THORACOPLASTY
April, 1937]
IN
TUBERCULOSIS: BENJAMIN
T
THORACOPLASTY
in pulmonary and PLEURAL TUBERCULOSIS
^^ % P. V. BENJAMIN, m.b., b.s. (Madras), t.d.d. (Wales^ Assistant Medical Superintendent, Union Mission Tuberculosis
Sanatorium,
Arogyavaram,
near
Madanapalle,
South India
Historical
survey
Thoracoplasty as an operation for Pu^01^7 wit tuberculosis is being increasingly used osis 1 tubercu modern results in encouraging
tutions.
In the latter part of last centurytwo methods of trying to secure a and consequent healing of cavities bot
developed
closure
227
based on the same principle. One of these methods was that of artificial pneumothorax introduced by Forlanini. The other started with the assumption that it is largely the rigidity of the chest wall which prevents the walls of a cavity from collapsing where fibrous tissue tends to retract the lung.
therefore proposed that the the affected lung should be mobilized by resection to give free play to the natural process of healing by retraction. Two years later Karl Spengler adopted this method in dealing with cases complicated with pleural effusion, but by 1903 he had developed the operation now known as extra-pleural thoracoplasty. Still the results of these earlier operations were very imperfect and uncertain. It was Brauer followed by Friedrick (1907) who rib extensive resection. advocated They reasoned that a collapse approximating to that obtained by artificial pneumothorax must be achieved before it could be hoped to obtain the same results. Although the theory was right the operation was attended by a very high mortality and it was only between 1911 and 1913 that Wilms and Sauerbruch developed the technique of the present-day thoracoplasty ?' extra-pleural paravertebral thoracoplasy '. The principle of this operation is the removal of the posterior ends of the ribs as far back as the transverse processes of the vertebrse. The removal of comparatively small segments of the posterior ends of the ribs gives greater collapse of the lung than the removal of larger segments of the anterior or lateral portions. At the same time it was recognized that it was essential that part of the first rib should also be removed, as this greatly influences the collapse. Since that time the operation has gained popularity all over the world.
Quincke (1888)
ribs
over
Selection of cases for thoracoplasty In all cases where surgical intervention is indicated, artificial pneumothorax is the method of choice, as it produces a better collapse, if adhesions are not present; it is of less strain to the patient and it can be stopped at will, if the other lung gets worse. If pneumothorax fails, owing to the presence of adhesions, the ideal case for thoracoplasty is one with a unilateral lung affection of a chronic proliferative type in a patient whose general Such cases condition is comparatively good. usually have cavities and a tendency to retraction of the lung seen by the falling in of the ribs and by the dragging of the mediastinum towards the affected side. These signs show that Nature is attempting to deal with the disease, but unfortunately Nature's attempts frequently fall far short of what is required. Immobilization of the ribs over the affected area helps this
natural process. Among Indian patients, however, such ideal The disease is not often cases are rarely seen.
228
THE INDIAN MEDICAL GAZETTE
unilateral and instead of the chronic fibrotic type are found more frequently the acute or semi-acute exudative types. But experience has shown that good results can be obtained by thoracoplasty in many of these cases, although not ideal; for many of them no other procedure is known which can offer hope of improvement. In the selection of these cases and in the decision as to the type and extent of the operation, the utmost co-operation is required between the physician and the surgeon. The best would be that the surgeon and the physician be the same individual, but this is not always possible. The physician is in a better position to underconnected with stand the various problems tuberculosis, especially the question of allergic and focal reactions and the immuno-biological factors which vary from time to time even in the same individual, and in planning the operation the surgeon has to take into consideration the results of this individual study of the patient by the physician. Following a standardized technique described in textbooks without this individual study is bound to lead to failure. This is recognized as a necessity by all chest surgeons in the West and it is even more necessary in India where we have to deal with nonideal cases. It has to be emphasized in this connection that it is of the utmost importance for the patient to be treated on sanatorium lines after the operation. The operation is only a help to supplement the natural healing process which is best achieved under sanatorium regime. C on tra-indications
important contra-indication to thoracoplasty is, of course, widespread contralateral affection. Extensive emphysema, bronThe
chitis
most
or
asthma
or
any other condition
which
seriously reduces the vital capacity; myocardi-
serious kidney disease or advanced tuberare all enteritis culous contra-indications. Wasting may be present, but not extreme cachexia. Patients over 45 years of age do not stand the operation well.
