Collapse Therapy

Abstract: Before the days of antituberculous chemotherapy various surgical methods were used to collapse tuberculous pulmonary cavities.' These included artificial pneumothorax (often requiring adhesion section), phrenic nerve crush, and the major operations of extrapleural or extraperiosteal pneumonolysis and thoracoplasty. The latter had several disadvantages23 (table 1) and pneumothorax techniques were plagued by rapid disappearance of the air, and by infection or haemorrhage4 in the space. Extrapleural pneumonolysis consisted of mobilising the cavitated apex of a lung in the extrapleural plane.5 Advantages were that a tuberculous cavity was less likely to be breached and it was a single stage operation that did not interfere with the integrity of the chest wall. The collapse had to be maintained, however, and it was in the continuing search for substances other than air suitable to fill the space that plombage evolved. Over the years many tissues and materials were tried as a filler, or plombe, with varying degrees of success6-12 (table 2). When the more unyielding plastics became available, extraperiosteal pneumonolysis was preferred'3 because a thicker, tougher base was presented to the plombe inside the ribcage (the \"birdcage operation\"). It was thought moreover that subsequent ossification might deter late migration of the foreign material. Plombage was considered to have several advantages over thoracoplasty'4 (table 3) and was used, especially from 1948 to 1955, either alone or in combination with limited thoracoplasty.'5 The prime indication for plombage was the presence of an apical cavity less than 4 cm in diameter at or above the first interspace on the chest radiograph (fig 1). A review of major surgery in the treatment of pulmonary tuberculosis in the year 1953-4 was published