Artificial pneumothorax

ARTIFICIAL PRACTICAL

PNEUMOTHORAX

ASPECTS OF ITS APPLICATION

EDGAR MAYER,

TO PULMONARY MARTIN

AND

M.D.

TUBERCULOSIS

DWORKIN,

M.D.

Physician to Out-patient Department, Gouverneur Hospital

Assistant Professor of Clinical Medicine, CornelI University MedicaI College

NEW YORK

T

HE appIication of artificia1 pneumothorax, air or gas introduced into the to the treatment of pIeura1 cavity, puImonary tubercuIosis constitutes one of the major medica advances of the past haIf century. With this treatment, many patients who wouId otherwise be undergoing proIonged confinement to bed at home or in sanatoria, are abIe to resume exercise and occupations much sooner whiIe the Iung is stiI1 heaIing. CoIIapse of the Iung by artificia1 pneumothorax has become a universaIIy accepted procedure. Through it the toxic effects of the disease are controIIed, spread of infection to the hitherto unaffected Iobes or to the opposite Iung are prevented, and healing is hastened, so that prolonged bed rest is Iess necessary. Twenty-five per cent of patients with puImonary tuberculosis who were admitted to institutions during 1934 received initia1 pneumothorax treatment the same year. The increasing use of pneumothorax may be correIated with the continuous and marked faI1 in mortaIity and morbidity rate of puImonary tubercuIosis during this century. In New York State the death rate for puImonary tubercuIosis has dropped from 124 per IOO,OOO in 1919 to 51.8 in 1934. It has been estimated that 77 per cent of a11 cases today are undergoing some form of coIlapse therapy. Pneumothorax accompIishes economic recovery in 40 to 30 per cent of cases receiving it under the usua1 indicati0ns.l The greater saving of Iives occurs in cases with cavity in whom this therapy is instituted. Without its aid reported figures are appaIIing. Figures from the Trudeau 1MAYER, E.

ment.

Cavity

in the tubercdous, its manage1478 (May 13) 1933.

J. A. M. A., 100:

403

Sanatorium at Saranac Lake are significant. In cases with cavity and disease of far advanced extent, without pneumothorax, death occurred in 69 per cent at the end Even more ominous are of five years. figures from studies made among patients of poorer economic circumstances with more extensive and destructive type of puImonary pathoIogy. INDICATIONS

Pneumothorax is aImost aIways indicated before an attempt is made at more radical surgery. A patient with a positive sputum and a recentIy deveIoped tubercu[ous cavity of moderate size, about 2 cm. to 4 cm. in diameter, which persists with Iittle favorable change despite a few weeks of bed rest should have the Iung coIIapsed without deIay in the absence of definite contraindications. Cavities of oIder age or of Iarger size, resuItant from sIoughing in caseous pneumonias usuaIIy indicate immediate attempt at coIIapse. Hemoptysis, tubercuIous Iaryngitis, and moderateIy advanced tubercuIous enteritis are no Ionger considered contraindications. By collapsing the diseased Iung and cIosing the cavity itseIf, the source of production of tubercIe bacilli is eIiminated and the compIications tend to cure. Progressive phthisis caIIs for earIy estabIishment of pneumothorax to Iocalize the Iesion, when spontaneous arrest is unIikeIy after a brief period of observation, arbitrariIy for three weeks. It shouId be estabIished without deIay when the process is of the acute caseous pneumonic character to combat prostrating toxemia and exhaustion, even if one anticipates progressive ca\Ternous sloughing of tissue.

