D-TUBOCURARINE CHLORIDE for CHEST SURGERY by T

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. clinical dosage. It is therefore in a sense non-toxic, Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

5I6 POST GRADUATE MEDICAL JOURNAL October 1948 for the heart, liver, kidneys and other organs are isolated phrenic nerve diaphragm* preparation unaffected. After the intravenous injection of that after paralysis of the muscle with large doses normal doses the maximum effect is developed in of d-tubocurarine chloride its excitability to two to three minutes and it diminishes in intensity indirect stimulation cannot be restored by neo- after twenty to thirty minutes. There is a cum- stigmine in any dosage. ulative effect, in that, after an initial dose, small In clinical practice neostigmine is a very effec- increments will produce a marked effect. tive antidote to partial curarization and has been The use of this substance to produce relaxation most useful in the work under consideration. The during anaesthesia for general surgery is now well reason for the dissatisfaction shown by American established. Its application to chest anaesthesia writers with the effectiveness of this substance has although less apparent is no less fundamental and been that they have used it in inadequate dosage. produces equally gratifying results. In thoracic The dose of neostigmine which has been found surgery it permits the chest to be opened and the most effectual is 3-5 mgm. administered with lung to be handled under light anaesthesia. The atropine gr. i/iooth to 1/5oth (o.65 mg.-I.3 mg.). laryngeal and cough reflexes are depressed and the The atropine is given to neutralize the undesirable respiratory movements can be quietened and if parasympathomimetic effects. Whenever there is necessary completely abolished. Because of the the slightest doubt concerning the complete freedom from respiratory spasm very light anaes- recovery of the patient from the effects of tubo- thesia can be maintained easily while ideal operat- curarine, the anaesthetist should not hesitate to ing conditions are ensured. The principle of administer neostigmine, and, in fact, it is advisable minimal narcotization with adequate curarization as a routine following chest operations. is the basis of the techniques which are to be des- The preparation of the patient for operation. cribed and which have been used in the Anaesthetic The adequate preparation of the patient before a Section of the Liverpool Chest Surgical Centre thoracic operation plays a most vital part in during the past three years. ensuring a successful result. It is hardly necessary Action of physostigmine and neostigmine as anti- to stress that the patient must be seen before dotes to d-tubocurarine chloride. d-Tubocurarine operation and the anaesthetist ensure that hiscopyright. chloride is a powerful drug and its use is only preparation has been efficiently carried out and justified if an equally powerful antidote is immed- that he himself is fully acquainted with the par- iately available. Fortunately we have in physo- ticular pr'oblem on hand. stigmine and neostigmine that antidote. The A very full and complete investigation of the action of physostigmine was first observed by Pall cardiorespiratory function of the patient should (I900) who noted that normal respiration was be a routine in every major case and it should resumed in curarized dogs after the intravenous include a blood count, vital capacity and exercise administration of physostigmine salicylate. tolerance estimations. Although not absolutely Koppanyi and Viveno (i944) showed that neo- necessary a routine electro-cardiograph in patients http://pmj.bmj.com/ stigmine methylsuphate (Prostigmine) had a similar over thirty years of age will provide occasional anti-curare effect and was, in fact, dose for dose, surprises and prevent some avoidable accidents. twice as effective as physostigmine. The recent The paramount features of the pre-operative work of Burke, Linegar, Frank and McIntyre preparation can best be considered in relation to (1948) has confirmed these findings and placed those types of major cases with which the thoracic beyond all doubt that up to the present neostig- anaesthetist is concerned. mine is the most effective drug in this respect. In Cases undergoing lung surgery have pulmonary the light of the humoral theory of neuro-muscular disease requiring complete pneumonectomy, on October 1, 2021 by guest. Protected transmission physostigmine and prostigmine lobectomy, segmental resection of a lobe or some inhibit the action of cholinesterase and permit an form of thoracoplasty. They are not infrequently unusually large concentration of acetylcholene at in poor condition as a result of toxaemia and the myoneural junction. This may succeed in infection and may be producing large quantities of overcoming the inhibition by tubocurarine of the sputum. In such cases adequate physio-thera- receptive substance of the muscle. A more recent peutic preparation is of importance and should observation is that these drugs cause a rise in include the education of the patient in the art of excitability of the muscle by some other action breathing. Frequent vital capacity estimations and there appears to be good evidence that they should be made in order to assess improvement. prolong the action of a nerve volley on muscle or If there is sputum production, a morning and ganglion cells (Lloyd I946). When curarization evening postural drainage routine must be carried is complete neostigmine is less effective as an out and the quantity of sputum produced every antidote and Trevan of the Wellcome Research twenty-four hours charted. In those cases which Institute has shown by experiments on the rat's do not respond to postural drainage a course of Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