tis,
The extent of rib resection
required
In the earlier years of the operation the rule was always to do a total thoracoplasty either in one or several stages, even if there was only lobe affection. But the modern an upper tendency is to confine the collapse of the lung as much as possible to the diseased areas and to leave the healthy parts to function normally. In the majority of cases as the disease is confined to the upper and middle zones, a partial upper thoracoplasty is all that is required. This modern technique of localized thoracoplasty has even made it possible to do a bilateral thoracoplasty when the disease is confined to the upper lobes of both lungs. In earlier years also a preliminary lower thoracoplasty, and in some cases a phrenic
[April, .1937
clone with the idea of preventing an extension of the disease to the lower healthy part of the lung by secretions from the collapseo ^ upper part after operation. The danger such an extension, however, is not a very rea are now one, and these preliminary operations considered unnecessary and may even be harmful when the lower lobe is free from the disease. e But when the lower lobe is affected a comple is essential, even if the upper
evulsion,
was
thoracoplasty lobe is free.
Occasionally, when the cavities are very large to posterior thoracoplasty may not be enough Then a supplesecure a complete collapse. some mentary anterior thoracoplasty or in pneumocases a supplementary extra-pleural lysis may be required.
a
Stages of
the
operation
The number of stages in which the thoracoplasty operation is to be done is still a matter of controversy. But this is mainly when a coma plete thoracoplasty is done in patients with in found is unilateral chronic affection such as
European patients. In Indian patients, where the disease is more acute with the possibility of severe allergic to reaction following the operation, tending shown has spread the disease, our experience
that there is not much doubt that a complete the thoracoplasty in one stage is exposing a Even to an danger. patient unnecessary have partial thoracoplasty in some patients may to be done in two stages, removing only three or four ribs at a time.
Thoracoplasty
in tuberculous empyema
There are certain types of tuberculous empyema either produced by a pulmono-pleura fistula or developed as a complication in artificial pneumothorax treatment where the close method of aspiration and drainage even wit negative pressure suction apparatus may n? allow the lung to expand and obliterate the pleural cavity. It is well known that in oldstanding cases of empyema the visceral pleura gets so thick that it is difficult or impossible to expand the lung. In such cases
underlying to complete thoracoplasty is often necessary into bring the parietal and visceral pleurae apposition that they may become adherent. Here the operation is a much more severe one than in ordinary lung tuberculosis as a complete removal of all the ribs, and not only the posterior ends but the anterior ends also, may be to be done necessary. The operation may have ^
in several stages. In some cases the pleura may not become adherent even with these extenin sive rib resections, and it may be necessary an such cases to remove the parietal pleura stitch the muscles directly over the a pleura or allow the wound to heal by granu tion from the bottom.
viscera^
Plate XIV
+* ,,, '
Pio- !??Mrs. cavity large cavity Mrs.F.F. G. admission large G. On On admission base. left base. infra-clavicular infiltrationleft ra~clavicularregion regioninfiltration
?Fig. Fig. 3.?Mrs.
F. G.
After thoracoplasty.
Cavity collapsed.
Fig. 2.?Mrs. F. G. After phrenic evulsion and sanocrysin treatment cavity smaller, but sputum level in cavity?left base clearer. Left diaphragm seen higher.
On admission. Pleural left side?but cavity seen upper
j?jg# 4.?K. J. j?jg,
thickening zone.