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The “ aI1ergic ” or so-caIIed exudative type of tubercuIosis, often found as the subapica1 inCItrate, deserves carefu1 watching for a few weeks under strict bed rest before pneumothorax therapy is instituted. This type of disease often resoIves spontaneousIy. If not, it may go on to rapid excavation or extension. Any evidence of such change immediateIy caIIs for coIIapse therapy. In Negroes who are prone to softening and Iiquefaction of caseous foci, particuIarIy those in poor economic circumstances, pneumothorax shouId be instituted earIy. Patients without means to provide sanitary surroundings, good food and fresh air as is commonIy the case in the dweIIers of tenement districts of Iarge cities, are Iess IikeIy to spontaneous arrest of the tubercuIous process than are those of more fortunate means, so that economic factors often force immediate institution of coIIapse therapy. There are some workers who Iook upon even active minima1 puImonary tubercuIosis with positive sputum as an indication for immediate artifIcia1 pneumothorax. However, considering the compIications of pneumothorax, such as effusion, tuberculization of the pIeura, empyema and bronchia1 or subcutaneous fistuIa, a11 earIy cases shouId not indiscriminateIy receive pneumothorax. Pregnant women with active tubercuIosis shouId have their disease put under contro1 of pneumothorax during pregnancy if the disease is not of a productive nature. In even extensive exudative uniIatera1 disease, pregnancy is often we11 tolerated if supported by pneumothorax. In chiidren and adoIescents, existence even of a minima1 puImonary tubercuIosis usuaIIy requires earIy induction of pneumothorax. It must not be forgotten that the open case is, from the epidemioIogica1 standpoint, a menace to the community. CONTRAINDICATIONS

There are a few contraindications to the institution of pneumothorax. In the main they are cardiopathy, cardiovascuIar-renaI

APRIL, 1937

disease, asthma, severe emphysema with marked reduction of vita1 capacity, and perhaps advanced biIatera1 tubercuIosis with both Iungs active. However, in cases with biIatera1 cavitation, institution of pneumothorax on the worse side may improve the Iesser invoIved opposite Iung and subsequent pneumothorax may be instituted for the contraIatera1 Iesion. TerminaI enteritis and advanced Iaryngitis present contraindications to pneumothorax. Diabetes is not a contraindication but on the contrary, is an indication, though here the metaboIic disorder must be carefuIIy controIIed. Pbysiology and Dynamics of PneumoNormaIIy there is aIways a negathorax. tive intrapIeura1 pressure of minus 4, minus

8 C.C.of water in expiration and inspiration, respectiveIy, which is maintained by the puI1 of smooth muscle and eIastic Iung fibers contracting concentricaIIy about the hiIus or the center of gravity of the Iung. Intrathoracic or intrapIeura1 pressure is equivaIent to intrapulmonic pressure minus the eIastic puI1 of the Iung. This puI1 is greater on inspiration than expiration so that the Iung foIIows the expanding thoracic cage in response to the inflating force of normal atmospheric intrapuImonic pressure. This baIIooning force aIong with negative intrapIeura1 pressure and cohesive attraction between viscera1 and parieta1 pIeura1 Iayers keeps the expanding Iung in even contact with the chest waI1 and diaphragm. On introducing air between the pIeura1 surfaces, the puI1 of the chest waI1 and diaphragm is progressively decreased as the negative intrapIeura1 pressure is Iessened. The Iung is permitted to contract, and as the intrapIeura1 pressure approaches zero, the Iung continues to contract unti1 it is compIeteIy coIIapsed and quiescent. In regions of diseased Iung parenchyma, with infXtrations, fibrosis, or cavities, there is increased eIastic tension of Iung tissue and Iessened expansibiIity by respiratory pressure changes and consequentIy retraction of these parts occurs to a greater extent than normal tissue. In the absence of

