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This article recounts the clinical background and the legacy of tuberculosis chest surgery, the historical alliance of two McGill teaching hospitals, and the timing of and way in which a joint medical-surgical decision to attempt the first human lung transplantation in Canada was made. The experimental phase, involving the use of identical twin calves, was accomplished with the help of L'Ecole de médecine vétérinaire de Québec. The reasons are given for the universal failure of all the early cases, and an updated summary is provided of the remarkable results obtained in the last decade.

Patients with empyema not responding to simple chest-tube drainage and antibiotic therapy have been managed by a "Clagett"-type procedure that consists of open-window thoracostomy, antibiotic irrigation and closure of the window. The results of such treatment were reviewed. Of the 103 patients with empyema treated between 1967 and 1983, 41 underwent open-window thoracostomy. Twenty-eight (group 1) had empyema after pneumonectomy, 13 (group 2) did not; however, 9 of the 13 in group 2 had undergone lobectomy. The mean follow-up was 46 months for group 1 and 42 months for group 2. When surgical closure of the open-window thoracostomy was attempted, the success rate in group 1 was 85% for those without concomitant bronchopleural fistula, but only 36% in patients with a fistula. In group 2 the respective success rates were 50% and 57%. Unsuccessful closure resulted in chronic fistulas in four patients in each of the two groups. Six deaths in group 1 and two in group 2 were related to the original disease, but one was an operative death. These results demonstrate both the effectiveness and limitations of open-window thoracostomy in the management of these difficult cases.

Mediastinoscopy is an efficient method of assessing lymphatic spread in carcinoma of the lung. It is also valuable in providing a definitive diagnosis of other lung diseases. At the Montreal Chest Hospital Centre diagnostic mediastinoscopy was performed in 60 patients with diseases of the lung other than primary carcinoma. All had preoperative radiologic evidence of hilar adenopathy. A definitive diagnosis was obtained in 91.7% of cases. Nonspecific adenitis was diagnosed in four patients and in none was there evidence of serious intrathoracic disease subsequently. Morbidity was minimal and there were no deaths. Mediastinoscopy is a safe, accurate and efficient aid in the evaluation of primary or secondary disease of the anterior intrathoracic lymphatic system.

Left lung homotransplantation was performed in a 31-year-old man in terminal irreversible respiratory failure due to advanced silicosis. Within 10 minutes of completion of transplantation, arterial pO(2) rose from 52 to 211 mm. Hg, pCO(2) dropped from 90 to 43 mm. Hg, and pH rose from 7.15 to 7.42. On assisted ventilation, arterial O(2) tension was maintained within normal limits for the first four days. Thereafter, arterio-alveolar difference for O(2) increased to 300 mm. and that for CO(2) to 25 mm. Xenon-133 ventilation perfusion ratios confirmed differences between the two lungs. Terminally, bronchopneumonia and hypoxemia were present. Surfactant content of the lung was within normal limits. Postmortem examination revealed bronchopneumonia, bronchial infarction, lymphatic engorgement and mild rejection. Future efforts should emphasize selection of non-infected donors, minimal reliance on steroids for immunosuppression, cardiopulmonary bypass during transplantation, and more definite criteria for rejection.