D-TUBOCURARINE CHLORIDE for CHEST SURGERY by T
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Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from 514 POST GRADUATE MEDICAL JOURNAL October I948 all round sense to other methods but even in its go wrong and create dangers that are just as great, most refined standards it is doubtful whether, if not greater because they are more insidious alone, it serves fully the requirements of the long than those associated with the older, and simpler and severe operations now carried out in the methods. abdomen. Success with inhalational anaesthesia The observation so often made in the past that demands a much higher degree of technical dex- the choice of the anaesthetist is more important terity and more fundamental physiological and than the choice of anaesthetic is indeed truer pharmacological knowledge on the part of the today than ever for the scope for unintentional administrator than ever before. In the hands of foolishness and possible disaster has widened the. inexperienced there are many things that may considerably. A SYSTEM OF ANAESTHESIA USING D-TUBOCURARINE CHLORIDE FOR CHEST SURGERY By T. CECIL GRAY, M.D., D.A., F.F.A., R.C.S. et- Reader in Anaesthesia, University of Liverpool ; Atiaesthetist, Liverpool Chest Surgical Centre The exciting and exploratory spirit which has mechanical disorders in the respiration are likely become apparent of recent years in surgery would to occur. On the affected side the lung will collapsecopyright. have been frustrated were it not that anaesthesia on inspiration and expand on expiration. This advanced contemporaneously. In no field has this phenomenon has been described as 'paradoxical spirit in surgery and this progress in anaesthesia respiration' and it results in a certain amount of been more in evidence than in the radical treat- vitiated air passing from the collapsed to the ment of disease of the thoracic viscera. The normally expanded lung on each inspiration, and, pioneer work of Sauerbruch (I904) in Germany if there is a sufficiently big respiratory excursion, and the modem developments in America and it may lead to the spread of infected secretion into Great Britain have produced an era in which the bronchial tree and so from the diseased to the surgical procedures of a gravity and extent hitherto sound lung. Paradoxical movement of this kind considered impossible have become everyday will cause the mediastinum, if it is mobile, to http://pmj.bmj.com/ events. The total or partial removal of a lung is swing away from the open side on inspiration and now a rather less hazardous proposition than a back on expiration. This ' flap' may interfere major abdominal operation. Intra-cardiac surgery with the normal inspiratory filling of the opposite and the operative treatment of congenitally lung. and by reducing the venous return to the abnormal vascular channels are possible and new heart result in sudden circulatory collapse. hope has been given to many patients hitherto For these reasons it is advisable during a thora- doomed to starvation by removal and reconsti- coplasty under general anaesthesia and essential in tution of the diseased oesophagus. Moreover the the presence of an open thorax, to control the res- on October 1, 2021 by guest. Protected surgery of tiiberculous disease of the lungs has piration and avoid such irregular movements. progressed far since the first thoracoplasty was Sauerbruch (1904) devised two methods of performed in this country by Mr. H. Morriston counteracting these undesirable effects both of Davies in 1912. It is the purpose of this paper to which depend upon the production of a pressure show how one of the most recent discoveries in gradient between, on the one hand, the atmosphere anaesthesia is playing its part in these advances breathed by the patient and, on the other, the and materially contributing to successful surgery exposed lungs. In his' Unterdruck Kammer' the within the thorax. It is necessary first, however, head of the patient was occluded by an airtight to consider how the upset to a patient consequent rubber diaphragm from a room in which the upon the creation of an open pneumothorax can remainder of his body together with the surgeon be offset by the anaesthetist. and his assistants were subjected to a pressure Controlled resiration. In the presence of an lower than atmospheric. The patient continued to open pneumothorax or when the pleura has been breathe air at atmospheric pressure. Thus when freed from the chest wall in thoracoplasty, certain the chest was opened there was no increase of Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from October I948 GRAY: d-Tubocurarine Chloride for Chest Surgery 5I5 pressure on the lungs and the normal respiratory It is, however, not always necessary to produce pressure difference was maintained. Conversely complete apnoea and paradoxical movement can the same effect was achieved by Sauerbruch's be prevented in quiet respiration by exerting alternative method in which the patient's head was slight positive pressure on the rebreathing bag enclosed in an apparatus, the ' Ueberdriick during inspiration. It seems likely that this degree Apparat,' in which the pressure was slightly above of positive pressure will not balance completely the atmospheric. These original methods, however, intra-thoracic negative pressure produced by were not altogether satisfactory and involved the inspiration, particularly on that side of the chest use of complex and bulky apparatus. Meltzer which remains closed and, therefore, the physio- (I909) and later Beecher (I940) achieved the same logical upset will be less than when there are no result by the continuous intra-tracheal insufflation active respiratory movements. This modified con- of air and anaesthetic gases under a pressure trol of the respiration has been preferred except, sufficient to prevent collapse of the lung when the as will be amplified later, when complete apnoea is chest was opened. But this procedure facilitates desirable to assist the operative technique. the spread of infected material to healthy areas of Inaccuracy in terminology is not uncommon the lungs and, according to Crafoord (1938), may and this latter maneouvre has been called by some result in a steadily increasing alveolar carbon ' assisted respiration.' However, in ordinary dioxide tension. assisted respiration there is no attempt by the The advent of closed circuit anaesthesia lead to anaesthetist to control the respiratory movements; the development of a method whereby the anaes- they are simply augmented in order to overcome thetist achieved perfect control of the respiration. the depressant effects of, for example, Cyclopro- The normal respiratory movements of the patient pane or d-Tubocurarine Chloride. are completely abolished and the lungs are arti- The use of d-Tubocurarine Chloride to provide ficially inflated either by mechanical means as in respiratory control. In the past the impaired and Crafoord's spiro-pulsator, or by manual compres- quiet respiration necessary for control has been sion of the rebreathing bag of the anaesthetic achieved by depression of the respiratory centre apparatus. In this way the lungs are inflated and with heavy premedication and- large doses of copyright. deflated rhytihmically and paradoxical respiration anaesthetic agents. Unfortunately, this resulted which depends on active respiratory movement also in depression of the other medullary centres can no longer occur. An added advantage of this which are concerned with the maintenance of the method of controlled respiration is that the move- circulation. Such ' depression anaesthesia' pre- ments of the lungs can be adapted to the require- disposes to shock and not infrequently resulted in ments of the surgeon. Even this maneouvre, how- toxic sequelae and prolonged periods of post- ever, is not without disadvantages for it may pro- operative prostration. The same diminution of duce certain undesirable physiological effects. respiratory movement can be achieved by the use During apnoea the absence of a negative pressure of very light narcosis and judicious doses of d- http://pmj.bmj.com/ within the thorax removes the respiratory venous tubocurarine chloride. pump mechanism and may lead to a deficient d-Tubocurarine chloride is a pure alkaloid filling of the heart during diastole. Perhaps more extracted from a tropical vine, the chondodendron important is the fact that the normal relationship tomentosum, which is found in the Amazonian between the respiration and the intra-pulmonary jungles. For centuries Curare, the name given to blood circulation is disturbed. In normal inspira- extracts of this vine, was known only as a potent tion the alveolar blood capillaries are dilated by arrow poison and not until the time of Claude the negative intra-thoracic pressure and an effective Bemard was its action scientifically investigated. on October 1, 2021 by guest. Protected and efficient interchange of gases between the Isolation of the pure alkaloid by King in I935 blood and alveolar air is thus facilitated. When made possible accurate pharmacological research there is positive pressure on inspiration, as in into the properties of the drug and ultimately complete control of the respiration with apnoea, made safe its clinical application. d-Tubocurarine these capillaries are flattened and many may be chloride produces paralysis of the voluntary emptied. These effects have been investigated on striated muscles. This paralysis is peripheral in animals by Humphries and his colleagues (1938) origin and is due to an interference at the neuro- and they have shown that under similar conditions muscular junction with the conduction of the significant changes may result in both the cardiac nerve impulse from the nerve to its muscle. The output and pulmonary artery pressure. It is pos- muscles of respiration being striated are affected. sible that circulatory changes brought about in It is important to appreciate that paralysis is the this way may have an important bearing on the only significant effect of an injection of d-tubo- outcome of a critical case when there is only a curarine chloride when it is administered in small circulatory reserve.