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adhesions inserted over the Iesions, these parts are seIectiveIy put at rest whiIe heahhy Iung continues to function. A seIective or “ hypotensive” coIIapse is the most idea1 type of pneumothorax and is preferabIe to compIete immobiIization of the Iung by positive intrapIeura1 pressure. Most important among factors cited as responsibIe for heaIing under pneumothorax are, (I) partia1 or compIete rest of the coIIapsed Iung, (2) reIease of eIastic tension of the lung, (3) production either of puImonary hyperemia or ischemia. Four-fifths of the air introduced in pneumothorax exerts an expanding force on the mobiIe thoracic cage, whiIe only one-fifth acts to reduce Iung voIume. This and the expuIsion of residua1 air from the compressed Iung as we11 as the coIIapse of non-functioning parenchyma account for the very sIight reduction of Iung voIume with pneumothorax therapy. 2 Spirographic measurements show that the vita1 capacity after coIlapse is not decreased in proportion to the amount of air insufllated. Thus, the coIIapsed Iung continues to move and ventiIate with very IittJe diminution caused by pneumothorax, except in positive pressure pneumothorax or with pIeura1 effusion and pIeura1 fibrosis with paradoxica1 diaphragmatic motion, in which events the Iung is immobiIized. With an easiIy shifting mediastinum, the coIIapsed Iung does not ventiIate but moves as a mass with respiration. There is no interference in uncomplicated puImonary coIIapse with normal oxygenation of arteria1 bIood. In biIatera1 pneumothorax the two coIIapsed Iungs maintain norma gaseous exchange. CoincidentaIIy, there is sIowing of Iymphatic circuIation and toxemia and the tendency of the disease to spread is Iessened. Rather than ischemia there is increased congestion and venous stasis of the Iung3 with impaired distensibiIity so 2PINNER, MAX. Mechanisms of heaIing in coIIapse therapy. Ann. Int. Med., 9: pr (Nov.) 1932. 3 CHRISTIE, R. V. Pdmonary congestion foIlowing artificia1 pneumothorax; its clinica significance. Quarterl~ Jour. Med. (Aug.) 1936.

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that healing and fibrosis are promoted. RareIy, bronchia stenosis with ateIectasis may be a factor though postmortem evidence for this is wanting. ReIease of eIastic tension by pneumothorax reIieved the disease bearing area from the strain of continuous respiratory movement. Spread of disease in the coIIapsed Iung is extremeIy rare. This is true of hematogenous, as we11 as Iymphatic and bronchogenic forms of dissemination. PROCEDURE

Substance Injected. FiItrated air is commonIy used as it is most satisfactory and practical. It has the obvious advantages of being readiIy avaiIabIe and absorbing sIowIy enough to obviate too frequent repIacement. Equipment shouId be simpIe and need not be expensive. A simpIe apparatus of the type iIIustrated may be instaIIed with or without cabinet at very IittIe expense, for offIce or bedside use (Fig. I). It consists essentiaIJy of a water manometer, A, for registering intrapIeura1 pressure. By means of a pinch-cock or two-way stop-cock, B, this may be shut off whiIe air is administered from bottIe c. By reversa1 of the petcock, the ffow of air may be interrupted and readings taken at intervaIs during the administration. From bottIe D water coIored with green chIorophyI1 flows by gravity into bottIe c through the connecting tubing, E, the amount entering bottIe c dispIacing an equivaIent volume of air aIong the tubing, F, into the thoracic space through pneumothorax needle, G. By simpIy reversing the bottIes air may be withdrawn from the pIeura1 cavity. CIinicaI observations and experience of many workers, suppIemented by mathematica1 computation and consideration of the physica principIes invoIved, have been embodied in the preparation of standards and specifications for construction of artifIcia1 pneumothorax apparatus recommended b.y the Committee on ArtificiaI

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Pneumothorax Association.4 The caIibre

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of the American’Sanatorium of the pneumothorax

needIe

recommended is 17 to 20 gauge Luer (0.8 to I .2 mm. in diameter), average I 8 to Ig gauge Luer (or about 1.0 mm. diameter), and 2 to 2% inches Iong. For the initia1 insuflIation of air, the larger caIibre is desirabIe, with a short or bIunted beve1. ' PETERS, A., POPE, A. S., CRAMER, J.: Manometric readings of intrapkural pressures in artificial pneumothorax. Am. Rev. Tuberc. 34: 614 (Nov.) 1936.

