Local Compression Therapy in the Treatment of Pulmonary Tuberculosis

Doctor Dolley’s discussion shows the ingenuity that the surgeon has been obliged to use in coping with the destructive phases of tuberculosis. It is a clear and concise presentation of the subject. 

It was formerly taught that tuberculosis is an insidious disease and that all cases showing destructive lesions had been neglected in diagnosis. We now know that this is untrue; for tuberculosis often comes on as an acute process and shows cavity formation soon after clinical symptoms have first manifested themselves. The appreciation of the fact that tuberculosis often comes on as an acute destructive process is one of the real advances in our clinical conception. The fact that tuberculosis with insidious onset sooner or later goes over into an acute process, often with cavity formation, emphasizes the importance of immediate treatment when active disease has been diagnosed. 

When acute destructive process with cavity forms in the lung, if the patient is put at rest immediately, preferably in an institution, and given the benefit of the well-recognized methods of treatment, a large percentage of arrests will result without collapse therapy of any kind. The danger of waiting is that pleural adhesions will form and that these will prevent effective collapse, should pneumothorax treatment be undertaken later. From the standpoint of choice, however, every patient who can secure healing of his pulmonary tuberculosis without any form of interference with his pleural space is in a better position as regards future physical efficiency than he would be were this principle disregarded. A cure may be brought about by the usual dietetic, hygienic regimen with bed rest in a large proportion of such patients in about a year’s time; whether such method is going to be successful can usually be determined in five or six months’ time. The disadvantage of a noninterference policy lies in the danger that pleural adhesions may form in the meantime and make pneumothorax out of the question. This has caused many to collapse such acute cavities as soon as the diagnosis is made. Pneumothorax does not produce its results any more quickly, for the lesion cannot heal short of many months. It does, however, permit the patient to be up and about sooner because it reduces or abolishes symptoms. This, however, is often of doubtful advantage, because rest and a careful regimen for a prolonged time is the best guarantee of permanent healing, whether a collapse therapy is employed or not. 

Many of these cases start in apices which have previously been infected and which already are surrounded by a cap of pleural adhesions which preclude collapse by pneumothorax; others form adhesions during the period between cavity formation and attempted compression. In both of these, pneumolysis may bring about a favorable result. 

One other group of cases in which pneumolysis is the ideal operation, provided it can produce a satisfactory collapse, is the type in which a permanent cavity forms in an apex surrounded by a pleural cap and adherent mediastinum. Tension from all sides holds such a cavity open and prevents compensatory closure. If such are treated by pneumolysis, or pneumolysis and a limited rib resection, the patient attains his result with the least loss of pulmonary tissue. Since most of these cases have had extensive involvement of pulmonary tissue outside of the area involved in the operative field, it is of great importance that the operation be done with the sacrifice of as little lung tissue as possible. For this reason pneumolysis makes a special appeal in such cases.