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Antero-lateral thoracoplasty in pulmonary tuberculosis

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Page 1: Antero-lateral thoracoplasty in pulmonary tuberculosis

152 TUBERCI,g [Jalluary, HJ36

ANTERO~LATERAL THORACOPLASTY IN PULMONARYTUBERCULOSIS.

By JOSEPH TIIEYAHTHU~DIL,B.A. ~I.B., B.S.OJ thc Union Jlissioll, Tubcrculosis Sanatorilllll, Arogyat"al'Cllll, S. Illdia.

" Bmito Jrlls8olilli" Scholar, ROII/c, l!Jai!-3·t,'

DURU\G recent times there has been a tendency on the part of phthisi­ologists to substitute the term "relaxation therapy" in the place of theolder term" collapse therapy." This tendency has been the result 6f acloser study of the physiopathology of the respiratory apparatus and alsoof the clinical observation of large numbers of patients under "collapsetherapy," which have shown that often a complete collapse is not necessaryfor obtaining pulmonary repose sufficient to induce and continue healingprocesses in the lung. 'l'his new conception has led to a general reduc­tion in the dosage of artificial pneumothorax. Nowadays smaller quantitiesof air are injected at shorter intervals, thereby avoiding or reducing manyof the complications of artificial pneumothorax; such as displacements ofthe mediastinum, pleural effusions, inexpandable lung, etc.

Phthisiologists of the school of Forlanini attach great importance towhat they call "trauma respiratoria" as a causative factor in phthisio­genesis. By" trauma respiratoria" is meant the constant movementsof the lungs under tension, this tension being the resultant of theoutward traction of the expanding thoracic wall, and the inward elasticpull of the lung in its coustant tendency to retract. 1'he tension is greaterduring inspiration, lesser dming expiration, but always present, even inrespiratory repose. The l!'orlanini school draws a distinction betweentuberculosis and phthisis, defining phthisis as the process of ulcerationand cavitation which comes about as a result of infection by thetuberCle bacillus. They attribute the chief beneficial action of artificialpneumothorax to the removal or reduction of the respiratory trauma fromthe lung by the interposition of a cushion of air between the lung andthe thoracic wall. The air, being more elastic and expansile than lungtissue, "breaks" the repercussions of the movements of the thoracic walland prevents them from falling upon the lung. Experience has shownthat this "break action" can be effective enough even in the absence ofcomplete pulmonary collapse. Hence the new conception of the so-called"retraction"· or "relaxation pneumothorax," where the lung is onlypartially collapsed, the air forming only an elastic protective covering forthe lung, but where sufficient pUlmonary repose is obtained to arrest in­flammatory and ulcerative processes and to start and continue fibrotic andhealing processes. (This does not, of course, mean that l;elaxation issufficient in all cases, nor that compression of the lung is always to beavoided.)

Up to the present time the idea underlying thoracoplastic operations, hasalso been that of compression; and techniques were devised with a view togiving the maximum amount of compression of the lung and immobility ofthe hemithorax. For example, in the posterior paravertebral thoracoplasty

I I fim vcry grateful to Professor Y. 1Ifonaldi nnd the nuthorities of the Benito MussoliniInstitute for allowing me free access to the clinical materials find records of the Institute.

Page 2: Antero-lateral thoracoplasty in pulmonary tuberculosis

January, HJ36] ANTERO-LATERAL 'fHORAGOPI,ASl'Y 153

of Sauerbruch, great importance .is attached to the removal of theposterior-most portions of the ribs in order to effect the maximumamount of falling-in of the chest wall. But now, in the Benito l\IussoliniInstitute in Rome is being perfected a technique of thoracoplasty basedon the power of retraction of the lung, rather than on cOlilpression fromwithout.