APRIL. ,937

Too fine a needIe hinders satisfactory manometric oscilIations. The needIe Iumen may be too readiIy obstructed by water

from the steriIizer or by anesthetizing ffuid if the syringe has been attached, or by a tiny bit of extrapIeura1 tissue picked up on the way into the pIeura1 cavity. A needIe Iength sized steriIe styIet should aIways be handy to free the needIe track under these circumstances. The manometer and connecting tubing shouId be 3 to 3 mm., but averaging 4 mm.,

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in diameter. SmaIler bore than this is not desirable as capiIIary force may cause the water column to break. Connecting tubing shouId be of sufficient Iength to extend from the outIet of the pneumothorax apparatus to the needIe when inserted into the patient’s chest. It shouId be as short as feasible. The inteIIigent use of the manometer ranks in importance with that of the radiograph machine and fluoroscope as a guide in pneumothorax practice. Best adapted for ordinary use is the u-tube type of water manometer cahbrated 15 to 20 cm. in height above and below the zero mark. To faciIitate direct reading of correct pressure, the scaIe shouId be marked off in half centimeters, each graduation being cardinaIIy numbered and read in terms of centimeters of intrapIeura1 pressure. If marked in centimeters directIy the reading obtained must be corrected by doubIing the figure. CoIoring matter to aid reading, such as powdered chIorophyI1 or fuchsin may be used, through the vegetabIe dye is preferable as it is less apt to stain the glass with proIonged use. TECHNIQUE

The patient shouId be pIaced Iying on the good side with a smaI1 piIIow under the dependent thorax in order to stretch apart the intercosta1 spaces on the uppermost or affected side. This position affords widest respiratory and manometric excursions. With the patient turned on his back, intrapleura1 pressures are higher due to the rising of abdominal viscera and diaphragm, diminishing the size of the hemithorax. The rib interspace seIected for the site of introduction of the needIe is determined by the Iocation of the disease. There is more Iikelihood of finding free pIeura1 spaces and less likelihood of puncturing diseased Iung tissue when the needIe is introduced at some distance from the area of disease. OrdinariIy the optima1 site is the seventh or eighth interspace in the posterior axiIIary Iine, we11 beIow the scapuIar angle. For

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reMIs it makes no difference where the needIe is inserted as long as there is good coIIapse and the needIe is introduced at some distance from the attachment of adhesions to the chest waI1 as previousIy visuaIized by Auoroscopy or obIique roentgenography. In difficuIt cases, pneumothorax may be best administered under Auoroscopic guidance. Before the attempt is abandoned, severa different sites may successively have to be tried when free pIeura1 space is not found at the initia1 site seIected. In ofhce practice we have not found necessary the adoption of forma1 hospita1 routine ordinariIy used in preparation for major surgery. However, though we dispense with steriIe gown and gIoves and draping of the patient, meticuIous asepsis is wise to obviate exogenous infection of the pIeura1 cavity. The happier psychoIogic effect on the patient when the procedure is simpIe and unostentatious is not to be undervaIued. Tincture of iodine, 3.5 per cent, is appIied over the seIected site and the excess removed with aIcoho1. Using a 25 gauge, 1% inch needIe, an intraderma1 bIeb is first made and through this the skin and subcutaneous tissues are infiItrated with 2 per cent procaine solution, down as near as possibIe to the parietal pIeura. The novoCaine is introduced as the needle foIIows cIose to the upper border of the Iower rib, avoiding intercosta1 vesseIs and nerve. After a few minutes the short beveled “ initia1 pneumothorax needIe ” which is stiII attached to the novocaine-containing syringe, is inserted at a safe angle of 45 degrees with the body surface. As the parieta1 pIeura is entered the easiIy movabIe pIunger descends, permitting the suction of the negative intrapIeura1 pressure to draw novocaine into the pIeura1 cavity. When this happens, the syringe is detached and the needIe connected with the tubing to the manometer. With the patient breathing quietIy and the needIe in the pIeural cavity a negative pressure minus 4 cm. water on expiration, minus

