An experimental study of plastic synthetics in thoracic surgery.

Since Tuffier's original description of the extrapleural operation in 1891, the procedure has been subjected to various modifications, particularly the introduction of different plombage materials. Fat was probably the first solid plombe to be employed, but was discarded rather early because of its inherent deficiencies: lack of resistance to pressure and tendency to liquefy. Bear's introduction of the paraffin pack was a notable step forward, and indeed this method is still in use. Subsequently, in a attempt to find the ideal type of plombe, various investigators have used gauze, rubber dam, rubber balloons, muscle flaps, and oil. As in all therapeutics, the very multiplicity of the agents used attests to the universal lack of applicability of any one. However, some of the discredit which has accrued to the procedure stems not only from the individual substance themselves, but from the very nature of the operation. One of the most frequent and disastrous complications of the procedure is broncho-extrapleural fistula. This has been commonly attributed to perforation of large, peripherally placed cavities either by pressure of the plombe, or secondary to necrosis of the cavity wall following stripping of its parietal extrapleural blood supply. Although there is no universal agreement on the pathogenesis of broncho-extrapleural fistulae, there is some evidence that pressure of an extrapleural pack may play a part. Certainly, too, those series in which case selection has been carefully carried out with regard to size, type, and position of cavities have shown a notably low incidence of fistu1ae.l The inadequacy of the plombage materials devised to date has led many phthisiologists to return to extrapleural pneumothorax as a definitive procedure or as a preliminary procedure to a permanent oleothorax. This approach has been particularly popular in Scandinavia and Mex i~o ,~ and workers in those countries attribute its efficacy to meticulous attention to detail in its performance. In this country, extrapleural pneumothorax has not become widely popular, chiefly because of the technical factors in the operation, ' the difficulty encountered in maintaining the space, and the need