October 1948 GRAY: d-Tubocurarine Chloride for Chest Surgery 517 penicillin inhalation is often very helpful. Com- fluids the preparation is easier, but if adequate plete otolaryngological toilet is necessary and a oral fluid replacement is not possible, a rectal or final careful check up should be made immediately intravenous routine must be adopted. In com- prior to operation as to the presence of any acute plete obstruction an attempt should always be naso-respiratory infection. In cases for thoraco- made to dilate the stricture under anaesthesia plasty it is wise to make a radiological examination sufficiently to take a Souttar's tube or allow a twenty-four hours prior to operation, in order to Ryle's tube to be passed so that a high protein ensure that there has not been any unsuspected fluid diet of ' fortified milk' can be given. spread (Langton Hewer I948). The anaesthetist must not allow himself to be Cases for cardiac surgery frequently have a too depressed by the pre-operative condition of very poor circulatory reserve. In the presence of these patients. Although by all the ordinary actual decompensation the cardiac function must standards they would appear to have little chance be improved as much as possible by rest in bed and of survival they not infrequently tolerate long adequate digitalization where it is required. operations remarkably well. It is a grave decision Oedema may be a very prominent feature and in to refuse to give the only possible chance to one cases of constrictive pericarditis there may be, doomed to slow death by starvation. besides oedema, massive ascites and extensive Pre-medication. The rationale for pre-medica- pleural effusions. The effusions should be treated tion is that certain drugs are administered to by repeated aspiration and a course of one of the prevent bronchial and salivary secretions during mercurial diuretics before operation will often anaesthesia and to reduce the quantity of anaes- greatly improve the clinical picture. It is important thetic required. Atropinization is very important to ensure that the chest is free from fluid on the especially when d-tubocurarine chloride is to be day of operation as in these cases a rapid overnight used. If atropine is omitted, or if it is given too accumulation may occur. Coincident bronchitis late for it to be effective before the induction of is common and should be treated by breathing anaesthesia, the injection of tubocurarine may exercises and if necessary penicillin. Arithmetical result in the production of large amounts of a estimations of the cardiac efficiency such as that sticky, glairy salivary secretion. This may cause copyright. devised by Moot serve no useful purpose in these laryngeal spasm and result in a critical situation. cases. Furthermore, exercise is often tolerated The second purpose of premedication is achieved extremely badly by patients who are very suitable by the administration of sedatives which allay for and must undergo cardiac surgery. Perhaps apprehension, relieve pain and thus reduce the the breath holding test of Sebrasez gives the best metabolism of the patient (Guedel I937). Sedative indication to the anaesthetist of the patient's drugs, such as morphia and scopolamine have also cardiac reserve. The patient resting in bed takes an action on the medulla and the reduction ofthe a deep inspiration and holds it for as long as pos- excitability of the respiratory centre by large doses sible. Normally this period is thirty seconds, but of omnopon and scopolamine have in the past http://pmj.bmj.com/ anything less than fifteen seconds indicates a been an important part of the technique of con- marked reduction in the cardiac or respiratory trolled respiration. This depression is likely to be reserve. In dealing with these patients, however, prolonged into the immediate post-operative no test can replace a good clinical acumen and a period at which time it is most desirable to have a judgment based upon observation of the patient full respiratory function and active cough reflexes. as a whole. Control of the respiration can now be achieved Cases for transthoracic gastric or oesophageal without such depression and heavy sedation is not resection are not infrequently elderly and necessary and is in fact definitely harmful. In on October 1, 2021 by guest. Protected emaciated. A full investigation of their respiratory Centres