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8 cm. water on inspiration wiII be indicated When no adhesions are present the deon the manometer with good respiratory sired degree of coIlapse may be attained oscihations. SIight oscihation of the ma- without the use of positive intrapIeura1 nometer around the atmospheric IeveI pressures. In the presence of adhesions, may occur with the needIe just outside the particuIarIy those suspending a stiff-waIIed parieta1 pleura. When a proper reading is cavity in the disease bearing area, positive obtained, insufllate 25 C.C. of air. Take fre- pressures are justified in order to stretch quent readings whiIe giving the first 50 C.C. the adhesions and permit cavity cIosure and negative sputum. Tension pneumoto precIude the possibiIity of the needIe tip, originaIIy intrapIeura1, having penetrated thorax often obviates adhesion cutting. the Iung. If the pressure is stiI1 negative High positive intrapIeura1 pressures are introduce 50 cc. more, continuing with to be used with caution as there is danger smaI1 amounts periodicaIIy administered of tearing caseous foci present in the Iung adjacent to the attachment of the tensed unti1 about 200 to 300 C.C. have been introduced. The instihation shouId be ended adhesion. The patient is instructed to Iie on the with a mean negative intrapIeura1 pressure. Within forty-eight hours a refiI1 is given treated side between refiIIs in order to infected sputum from being insuf%Iating in Iike manner smaI1 amounts prevent aspirated into the bronchi of the opposite of air with periodic manometric readings until 300 C.C. are given, Ieaving as before a lung. Laboratory Aids to Management of Pneunegative intrapIeura1 pressure. A third MonthIy sputum examinations refiI1 is given two to three days after the mothorax. shouId revea1 a progressive reduction of second, a fourth four to five days after baciIIary content to the point of conversion the third, and subsequent refiIIs at weekly intervaIs. As the degree of cohapse in- to negative. The rate of disappearance of creases, in the absence of restraining ad- baciIIi from the sputum depends upon the presence or absence of pIeura1 adhesions hesions, patients may have refill intervaIs on the treated side or cavitation in the conproIonged to ten days, to two or three weeks and more. Patients should be kept traIatera1 or untreated Iung. The earliest conversion takes pIace in cases with uniin bed for severa weeks during the estabIateraI cavitation and no Iimiting adheIishment of pneumothorax. A definite routine should be folIowed in sions. Concentrated sputum study shouId be made and, during reexpansion, guineacarrying out pneumothorax treatments. pig inocuIation, to confirm the absence RefiIIs shouId be frequentIy given, introof baciIIi. It is onIy in retrospect from ducing amounts requisite for obhterating as promptIy as possible a11 excavation and this point of sputum conversion that the spIinting satisfactoriIy the whoIe Iesion Iength of the coIIapse period can be properIy dated. with conversion of sputum from positive ReguIar fIuoroscopic visuaIization of the to negative. At this point onIy may we be Iung during inspiratory and expiratory assured the patient has a cIinicaIIy effective pneumothorax. When symptoms and signs movement is essentia1 to the conduct of of activity have disappeared, the Iung pneumothorax for determining the degree should very sIowIy and graduaIIy be aI- of coIIapse, detection of extension of the Iowed to reexpand ideaIIy to a state of se- process, adhesions, compIicating pIeura1 Iective coIIapse. Thus by the second or effusions, and mediastina1 dispIacement. third year of treatment, the depth of coI- Serial roentgenograms at three month interIapse of the disease bearing portion may be vaIs shouId revea1 evidence of progressive resaIution, organization and fibrosis, probmaintained at about IO to 20 per cent, with abIy with caIcium deposits in successfu1 the remaining heaIthy Iung actively funccases. tioning in respiration.