The lung is traumatised not only during its movements (traumadynamica), but also in repose in a distended state (trauma statica). Detailedthoracopneumographic studies of the movements of the chest wall bydividing the surfaces of the hemithoraxes into a large number of sym­metrical areas by means of horizontal and vertical lines, have demonstratedthat the areas of maximum movement of the hemithorax falls along a linewhich runs from the parasternal line in the upper part of the hemithorax,obliquely downwards and laterahvards to the posterior axillary line in thelower part of the hemithorax. That is to say, the regions of maximummovement of the hemithorax in the upper, middle and lower parts of thethorax are the anterior, antero-lateral and lateral parts respectively, theposterior surface moving comparatively little. It has also been shown thatthe lines of maximum trauma dynamica coincides with the line ofmaximum trauma statica. .

Professor Vincenzo Monaldi of the Benito Mussolini Institute hasmade an analytic study of the traction action of the thoracic wall uponthe lung, and in his book, ":Fisiopato!ogia dell'Apparato Respiratorio nellaTubercolosi Polmonare," published in 1934 by the Italian NationalFederation against Tuberculosis, has called the chief lines of such action" the dominants." According to him the dominants are four in number:The supcrior vertical, acting upwards mainly in the antero-superior partof the lung and depending for its action on the muscles of the upperthoracic aperture, especially the scalines; the inferior vertical, actingdownwards on the whole of the lung, especially on the lower two-thirdsalong the vertical axis, and depending for its action on the contractionsof the diaphragm; the antero-posterior and the transtlcrse dominantsacting mainly on the anterior and lateral parts of the lung, and dependingfor their action on the movements of the ribs by the intercostal muscles.It will be noticed that the posterior thoracic wall does not give. rise to adominant, the movements of the posterior wall· being very limited whencompared with those of the anterior. The posterior parts of the lung arethus subject to only distant repercussions of the dominants arising in otherparts.

In antero-lateral thoracoplasty, an attempt is made to give repose tothe lung by the elimination of the dominants, i.e. to interrupt the chieflines of traction of the thoracic wall on the lungs.

The operation consists of a phrenic-exairesis combined witb the removalof variable lengths of ribs along the line of maximum movement describedabove.

The tcchnique described below is the original one being perfected in theBenito l\Iussolini Institute by Professor Manfredo Ascoli.

Previous to the operation the patient is subjected to careful thora­cometry, and functional tests of the respiratory and cardiovascular apparatusare made. Also, the line of maximum movement of the hemithorax is

Page 3: Antero-lateral thoracoplasty in pulmonary tuberculosis

154 TUBERCLE [January, 1936

determined, this line being variable within limits according to the patho­logical conditions present in the underlying lung.

The patient is prepared in the usual way, and on the table the skinand deep tissues along the line of ircision are anresthetised with novocain?i to 1 per cent. The intercostal nerves are also blocked with novocain.In very sensitive or nervous patients only, slight general anresthesiaisadministered during the resection of the ribs. '.rhe general rule is toremove as much of the first db as possible, about 10 to 12 cm. of the 2ndand 3rd ribs, and about G to 8 cm. of the rest up to the 8th rib. 'Vherethere is any hope that a phrenic interruption alone might benefit thepatient sufficiently as to avoid a thoracoplasty, the phrenic operation isdone first and the results watched for a few weeks before thoracoplasty isdecided upon. But where it is evident that a phrenic exairesis alone will

FIG. I.-Photograph showiug first aud secoud stage incisions. This particular case illustrat'Jsvariations from the normal rather than the typical Butero-lateral incision.

not be sufficient, the phrenic and the first stage of the thoracoplasty maybe done at the same time. In subjects with good general condition,the operation may be done in one stage. But generally it is done in twostages, the lower part, i.e. from the 4th to the 7th or 8th ribs being donefirst. 'Where the phrenic interruption has been done some time previously,the extent of rise of the diaphragm wiIl, of course, determine the numberof lower ribs to be resected. It is well known that interference withlesions in the upper part of the lung often causes homolateral basilardiffusion of disease. The Roman school holds that in the presence ofa paralysed diaphragm, this danger of basilar diffusion is less. In anycase, with or without a previous phrenic exairesis, it is better to do the

Page 4: Antero-lateral thoracoplasty in pulmonary tuberculosis

January, 1936] ANTERO-LATERAL THORACOPLASTY ]55

lower thoracoplasty before the upper. Diffusion upwards is a. much rareroccurrence than diffusion downwards.