where an intravenous induc.tion of an- and cardio-vascular systems must always be car- aesthesia is routine, patients, even quite small ried out and an effort made to restore their con- children, have little pre-anaesthetic apprehension. stitution to a state approaching normal. A con- Very light premedication is desirable and is an im- sideration of their plasma protein and blood count portant part of the technique advocated in this in conjunction with the haematocrit value will paper. For adults, morphia, gns. k i i mg.) and ensure control of the fluid and protein adminis- atropine gr. T o (0.4 mg.) is given at least tration. It is necessary to stress that the haema- one hour prior to the induction of anaesthesia. tocrit value should always be considered in deter- The dosage of atropine is the same for children, mining the fluids to be administered, as in the but that of morphia is modified according to age. presence of haemoconcentration, an anaemia may If it is impossible to give the premedication at the not be apparent and the fact not appreciated that proper time it should be given intravenously in whole blood rather than saline or plasma is the the anaesthetic room. In such circumstances correct transfusion. If the patient can swallow sedation is obviously not part of the function of Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

Si8 POST GRADUATE MEDICAL JOURNAL October 1948 the injection, but the morphia assists in reducing relaxation. The Macintosh laryngoscope facilitates the amount of anaesthetic required and serves a the introduction of the tube by avoiding stimu- useful purpose in a balanced technique of anaes- lation of that most sensitive area of the larynx, the thesia. On those occasions when a child has posterior part of the epiglottis. The cheeks are proved unco-operative and excited, rectal thio- packed with gauze to ensure a close and airtight pentone (o.i g. per year) has been administered fit of the anaesthetic facepiece. Where an endo- and given a most satisfactory and transient tracheal tube is employed the firmness of the lips sedation. and cheeks ensured by this pack enables the tube Technique of anaesthesia. A standard anaesthetic to be fixed in position by a piece of soft tubber tape arrangement and procedure for induction is used passed round the occiput. (Figure 2). It is better and slightly modified to suit the different types of to leave the connection between the endotracheal operation. As the anaesthesia is mainly intra- tube and the absorption canister free for if it is venous it is important to have a reliable and fixed, as for example by Hudson's harness, the dependable method of making the injections and endotracheal tube is apt to become kinked when for these the three way tap originally described the head is moved. by Gray and Halton (1946) and its recent modi- Anaesthesia is maintained with a mixture of fication by Halton as described below have been 70 per cent. to 50 per cent. of nitrous oxide in found invaluable. oxygen, occasional injections of a 5 per cent. The tap (Figure i) is mounted on a small base solution of Kemithal (I.C.I.) and increments of moulded to the curve of the forearm and is easily d-tubocurarine chloride as required. Kemithal is strapped in position. The male end connects preferable for maintenance having a less depres- directly to a serum needle, size ten, and an intra- sant effect on the respiration and giving more venous drip is led to one of the two female inlets, rapid recovery than thiopentone (Halton). A the other being used to inject the solutions. The Water's to and fro circuit is always employed. tap can be used either after the manner of a Gordh This apparatus is more reliable and has less pos- needle (Torston Gordh 1945) or in association sibility of leaks than the circle type of absorber. with a continuous intravenous transfusion. In It permits a sensation of closer contact betweencopyright. the former case when the tap is turned off between the administrator and the patient which is most injections there can be no reflux of blood into the important when the depth of anaesthesia and the needle and blockage by clot is thus prevented. freedom of the airway must be assessed mainly For longer procedures when a continuous drip of by the feel of the rebreathing bag. A long exten- saline or blood should be used the arm is splinted sion tube between the distal side of the absorption before the apparatus is fixed in position. For con- canister and the bag affords greater freedom of venience the arm opposite to the side of operation movement to the anaesthetist and provides less is the most suitable choice. risk of disturbing the apparatus during the opera-

