DISEASES OF THE CHEST Closed Intrapleural Pneumonolysis

In the early stages of his pioneering work with artificial pneumothorax, Forlanini realised that effective collapse of tuberculous lungs was frequently prevented by the presence of adhesions between the visceral and parietal pleurae. He stated that in time the adhesions would often stretch sufficiently to allow a satisfactory collapse, but it was soon found that in many cases cavities remained open after months of pneumothorax treatment. Early attempts to remedy the situation and allow complete collapse of the diseased areas consisted of opening the chest and severing the adhesions under direct vision (open intrapleural pneumonolysis), but not for many years was this method developed to the point of reasonable safety and freedom from complications. It remained for Jacobaeus, in 1913, to devise a method of severing adhesions under direct vision, but without opening the chest. He utilised two cannulas, inserted through neighboring intercostal spaces, one resembling a cystoscope, by means of which the adhesions were brought into direct view, the other providing a means of introducing the galvanocautery. With a few technical modifications this is the method used most widely today. Intrapleural pneumonolysis by the Jacobaeus technic soon established itself as a valuable procedure in the collapse therapy of pulmonary tuberculosis and its use has become widespread. Unlike most other surgical procedures, it is not in itself a collapse measure; it merely serves to improve the collapse resulting from a previously established artificial pneumothorax. During the past three years, 130 patients at the Texas State Sanatorium have been subjected to thoracoscopy. In eight of these cases it was found that the adhesions were of such extent or thickness that it seemed inadvisable to attempt to sever them. It has been the policy here not to attempt wide dissection of extensive adhesions in cases in which the disease is essentially unilateral; in these it is felt that thoracoplasty offers less risk and a better prognosis. In cases with