The second stage of the operation is generally done about a. week afterthe first. Removal of as much as possible of the 1st and 2nd ribs isimportant, and especially so in cases of apical or subapical cavities. Tofacilitate this part of the operation, the upper end of the incision isoften prolonged outwards about! to 1 in. below the clavicle.

To avoid the dangers arising from the vicinity of the importantstructures in relation with the 1st rib, care is taken not to use sharpinstruments and to see that the instruments work constantly underneaththe periosteum and in close contact with the bone. \Vhere, on accountof the exigencies of a major operation on a. tubercular patient or on accountof other reasons, the 1st rib is left untouched, '.it has been found useful todo a simple extra pleural apicolysis (without filling) by the anterior sub­costal route before closing the thoracoplasty wound, and later, in anothersitting, do a scaleniotomy. .

The lengths of individual ribs removed are varied in particular cases, soas to eliminate the chief dominants that act upon the cavities. . The shapeof the cavities, as well as the changes in their form and the direction oftheir "migration" after particular interventions, will give some indica­tions as to the chief dominants that act upon them. For example, acircular cavity situated about the centre of the lung parenchyma. and actedupon by all the dominants, will often be found to have flattened at thebottom, and at the same time to have been displaced as a. whole upwards,as a. result of the elimination of the inferior vertical dominant by meansof a phrenic exairesis.

The mechanism of action of the operation being by relaxation ratherthan by compression, it is necessary to i'etard as far as possible the regen­eration of the ribs, thus preventing the chest from regaining it,;; rigidityand allowing the flaccid portions of the chest wall to move paradoxicallywith respiration. To prevent the ribs from regrowing too quickly, asmuch of the periosteum as possible is cut off. But the periosteum inrelation with the parietal pleura cannot be removed mechanically andtherefore chemical means are used. The method employed in the Benitol\Iussolini Institute is to plug the beds of the ribs with long strips of gauzesoaked in 10 per cent. formalin. The gauze is kept on for about fiveminutes and then removed before the wound is closed. In practice thismethod has not been found quite successful and other means for retardingthe regeneration of the ribs are being sought for.

. The mechanism of action of the operation may 'be broadly describedas the production of pulmonary repose by the elimination of the dominant·lines of respiratory trauma. The effect produced is a general relaxationof the whole lung combined with special relaxation and retraction of

. particular parts of it. The contribution of the different parts of theoperation to this result may be analysed as foHows:-

(1) Phrenic Exaire.~is.

(a) The paralysis of the diaphragm eliminates 'the inferior vertical.dominant and thus contributes to the general relaxation of the lung.

(b) The elevation of the paralysed diaphragm produces partial collapse

Page 5: Antero-lateral thoracoplasty in pulmonary tuberculosis

15G TUDEIWLE [January, 1936

of the lower part of the lung. and also helps the retraction of the lungupwards.

(c) The pamdoxical1llovcmcnt of the diaphragm serves to compensatefor and neutralise the" trauma" caused by any residual inspiratory expan­sion of the chest-,vall after the operation.

(2) 'The rClIlOl:al of as much as possible 01 the 1st alld 2nd ribs plays animportant part in the mechanism of action of this intervention, as hasbeen specially pointed out by Professor l\fanfredo Ascoli. This part, of theoperation produces partially the effect of an apicolysis and scalenotomycombined. That is to say, it produces considerable depression of the apexof the lung and nullifies the action of the scalene muscles by taking awaytheir points of insertion. 'l'his part of the operation helps general relaxa­tion of the lung and produces special retraction of the apical and subapicalregions by reducing the superior vertical dominant to a minimum.