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BIood sedimentation rate determination is a vaIuabIe Iaboratory aid to management of pneumothorax when correIated with seria1 bIood counts and bacterioIogy findings, as a good indicator of cessation of pathoIogica1 activity of the tubercuIous process under compression. The rate of settIing of red bIood corpuscIes paraIIeIs the degree of activity of the disease focus. By the ratio of Iymphocytes to monocytes in the differentia1 count, and shift to the Ieft of the SchiIIing poIymorphonucIear index, we have an additiona and perhaps more dehcate measure for evaIuating the activity of the tubercuIous process and that indefinabIe something of prognostic importance which we caI1 resistance. ACCIDENTS

AND

COMPLICATIONS

OF

PNEUMOTHORAX

Gus embolus, carried from pulmonary veins to coronary or cerebral arteries, occurs about once in every 500 or IOOO pneumothorax treatments. Most frequently it occurs at the induction of pneumothorax. It may be prevented by making sure the needIe tip is in the pIeura1 cavity before administering air. Manometric oscillations must show a negative pressure sufficientIy great to indicate that the needle is in the pIeural cavity and not in a puImonary vesse1. Air introduced into the pIeural cavity may be sucked into puImonary vessels when rupture of an adhesion at its puImonary attachment exposes the open vesseIs to intrapIeura1 air. This compIication has been reported as proving fata in as many as 50 per cent of the cases. Pleural shock, a syndrome due to irritation or puncture of the pleura may be difficult to differentiate from air embolism, which it resembIes cIinicaIIy, but is usuaIIy not fata1. Spontaneous or accidental pneumothorax may resuIt from the needIe penetrating the lung, aIIowing the air from the Iung to leak into the pIeura1 cavity. More commonly an adhesion may rupture at its puImonary attachment producing a bronchopIeura1

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IistuIa. A further cause may be extension of a subpIeura1 focus burrowing into the pIeura1 cavity. When a IIap of viscera1 pIeura acting.as a check-vaIve at the fistuIous opening prevents return of air from the pIeura1 cavity to the bronchia tree, air may have to be aspirated to prevent death. Mediastinal shijting and berniation may produce embarrassment of respirocircuIatory nature. A weak or IIexibIe mediastinum resuIts in delayed rise in manometric readings with little difference in inspiration and expiration. A rigid mediastinum produces opposite effects. A mobiIe mediastinum may be stabiIized by shortening the refiI1 intervaIs and varying the amounts of air administered. At times it is necessary to stiffen the mediastinum by injection of sterile ohve oi1 or minera oil into the pIeura1 cavity. OccasionaIIy subcutaneous emphysema resuIts from Ieaking of air directIy foIIowing treatment into the tissues. The patient shouId be reassured it is of no significance. During the first day foIIowing induction of pneumothorax the patient may experience a sensation of heaviness in the chest with discomfort, aching or pain. This is due to stretching of adhesions in most cases and may be controIIed readily with codeine. Pleural efusion occurs in 30 to 70 per cent or more of cases of pneumothorax. About IO per cent of these fluids become puruIent and contain tubercle baciIIi. Empyema is most serious when it is due to mixed infections and associated with a bronchopIeura1 or subcutaneous fistuIa. Of IittIe significance is the smaI1 serous effusion which consists of fluid normaIIy present Iubricating the pIeura1 surface. During pneumothorax this fluid gravitates to the costophrenic sinuses and may be found by carefu1 search in aImost every case. Less frequentIy, Iarge serous effusions occur of low ceIIuIar, protein and fibrin content. Its formation is heraIded by low grade fever and miId toxemia for severa days. Such effusions usuaIIy develop during the first three to six months of treatment