Induction of anaesthesia is carried out with d- tion. Once the patient has been turned into the http://pmj.bmj.com/ tubocurarine chloride and thiopentone. The dose lateral position, for greater security the absorption of d-tubocurarine chloride is 15 mgm. for adults canister may be fixed to the table. and 0.3 mgm. per kilo body weight for children To employ this technique successfully the and that of thiopentone 0.5 gm. for healthy adults anaesthetist should make a mental resolution to with suitable reductions for children, the elderly administer further doses of anaesthetic only when and those with a poor cardiac reserve. it is absolutely essential. After induction it is A test dose of d-tubocurarine chloride is first seldom necessary to inject more barbiturate until injected in order to detect any hypersensitivity to the surgeon is about to make his incision and then on October 1, 2021 by guest. Protected this substance (Gray and Halton I948). In adults as little as 0.2 gm. of Kemithal will produce a this is usually 5 mg. i.e. i of the calculated quiet and relaxed patient. A further io mg. of induction dose. If after two minutes there is no d-tubocurarine chloride will be required to control sign of an unusual reaction, the remaining io the respiratory movements before the chest is mgm. is injected followed by the thiopentone. opened and after that control can be maintained Following this injection the lungs are immediately by further doses of 2-5 mg. as required. New- inflated two or three times with oxygen and a comers to this method of anaesthesia often have pharyngeal airway or endotracheal tube is intro- difficulty in deciding between the indications for duced. Oral intubation is invariably performed the administrations of barbiturate and d-tubo- with ease if the injections are given in this order curarine chloride, and there is no doubt that and when a Macintosh laryngoscope is used. success depends largely upon a correct decision When the d-tubocurarine chloride is given before in this respect. d-Tubocurarine chloride provides the thiopentone the maximum effects of both respiratory control and relaxation. If the patient drugs are synchronized and provide excellent is resistant to inflation of the lungs, is straining, Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

October 1948 GRAY: d-Tubocurarine Chloridefor Chest Surgery 519 begin to compete with the interpretation of the pressure sensations by the human hands. The feel of the rebreathing bag helps the anaesthetist to determine not only the depth of anaesthesia and degree of curarization, but also the efficiency and freedom of the airway. It gives him warning of the collection within the bronchi of any sputum which requires removal by suction and enables him to adjust the movements of the lungs to the r.3S, *33 3 ; ..i...... -.; I' manipulations of the surgeon. Before considering details there is one further I 8 I point of principle which needs to be emphasized. In long traumatic and potentially shocking operations the circulatory blood volume should be 1. 71. maintained as it is lost, drop for drop. Under no It . ,:J! circumstances should a blood transfusion be with- held until there is evidence of impending circulatory collapse. Neither is it advisable to depend upon the transfusions set up in the arm for blood replacement and a cannula should be inserted into the leg vein as soon as anaesthesia has been induced. FIG. i.-Halton's modification of three way tap. The standard technique which has been described has been adapted to all types of operations coughing, or there are ' bumpy ' respiratory move- and the points peculiar and special to the individual ments when the chest is opened, an injection of thoracic procedures must now be discussed. Endoscopy. Both oesophagoscopy and broncho- d-tubocurarine chloride will restore the situation. copyright. On the other hand more barbiturate is indicated scopy can be performed under local surface anal- when there is inadequate anaesthesia as evidenced gesia. Even with adequate premedication, how- directly by a slight movement of a limb or of the ever, this is usually a very unpleasant experience facial muscles and reflexly by a rising pulse rate. for the patient. The administration of a small With experience and practice the discrimination dose of thiopentone removes this objection, but is not difficult and niceness of decision will amply when there is a long list, anaesthesia with d-tubo- repay the careful observation of the patient which curarine chloride and thiopentone alone gives is necessary. excellent results and is less time consuming. The indications for endotracheal intubation and The procedure and dosage is exactly that which bronchial tamponage or occlusion will be discussed http://pmj.bmj.com/ when the particular technique for pulmonary operations is described, but a word must be said on the dangers of ' mechanic-al respiration.' Mechanical aids to assist or control respiration are '-td t .'-$b J popular in Scandinavia. Crafoord's (1938) modification of the Franckner Spiropulsator and Merck's Spiropulsator (1948) undoubtedly relieve the anaesthetist of a great deal of what might be on October 1, 2021 by guest. Protected considered monotonous work. It may be tedious to have to compress rhythmically a rebreathing bag for five hours and these machines free the tn.4, . 5 anaesthetist to perform other useful functions, but they cannot replace trained hands. Auto- matic devices have no feeling or discrimination. - X ;j-.. .. A case was recently observed in which a patient @, $.iW'4 !;.r'ti.1s undergoing thoracoplasty was artificially ventilated by mechanical means. Not only was the apex ,i }i hk;L} ;.1 jiIF 2'lt i; 'vi; r'h*w comparatively uncontrolled but an unsuspected .{.' ; ? §pill over occurred and resulted in a spread of the ;e* <.- jt .. Yri.|!i dt svl rhmw,} psn4rI disease. A disaster of this nature persuades one t>4* '-n&~ s '4.4* : , ..is¢ tr.Xr;qlfi that these interesting mechanical achievements require much greater refinement before they can FIG. 2.-Method of fixing endotracheal tube. Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