(3) ~'he effect of the resection of the ribs aloJ/g the lillc of maximummovement, is to get the maximum reduction in the movement of the· hemi­thorax with the removal of minimum lengths of ribs. This procedureeliminates to a large extent. the antero-posterior anJ the transverse domi­nants and contributes to general relaxation.

The general retraction and iinmobility thus obtained helps the healingof lcsions situated not only directly under the line of rib resection but alsoin other parts of the lung. Thoracopneumographic studies of the move­ments of the hemithorax before and after the operation, and comparisonsof the operated side with the opposite side have demonstrated the greatreduction in the movements of the treated hemithorax and also the para­doxical movements of the flaccid parts of the thoracic wall. Professorl\I6relli, the eminent disciple of Forlanini, and head of the Benito l\IussoliniInstitute, attaches much importance to these paradoxical movements, andinsists on the prevention of rib-regeneration so as to preserve these inversemovements which according to him have the effect of lifting the" respi­ratory trauma" from off the underlying diseased parts.

. Up to July H)34, 71 cases had been operated upon. This number isnot lal'ge enough to have much statistical value, but an analysis of theresults obtained may help to form an impression of the degree of promiseof the method.

Of the 71 operated, only one died as a direct result of the operation,giving a negligible operative mortality. ~Ihirty of the cases have beenopei'ated upon too recently· and therefore are excluded from this analysis.The results of the remaining' ,jl may be analysed under the headings oftemperature, physical findings, expectoration, presence of 'r.B. in sputum,radiological findings, weight and general condition, &c. It should beremembered that in the early cases included in the analysis and illustratedbelow, the technique employed was very imperfect. :For example, in manycases the 1st rib was left untouched or only partially removed.

Temperature.-Soon after the first stage operation the temperature mayrise to lo:r) or 103°F. to corne down again during the following ....;eek.'l'he rise in temperature after the second stage is generally not so marked.In some cases the post-operative rise in temperature is very slight. Twentyof the cases under analysis had fever before the operation and in IG of them

Page 6: Antero-lateral thoracoplasty in pulmonary tuberculosis

January I HJ36] ANTEHO-LATERAL THORACOPLASTY 157

the temperature came down to normal within one month of the operationand continued to he normal.

Physical Findings.-On inspection soon after the operation there isconsiderahle retraction of the chest wall, especially marked antero-posteriodyin the upper part and transversely in the lower part. This is evident toinspection and demonstrated by thoracometry before and after the operation.The supra and infra clavicular fossm are depressed. The general immobilityof the treated hemithorax contrasts with the paradoxical movements ofthe flaccid parts of the same hemithorax and with the normal or slightly

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FIG. 2.-P. RafIaele. Case illustrating the usual variations in the quantity of expectorationaft<lr operation. The asterisk marks the completion of the operation.

accentuated movements of the sound hemithorax. On palpation, painfulpoints are hardly met with in any case. The immobility of the treatedside is marked. The vocal fremitus is generally increased especially behind,but in some cases it is decreased. On percussion there is dullness of thewhole hemithorax especially marked anteriorly and laterally. On auscul­tation the most striking featlU"e is the respiratory silence all over thehemithorax. As time goes on there is progressive diminution of the moistadventitious sounds.· .. .

Page 7: Antero-lateral thoracoplasty in pulmonary tuberculosis

158 TUDEUOLE LJauuary, 19::lG

Among auscultatory findings there is one Cactor which de3erves to bespecially mentioned. On listening to the chest even long aCter the operationone oCten comes across areas of semi-moist crepitant ni.les. One notaccustomed to listening to post-operative chests is likely to mistake theseCor signs oC residual activity in the lungs. But these crepitant niles,uniCorm in character and distribution and nnchanged by cough, are thesigns of the recognised condition oC post-operative atelectasis. rl'hese arecomparable to the alarming sounds often heard in lungs expanding aCterlong collapse and are compatible with perfect health.

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FlO. 3.-T. riTgilio weight curve (in kilogrammes) to illustrate the post.operativBfall and subsequent rise.

