l

pneum othorax o n ly where

co lla p se free

the

of

therapy

p leu ra l

d isea se

is

by

a d h esio n s*

and c a v i t a t i o n

is

lim ited 0 4 P ca v ita tio n

is

a

an

lu n g w ith in d ica tio n

pneum othorax b e in g lesio n s

respond

closed *

esp ecia lly

p h ren ic

crush

in

best

th is

ex ten siv e for case

but dorsal

w ith

the

d isea se

and

th o ra co p la sty p a r t i f i c i a l in e ffe c tiv e . lo b e

c a v itie s

p o st-o p era tiv e

Upper l o b e can be

a d d itio n

and p n e u m o p e r ito n e u m . C o n t r a l a t e r a l

of

lu n g

a

d isea se

o r pneum othorax

req u ires

carefu l

movement o f

the

t h o u g h no

co n tra in d ica tio n

assessm en t, p a r tic u la r ly

the

re sp ir a to r y

lu n g 0 5o T h e p r e ^ o p e r a t i v e m a n a g e m e n t o f

is

d iscu ssed

and r e f e r e n c e

co n tra la tera l m easure

in

for

th is

o n ly

in

le sio n s,,

ex u d a tiv a

or the

made to

P neu m op eritoneum

d isea se

en d o -b ro n ch ia l

tu b e r c u lo sis

im m ed ia te p r © « o p e r a tiv e

perform ed under e x tr a -fa sc ia l about

a ch iev ed

in

lo ca l

a

rela x a tio n

of

a p relim in a ry

is

therapy

in stitu ted

p erio d o the

o p era tio n ,

an a esth esia ^

the the

The r e s u l t s

apex lu n g

is

n o rm a lly

and t h e

d escrib ed ,6 t h i s

co m p a ra b le

to

but

th e its

o f 100

co n secu tiv e

th at

cases

9 w e r e empyema c a s e s )

( o f w h ich

and g r o u p e d

ch aracter o f to le r a te d

of

th e

a p n eu m oth orax.0

th o ra co p la sty

d iscu ssed

ep id u ra l

m o b ilisa tio n

7. of

or

is

and s t r e p t o m y c i n

6 0 The t e c h n i q u e o f

b rin g s

treatm en t o f

cases

a cco rd in g

to

the

a m ou nt and

d is e a s e 0 C o n tra la tera l exten t has

are

d isea se

an im p o r ta n t

is

w ell

b ea rin g o n ,th e

resu lt© *, 8 0 The not

ex ceed in g

th e

poor

4 e m o0

good

show s

ch ro n ic, group,

d eterio ra tin g

group

ch ro n ic

group,,

w ith

9 Io 6 ^ h ave becom e

the

la r g e st,

a ca v ity

sputum n e g a t i v e

6 4 0S>% a n d t h e

2$% s p u t u m n e g a t i v e 0

9 o The t u b e r c u l o u s m o r t a l i t y i n c l u d i n g 6 0% o p e r a t i v e a n d 3 „2 % l a t e 10 o S i x

case©

have^ b e e n

is

9 08j2

deaths0 set

forth

as

© m all

exam p les

of

advanced

d isea se

Many p a t i e n t s

w ith

th o ra co p la sty

and b e c a u s e

a ch iev ed

sh o u ld

they

w ith

a h o p eless

not

a good o p e r a tio n

p ro g n o sis

a p erfect be d en ied

b e n e fit

r e su lt

w h ich has

o f th eatre

d isa p p ea red

fo llo w in g

been

ca n n o t be

few

apart

a recent

from

m o d ifica tio n

te c h n iq u e „

1 2 , a ta b u la r cases,

from a

th is0

I I 0 C o m p lica tio n s have been sep sis

resu lt,,

w h ich

are

not

su m m a r y o f

in clu d ed

in

the

th e

above

n in e

empyema

fig u r e s,

has

d isp la y ed ,,

CONCLUSIOJff. T h o ra co p la sty c o n sid era b le cla ss, els©

d isea se,

m ore c e r t a i n

a v a i l a b l e „ The l u n g

co lla p sed ,

not

a rtificia l

pneum othorax

e v erla stin g

sub jected

tie

of

to

a n d many p a t i e n t s

a treatm en t w ith

at present

o ffers

to

in to

th is

resu lts

than

a n y th in g

is

the v a ry in g

and t h e

p a t ie n t w ith

come

and t h e p a t i e n t

r e fills

the

p erm an en tly stresses is

of

reliev ed

p erp etu al

of

fear o f

c o m p lica tio n s 0

X w ish p h y sicia n

to

su p er in ten d en t,

c o n su lta n t

th o ra cic

tq> p u b l i s h

th ese

thanlc D r 0 G0 I v o r D a v i e s , a n d M r , B 0G0 W y n n e - E d w a r d s ,

surgeon,

cases0

for

th e ir

k in d

p erm issio n

the

iryxj

KEFBRMCBS 0 r-i c-n f?-> crs. ca «w #ri

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The C o l l a p s e T h e r a p y o f P u lm on ary TubercuXo s i s . ( S p r in g f ie ld , 111.) 1937«

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