VOL. 48, No. 6 November, 1956 407

Lung Resection in the Treatment of Pulmonary Tuberculosis*J. F. NUBOER, M.D.

Professor of Clinical Surgery, University of Utrecht;Head, Department of Surgery, Utrecht University Hospital, Utrecht, Holland

IN the period before World War II there was ahigh degree of agreement in the Western Euro-

pean countries regarding the treatment of pulmon-ary tuberculosis. The treatment consisted of a moreor less rigorous sanatorium regimen which wasoften supplemented by collapse therapy. Onlyas to a few details was there any difference ofopinion. In the Netherlands, for example, thesanatorium treatment was carried out extremelystrictly and a large proportion of cavities washealed by those means only. Intrapleural pneumo-thorax was little used and only when the processhad largely become inactive. As a result of this,one saw but rarely, on the one hand, tuberculousempyemata after application of intrapleural pneu-mothorax, but on the other, the application of thistherapy was frequently unsuccessful in the laterstages of the disease, on account of extensiveadhesions. For this reason extrapleural pneumo-thorax was extensively used in this period.

Apart from these relatively slight differences,there was a large degree of agreement, as to thebest method of treatment. With the introductionof the antibiotics the situation changed completely.As a result of the anti-tuberculosis organization,set up before the war in the Netherlands, prac-tically every case passed through the tuberculosisdispensary and the treatment was from the outseteither conducted or controlled by the lung physi-cian. When it appeared, sometime after the intro-duction of streptomycin, that after long continuedapplication of this drug resistance could develop,in certain cases remarkably quickly, it becamenecessary to take account of this possibility at thebeginning of the treatment of each case. We havetherefore been extremely economical with strepto-mycin in the Netherlands, particularly in thosecases where the possibility of eventual surgicaltreatment had to be considered. A large proportionof the patients treated surgically by us, had re-ceived no streptomycin before the operation. The* Read at the 38th Annual Meeting of the John A. Andrew

Clinical Society, Tuskegee Institute, Alabama, April 8-13,1956.

problem of resistance to this drug in surgical caseswas of little significance. There has thus developedin this respect, a definite difference in the modeof treatment in different countries.

In France, for example, every case of tubercu-losis receives streptomycin, I.N.H. and PAS fromthe beginning, so that in practically every casecoming to operation, one should be prepared forresistance to one or more of these substances. Ihave also the impression that in England one tendsto apply the chemotherapeutic and antibioticagents on a much larger scale, and this in myopinion, leads to limitation in the application ofresection therapy.

These differences in therapeutic methods, makeit important to compare large series of treated pa-tients. However, in such a chronic disease as pul-monary tuberculosis, it is only possible to discussdefinite results after the passage of at least 10years and the time is nearly ripe to draw conclu-sions. It may, however, be of value to report alarge series of treated patients and to discuss theresults in those cases treated between 5 and 10years ago.Lung resection for tuberculosis has been carried

out in the Netherlands for approximately 10 years.In the University clinic of Utrecht, up to March1, 1956, 1173 lung resections were carried out fortuberculosis, 1161 under cover of chemotherapeu-tic and antibiotic drugs.

Pulmonary tuberculosis is a medical disease.The majority of sufferers from this condition maybe clinically healed by medical treatment only;surgical therapy, including lung resection, shouldreally only be considered when medical therapyhas failed. In the Netherlands, despite this factthat resection therapy is carried out on a largescale, it is nevertheless utilized for not more thanapproximately 30 per cent of sanatorium patients.