Expectoration.-The quantity 01 sputum expectorated during twenty­Cour hours has been carefully measured in many cases beCore and after theoperation. After each of the stages of the operation there is a rapid risein the quantity of the sputum, but soon afterwards it diminishes rapidly,while the quantity decreases the quality also changes. From being thickyellow and putrid, the sputum becomes gradually thinner, clearer and moresalivary.

Page 8: Antero-lateral thoracoplasty in pulmonary tuberculosis

January, 1£)36J AN'l'EHO-LATEHAL THORACOPLASTY 159

T.B. were present in the sputum of all cases operated. In 23 out ofthe 41 cases under analysis, i.e. in 56'1 per cent. of the cases, the sputumbecame negative to '1'.B. after operation. In many of these '.r.B.disappeared from sputum ,within two months of the operation. ThedeeL'ease and disappearance of T.B. in sputum is accompanied by thegradual disappearance of other associated organisms in the sputum asrevealed by microscopic examinations.

Radiological Findings.-All the cases operated have been controlled byradiological examinations. 1'he immediate result. of the operation is areduction in the size of the cavities in the lung. As time goes on thecavities continue to retract till in 26 out of the 41 cases the cavitiescompletely disappeared. 'l'he resolution of bronchopneumonic patchesand the prevalence of fibrotic changes begin soon after the operation. 1'he

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FIG.4.-T. Enrico. To illustrate the fall in the sedimentation rate after antero·lateraIthoracoplasty (marked byasteri:lk).

paralysed diaphragm is found to rise higher in the ches't after an antero-,lateral rib resection. In no case has radiology reveale51 a diffusion or

exacerbation of disease on the contralateral side as a direct result ofthe operation. The radiograms of two ordinary cases are given toillustrate the manner and time of disappearance of the cavities after theoperation.

Weight and General Gondition.-As may be expected there is a fallin weight during the immediate post-operative period. But in the

Page 9: Antero-lateral thoracoplasty in pulmonary tuberculosis

wo TUBERCLE [January, 1936

large majority of cases the weight begins to increase soon after theoperation.

The disintoxication which follows the operation is marked by thedisappearance of night sweats, increase of appetite and a feeling of generalwell-being. Systelnatic blood examination· of operated cases shows adefinite shift to the right in the differential count (i.e: decrease in poly­morphs and increase in lymphocytes) and in the Schilling count (i.e. increasein the percentage of neutrophiles with more segmented nuclei), accom­panied by a marked fall in the sedimentation rate of R.B.C.

Seventeen of the 41 cases under analysis had repeated hffimoptysesbefore the operation. In only one has hmmoptysis returned after theoperation.

Some speCial features of the operation may be pointed out: The typeof thoracoplasty most widely used during recent times has been the posteriorparavertibral thoracoplasty of Sauerbruch. It must be admitted that withthe best of technique and operative skill, the trauma in that procedure isgreat. The scapula overlapping part of the field of operation and also thenarrowness of the intercostal spaces posteriorly add to the inconveniencesof operative manipulation. These added to the sudden compression ofthe thoracic organs make a certain degree of shock unavoidable. On theother hand, in the antero-Iateral thoracoplasty the incision runs along linesmore thinly clad with muscles, the ribs in the field of operation are widerapart and more easily cleaned and cut, and the retraction obtained is morethe result of a gradual shrinking of the lung rather than produced bycompression from outside, and a condition of shock is hardly everinduced.

The operative trauma and shock in the antero-Iateral operation are soslight that one is justified in widening the indications for thoracoplasty.The posterior paravertebral operation is generally thought of only in casesof unilateral fibrothorax with cavities, and in patients with good generalcondition. Rut considering the nature of the antero-Iateral operationabsolute freedom fWIll contralateral disease need not be so strictly insistedupon, and it has been and can be done successfully in comparative!y lesschronic cases and where the general condition is not so good as to warranta graver operation. ModEll'ate degrees of fever and toxffilllia, recenthffillloptysis, &c., need not be c·ontra-indications. '1'here is always a groupof cases where artificial pneumothorax has failed and phrenic-exairesisalone is insufficient. In many such cases the general condition is poorand the tendency of the disease is for local diffusion and cavitation ratherthan for fibrosis; 'and often these patients do not live long enough toattain the classical indications for the older radical forms of thoracoplasty.It is in these cases specially that the antero~lateral thoracoplasty can filla gap in the therapeutic armaments of the phthisiologist.