520 POST GRADUATE MEDICAL JOURNAL October 1948 has been de2scribed for the induction of anaesthesia and pleasant induction permitting quiet and cough using the three way tap after the manner of a free respiration at the time the bronchogram is Gordh needle. There are a few points of detail in being taken and, most important, results ih a quick respect of oesophagoscopy and bronchoscopy recovery. The dose of tubocurarine suitable for which are important. Patients for oesophagoscopy the child (0.3 mg. per kilo) is injected intraven- are often poor risks and for the aged and cachectic ously a test dose being fir'st given in the manner a 2.5 per cent. solution of thiopentone should be which has been described. This is followed by used and the dosage reduced to 0.25 gm. with io an injection of thiopentone of the order of 0.25 to mg. of tubocurarine. A gum elastic catheter 0.4 gm. the actual dose depending on the age and through which oxygen is continuously insufflated physique of the patient. After a bronchoscopy, should be introduced into the trachea as the oeso- during which excessive secretions and sputum can phagoscope is passed. It is not uncommon to be removed by suction, a catheter is passed down encounter some resistance due to spasm of the the bronchoscope and left in situ while the instru- inferior constrictor of the pharynx. This will ment is withdrawn. Oxygen is continuously usually relax after a few moments, but if it does insufflated down the catheter as the child is taken not a small increment of thiopentone will enable to the X-ray room. When all is ready the anaes- the instrument to be passed with ease. thesia is momentarily deepened with a further During bronchoscopy oxygen should be in- small amount of thiopentone and the lipiodol sufflated down the side tube of the bronchoscope. injected down the catheter. Once the photograph From the surgeon's point of view the conditions has been taken the child must be turned at once during the examination are usually ideal. A resis- into the semiprone position, the head lowered and tant patient may cough and strain a little but satis- the catheter used again to insufflate oxygen. If factory control can be regained with a further there should be any respiratory depression or small dose of thiopentone. When there is a great impairment of the cough reflex 1.0-2.5 mg. of deal of sputum or blood in the bronchial tree it neostigmine and atropine o.65 mg. should be should be aspirated before the bronchoscope is injected intravenously. Figure 3 shows a broncho- withdrawn, following which the patient is turned gram taken using this type of anaesthesia. copyright. at once on to the same side as his lesion with the Thoracoplasty. There has been a great deal of head of the table lowered. discussion concerning the relative merits of local Under general anaesthesia patients with a con- and general anaesthesia for this operation. Many siderable amount of sputum or a tendency to of the objections to general anaesthesia, which haemoptysis should be bronchoscoped in the have been raised, no longer apply. The perform- head down position. If it is proposed to remove a ance of a nerve block of the chest wall is a lengthy foreign body or tumour endoscopically it is likely procedure and entails no little discomfort for the that a quantity of pent up secretion will be liberated patient. Very heavy pre-operative sedation with and the head down position should be adopted long acting drugs is required and the protective http://pmj.bmj.com/ before the endobronchial manipulation is started. reflexes are thereby rendered less active for an A patient cannot drown in this position, but he indefinite period. Moreover, for second and may easily do so in the usual decubitus position. third stage operations, the analgesia is difficult to An intense laryngeal and bronchial spasm may produce and is not always satisfactory. It has to develop when the bronchoscope is withdrawn. be helped out not infrequently by ' chloroform This is most likely to occur when the premedication analgesia.' has been given late and when the endobronchial The presence of the cough reflex throughout reflexes have been depressed insufficiently by the the operation has been postulated as an advantage on October 1, 2021 by guest. Protected anaesthesia. Further small doses of thiopentone, of local anaesthesia; yet illogically it is suggested should, therefore, not be witheld if the patient is that the vagus should be blocked to diminish this. too light. The most effective treatment for spasm same reflex (Joan Miller 1948). Coughing produces once it has developed has been the injection of a two effects. It is expulsive, but it also produces small dose of thiopentone and inflation of the peripheral spread as can easily be demonstrated by lungs with oxygen. Endotracheal intubation should a study of bronchograms taken after coughing. not be performed unless absolutely necessary, as In the absence of a rigid chest wall during thora- the presence of an endotracheal tube in the trachea coplasty the expulsive function of the cough is tends to set up further respiratory spasm. lost, but the peripheral spread remains and may Anaesthesia for bronchography in children do irreparable damage. The surgeon may manually presents problems which have not been satis- control the apex when he tells the patient to cough, factorily solved by any of the methods usually but such control can only be partially effective employed. The method at present under con- and an involuntary and unexpected cough is not sideration has many advantages. It gives a smooth infrequent and cannot be anticipated. Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

October 1948 GRAY: d-Tubocurarine Chloride for Chest Surgery 521 Patients who are anaesthetized with barbiturate, method for lung resection. Cyclopropane is nitrous oxide and tubocurarine have all their generally considered the anaesthetic agent of reflexes fully active at the end of the operation and choice for maintenance in these cases and it was most of them are able to talk before they leave the undoubtedly this agent which first opened the theatre. They have a cough reflex which is door to modem thoracic surgery. Cyclopropane immediately effective. Their convalescence is as has many desirable properties from the point of trouble free as any who are given a full local block. view of the thoracic anaesthetist. It is non- In these cases the routine procedure for induc- irritant, controllable, and capable of producing tion and maintenance of anaesthesia which has anaesthesia in a very high concentration of oxygen. been described is adopted. Except where there is Furthermore the depression of respiration which a large cavity and much sputum production an accompanies its administration is of great assistance endotracheal tube should not be used for its intro- when the respiration has to be controlled. But duction may result in slight trauma and the pos- the disadvantages of cyclopropane should make sible appearance of a new tuberculous focus in the the anaesthetist welcome an alternative. Its larynx. In ' wet' cases, however, intubation and explosibility and tendency to cause troublesome suction drainage must be the rule and the operation oozing in the wound no matter how efficient the carried out in the Trendelenburg position. ventilation are minor and tolerable defects, but When a pharyngeal airway only is used the prop more serious are its effects on the circulation. originally described by Moreland Smith (i944) Recent studies in America (Dripps I947) have will support the jaw and be of great assistance. lent authority to a clinical impression that cylco- It is held in position by a Clausen's harness and, propane is apt to give a false sense of security in provided that the artificial airway is of adequate regard to the circulatory condition of the patient. size and a good shape, perfectly satisfactory aera- The blood pressure, pulse, colour and general tion can be maintained. After the induction of condition of the patient may be perfectly satis- anaesthesia the line of incision is infiltrated with a factory until the anaesthetic mask is removed at I.2000 solution of'amethocaine and, as the neuro- the end of the operation, when the patient may

muscular bundles are exposed, an intercostal block collapse suddenly with all the signs of ' shock' or copyright. is performed with the same solution. This is of gradually, over a period of half an hour, pass into undoubted assistance ag it allows the'wound to be a state of hypotension. This phenomenon has stitched at the end of the operation under extremely variously been attributed to a specific effect of light narcosis and may reduce the operative shock. cyclopropane, to the respiratory depression which The respiration must be controlled from the attends its administration with consequent carbon time that the parietal pleura of the apex has been dioxide retention and acidosis, and to closed circuit freed from the chest wall. Complete apnoea is anaesthesia itself. But whatever its aetiology seldom required and a modified controlled res- ' cyclopropane shock' is a very real entity. For piration a these reasons the agent has been used ony rarely with constant slight positive pressure http://pmj.bmj.com/ (of the order of 4 mm. of mercury) will keep the and sparingly in the technique under consideration. lung steady and greatly facilitate the work of the For routine intra-thoracic procedures d-tubocura- surgeon. The responsibility of the anaesthetist rine chloride with a barbiturate and nitrous oxide during these operations is very great indeed and gives very satisfactory anaesthesia. The anaesthetic