Plate XV
Fig. 5.?K. J. After thoracoplasty.
first two 10.?Mrs. E. F. After thoracoplasty first two Fig. 10?Mrs. obliterated. not obliterated. still not stages, lower pleural space still
Fig. 9.?Mrs. E. F. On admission, spontaneous pneumothorax. Photo after aspiration of empyema.
Fig. 11.?Mrs. E. F.
Complete
After thoracoplasty third stage. obliteration of pleural cavity.
IN
THORACOPLASTY
April, 1937]
TUBERCULOSIS:
Review of cases operated on in U. M. T. Sanatorium, Arogyavaram Since November 1932, 26 thoracoplasty operations in 17 patients have been performed at this sanatorium. In 14 of the patients the operation was done for pulmonary tuberculosis, and .
three for tuberculous empyema. In 13 of the 14 patients operated on for pulmonary tuberculosis, the operation was an upper Posterior paravertebral thoracoplasty. In these cases from 5 to 8 ribs were removed in one stage, except in one 7 ribs being the maxim
patient;
mum removed in one
stage.
The results of these
cases are as
follows
:?
Table
Operations
Much
1
improved
;
impr0ved H
Worse
Died
seen
out of 13 of these
that 9
Patients obtained positive results, and of these Jh{ldWere much improved All the 13 patients tubercle bacilli in the sputum at the time ?f operation and in 6 the bacilli disappeared ln '
?ne to three months after.
.
ln
There
the 26
immediate
was no
operative mortality
thoracoplasty operations.
Of the three
Patients who died, one died four days after the ?Peration of acute dilatation of the stomach; another died on the 11th day most probably because of a general dissemination of the
disease;
the third death occurred about
after the operation. In one case a full
plasty
a
year
antero-lateral thoraco-
was done because the patient was too ^eak to stand the more severe posterior thoiadone in two was The
c?plasty.
operation
Figs. 6,
229
stages, the anterior ends of ribs 1 to 5 being removed in the first stage and the lateral segments of ribs 6 to 10 in the second stage. The patient has improved considerably, but bacilli in the sputum (four months are still present after the operation) and collapse of the lung is It may ultimately be necessary to not marked. do a posterior thoracoplasty. The three cases in which thoracoplasty was done for tuberculous empyema have all improved. One patient is alive and well, nearly two years after the operation. The other two are still under treatment, six months and two months after the operation, and both have improved much. Illustrative
13
It will be
BENJAMIN
case
notes
(1) Mrs. F. G., aged 30; admitted 15th September, 1931. Left side extensively affected, with large cavity about three inches in diameter in infra-clavicular region. Temperature on admission 100?F. to 100.6?F.; tubercle bacilli present in sputum. Artificial pneumothorax attempted on 25th September, 1931, but failed; phrenic evulsion on 3rd October, 1931, because lower lobe Two courses of sanociysin given. was also affected. Lung improved, cavity shrunk to two inches diameter, but sputum still positive. On 24th November, 1932, ribs 1 to 7 being removed. upper posterior thoracoplasty, ' much improved' on 17th April, Patient discharged 1933, and is still alive and well over three and a half years later (plate XIV, figures 1 to 3). (2) K. J., male, aged 23; admitted 19th June, 1933, from another sanatorium where he had been since 1930 and had had artificial pneumothorax, 25 injections and phrenic evulsion. Admitted here for thoracoplasty. Patient had extensive affection on left side with large cavity in upper zone; pleura thickened; vocal chords ulcerated. Fever 100?F. to 101 ?F. Sputum tubercle bacilli positive. On 25th July, 1933, left upper thoracoplasty: ribs 1 to 6 removed. Within one month patient had found in the sputum. no fever and no bacilli were ' Discharged 26th February, 1934, as much improved' and is still keeping well and working as a teacher, nearly three years later (plates XIV and XV, figures 4 and 5, and text-figures 6, 7 and 8).