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which represents the period in which the cohapse is stiI1 recent and incompIete and the lung most accessibIe to the effects of sudden or too excessive pressure ffuctuations.5 IncompIete pneumothorax because of adhesions favors the formation of effusion. Too sudden puImonary compression and too sudden and excessive Auctuations of pleura1 pressure are to be avoided as this upsets the norma correlation between ventiIation and circuIation in the lung. If not aspirated, fluid may remain for weeks or months. When aspiration it is carried out to reIieve pressure symptoms, at times more active pIeura1 absorption is apparentIy stimuIated. By diminishing the size of the pIeura1 space the presence of pIeura1 effusion resuits in abnormaIIy high initia1 pressures or an abnormaIIy high rise in pressure soon after air is administered during refiI1. If there is much Auid depressing the diaphragm, respiratory excursions may be absent or paradoxica1 diaphragmatic movement may occur. Long standing pIeura1 effusions favor the formation of obliterative adhesions with resuIting Ioss of pneumothorax space. Perhaps one-third of pneumothoraces are abandoned in three months time for this reason. To prevent this compIication frequentIy oleotborax is given. Fibrotic and fibrinous changes resuIting in eventua1 pachypIeuritis are more promptIy manifested if exudation has occurred. In the presence of pleura1 adhesions restricting the pIeural space, the rise of pleura1 pressure is accelerated on the administration of air. When adhesions are deemed severabIe, intrapIeura1 pneumoIysis as an adjunctive measure results in a more compIete coIIapse of Iung in 60 per cent of cases.

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CRITERIA

FOR TERMINATION

OF

PNEUMOTHORAX

The condition of the Iung before cohapse with regard to the extent and particuIarIy the type of the origina Iesion, is one of the most important points in determining reexpansion. OId x-ray films prior to institution of treatment should be reviewed. If extensive uIcerocaseous disease with Iarge cavity formation and marked constitutiona1 disturbances existed, the pneumothorax shouId be continued for more than three years, in some cases six to seven years, if reIapse would be avoided. Cavities coIIapsed and with negative sputum for more than two years are quite free from the danger of reactivation on reexpansion of the Iung. Eighty per cent of the patients with cIosed cavities and who are symptomfree and with a negative sputum, as a resuIt of satisfactory coIlapse of the lung, regain compIete working capacity; those with uncoIIapsed cavities and positive sputum rareIy make an economic recovery.6 More favorable for reexpansion are Iesions which under pneumothorax show changes of resoIution roentgenoIogicaIIy, steIIar fibrosis and caIcification of foci. Exudative lesions may hea compIeteIy, Ieaving no scar. Where there was considerabIe origina Iung destruction, a phrenicectomy or partia1 thoracopIasty may be necessary to compIeteIy obIiterate the pIeura1 cavity. More confidence is feIt in considering reexpansion in cases in whom there was conversion of positive to negative sputum, with signs of rapid cessation of pathoIogica1 activity within three to six months after induction of the treatment. In younger patients even with an exudative Iesion between the ages of fifteen to thirty years, reexpansion shouId not be permitted within three years. This is likewise a consideration with patients of poor means, especiaIIy if they must return to hard Iabor, or unsanitary ‘MAYER, E. and DWORKIN, M. Nature of pleural surroundings with poor food and Iack of effusions compIicating art&ciaI pneumothorax. Read fresh air. at the Symposium of the Metropolitan Sanatorium

Conference, N. Y. TubercuIosis and HeaIth Association, Oct. 7, 1936. To be pubIished.

6MAYER, E. Cavity in the tubercuIous, its management. J. A. M. A., too: 1478 (May 13) x933.

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In reexpanding the lung, it is a good pIan to maintain a IO to 20 per cent degree of collapse for four to six months so that during this period the lung may be given a trial of reexpansion under conditions approximating normal activity and exercise. If the roentgenogram shows no change under this altered regime and the sputum remains negative on concentration and guinea-pig inocuIation test, refiIls may be discontinued and the pleural space ahowed to obIiterate. SUMMARY

PracticaI thorax as

aspects appIied

of artilicial pneumoto the treatment of

puImonary

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are

briefly

pre-

sented for o&e and bedside use. Indications for the institution of treatment are fairIy cIear cut. The physioIogic dynamics of pulmonary compression, technical de&Is of the operation, criteria of management and termination of coIlapse therapy are briefly outIined. IncIuded also is a discussion of accidents and compIications of treatment and their management, as we11 as indications for adjunctive measures for securing adequate collapse as pneumocautery, phrenicoexeresis and thoracopIasty.