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End-results with selective collapse therapy in pulmonary tuberculosis
ENDeRESULTS WITH SELECTIVE COLLAPSE THERAPY IN PULMONARY TUBERCULOSIS FRANK S. JOHNS, M.D., F.A.C.S. RICHMOND, VA.
T
HE purpose of this paper is to set forth the advantages of seIective coIIapse therapy over certain other surgica1 measures in the treatment of puImonary tubercuIosis. Increasing activity in this fieId of surgery has brought about radica1 changes and modifications in the methods of treatment. Many of these changes have proved admittedIy non-progressive. But in the Iatest anaIysis, our fina resuIts show a distinct and gradua1 improvement. The pIan of treatment which I wish to emphasize, and to advocate before this body, is one Iess radica1, less hazardous and more economica than its predecessors. It departs in these respects from the usua1 course of the surgery of serious disease, which is wont to become more radica1 and boIder as it advances. But the very nature of the pathoIogy of puImonary tubercuIosis prohibits us from such a course, and encourages the benefits of conservative treatment. Important advances in thoracic surgery began about two decades ago. The names of Brauer and Dederick, DeCerenviIIe and SpengIer are Iinked with the earIiest deveIopment of thoracopIasty. And as earIy as 1885, DeCerenviIIe sounded the same note of conservatism in this operation that we observe today as the most important Iate deveIopment in coIIapse therapy. DeCerenviIIe reported 4 cases operated on for apica cavities, in which he resected 3-5 cm. of the second and third ribs anteriorIy, “or as many as necessary according to the extent of the cavity.” The operation entitIed compIete thoracopIasty was Iater deveIoped and “perfected” unti1 the socaIIed Standard ExtrapIeuraI ThoracopIasty came to be practiced by a11 surgeons interested in thoracic work. The 737
738
FRANK S. JOHNS
operation consisted in the resection of the first to the eIeventh ribs posteriorIy. As its popuIarity increased, astounding resuks foIIowed that bold surgica1 procedure. Over 60 per cent of bedridden patients suitabIe for this operation were suffrcientIy restored by it to be discharged from tubercuIosis sanatoria; which fact was fuI1 evidence of its vaIue. This extensive resection of the chest waI1 became the operation of choice. But we have recentIy deveIoped a Iess extensive procedure, which proves equaIIy vaIuabIe and notabIy Iess hazardous for the majority of our cases. No presentation of the surgica1 aspect of puImonary tubercuIosis can open without primary reference to the vaIue of artificia1 pneumothorax. We recognize it to be the most wideIy usefu1 measure of a11 coIIapse therapy. Its usefuIness is greater today than ever before. As Iong as the possibiIity remains that artificia1 pneumothorax wiI1 give resuIts, no other coIIapse therapy shouId be considered. This procedure has the dua1 advantage of being easiIy administered and readiIy discontinued as indicated; the compression is not necessariIy permanent; it is we11 borne where biIatera1 coIIapse is required; and is the Ieast periIous of a11 coIIapse therapy. A review of my series of IOO patients operated on for puImonary tubercuIosis, on a11 of whom some form of thoracopIasty was done, shows interesting resuIts in the most recent group, each of whom had onIy a Iimited seIective coIIapse operation. The first patient on whom I resected only the upper five ribs got such reIief from the Iimited operation that she refused to undergo further surgery. Her sputum became free from tubercIe baciIIi and the apica cavity remained coIIapsed. This was in 1924; I feared that this patient wouId soon be forced by recurring symptoms to return for further coIIapse therapy. I was aware that certain European authorities were warning against seIective coIIapse; arguing that if the upper ribs were resected and the Iower ribs Ieft undisturbed, there wouId be an extension of the involvement to the Iower Iobe. But beginning with the above, in my series of such cases
SELECTIVE COLLAPSE THERAPY
739