It is not only so, that lung resection is indicatedonly when medical therapy has preceded operation,but it is also of the greatest importance, that thispreoperative treatment of the patient has been as

408 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION NOVEMBER, 1956

complete as possible. A strict sanatorium treatmentis essential, preferably with absolute bed rest,which includes mental rest. At the same time it isadvisable to administer PAS, which may, if neces-sary, be combined with INH. Streptomycin is, asa rule, not given as preoperative therapy in Dutchsanatoria. However if this drug is used, this occursonly on special indication, e.g. in the presence ofhematogenous spread or tuberculous bronchitisand in those cases with extensive processes, whichhave not responded to the other medical treat-ments. One tries however, in view of the possi-bility of a future operation, to reserve streptomycinfor the postoperative treatment of the patient andto control its use in such a way that resistance tothe drug does not occur.

If, after six to twelve months sanatorium treat-ment, healing has either not occurred, or is stillso incomplete that the probability of recurrenceis great, surgical therapy must be considered.

In the consideration of resection therapy forpulmonary tuberculosis one must always bear inmind the fact, that lung tuberculosis is not a local-ized process. It affects as a rule a much largerarea of the lung than the results of clinical in-vestigation indicate.

It is thus certain that by surgical removal of alobe, or even an entire lung the disease processcannot in the large majority of cases be completelyremoved. On this account lung resection for tuber-culosis should always be regarded as an incompleteoperation and it is of great importance to keepthis fact constantly in mind. Experience has taughtus that the results of surgical treatment of tuber-culosis of the other parts of the body are as arule unsatisfactory, unless it is possible to removecompletely all diseased tissue. In any operation,tissue planes are separated, blood and lymph ves-sels opened and the barrier which the body hasbuilt against spread of the disease is broken down.In connection with the operation it was not seldomseen that a dissemination or local spread of thetuberculous process occurred.

Experience following resection of tuberculouschanges in the lung was not more favourable. Theoperative mortality was appallingly high, accordingto Thornton and Adams, 45 per cent for pneu-monectomy and 25 per cent for lobectomy.1 Thefatal outcome was usually a result of dissemina-tion, reactivation or bronchial fistula development.

In a small series of 12 cases treated by us in 1946,at a time when chemotherapeutic agents and anti-biotics were not available, we had a mortality of25 per cent.

Since the introduction of the use of chemo-therapeutics and antibiotics, the state of affairshas completely changed. Streptomycin in particularhas a powerful action in fresh tuberculous inflam-mations and it appears to be possible by its use toprevent dissemination and early local establish-ment and growth of tubercle bacilli. By the use ofstreptomycin the incomplete removal of a tubercu-lous process was freed from one of its greatestdangers.

It was unfortunately soon to become evidentthat the tubercle bacillus can become resistant toall of the active anti-tuberculous drugs. Shouldresistance against all these substances develop, thesituation is then precisely the same as it was inthe days before these drugs were available. It ishardly remarkable, therefore, that the results ofresection therapy in the presence of drug resistanceare so unsatisfactory and that the likelihood of thedevelopment of bronchial fistulae and dissemina-tion is so great. On this account it is advisable toconsider operation only when there is susceptibil-ity to at least one of the above named substances,and, in view of the fact that of these the mostpowerful is streptomycin, it is of the greatestimportance that the bacilli of the patient be stillsufficiently sensitive to this drug.Lung resection for tuberculosis has not thus as

object the removal of all tuberculosis tissue. Theintention of the operation is rather to assist abody, not of itself capable of spontaneous healing,in the attainment of a clinical cure. The surgeon,therefore, must remove those parts which standin the way of a cure or which have become uselessto the body or dangerous to life because of seriousanatomical changes. There are however processessuch as bronchogenic disseminations which showin general a great tendency to cure and these may,if not too large or too extensive, be left behindundisturbed after the removal of the most seriouslyaffected areas. This opinion is common to manysurgeons who have a large experience in this field.

There should be little difference of opinion inthe matter of what constitutes functionally worth-less or dangerous parts of a lung. If there is abronchial stenosis with bronchiectasis and reten-

VOL. 48, No. 6 Lunig Resec-tion in the Treatmenit of Pulmonary Tube rculosis 409

tion of secretion, or if a lobe or an entire lungbe practically destroyed by multiple cavity forma-tion, the retention of these parts is of little valueto the patient; they constitute moreover a risk onaccount of a possibility of extension to the remain-ing healthy lung tissue.