In old-standing large cavities with rigid walls and in chronic empyemiccavities with undilatable lung, retraction thoracoplasty is not likely to

'attain its object. In such cases 11 radical compression thoracoplasty of thetype of Sauerbruch is to be preferred. Some help in determining theretractability of a cavity may be obtained by watching radiographically its

Page 10: Antero-lateral thoracoplasty in pulmonary tuberculosis

January, H)3li] ANTERO-LATERAL TllORACOPLASTY IGI

size, form and position before nnd after a phrenic cxaircsis. For example,a round cavity situated ccntrally and in the line of action of. the inferiorvertimil dominant will often be found diminished in size and flattened atthe bottom soon after a phrenic. intelTuption. Such deformation andespecially diminution in size would indicate that an antero-Iateral thoraco­plasty is likely to produce satisfactory retraction. But when such a cavityis only displaced upwards without any change in form or size, then com- .pression is indicate~. ~'hus, in a general way it may be said that theantero-lateral is the operation fOl' phthisis while the posterior para­vertebral is the op(!ration more suited for the sequelm of phthisjs and itscomplications.

Careful studies of the respiratory and cardiovascular functions made onpatients before and aftcr nntero-lateral thoracoplasty have shown that theintervention does not give rise to any great disturbance in thesc functions.As may be expected, there is generally a reduction in the vital capacity,complementary air and supplementary air. But the pulmonary ventilationand the gaseous exchange are unaltered, or if slightly reduced during thepost-operative period, soon regain normal conditions. In some cases theoperation has been the means of getting rid of respiratory disturbanccslike dyspnmu, whether due to mechanical causes or due to toxmmia.. After antero-Iateral thoracoplasty the falling-in of the chest wall beingnot very greah thcrc is practically no mutilation or defoqnity such a'Sscoliosis, drooping shoulders, &c. :i\Ioreover, thc aim of the operationbeing retraction rather than compression, inconvenient post-operativetreatment such as tight bandaging, strapping, the bearing of weights onthe chest, corr~ctive postures and exercises, &c., are avoided.

Concluding, one may say that the antero-lateral thoracoplasty, basedon theoretical and experimental studies, has been shown by experienceto be a procedure capable of wide practical application. It is based onthe same principles that govern an artificial pneumothorax and yieldsresults comparable to those obtained by that procedure.

Sm.nIARy.

1. '.rhe author describes "Antero-lateral thoracoplasty"-a type ofoperation which is being practised in the Benito J.\Iussolini (now CarloForlanini) Institute, Home. 'I'he operation is described under the followingheadings: (a) The theory underlying the operation. (b) '1'he techniqueof the operation. (c) '1'he mechanism of action of the operation.

II. An analysis of the results obtained in 41 operated cases is given.III. The indications for the operation and some sliecial features of it

are pointed out. ,Yhile it is admitted that an antero-Iateral thoracoplastywill not produce . much immediate lung collapse, it is claimed that itbrings about considerable immobility Of the hemithorax and allows lungretraction and rest. It is also claimed that the operation being lesstraumatising and shock-producing than a posterior paravertebral operation,it is capable of being used with benefit in cases less chronic than thoseusually selected {or posterior thoracoplasty and in cases where the generalcondition of the patient does not \\"Urrant a serious compression operation.