(Continued
at
foot of
next
page)
and function of fj.__ the deformity, and function of the after discharge-no j;?oharfre?no deformity, two years years after d.sehar?e-a 8.-Patient two 7 and 8-Patient
arm arm
6ood. good.
(Continued from previous page) (3) Mrs. E. F., aged 39; admitted 7th July, 1933, with high fever, very toxsemic. Found to have spontaneous pneumothorax on left, with empyema. This was treated by frequent aspiration and washing out by closed method and gomenol-oleothorax. Later, on sinus forming, a permanent open drainage introduced and frequent washing continued. The temperature was lower and general condition improved, but sinus persisted and there was no sign ot lung expanding and obliterating pleural cavity. On 10th December, 1934, first stage of complete thoracoplasty, ribs 1 to 5 posterior ends removed; 23rd January, 1935, second stage, ribs 6 to 7 posterior ends removed; 22nd February, 1935, third stage, whole of 8th and 9th ribs and anterior ends of ribs 5 to 7 removed. Patient improved steadily, sinus healed. Patient empyema cavity closed and discharged on 15th March, 1936, as 'much improved' and is still alive and well (plate XV, figures 9 to 11).
Summary (1) A short historical survey is given of the development of the thoracoplasty operation. (2) In dealing with selection of cases for thoracoplasty it is pointed out that the ideal unilateral cases of the West are rarely found in India, but yet good results can be obtained in
selected non-ideal cases. (3) Emphasis is placed on the necessity of the utmost co-operation between the physician and surgeon in planning the operation. (4) The main contra-indications to the operation are given. (5) The nature and extent of the operation and the number of stages required with reference to Indian patients are discussed. (6) The scope of thoracoplasty in tuberculous empyema is described. (7) Results are given of 26 thoracoplasty operations in 17 patients. Out of 14 patients operated on for pulmonary tuberculosis, 10 obtained positive results, and in 6 out of 14 tubercle bacilli disappeared from the sputum; three patients in whom thoracoplasty was done for empyema have all obtained positive results.
April, 1937]
IN
TUBERCULOSIS: BENJAMIN
T
THORACOPLASTY
in pulmonary and PLEURAL TUBERCULOSIS
^^ % P. V. BENJAMIN, m.b., b.s. (Madras), t.d.d. (Wales^ Assistant Medical Superintendent, Union Mission Tuberculosis
Sanatorium,
Arogyavaram,
near
Madanapalle,
South India
Historical
survey
Thoracoplasty as an operation for Pu^01^7 wit tuberculosis is being increasingly used osis 1 tubercu modern results in encouraging
tutions.
In the latter part of last centurytwo methods of trying to secure a and consequent healing of cavities bot
developed
closure
227
based on the same principle. One of these methods was that of artificial pneumothorax introduced by Forlanini. The other started with the assumption that it is largely the rigidity of the chest wall which prevents the walls of a cavity from collapsing where fibrous tissue tends to retract the lung.
therefore proposed that the the affected lung should be mobilized by resection to give free play to the natural process of healing by retraction. Two years later Karl Spengler adopted this method in dealing with cases complicated with pleural effusion, but by 1903 he had developed the operation now known as extra-pleural thoracoplasty. Still the results of these earlier operations were very imperfect and uncertain. It was Brauer followed by Friedrick (1907) who rib extensive resection. advocated They reasoned that a collapse approximating to that obtained by artificial pneumothorax must be achieved before it could be hoped to obtain the same results. Although the theory was right the operation was attended by a very high mortality and it was only between 1911 and 1913 that Wilms and Sauerbruch developed the technique of the present-day thoracoplasty ?' extra-pleural paravertebral thoracoplasy '. The principle of this operation is the removal of the posterior ends of the ribs as far back as the transverse processes of the vertebrse. The removal of comparatively small segments of the posterior ends of the ribs gives greater collapse of the lung than the removal of larger segments of the anterior or lateral portions. At the same time it was recognized that it was essential that part of the first rib should also be removed, as this greatly influences the collapse. Since that time the operation has gained popularity all over the world.