It is more difficult to answer the question as towhich of the more limited changes stand in theway of a clinical cure. On the basis of experiencethe Dutch surgeons have come to the conclusionthat it is mainly those foci of lung phthisis, fociof hematogenous origin arising after the primarytuberculosis, usually in the apical and dorsal seg-ments of the upper lobe and in the apical segmentof the lower lobe, which should be removed.

It is customary when discussing tuberculosis ingeneral, to distinguish between exudative andproliferative forms. It is usually stated that in theexudative form the process tends to spread, be-cause the balance between the pathogenic agent,on the one side, and the defenses of the body, onthe other, is upset to the disadvantage of the body.In the proliferative form, however, the resistanceof the body in relation to tuberculosis is relativelyhigh and the spread of the disease process islimited.

It has for a long time been known that in suchchronic disease processes as tuberculosis, surgicaltherapy gives in general the best results when itis applied in the proliferative phase. As opposedto this, the results obtained by intervention in theflorid phase are as a rule bad. This is completelyunderstandable viewed from a biological stand-point. Surgery is not a cure for tuberculosis; itmakes a cure possible and gives support to thenatural power of the body in the fight against thetubercle bacillus. The surgical procedure produceshowever at the same time tissue damage. Shouldsurgical therapy be applied under conditions inwhich the defense of the body is of itself inade-quate to offer resistance to the tubercle bacillus,then the results of the therapy can only be dis-appointing. The results of lung resections forexcaveated pulmonary tuberculosis were in the be-ginning particularly bad because little attentionhad been paid to the basic principles in decidingupon operation.One cannot insist too strongly upon the fact

that lung resection should only be carried out whenthe process is as reduced in activity as possible.

Early operations should be definitely discarded.Even when the activity of a process has been

reduced as far as possible for a particular case,it is still necessary to observe the patient carefully.Should the operation be carried out in a stage ofreactivation such as repeatedly occurs in tubercu-losis, there is a great possibility of a bad result.The choice of the right moment for surgicalintervention is thus of the greatest importance,.This choice can however be extremely difficult,particularly when cavities are present.

Resection therapy of tuberculosis is but a smallpart of the total treatment of this condition. Sur-gery does not cure tuberculosis, it makes the curepossible. It is, therefore, essential for this form ofsurgical therapy to be followed by a strict andintensively carried out sanatorium cure whichshould last at least 6 to 8 months and sometimeseven longer. During this postoperative treatmentthe various chemotherapeutic and antibiotic drugs,especially streptomycin, are given in order to per-mit consolidation of the remaining tuberculousprocesses and the complete clinical cure of thepatient.

It is not necessary here to say very much aboutthe indications for lung resection as you are allwell acquainted with these, Table 1. I should like,however, to emphasize one of our relative indica-tions, namely the removal of bad cavity scars.The experience shows that these large scars

always represent an inadequate healing of thecavity, particularly when they are surrounded by

TABLE 1-SlPECIAL INI)JCATION_;S FOR LlTU\(;RESECTION

Standard Indicationisa. Tuberculous broncliial stenosish. Destroyed lungc. Tuberculous hronchiectasisd. Tuberculomae. Filled up) cavityf. Caseous foci of limiiite(d extenitg. Persistent large primary focush. Cavities persisting after collapse therapyi. Tuberculous empyema with or bithouthroncho-pleural

fistula and with associated tuberculous processes inhomolateral lung

Relative Indicationisa. Cavities

i. tUnder tenisionii. Thick-walle(d

iii. Extremely largeiv. In mniddle and lower lobes, also those situate(l para-

vertebrally in upper lobesb. Bad scars remaining after clinical healing of cavity.