11

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1U2 TUBERCLE [January, HJ36

REFERENCES.lIIo~ALDI. V. Sez. Laz. Fed. Fasc. lJer la Lotta contra la Tub., Juno, 1932.MO~ALDI, V. Lotta contro la Tub., January, H133.MORELLI, E. ..lUi. Conv. Scient. Sez. Laz. Fed. Ital. per la Lotta contra la Tub.,

lIIarch, 1933.lIIo~ALDI, V. Ibid.ASCOLI, M. Ibid .

. TORELLI. G. Ibid.SISTI, nI. A. Ibid.STEG:\IEYER, G., and CATI, L. Ibid.BESTA, B. Ibid.)IO~AI.DI, V. Conv. Venezia. Tridentina della Fed. Italiana Fascista per la

Lotta contra la Tub., Area, December, 1933.ASCOLI, nI. July, 1934. Forze Sanitarie, March. 1934.MONALDI, V. Forze Sanitarie, July, 1934.

A NOTE ON THE LARYNGEAL MIRROR TEST FOR THEDETECTION OF TUBERCLE BACILLI.

By 'V. BURTON 'VOOD, l\I.D., D.P.H., l\I.R.C.P.Physician, City of London Hospital jo/' Diseascs of Heart and Lungs, Victoria Park.

IN the light of X-rays the classical methods of physical examination inthe diagnosis of thoracic disease have been tried and found wanting and it isto-day generally recognised that in the recognition of incipient tuberculosisno reliance can be placed upon the results of percussion or auscultation. 'Vehave come to rely upon the skiagram to answer the question whether apatient is suffering from pulmonary tuberculosis or not. The shadowR castby tuberculous lesions in the lung, though not peculiar to this disease, arein most instances so characteristic that considered in relation to clinicalfeatures it correct opinion can often be given without further proof thanthat supplied by the skiagram. There has recently been a tendency toforget that the final proof of the tuberculous nature of a lesion can only besupplied by the microscope. There can be no tuberculosis without tuberclebacilli, and until these have been demonstrated the establishment of adiagnosis of active disease cannot be claimed, even though the suspicionsaroused by a patient's history, appearance or symptoms are confirmed byradiographic appearances. Before the advent of chest radiology sputumtests were in no danger of being neglected by the special worker; for theexpert opinion given by the Tuberculosis Officer depended in the main onhis possession of an unlimited supply of sputum outfits and ready accessto a county laboratory. The special worker can now claim a peculiarskill in the interpretation of chest skiagrams, and the evidence suppliedby radiology is often so convincing that the paramount importance ofbacteriology is apt to be overlooked.

It is, however, surprising how readily tubercle bacilli can be demon­strated in most instances of early infiltration. The exceptions would beeven rarer if more care were taken to insist on pulmonary expectorationand to reject samples of saliva. l\lany patients, however, refuse to admitthat they ean raise any sputum and no samples are forthcoming forexamination. After admission to hospital or sanatorium sputum can usually

Page 12: Antero-lateral thoracoplasty in pulmonary tuberculosis

TunERCLE.

C.\~~; I.-c. Y.

JANUAlt., Hl3G.

FIG. 5.-Before operation. Large cavitrupper part of left lung.

FIG. 7.-Same case, two months nIteroperation. The cavity is still more

reduced in size.

PIG. G.-Same cnse, thirtr-six un}"s afteroperation. The cavity is changed in shape

and much reduced ill size.

FIG. S.-Sallle case, six months afteroperation. The cavitr has completely

disappeared.

To illustrate article, .. Antero-Iaternl Thoracoplasty in Pulmonary Tuberculosis,"b)' J. TIIEYARTUUNDIL, 1\[,0.

F,ce p. 1m.

Page 13: Antero-lateral thoracoplasty in pulmonary tuberculosis

TUlJImCLl:.PI,,\TE II.

CASE 2.-T. V.

JANUARY, 1!J3G.

FIG. !J.-Large pamhilar cavity on the left side. Artificial pneumothorax failed andphrenic exairesis alone produced no effect.

FIG. 1O.-Same case, nine months after antero-Iateral thoracoplasty, cavity completelydisappeared and patient discharged clinically cured.