which comprise 33 per cent of my thoracopIasties, I have had no extension of pathology to the Iower Iobes. Nor has there been any succeeding invoIvement extending to the contraIatera1 Iung, which couId be in any way attributed to the operation. I have foIIowed this smaI1 series of cases cIoseIy. Our resuIts have been better with these than with our other patients who had the compIete or standard thoracopIasty. The seIective operation has proved definiteIy Iess hazardous. The majority of these operations were compIeted in one stage and their days in the surgica1 division were correspondingIy reduced. The 33 cases of this series have had onIy the upper five to seven ribs resected; the Iength of the section removed depending on the size of the cavity. In every apica case Iarge sections of the first rib shouId be resected. For in these seIective cases the first rib is IiteraIIy the key to the situation. It has been we11 described as “the keystone of the thoracic dome.” For a few of our cases, we have removed the first and second ribs entirely. The size of the cavity and its Iocation are the governing factors in our choice of procedure. Our system of approach with cases suitabIe for seIective coDapse has been to suit the type of operation to the pathoIogicaI Iesion. A patient who has an apica cavity with a sound Iower Iobe shouId have the cavity in the apex obIiterated; but the good Iower Iobe shouId not be handicapped by the compression resuhing from a compIete thoracopIasty. We firmIy beIieve that the cavity shouId be cIosed, even if it requires muItipIe stages of operation. In severa cases, we have found it necessary to do an anterior resection of the ribs in addition to the posterior operation. The coIIapse of the cavity is essentia1 to the cure of the patient. Fragenheim resects the first rib in apica Iesions, and Graf, for the same type of disease, removes the first rib, sometimes the second and aIso decreasing amounts of the third to the fifth, even to the seventh, incIusive. The pIan which these authors advocate is simiIar to the method we began to practice
740
FRANK
S. JOHNS
nine years ago. We discussed it before the Association Thoracic Surgery in 1928, and its continuing good resuks report today.
for we
FIG. IA.
Great benefit is derived by seIective with puImonary tubercuIosis from the phrenic nerve. This rather new operative
groups of patients operations on the measure has been
SELECTIVE COLLAPSE THERAPY
741
greeted enthusiasticaIIy by surgeons working in this fieId. It is a usefuI procedure if “temporary or permanent paraIysis of the diaphragm is desired; for recent thin-waIIed superficia1
FIG.
FIG.
I. A
and
B.
IB.
Large apical cavity. Phrenicotomy, no results. ThoracopIasty, of four upper ribs, cavity closed.
resection
cavities; for moth-eaten, soft-waIIed cavities; as an aid to pneumothorax when the base of the Iung remains uncoIIapsed and with or without diaphragmatic adhesions. It is seIdom indicated in patients with adhesions immobiIizing the dia-
FRANK
742
S. JOHNS
phragm, or in patients with acute progressive disease.“l Where surgery of the phrenic nerve was indicated, aIcoho1 injections, crushing of the nerve and phrenicectomy have given sur-
FIG.
2A.
prisingIy good resuIts. In a smaI1 percentage of our cases, these resuIts were so satisfactory that no further seIective coIIapse operation was indicated. l See JOHNS, F. S., and
treatmentof
puImonary
COLE. End resu1t.s with seIective coIIapse therapy in tuberculosis. J. Tboracic &rg., 2: 247-254, ApriI, 1932.
the
SELECTIVE
COLLAPSE
THERAPY
743
We now advocate and practice the importance of aHowing this Iess extensive and safer operation on the phrenic nerve to prove its utmost usefuIness before we proceed with a thora-
FIG. FIG. 2.
A
and B. Bilateral cavitation
28.
of both apices. Upper biIatera1 thoracoplasty.
copIasty. We have abandoned our former pIan of doing this operation as mereIy a preIiminary or index to a more radicaI procedure. It has earned a pIace of its own among our surgica1 resources and shouId be accorded pIenty of time after the operation to effect its maximum resuIts.