410 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION NOVEMBER, 1956

a dense mass of connective tissue. Investigationof these scars reveals the presence of encapsulatedcaseous material. These incompletely healed cavi-ties are a source of reactivation which occurs inapproximately 30 per cent of the cases. Lungresection is definitely indicated whenever an insu-fficient degree of healing is reached after a recur-rence and we consider that one can do better toproceed to resection before the recurrence devel-ops, that is, in every case showing a badly healedscar. In these cases a segmental resection is usuallysufficient.

It is hardly necessary to state that resectionshould only be carried out for tuberculous cavitieswhen the acute stage of the disease has been passedand when the healing cannot be obtained by othermeans. The operation should never be performedin fresh cases.

Resection therapy for tuberculosis is, in fargreater degree than is the case with other modesof treatment, a strictly individual therapy. Apartfrom the fact that in every case the advantagesand disadvantages of lung resection must be care-fully weighed against other available forms oftherapy, there are certain circumstances which ren-der the operation less desirable, Table 2.

I should like here to emphasize two contraindica-tions which we consider to be important: organicdisease of the heart and pulmonary hypertension.Nineteen of the 1161 patients, operated underantibiotic and chemotherapeutic cover up to thefirst of March 1956 died as a result of the opera-tion. In not less than 13 of these was death dueto cardiovascular disturbances, six died of lungembolus, which indicates the necessity for theprompt institution of anticoagulant therapy at thefirst sign of a developing thrombosis; one patientdied as a result of thrombosis of the pulmonaryartery at the other side and in the remaining sixpulmonary hypertension was almost certainly in-volved. In addition, of those patients returning tothe sanatorium for after-treatment, two died as

a result of cor pulmonale, two of heart infarctionand three of late embolism. The presence of pul-monary hypertension, developing as it may inpatients with chronic bilateral disease, is extremelydangerous. The investigation of the cardiovascularsystem in every patient who is to be submitted tolung resection, is of primary importance. In doubt-ful cases, particularly in middle-aged patients, thisinvestigation should include cardiac catherization.A number of complications may arise after lung

resection and these may or may not be directlyconnected with the tuberculous process. The latterare as a rule not serious and heal or tend to healwithout treatment, while others, for example post-operative atelectasis leave no permanent ill effect,always assuming that the proper measures areinstituted with minimum delay.More serious, however, are the complications

arising directly as a result of the tuberculousnature of the disease. These are principallybronchopleural fistulae, reactivation and extensionof the disease.

Bronchopleural fistula always constitutes a mostserious complication and occurs most frequentlyas a result of lung resection carried out for pul-monary tuberculosis. They are particularly danger-ous when in association with an open pleura. Theinvariable result of this combination of circum-stances, is the development of an empyema whichis always tuberculous.

There are various factors involved in the devel-opment of such a fistula. Division of the bronchustoo close to the site of the process, is in manycases responsible, but possibly still more importantas an etiological factor is a process of relativelyhigh activity. The latter can lead to the develop-ment of a tuberculous inflammation, occurring inthe bronchus stump with subsequent failure ofthe closure. Our impression is that resistance tostreptomycin also increases the possibility of thedevelopment of a fistula.

In the university clinic in Utrecht over the last

TABLE 2-CONTRAINDICATIONS FOR RESECTION

Absolute Contraindicatiotzs Relative Contraisdicationsa. Inadequate lung function a. Resistance to streptomycinb. Organic diseases of heart and pulmonary hypertension b. Activity of the tuberculous processc. Resistance to all existing anti-tuberculous drugs c. Tuberculosis in the older age groupsd. Actively ulcerating or granulating tuberculous bronchitis d. Pneumothorax of the contralateral sidee. Active tuberculosis in the contralateral lung e. Diffuse ulcerations of the smaller bronchif. Extensive active extrapulmonary tuberculosis

