Increasing surgical interest in bullous emphysema has been manifest in recent years. Justification for surgery in many series of cases has been vague but there is more and more agreement on the necessity for considering an increasing number of these patients for surgery. The first American reference on this subject was in 1925 when Koontz reviewed the literature and collected 105 cases. The surgical program was somewhat vague at this early date due to the undeveloped status of resection surgery. By 1937, Schenck had collected 381 cases and presented five of his own. Of these, four were subjected to local excision and one was lobectomized. He remarked that cysts easily herniated from the wound facilitating excision. In fact, he stated that bullae might continue to increase in size with each breath, necessitating opening them to facilitate dissection. Tyson, in discussing this presentation, emphasized the short life expectancy in many of these patients and related a case operated 11 years previously who expired with cor pulmonale. In 1949, Ravitch and Hardy reported 12 patients and advised surgery as soon as the condition was diagnosed. Ten of their patients underwent lobectomy and one pneumonectomy. This was apparently the ultraradical approach. By 1950, another group of 14 cases was reported by Samson and Dugan, and in 1952 Crenshaw and Rowles added 11 more. Both of these groups took a more conservative surgical approach, limiting the operation to local excision where possible and thereby conserving lung tissue. Many other significant contributions were made in the literature about this time, namely, Nissen, Head and Avery, Brock, Naclerio and Langer, Albritton and Templeton, and Massie and Weichon. The cause of bullous emphysema is not completely clear, but there appears to be a loss of elastic tissue in the lung. Certain predisposing causes may be present as a chronic cough, from repeated infections, spasm, or occupational hazards, or the condition may be secondary to chest wall changes. Many terms have been applied to the disease: blebs, bullae, tension cysts, air cysts, builous emphysema, pneumatocele, and “vanishing lung.” More important than the designation is the extent of involvement. This may not be fully apparent until lung function studies give some clue and actual thoracotomy reveals the true nature and extent of the process. Bullae may be uniloculated or multiloculated. They may be segmental in distribution or completely unanatomical in location. Frequently a group of pea sized blebs may be seen along fissure borders which is not discernible in roentgenograms. The capsule of the bulla is thin and translucent with many areas of fibrous thickening. On opening larger bullae, one sees many loose strands of connective tissue, lung substance and denuded vessels traversing the spaces. These may be so numerous and lacy as to resemble cotton candy, a term frequently applied to the diffuse category. Many bullae communicate with
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