744
FRANK
S. JOHNS
I have had no persona1 experience with ” FiIIs” in the treatment of puImonary tubercuIosis. ArchibaId, AIexander, Harvey, Dumarest, Berard and FeIix, Maurer and RoIIand a11 vary in their opinions of their vaIue. FeIix’s report is of interest because of his cIose association with Sauerbruch’s work and for the Iarge number of his reported cases. FeIix states that “in cases where pneumothorax has succeeded and where thoracopIasty promises success, FiIIs must be put aside; for pneumothorax and thoracopIasty constitute our sovereign methods in the treatment of puImonary tubercuIosis.” The observation of Maurer and RoIIand strengthens FeIix’s views. They state that the FiII must be considered an “exceptiona method.” I wouId urge a more intensive surgica1 treatment of patients with puImonary tubercuIosis. In some of the Ieading tubercuIosis institutions more than 75 per cent of the patients receive some form of coIIapse therapy: pneumothorax, phrenicectomy and thoracopIasty. Such active treatment Iowers the immediate mortality and aIso materiaIIy shortens the patient’s stay in the hospita1. Pneumothorax is the recognized primary coIIapse treatment of choice. SeIective extrapIeura1 thoracopIasty ranks second in our hands. Phrenicectomy pIaces third, with its varied procedure and appIication. DISCUSSION
DR. LOUIS FRANK, LouisviIIe, Ky.: I have a feeIing that this is a fieId that is stiI1 open for considerabIe development. We do not see so many of these cases requiring rib resections but we have a few. We have done 25 thoracopIasties. Of this number one patient died as the direct resuIt of the operation, mediastinal shift. Our fina resuIts are considered from the standpoint of the disappearance of tubercIe baciIIi from the sputum and the patients’ abiIity to resume their usua1 activities and evaIuated upon this basis our recoveries are about 35 per cent. We have eight of the twenty-four surviving who are activeIy engaged in their former usua1 occupations. I wouId be interested in hearing just what the end-resuIts in this Fxies were, whether a11 patients made recoveries with disappearance of the bacilIi from the sputum and abiIity to resume their activities.
SELECTIVE
COLLAPSE
THERAPY
745
We have done no resections of the type Dr. Johns spoke of, taking out onIy the upper ribs. We have taken out ten or eIeven ribs and in most instances have done this in two stages, taking out the Iower ribs at the primary operation. We found in one of the first cases we treated that in the Iapse of time between the two stages the upper ribs had regenerated to such a degree that it invoIved many diffrcuIties. We found it more satisfactory to remove the Iower ribs before the upper were attacked. I beIieve there is a great future for this work, and one shouId not wait unti1 the patient is almost dead before doing anything. The operation should not be considered as absolutely the Iast resort but should be undertaken as soon as it is demonstrated that the Iess radica1 procedures do not bring about the desired coIIapse. We very much question the possibiIity of securing the necessary and desired coIIapse by the pIan advocated. DR. FRANK K. BOLAND, Atlanta, Ga.: My work has been somewhat simiIar to Dr. Frank’s, in that we have not been content with resecting the upper ribs but do a compIete thoracopIasty in two stages. However, the work of Dr. Johns appeaIs to me. If the lower portion of the Iung is in good condition, why coIIapse it? The patients need a11 the breathing space they can get and if we can stop the disease by this operation that shouId be sufficient. However, as Dr. Frank said, we cannot wait too Iong between the two stages if we do the compIete thoracopIasty, for if we wait Ionger than ten or tweIve days there is so much fixation from the upper operation due to regeneration of bone that we do not get as thorough a coIIapse as we wouId if we operated within ten days or two weeks after the first stage. I think it is important not mereIy to excise the ribs but to be sure that there is a good coIlapse of the lung. In one case, after excising suitabIe segments of the upper five or six ribs perfect strapping of the chest was not done and a roentgenogram later showed that very IittIe coIIapse of the Iung had occurred. The ends of the ribs were standing out as they had at the time of operation because there had not been proper strapping of the chest waI1 foIIowing operation. I think this feature shouId be given attention. Dr. LiIienthaI has advised the use of an elastic adhesive pIaster that is very exceIIent for this purpose for it holds the chest waI1 down and at the same time does not embarrass the respiration. I think it important that we have fixation of the diseased Iung by scar formation before we attempt extrapIeura1 thoracopIasty, for if we do not we are Iikely to coIIapse the heart also. We have had two deaths in these cases which I am sure were cardiac deaths and not puImonary, because the heart was coIIapsed as we11 as the Iung whereas if the Iung had had sufhcient fixation by scar tissue collapse of the heart wouId not have occurred. I think the operation shouId not be done if the trachea is in the midIine. As emphasized by ArchibaId, the trachea shouId be drawn to one side before the operation is undertaken.