VOL. 48, No. 6 Lung Resection in the Treatment of Pulmonary Tuberculosis 411

TABLE 3-COMPLICATIONS: FISTULA

Cured after Treatment

Total - Conservative. Thoracoplasty R-e-resection Not yet cured Died

Pneumonectomy: 152 13 1 6 1 5

(1 re-resection) ,.Segmental resection: 528 3 - -- 3Lobectomy and segmental resection: 108 4 1 2 - -

31/2 years, not one person has developed a broncho-pleural fistula after lung resection for tuberculosisand we attribute this to the accurate closure of thebronchial stump, which is then subsequently cov-ered with pleura of lung tissue. In our entireseries, we have seen 32 bronchial fistulae; nine ofthese patients died, in 18 the fistula was closedoperatively and in four spontaneous healing wasobtained by conservative measures; in one casethe small fistula has not yet closed, Table 3.

Reactivation and spread are complications whichas a rule are first met during the postoperativecourse of therapy in the sanatorium. They havebeen seen in 75 of the 1173 operated cases,6 per cent, Table 4. Various factors may be in-volved in the development of these complications.They are occasionally due to the aspiration of pusor mucus into the remaining tissue. The cause issometimes to be found in atelectasis or incompleteexpansion of the lung, complications which shouldbe treated as quickly as possible, should theydevelop. In by far the great majority of our caseshowever, a too great activity of the tuberculosis

was the responsible factor. It is important to notein this respect that more than 50 per cent ofthese cases of reactivation followed operation fora cavity. We know from experience that, evenwhen the activity of this process has been reducedas far as possible, the immunobiological relation-ship is less favorable than is the case with afibrocaseous process or with tuberculoma. In theremaining cases the complication resulted from aninadequate resection or from a reactivation of fociremaining in other areas of the lung or from un-satisfactory after-treatment.

Examination of these figures shows withoutdoubt that reactivation and extension of the proc-ess have occurred too frequently. When one ob-serves that of the 36 reactivations developing afterlobectomy and the 20 after segmental resection, 27and 17 respectively, were observed to occur in theoperated lung, it is reasonable to surmise that thecomplication should in many cases be ascribed toa too limited resection. In other cases reactivationsarise in small foci of lung phthisis which were leftbehind during the operation, e. g. in the apical seg-

TABLE 4-COMPLICATIONS: REACTIVATION AND SPREAD

Cured after TreatmentNot yet

Total Conservative Thoracoplasty Re-resection Cured Died

Pneumonectomy 7 1 - - 4 2reactivation

Lobectomyhomolateral 27 7 - 13 5 2

Reactivationheterolateral 9 3 - 2 3 1

Segmental resectionhomolateral 17 4 1 8 3 1

Reactivationheterolateral 3 1 - 1 1 -

Lobectomy and segmental resectionhomolateral 12 2 - 7 2 -

Reactivation - - - - - -

heterolateral

TOTAL 75 18 1 31 18 6

412 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION NOVEMBER, 1956

TABLE 5-OPERATIVE MORTALITY: ENTIRE SERIES

Pnteuion ectomiv Lobectomyv Segmental resection, All cases

ANum- Oper-a- ANum- Opera- ANr1am- Opera- Numn- Opera-ber tive ber tize ber tize ber tive

All of mitortal- % of mortal- % of mortal- % of mitortal- %cases cases ity cases ity cases ity cases ity

No streptomycin all(IPAS 12 6 1 17 6 2 33 - - - 12 3 25

\i'ith streptomIycinan(I PAS 1161 146 6 4.1. 487 10 2.06 5'28 3 0.57 1161 19 1.63

TOTAL 1173 1 2 7 493 12 528 3 1173 22 1.87

ment of the lower lobe.It is usually possible to bring about healing of

a reactivation or spread by conservative measures,but it is unfortunately sometimes necessary to per-form a re-resection. Unfortunate because one isthus forced to sacrifice one of the great advantagesof resection therapy, that is, the cure of a tuber-culous lesion with a minimal loss of lung function.