Quincke (1888)
ribs
over
Selection of cases for thoracoplasty In all cases where surgical intervention is indicated, artificial pneumothorax is the method of choice, as it produces a better collapse, if adhesions are not present; it is of less strain to the patient and it can be stopped at will, if the other lung gets worse. If pneumothorax fails, owing to the presence of adhesions, the ideal case for thoracoplasty is one with a unilateral lung affection of a chronic proliferative type in a patient whose general Such cases condition is comparatively good. usually have cavities and a tendency to retraction of the lung seen by the falling in of the ribs and by the dragging of the mediastinum towards the affected side. These signs show that Nature is attempting to deal with the disease, but unfortunately Nature's attempts frequently fall far short of what is required. Immobilization of the ribs over the affected area helps this
natural process. Among Indian patients, however, such ideal The disease is not often cases are rarely seen.
228
THE INDIAN MEDICAL GAZETTE
unilateral and instead of the chronic fibrotic type are found more frequently the acute or semi-acute exudative types. But experience has shown that good results can be obtained by thoracoplasty in many of these cases, although not ideal; for many of them no other procedure is known which can offer hope of improvement. In the selection of these cases and in the decision as to the type and extent of the operation, the utmost co-operation is required between the physician and the surgeon. The best would be that the surgeon and the physician be the same individual, but this is not always possible. The physician is in a better position to underconnected with stand the various problems tuberculosis, especially the question of allergic and focal reactions and the immuno-biological factors which vary from time to time even in the same individual, and in planning the operation the surgeon has to take into consideration the results of this individual study of the patient by the physician. Following a standardized technique described in textbooks without this individual study is bound to lead to failure. This is recognized as a necessity by all chest surgeons in the West and it is even more necessary in India where we have to deal with nonideal cases. It has to be emphasized in this connection that it is of the utmost importance for the patient to be treated on sanatorium lines after the operation. The operation is only a help to supplement the natural healing process which is best achieved under sanatorium regime. C on tra-indications
important contra-indication to thoracoplasty is, of course, widespread contralateral affection. Extensive emphysema, bronThe
chitis
most
or
asthma
or
any other condition
which
seriously reduces the vital capacity; myocardi-
serious kidney disease or advanced tuberare all enteritis culous contra-indications. Wasting may be present, but not extreme cachexia. Patients over 45 years of age do not stand the operation well.
tis,
The extent of rib resection
required
In the earlier years of the operation the rule was always to do a total thoracoplasty either in one or several stages, even if there was only lobe affection. But the modern an upper tendency is to confine the collapse of the lung as much as possible to the diseased areas and to leave the healthy parts to function normally. In the majority of cases as the disease is confined to the upper and middle zones, a partial upper thoracoplasty is all that is required. This modern technique of localized thoracoplasty has even made it possible to do a bilateral thoracoplasty when the disease is confined to the upper lobes of both lungs. In earlier years also a preliminary lower thoracoplasty, and in some cases a phrenic
[April, .1937
clone with the idea of preventing an extension of the disease to the lower healthy part of the lung by secretions from the collapseo ^ upper part after operation. The danger such an extension, however, is not a very rea are now one, and these preliminary operations considered unnecessary and may even be harmful when the lower lobe is free from the disease. e But when the lower lobe is affected a comple is essential, even if the upper
evulsion,
was
thoracoplasty lobe is free.
Occasionally, when the cavities are very large to posterior thoracoplasty may not be enough Then a supplesecure a complete collapse. some mentary anterior thoracoplasty or in pneumocases a supplementary extra-pleural lysis may be required.
a
Stages of
the
operation
The number of stages in which the thoracoplasty operation is to be done is still a matter of controversy. But this is mainly when a coma plete thoracoplasty is done in patients with in found is unilateral chronic affection such as
European patients. In Indian patients, where the disease is more acute with the possibility of severe allergic to reaction following the operation, tending shown has spread the disease, our experience
that there is not much doubt that a complete the thoracoplasty in one stage is exposing a Even to an danger. patient unnecessary have partial thoracoplasty in some patients may to be done in two stages, removing only three or four ribs at a time.