FRANK
S. JOHNS
DR. GEORGE H. BUNCH, CoIumbia, S. C.: I think there is a fieId for partial thoracoplasty as advised by Dr. Johns. With a cavity in the apex if there is not much involvement of the Iower portion of the Iung I think this type of procedure is indicated. We have had diffIcuIty in being sure that these cavities are colIapsed even after the remova of the ribs over the apex. In one such case we packed the wound with vaseIine gauze so as to induce sufficient pressure on the apex to insure emptying and coIIapse of the cavity. That patient did very we11 and the sputum is free from baciIIi today, but we had the unfortunate complication of an empyema in the Iower pIeura1 space. This, however, after drainage heaIed and the resuIt as a whoIe I think is satisfactory. DR. FRANK S. JOHNS (Closing): The Iimited type of operation which is the subject of my paper is onIy suitabIe for cases with apica invoIvement, and I am not to be understood as advocating it for cases with invoIvement of the middIe and lower Iobes. That is why we have cIearIy termed it a operation. If a Iobe is sound, we see no reason to “ SeIective CoIIapse” compress it by resection of the ribs. Furthermore, this operation if on the Iower Iobe carries a higher mortaIity than the resuIts of upper thoracopIasties, due, in part at Ieast, to pressure on the great vesseIs and on the heart. In our experience, compression for apica Iesions has thus carried a more favorabIe mortaIity than our basa1 coIIapse therapy. In our earIy thoracopIasties, we aIways foIlowed out the compIete operation, in two or more stages, resecting the Iower ribs first, as advocated by Sauerbruch. But our work in recent years has shown us the definite advantage of the seIective or limited operation. Dr. BoIand, in his discussion, emphasized the necessity of waiting for the fixation of the mediastinum with these patients. I may add that a11 of the cases referred to in this paper have had hospitaIization for at Ieast two years, and were to be termed advanced cases before operation. Hence, they had of course reached a fixation of the mediastinum. The onIy difFicuIt part of this operation is the resection of the first and second ribs. The operation on the Iower Iobes is easiIy done. But in certain apica cases we have had equaIIy good resuIts and a Iower mortaIity with our Iimited operation. My pIea is that we try to get such patients earIier. I am convinced that many patients remain in the hospita1 too Iong under expectant treatment before they are referred for surgical consuItation. I beIieve that the seIection of cases is responsibIe for our resuIts, and that cIose cooperation between the surgeon and the internist trained in puImonary tubercuIosis is essentia1. In repIy to Dr. Frank’s inquiry as to the number of our cases stiI1 having positive sputum after operation, our records show this to be true in Iess than 7 per cent of our seIective coIIapse cases.
T
HE purpose of this paper is to set forth the advantages of seIective coIIapse therapy over certain other surgica1 measures in the treatment of puImonary tubercuIosis. Increasing activity in this fieId of surgery has brought about radica1 changes and modifications in the methods of treatment. Many of these changes have proved admittedIy non-progressive. But in the Iatest anaIysis, our fina resuIts show a distinct and gradua1 improvement. The pIan of treatment which I wish to emphasize, and to advocate before this body, is one Iess radica1, less hazardous and more economica than its predecessors. It departs in these respects from the usua1 course of the surgery of serious disease, which is wont to become more radica1 and boIder as it advances. But the very nature of the pathoIogy of puImonary tubercuIosis prohibits us from such a course, and encourages the benefits of conservative treatment. Important advances in thoracic surgery began about two decades ago. The names of Brauer and Dederick, DeCerenviIIe and SpengIer are Iinked with the earIiest deveIopment of thoracopIasty. And as earIy as 1885, DeCerenviIIe sounded the same note of conservatism in this operation that we observe today as the most important Iate deveIopment in coIIapse therapy. DeCerenviIIe reported 4 cases operated on for apica cavities, in which he resected 3-5 cm. of the second and third ribs anteriorIy, “or as many as necessary according to the extent of the cavity.” The operation entitIed compIete thoracopIasty was Iater deveIoped and “perfected” unti1 the socaIIed Standard ExtrapIeuraI ThoracopIasty came to be practiced by a11 surgeons interested in thoracic work. The 737
738
FRANK S. JOHNS