If the indication for resection has been care-fully assessed and the pre- and postoperative treat-ment, including the administration of antibioticand chemotherapeutic agents, has been carefullycarried out, the primary mortality of the opera-tion is low.Of the 1161 patients operated in the University

clinic of Utrecht under, (Table 5), cover of strep-tomycin and PAS, 19 died of the operation, 1.63per cent. If one includes the 12 patients treatedby us before the introduction of streptomycin thepercentage mortality is increased to 1.8 per cent,Table 6. The detailed study of the cause of deathin this series reveals the most important factorsinvolved to be cardiovascular disturbances andpulmonary embolism. The late mortality is alsolow and up to the present time considerably lowerthan that after surgical collapse therapy. In the

TABIE 6-PRIMARY MORTALITY

Dissemiintation (resistant to streptomycin) .. 1Fistula witli emnpyemlea (treated without streptomycin and

PAS) ...................... 3Cardiovascular irregtularities ................ 6Lung embolism ............... ..)......................Thrombosis of arteria pulmonis on the other side ... 1Anoxia, death during narcosis .. 3Bad lunig function, bursting of emphysema-vesicle on other

side ..............................................Hyperthermia without clear cause at autopsy .. 1

TOTAL 22

Utrecht department this late mortality to date is1.9 per cent and in the series operated in the Uni-versity of Groningen (Eerland) 2.1 per cent latemortality in 863 cases has been reported.

LATE RESULTS

The significance and the value of a particularmethod of treatment can only be judged from thedefinitive and permanent results. Similarly thesignificance of resection therapy for the treatmentof pulmonary tuberculosis can only be estimatedfrom a consideration of the late results. Becausewe are dealing with a chronic disease, the observa-tion time after the completion of the treatmentshould be at least 10 years. Because resectiontherapy is still in its youth, the results of 10 yearsand more are as yet hardly known and, therefore,no absolute comparison with other surgical meth-ods of treatment is possible. The results whichare quoted here should thus be regarded asprovisional.The results of resection therapy for tuberculosis

are not the same everywhere. In the Netherlandsthere appears to be great difference between thevarious results obtained in different sanatoria.Because little has as yet been published in this

TABLE 7-LATE 'MORTALITY

Disseminationi (2 resistanit to strel)tomnycin) ............. 3Fistula with emipyema (2 resistant to streptomiycin) ...... 6Haemoptysis (recurrent) .......... .................... 1Cardiovascular irregularities ......... .................. 4Lung embolism ................. ...................... 3Carcinoma pulmonis ............ ...................... 1Air embolism (Maurer drainage for recurrent cavity) ... 1Accident (drownel) ............1...................... 1Carcinoma uteri ................ ...................... 1Unknown cause ................ ...................... 2

TOTAL 23

VOL. 48, No. 6 Lung Resectionz in the Treatment of Pulmonary 7Tuberculosis 413

field, only the figures of the University surgicaldepartments in Utrecht and Groningen (Eerland)can be given here.

From a study of Tables 8 and 9 it appears thatthe results in the group operated five or more yearsago do not differ from those operated three ormore years ago. The follow-up examination givesone the strong impression that a patient who hasremained free from recurrence for three years aftera well carried out lung resection and careful post-operative treatment, has a very slight chance ofrecurrence of the disease. Such complications asreactivation, spread or bronchopleural fistula for-mation as have occurred, have done so in almostevery case within the first six months afteroperation.

If this impression should prove to be correct, itwould appear that lung resection offers a greaterchance of permanent clinical cure than do thevarious surgical collapse operations. Seip was ableto show that approximately a third of the patientsoriginally clinically cured by collapse operationssuffered recurrence of the disease within the firstten years after operation.

