Surgery of Lung Tuberculosis

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CARL H. GELLENTHIEN, M. D. Valmora, New Mexico PULMONARY TUBERCUBY LOSIS spreads by one of four methods: 1. Bronchogenic—a spilling of the sputum and pus into uninvolved lung areas. 2. Contiguity—by direct contact and extension. 3. By the blood stream. 4. By the lymphatics—and the lymph flow is largely dependent on the movement of the lung. Surgery of pulmonary tuberculosis is based on: 1. The principle of producing lymph stasis by immobilizing the lung and so preventing the spread of the disease. 2. On the idea that by having the lung collapsed, a bronchogenic spread or spilling of the sputum is less apt to occur. 3. On the principle that cavities will heal more readily if the cavity walls can be approximated. 4. That if a diseased lung can be made to rest, it will perhaps heal. Lack of space prevents a full discussion of the different surgical methods, many of which are of questionable merit. The procedures, however, which have widespread acceptance and are known to be of established value with a superior background of experience, are artificial pneumothorax, intrapleural pneumolysis, phrenic neurectomy and thoracoplasty. The various surgical methods are: I. The direct compression of the lung by the injection of some substance into the pleural cavity. a. Artificial Pneumothorax—the injection of sterile air or nitrogen into the pleural space. b. Oleothorax—the injection into the pleural space of either olive oil or liquid paraffin to which two to five percent of oil of gomenol has been added. Gomenol is an essential oil distilled from melaleuca viridiflera, a species of myrtle. It is not toxic or irritating and is bactericidal for common pathogenic micro-organisms. c. Intrapleural Pneumolysis—the division of adhesions with the cautery under d i r e c t v i s i o n thoracoscope or by open through the operation. d. Extrapleural Pneumolysis—stripping the parietal pleura from the chest wall in the desired area and packing the space with solid paraffin, wax, pectoral muscle or a rubber bag. II. Paralysis of the diaphgram on the affected side. To limit respiratory movement and produce compression of the lung by forcing the diaphgram up on the affected side, through abdominal pressure. a. Phrenic Nerve Interruption—Temporary—Permanent. III. Direct reduction in size of half of the thorax by removing portions of the ribs. a. Extrapleural Thoracoplasty — Complete—Partial. 1. Paravertebral—the excision of a segment from the posterior end of each rib as close to the transverse process of the vertebra as possible and including all ribs except the twelfth. This is the operation most commonly done. 2. Subscapular—this differs from the paravertebral in the greater length of rib removed and the non-interference with the eleventh rib. This operation is not commonly done. Besides the increase in shock, the regeneration of bone and later fixation of the ribs is usually incomplete, making it necessary for the patient to wear a support for the rest of his life. 3. Antero-lateral costectomy — removal of enormous segments of ribs. 4. Parasternal — the resection of the cartilages and anterior ends of the first to the fifth ribs. Usually from two to nine centimeters is removed subperiosteally. The chest is then firmly collapsed with adhesive until it has become fixed in the collapsed position. IV. Paralysis of half of the thorax on