operation consisted in the resection of the first to the eIeventh ribs posteriorIy. As its popuIarity increased, astounding resuks foIIowed that bold surgica1 procedure. Over 60 per cent of bedridden patients suitabIe for this operation were suffrcientIy restored by it to be discharged from tubercuIosis sanatoria; which fact was fuI1 evidence of its vaIue. This extensive resection of the chest waI1 became the operation of choice. But we have recentIy deveIoped a Iess extensive procedure, which proves equaIIy vaIuabIe and notabIy Iess hazardous for the majority of our cases. No presentation of the surgica1 aspect of puImonary tubercuIosis can open without primary reference to the vaIue of artificia1 pneumothorax. We recognize it to be the most wideIy usefu1 measure of a11 coIIapse therapy. Its usefuIness is greater today than ever before. As Iong as the possibiIity remains that artificia1 pneumothorax wiI1 give resuIts, no other coIIapse therapy shouId be considered. This procedure has the dua1 advantage of being easiIy administered and readiIy discontinued as indicated; the compression is not necessariIy permanent; it is we11 borne where biIatera1 coIIapse is required; and is the Ieast periIous of a11 coIIapse therapy. A review of my series of IOO patients operated on for puImonary tubercuIosis, on a11 of whom some form of thoracopIasty was done, shows interesting resuIts in the most recent group, each of whom had onIy a Iimited seIective coIIapse operation. The first patient on whom I resected only the upper five ribs got such reIief from the Iimited operation that she refused to undergo further surgery. Her sputum became free from tubercIe baciIIi and the apica cavity remained coIIapsed. This was in 1924; I feared that this patient wouId soon be forced by recurring symptoms to return for further coIIapse therapy. I was aware that certain European authorities were warning against seIective coIIapse; arguing that if the upper ribs were resected and the Iower ribs Ieft undisturbed, there wouId be an extension of the involvement to the Iower Iobe. But beginning with the above, in my series of such cases
SELECTIVE COLLAPSE THERAPY
739
which comprise 33 per cent of my thoracopIasties, I have had no extension of pathology to the Iower Iobes. Nor has there been any succeeding invoIvement extending to the contraIatera1 Iung, which couId be in any way attributed to the operation. I have foIIowed this smaI1 series of cases cIoseIy. Our resuIts have been better with these than with our other patients who had the compIete or standard thoracopIasty. The seIective operation has proved definiteIy Iess hazardous. The majority of these operations were compIeted in one stage and their days in the surgica1 division were correspondingIy reduced. The 33 cases of this series have had onIy the upper five to seven ribs resected; the Iength of the section removed depending on the size of the cavity. In every apica case Iarge sections of the first rib shouId be resected. For in these seIective cases the first rib is IiteraIIy the key to the situation. It has been we11 described as “the keystone of the thoracic dome.” For a few of our cases, we have removed the first and second ribs entirely. The size of the cavity and its Iocation are the governing factors in our choice of procedure. Our system of approach with cases suitabIe for seIective coDapse has been to suit the type of operation to the pathoIogicaI Iesion. A patient who has an apica cavity with a sound Iower Iobe shouId have the cavity in the apex obIiterated; but the good Iower Iobe shouId not be handicapped by the compression resuhing from a compIete thoracopIasty. We firmIy beIieve that the cavity shouId be cIosed, even if it requires muItipIe stages of operation. In severa cases, we have found it necessary to do an anterior resection of the ribs in addition to the posterior operation. The coIIapse of the cavity is essentia1 to the cure of the patient. Fragenheim resects the first rib in apica Iesions, and Graf, for the same type of disease, removes the first rib, sometimes the second and aIso decreasing amounts of the third to the fifth, even to the seventh, incIusive. The pIan which these authors advocate is simiIar to the method we began to practice
740
FRANK
S. JOHNS
nine years ago. We discussed it before the Association Thoracic Surgery in 1928, and its continuing good resuks report today.
for we
FIG. IA.
Great benefit is derived by seIective with puImonary tubercuIosis from the phrenic nerve. This rather new operative
groups of patients operations on the measure has been
SELECTIVE COLLAPSE THERAPY
741
greeted enthusiasticaIIy by surgeons working in this fieId. It is a usefuI procedure if “temporary or permanent paraIysis of the diaphragm is desired; for recent thin-waIIed superficia1
FIG.
FIG.
I. A
and
B.
IB.
Large apical cavity. Phrenicotomy, no results. ThoracopIasty, of four upper ribs, cavity closed.
resection
cavities; for moth-eaten, soft-waIIed cavities; as an aid to pneumothorax when the base of the Iung remains uncoIIapsed and with or without diaphragmatic adhesions. It is seIdom indicated in patients with adhesions immobiIizing the dia-
FRANK
742
S. JOHNS
phragm, or in patients with acute progressive disease.“l Where surgery of the phrenic nerve was indicated, aIcoho1 injections, crushing of the nerve and phrenicectomy have given sur-
FIG.
