Abstract: 1.1. Ventilation, or air movement, determined before operation is usually proportional to lung function. The patient who can move air well has few postoperative complications because the cough is effective to maintain patent airways. Ventilation is easily determined by listening to the patient's breath sounds at rest and comparing them with the sounds during vigorous breathing. The Class I young athlete who can accentuate his breath sounds markedly during vigorous breathing is in distinct contrast to the Class IV emphysematous old man whose costal and diaphragmatic fixation prevents air movement and therefore the accentuation of breath sounds. Class I, II and III patients are surgical candidates. Class IV patients are not.2.2. Mediastinal “flutter” is a complication of poor anesthesia. It is rarely seen today except as a result of trauma on the battlefield or of an automobile accident. Its presence at thoracotomy is due to the violent excursions of the opposite diaphragm. It cannot be controlled by the injection of the phrenic nerve on the operated side. A quiet opposite diaphragm implies normal oxygen and reduced carbon dioxide tensions of the blood. This is accomplished by the anesthetist's using an automatic machine, or by intermittent pressure upon the anesthetic bag synchronous with inspiration. Mediastinal “flutter” after a thoracoplasty is in direct proportion to the number of ribs removed. Staged procedures will avoid its complications.3.3. In thoracic surgery adequate exposure is best obtained by use of the time-consuming posterolateral incision. In difficult cases adequate exposure may be paramount to the control of accidental hemorrhage. The living time saved any one such patient more than compensates the surgeon for the time lost from his career.4.4. Antibiotic therapy is no substitute for, but is an established adjunct to, basic surgical principles. Its use in preparing some cases for surgery is often more important than its use after the operation.5.5. Blood is replaced as lost at an average speed of 500 cc. per hour of surgery. The apparatus for arterial transfusions should be available in cardiovascular surgery, but the excessive use of blood and fluids is to be discouraged in pulmonary resections. Mild dehydration is preferable to excess fluid.6.6. Drainage accomplished by the use of one or two intercostal tubes not only assures reexpansion and the preservation of lung function, but is a labor-saving device for the nurses, house staff and attendants who must otherwise prepare for, assist at and clean up after each needle aspiration of the chest. Furthermore, tube drainage helps to avoid infection, empyema, hemopneumothorax, subcutaneous emphysema, “trapped lung” and the associated corrective surgery. Drainage of the pleural cavity after pneumonectomy is a specialized problem.

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