From Tables 8 and 9 it may be seen that 97.5per cent of the surviving patients operated five ormore years ago in the University clinic of Utrechthave now negative sputum and that the same per-centage was found among the surviving patientsoperated three or more years ago. The results fromthe University hospital of Groningen are approxi-mately the same: negative sputum in 88.2 per centof patients after pneumonectomy, 93.3 per centafter lobectomy and 96.8 per cent after segmentalresection or combined lobectomy and segmentalresection.The loss of function after resection appears in

uncomplicated cases to be in direct proportion tothe amount of lung tissue removed. A loss of

TABLE 8-OPERATIVERESUIsLT, 1946;-195 1

Sput- Spui-illortalitY tuIni tlitIn

AVcga- Posi-No. Prim. Late J.it'i)n( ti.ve tin

Pneumnonectomyv 51 (; 9 30 35 1lohectomny 90 3 1 8(; 85 1Segmiiental

resectioI 13 0 1 12 12 (l

ToTAI, 154 9 11 134 132 2

- Represents 8.. /- of totail. 9)7.5 -. of sr11vN'nIv1,g.

function of 10 to 14 per cent after lobectomy and4 to 8 per cent after segmental resection has beenreported in uncomplicated cases (Kraan) 2 Kraanand v.d. Drifts found an average diminution ofthe vital capacity of 527 cc. after lobectomy.Seghers reported an average loss of 347 cc. ofthe vital capacity after segmental resection amongthe material of the University clinic of Gron-ingen. In the examination of the patients in hisown sanatorium Hirdes' noted little difference inthe effects on lung function of lobectomy andsegmental resection. After lobectomy the averageloss was 570 cc. and after segmental resection 400cc. This implies that for both types of operationthere is to be expected an average loss of approxi-mately 10 per cent of the vital capacity.

In the department of lung diseases in the Uni-versity hospital of Utrecht a further investigationwas carried out in 100 uncomplicated cases of lungresection. Only in two cases was the loss of vitalcapacity more than 12 per cent after segmentalrescction or lobectomy and more than 18 per centafter combined lobectomy and segmental resection.In both cases the excessive loss was a result ofdamage to the phrenic nerve with diaphragmaticparalysis. Significant loss resulting from insufficientexpansion or from postoperative bleeding wasnot seen.

It is also important to remark, that it appearedfrom the investigation of this last series of pa-tients that the ventilation after the operation wasqualitatively the same as or even better than be-fore the operation; the expiration speed was seento remain the same or even to increase after theoperation.

Despite the continued existence of certain prob-lems, in particular the problems of recurrenceafter resection therapy which still demand solution,

(Conttiniued oni /'age 441)

TABLE 9-01'ERIAT1IVL RESUtLTS, 1946-1953

.Stpa- Spat-.1 [o,rtalZitv hnt III timl

Nega- Posi-A'o. Pr)1.Inhat' 7 i.i;'In tetih e

Ptieumollectomyiv 93 7 9 77 73 3Lobectomy 250 10 8 232 226 (,Segmental

resectioin 175 1 172 16)9 3

TOTAI, 18 1 8 19 481 4(69 12

Represenits 90..11. 7 of total. 97.5 *of sutrvivors.

Voi.. 48, No. 6 Book Reviell'S 44t

IiI.AKISTON'S NEWv., GOULD MEDICAI. DICTIONARYbx'Normand L. Hoerr, M.D., and Arthur Osol, Ph.D., Edi-tors. with the cooperation of an editorial board and 88contributors. 252 illustrations on 45 plates, 129 in color.Second Edition. The Blakiston Division, McGraw-HillBook Comnpany, Inc., New York, 1956. xxvi + 1463 pp.,$1 1.50.

Thlis well edited book is miiore than jLlst a dictionary,it is at minute medical encyclopedia. Compiled by a dis-tinguIlished editorial board and 88 outstatnding specialistsfromii various fields, this newr edition has 1 2,00() newterms and 8,000 changes. Obsolete terms halve been(oitted.