2A.
prisingIy good resuIts. In a smaI1 percentage of our cases, these resuIts were so satisfactory that no further seIective coIIapse operation was indicated. l See JOHNS, F. S., and
treatmentof
puImonary
COLE. End resu1t.s with seIective coIIapse therapy in tuberculosis. J. Tboracic &rg., 2: 247-254, ApriI, 1932.
the
SELECTIVE
COLLAPSE
THERAPY
743
We now advocate and practice the importance of aHowing this Iess extensive and safer operation on the phrenic nerve to prove its utmost usefuIness before we proceed with a thora-
FIG. FIG. 2.
A
and B. Bilateral cavitation
28.
of both apices. Upper biIatera1 thoracoplasty.
copIasty. We have abandoned our former pIan of doing this operation as mereIy a preIiminary or index to a more radicaI procedure. It has earned a pIace of its own among our surgica1 resources and shouId be accorded pIenty of time after the operation to effect its maximum resuIts.
744
FRANK
S. JOHNS
I have had no persona1 experience with ” FiIIs” in the treatment of puImonary tubercuIosis. ArchibaId, AIexander, Harvey, Dumarest, Berard and FeIix, Maurer and RoIIand a11 vary in their opinions of their vaIue. FeIix’s report is of interest because of his cIose association with Sauerbruch’s work and for the Iarge number of his reported cases. FeIix states that “in cases where pneumothorax has succeeded and where thoracopIasty promises success, FiIIs must be put aside; for pneumothorax and thoracopIasty constitute our sovereign methods in the treatment of puImonary tubercuIosis.” The observation of Maurer and RoIIand strengthens FeIix’s views. They state that the FiII must be considered an “exceptiona method.” I wouId urge a more intensive surgica1 treatment of patients with puImonary tubercuIosis. In some of the Ieading tubercuIosis institutions more than 75 per cent of the patients receive some form of coIIapse therapy: pneumothorax, phrenicectomy and thoracopIasty. Such active treatment Iowers the immediate mortality and aIso materiaIIy shortens the patient’s stay in the hospita1. Pneumothorax is the recognized primary coIIapse treatment of choice. SeIective extrapIeura1 thoracopIasty ranks second in our hands. Phrenicectomy pIaces third, with its varied procedure and appIication. DISCUSSION
DR. LOUIS FRANK, LouisviIIe, Ky.: I have a feeIing that this is a fieId that is stiI1 open for considerabIe development. We do not see so many of these cases requiring rib resections but we have a few. We have done 25 thoracopIasties. Of this number one patient died as the direct resuIt of the operation, mediastinal shift. Our fina resuIts are considered from the standpoint of the disappearance of tubercIe baciIIi from the sputum and the patients’ abiIity to resume their usua1 activities and evaIuated upon this basis our recoveries are about 35 per cent. We have eight of the twenty-four surviving who are activeIy engaged in their former usua1 occupations. I wouId be interested in hearing just what the end-resuIts in this Fxies were, whether a11 patients made recoveries with disappearance of the bacilIi from the sputum and abiIity to resume their activities.