Thoracoplasty
in tuberculous empyema
There are certain types of tuberculous empyema either produced by a pulmono-pleura fistula or developed as a complication in artificial pneumothorax treatment where the close method of aspiration and drainage even wit negative pressure suction apparatus may n? allow the lung to expand and obliterate the pleural cavity. It is well known that in oldstanding cases of empyema the visceral pleura gets so thick that it is difficult or impossible to expand the lung. In such cases
underlying to complete thoracoplasty is often necessary into bring the parietal and visceral pleurae apposition that they may become adherent. Here the operation is a much more severe one than in ordinary lung tuberculosis as a complete removal of all the ribs, and not only the posterior ends but the anterior ends also, may be to be done necessary. The operation may have ^
in several stages. In some cases the pleura may not become adherent even with these extenin sive rib resections, and it may be necessary an such cases to remove the parietal pleura stitch the muscles directly over the a pleura or allow the wound to heal by granu tion from the bottom.
viscera^
Plate XIV
+* ,,, '
Pio- !??Mrs. cavity large cavity Mrs.F.F. G. admission large G. On On admission base. left base. infra-clavicular infiltrationleft ra~clavicularregion regioninfiltration
?Fig. Fig. 3.?Mrs.
F. G.
After thoracoplasty.
Cavity collapsed.
Fig. 2.?Mrs. F. G. After phrenic evulsion and sanocrysin treatment cavity smaller, but sputum level in cavity?left base clearer. Left diaphragm seen higher.
On admission. Pleural left side?but cavity seen upper
j?jg# 4.?K. J. j?jg,
thickening zone.
Plate XV
Fig. 5.?K. J. After thoracoplasty.
first two 10.?Mrs. E. F. After thoracoplasty first two Fig. 10?Mrs. obliterated. not obliterated. still not stages, lower pleural space still
Fig. 9.?Mrs. E. F. On admission, spontaneous pneumothorax. Photo after aspiration of empyema.
Fig. 11.?Mrs. E. F.
Complete
After thoracoplasty third stage. obliteration of pleural cavity.
IN
THORACOPLASTY
April, 1937]
TUBERCULOSIS:
Review of cases operated on in U. M. T. Sanatorium, Arogyavaram Since November 1932, 26 thoracoplasty operations in 17 patients have been performed at this sanatorium. In 14 of the patients the operation was done for pulmonary tuberculosis, and .
three for tuberculous empyema. In 13 of the 14 patients operated on for pulmonary tuberculosis, the operation was an upper Posterior paravertebral thoracoplasty. In these cases from 5 to 8 ribs were removed in one stage, except in one 7 ribs being the maxim
patient;
mum removed in one
stage.
The results of these
cases are as
follows
:?
Table
Operations
Much
1
improved
;
impr0ved H
Worse
Died
seen
out of 13 of these
that 9
Patients obtained positive results, and of these Jh{ldWere much improved All the 13 patients tubercle bacilli in the sputum at the time ?f operation and in 6 the bacilli disappeared ln '
?ne to three months after.
.
ln
There
the 26
immediate
was no
operative mortality
thoracoplasty operations.