Particularly helpful are the 45 bealutiful color illus-trations aind tables on isotopcs. enzyymes, arteries, musclesand hormones-to mention a few. In aiddition to beinga thorough dictionary, this book also has at wealth ofmedical data.

Fverv doctor will benefit by having this dictionary inlhis libratry for constant use and reference.

DIAG.NOSIS AND TREATM ENT OF PERIPIHIERAL VASCULIARDISORDERS by David I. Abramson, M.D., F.A.C.P. Pro-fessor aind Head of the Department of Physical Medicine,tn-niv ersity of Illinois, College of Medicine; and Chief()f Plysical Medicine and Rehabilitation, tniversity ofIllinois, Research and Educational Hospitals; AttendingPlysiclan, Michael Reese Hospital, Mt. Sinai Hospital.ind Veterans Administration Hospital (Hines); Con-sultalnt in Peripheral Vascular Disorders, Regional Office,Veterains Administration, Chicago. Hoeber-Harper Book.News York, 1956. xv + 537 pp. $13.50.

This well written book provides ain excellent guide forainyone interested in the care of peripheral vascular dis-orders. The book is divided into three main parts.

Palrt I deals chiefly wAith the differential diagnosis ofsymptoms and signs. Procedures for the study of the ar-terial and venous circulations are described. Tests usedare practical ones that can be performed without elabor-ate equipment.

Part II is concerned with the various peripheral vas-

cular diseases affecting the arteries, veins aind lymphatics.Not only discussed lare the disorders caused by degenera-tie changes, inflarnmation and tratuma buLt also those

produced by noxiouLS agents, the rare diseases and thlecongenital lesions. These are complete and detaliled de-scriptions whichi serve as useful clinical guides. Trealt-ment for all of the entities is described fullly. ManythcrapcLutic a1ids thalt may be uised in the office or Athome aire outlincd. The author gives his personall resuLltswith the various methods of therapy.

Part III suiiimmarizes the basic sciences as related toperipheral vascular disorders by talking of anatomy.physiology, pharmacology and pathology. Particularly in-teresting in this final part are the discussions on intrat-vascular blood clotting and its prevention aind the phar-macologic aiction of agents used in treating these dis-orders.The tables and photographs throughout this book pro-

vide wonderful teaching material. These contain treasuresof information themselves without additional description.

Surgeons, surgical residents and general practitionerswill find this book particularly informative and helpful.

(Nuboer. from page 413)

we are optimistic as regards the result of thismethod of treatment. The overall mortality fromtuberculosis in the Netherlands has diminishedconsiderably and is for 1955 6.6 per 100,000, a

figure which can be regarded as being among thelowest in the world.

LITERAT[JRE CITED

1. THORNTON, F. F. and W. E. ADAMS. Surg., Gynec.,& Obst., 75: 312. 1942.

2. KRAAN, J. K. 13th Conference International UTnionAgainst Tuberculosis, Madrid, 1954.

3. KRAAN, J. K. and L. v. d. DRIFT. Archivunm ChiroLr-gicum Neerlandicum, 4: 100, 1952.

4. HIRDES, J. J. Thesis, tTtrecht, 1951.5. HIRDES, J. J. Nederlandsch Tildschrift voor Gente-

skunde, 96: 299, 1952.

(Ross, from page 430)

In thus naming the new center for a former teacher,the founders of the Ross Medical Center halve estatblisheda precedent for Howard graduates. The Journal wishesthem the greatest suLccess in the rendering of service intheir venture and it is proud to join in their salute toDr. Ross.

(Tounsend. fromt1pge 431)

to Meharry Medical College. In 1954 $20()0 Nwas donatedto Howard Medical School and $2000 to the Legal Edu-cational and Defense Fund of the N.A.A.C.P. In 1956$2000 was given the National Fund for Medical Educa-tion, $200t) to the U'nited Negro College Fund and52000 to the ILegal Educational and Defense Fuind ofthe N.A.A.C.P.

(Coicluded onz Page 444)