SELECTIVE
COLLAPSE
THERAPY
745
We have done no resections of the type Dr. Johns spoke of, taking out onIy the upper ribs. We have taken out ten or eIeven ribs and in most instances have done this in two stages, taking out the Iower ribs at the primary operation. We found in one of the first cases we treated that in the Iapse of time between the two stages the upper ribs had regenerated to such a degree that it invoIved many diffrcuIties. We found it more satisfactory to remove the Iower ribs before the upper were attacked. I beIieve there is a great future for this work, and one shouId not wait unti1 the patient is almost dead before doing anything. The operation should not be considered as absolutely the Iast resort but should be undertaken as soon as it is demonstrated that the Iess radica1 procedures do not bring about the desired coIIapse. We very much question the possibiIity of securing the necessary and desired coIIapse by the pIan advocated. DR. FRANK K. BOLAND, Atlanta, Ga.: My work has been somewhat simiIar to Dr. Frank’s, in that we have not been content with resecting the upper ribs but do a compIete thoracopIasty in two stages. However, the work of Dr. Johns appeaIs to me. If the lower portion of the Iung is in good condition, why coIIapse it? The patients need a11 the breathing space they can get and if we can stop the disease by this operation that shouId be sufficient. However, as Dr. Frank said, we cannot wait too Iong between the two stages if we do the compIete thoracopIasty, for if we wait Ionger than ten or tweIve days there is so much fixation from the upper operation due to regeneration of bone that we do not get as thorough a coIIapse as we wouId if we operated within ten days or two weeks after the first stage. I think it is important not mereIy to excise the ribs but to be sure that there is a good coIlapse of the lung. In one case, after excising suitabIe segments of the upper five or six ribs perfect strapping of the chest was not done and a roentgenogram later showed that very IittIe coIIapse of the Iung had occurred. The ends of the ribs were standing out as they had at the time of operation because there had not been proper strapping of the chest waI1 foIIowing operation. I think this feature shouId be given attention. Dr. LiIienthaI has advised the use of an elastic adhesive pIaster that is very exceIIent for this purpose for it holds the chest waI1 down and at the same time does not embarrass the respiration. I think it important that we have fixation of the diseased Iung by scar formation before we attempt extrapIeura1 thoracopIasty, for if we do not we are Iikely to coIIapse the heart also. We have had two deaths in these cases which I am sure were cardiac deaths and not puImonary, because the heart was coIIapsed as we11 as the Iung whereas if the Iung had had sufhcient fixation by scar tissue collapse of the heart wouId not have occurred. I think the operation shouId not be done if the trachea is in the midIine. As emphasized by ArchibaId, the trachea shouId be drawn to one side before the operation is undertaken.
FRANK
S. JOHNS
DR. GEORGE H. BUNCH, CoIumbia, S. C.: I think there is a fieId for partial thoracoplasty as advised by Dr. Johns. With a cavity in the apex if there is not much involvement of the Iower portion of the Iung I think this type of procedure is indicated. We have had diffIcuIty in being sure that these cavities are colIapsed even after the remova of the ribs over the apex. In one such case we packed the wound with vaseIine gauze so as to induce sufficient pressure on the apex to insure emptying and coIIapse of the cavity. That patient did very we11 and the sputum is free from baciIIi today, but we had the unfortunate complication of an empyema in the Iower pIeura1 space. This, however, after drainage heaIed and the resuIt as a whoIe I think is satisfactory. DR. FRANK S. JOHNS (Closing): The Iimited type of operation which is the subject of my paper is onIy suitabIe for cases with apica invoIvement, and I am not to be understood as advocating it for cases with invoIvement of the middIe and lower Iobes. That is why we have cIearIy termed it a operation. If a Iobe is sound, we see no reason to “ SeIective CoIIapse” compress it by resection of the ribs. Furthermore, this operation if on the Iower Iobe carries a higher mortaIity than the resuIts of upper thoracopIasties, due, in part at Ieast, to pressure on the great vesseIs and on the heart. In our experience, compression for apica Iesions has thus carried a more favorabIe mortaIity than our basa1 coIIapse therapy. In our earIy thoracopIasties, we aIways foIlowed out the compIete operation, in two or more stages, resecting the Iower ribs first, as advocated by Sauerbruch. But our work in recent years has shown us the definite advantage of the seIective or limited operation. Dr. BoIand, in his discussion, emphasized the necessity of waiting for the fixation of the mediastinum with these patients. I may add that a11 of the cases referred to in this paper have had hospitaIization for at Ieast two years, and were to be termed advanced cases before operation. Hence, they had of course reached a fixation of the mediastinum. The onIy difFicuIt part of this operation is the resection of the first and second ribs. The operation on the Iower Iobes is easiIy done. But in certain apica cases we have had equaIIy good resuIts and a Iower mortaIity with our Iimited operation. My pIea is that we try to get such patients earIier. I am convinced that many patients remain in the hospita1 too Iong under expectant treatment before they are referred for surgical consuItation. I beIieve that the seIection of cases is responsibIe for our resuIts, and that cIose cooperation between the surgeon and the internist trained in puImonary tubercuIosis is essentia1. In repIy to Dr. Frank’s inquiry as to the number of our cases stiI1 having positive sputum after operation, our records show this to be true in Iess than 7 per cent of our seIective coIIapse cases.