Of the three
Patients who died, one died four days after the ?Peration of acute dilatation of the stomach; another died on the 11th day most probably because of a general dissemination of the
disease;
the third death occurred about
after the operation. In one case a full
plasty
a
year
antero-lateral thoraco-
was done because the patient was too ^eak to stand the more severe posterior thoiadone in two was The
c?plasty.
operation
Figs. 6,
229
stages, the anterior ends of ribs 1 to 5 being removed in the first stage and the lateral segments of ribs 6 to 10 in the second stage. The patient has improved considerably, but bacilli in the sputum (four months are still present after the operation) and collapse of the lung is It may ultimately be necessary to not marked. do a posterior thoracoplasty. The three cases in which thoracoplasty was done for tuberculous empyema have all improved. One patient is alive and well, nearly two years after the operation. The other two are still under treatment, six months and two months after the operation, and both have improved much. Illustrative
13
It will be
BENJAMIN
case
notes
(1) Mrs. F. G., aged 30; admitted 15th September, 1931. Left side extensively affected, with large cavity about three inches in diameter in infra-clavicular region. Temperature on admission 100?F. to 100.6?F.; tubercle bacilli present in sputum. Artificial pneumothorax attempted on 25th September, 1931, but failed; phrenic evulsion on 3rd October, 1931, because lower lobe Two courses of sanociysin given. was also affected. Lung improved, cavity shrunk to two inches diameter, but sputum still positive. On 24th November, 1932, ribs 1 to 7 being removed. upper posterior thoracoplasty, ' much improved' on 17th April, Patient discharged 1933, and is still alive and well over three and a half years later (plate XIV, figures 1 to 3). (2) K. J., male, aged 23; admitted 19th June, 1933, from another sanatorium where he had been since 1930 and had had artificial pneumothorax, 25 injections and phrenic evulsion. Admitted here for thoracoplasty. Patient had extensive affection on left side with large cavity in upper zone; pleura thickened; vocal chords ulcerated. Fever 100?F. to 101 ?F. Sputum tubercle bacilli positive. On 25th July, 1933, left upper thoracoplasty: ribs 1 to 6 removed. Within one month patient had found in the sputum. no fever and no bacilli were ' Discharged 26th February, 1934, as much improved' and is still keeping well and working as a teacher, nearly three years later (plates XIV and XV, figures 4 and 5, and text-figures 6, 7 and 8).
(Continued
at
foot of
next
page)
and function of fj.__ the deformity, and function of the after discharge-no j;?oharfre?no deformity, two years years after d.sehar?e-a 8.-Patient two 7 and 8-Patient
arm arm
6ood. good.
(Continued from previous page) (3) Mrs. E. F., aged 39; admitted 7th July, 1933, with high fever, very toxsemic. Found to have spontaneous pneumothorax on left, with empyema. This was treated by frequent aspiration and washing out by closed method and gomenol-oleothorax. Later, on sinus forming, a permanent open drainage introduced and frequent washing continued. The temperature was lower and general condition improved, but sinus persisted and there was no sign ot lung expanding and obliterating pleural cavity. On 10th December, 1934, first stage of complete thoracoplasty, ribs 1 to 5 posterior ends removed; 23rd January, 1935, second stage, ribs 6 to 7 posterior ends removed; 22nd February, 1935, third stage, whole of 8th and 9th ribs and anterior ends of ribs 5 to 7 removed. Patient improved steadily, sinus healed. Patient empyema cavity closed and discharged on 15th March, 1936, as 'much improved' and is still alive and well (plate XV, figures 9 to 11).
Summary (1) A short historical survey is given of the development of the thoracoplasty operation. (2) In dealing with selection of cases for thoracoplasty it is pointed out that the ideal unilateral cases of the West are rarely found in India, but yet good results can be obtained in
selected non-ideal cases. (3) Emphasis is placed on the necessity of the utmost co-operation between the physician and surgeon in planning the operation. (4) The main contra-indications to the operation are given. (5) The nature and extent of the operation and the number of stages required with reference to Indian patients are discussed. (6) The scope of thoracoplasty in tuberculous empyema is described. (7) Results are given of 26 thoracoplasty operations in 17 patients. Out of 14 patients operated on for pulmonary tuberculosis, 10 obtained positive results, and in 6 out of 14 tubercle bacilli disappeared from the sputum; three patients in whom thoracoplasty was done for empyema have all obtained positive results.