nothing can do more tragic harm than a bad is controllable and permits of the use of the cautery general anaesthetic. At no time nust he lose a grip in the chest. Furthermore the condition of the of the situation either in regard to the depth of patient does not deteriorate at the close of the anaesthesia or as to control of the lung. Too deep operation. It is usual to maintain the 50 per cent. on October 1, 2021 by guest. Protected an anaesthesia may result in atelectasis of the mixture of nitrous oxide and oxygen by running lower lobe due to stagnation of secretion and un- in 500-600 ml. of each,gas per minute. This controlled movement of the apex may lead to demands a certain small ' escape ' from the closed spread of infected material to non-infected areas circuit a feature which helps to avoid undue carbon of the lung. The doses of the anaesthetic agents dioxide retention (Dripps 1947). Cyclopropane is will depend on the type of case. As an indication used only when it is considered that barbiturates of the maximum dosage which will be required in will be tolerated badly, as in small children, the dealing with ex-servicemen the average for a first very elderly and those with evidence of myocardial stage thoracoplasty has been of the order of 0.5 gm. weakness. There are occasions too when the of thiopentone, 0.25-0.5 gm. of kemithal and 20- administrator is unable to obtain just the perfect 45 mgm. of d-tubocurarine chloride. conditions which he requires and a little cyclo- Lobectomy and pneumonectomy. Although local propane will tide him over a difficulty. When the analgesia has its advocates for thoracoplasty, bronchus is opened for example, prior to ligaturing, general anaesthesia has become the accepted a few minutes of overventilation will usually pro- Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

522 POST GRADUATE MEDICAL JOURNAL October i948 duce complete quietude ; but if this fails, it is often physiotherapeutic preparation and during the better to use a little cyclopropane than to give operation suction drainage with 350 of Trendelen- more tubocurarine, as the operation is generally burg. A plain endotracheal tube can be led out nearing completion. through a rubber diaphragm fitted in the facepiece Control of the respiration, is, of course, essential and the secretion allowed to pass up the trachea from the time the pleura has been opened. The round the tube into the facepiece as described by technique of this manoeuvre has been discussed Beecher (Beecher, H. K., 1940), but it is easier and but it should be pointed out that complete apnoea more satisfactory to use a cuffed endotracheal tube is required only during the dissection of an with a Magill's T-piece and pass a suction catheter unusually difficult hilum or in freeing adhesions through the rubber cap. In this case care must be of the lung to the diaphragm. At other times it is taken to ensure that the rebreathing bag is kept better to maintain some respiratory movement. inflated during suction otherwise there is a danger Some positive pressure should be maintained of collapse of the lung. Where there is a large during inspiration until the chest has been closed abscess cavity containing a fluid collection which so that the lung is kept fully expanded. Intercostal has not been completely controlled by the pre- drainage is usual and after the chest has been liminary postural drainage, pre-operative broncho- closed the spigot should be inserted into the tube scopy and suction has been found most useful. just after inspiration while positive pressure is Figure 3 shows such a cavity in a child aged 61 exerted on the rebreathing bag. In this way years. The diseased lung was successfully removed expansion of the remaining lobe is ensured. using simple postural and suction drainage after a The control of secretion in 'wet' cases can be pre-operative bronchoscopy and toilet. a difficult problem and the search for a satisfactory solution has fascinated every anaesthetist who has had to deal with such cases. There can be no routine, for every patient is a distinct and individual problem. Furthermore at a recent meeting atwhich this matter was discussed a speaker of some ex- copyright. perience (Organe I948) stated that he had yet to see an atraumatic bronchial occlusion, and with all the methods usually advocated this trauma is a factor which cannot lightly be dismissed. Endobronchial anaesthesia can be used for pneumonectomies but it is debatable whether one lung anaesthesia is really desirable for this operation. It is rational to conserve the function of the

useful part of the diseased lung as long as possible. http://pmj.bmj.com/ The extra aerating surface thus maintained may well help to tide the patient over a long operation. In lobectomy on the other hand it would seem ideal to block off the diseased lobe, but none of the methods of bronchial occlusion are completely reliable and satisfactory. The Thompson type of suction occluder is very apt to slip out of position. More than once the balloon has been on October 1, 2021 by guest. Protected known to collapse during an operation and nothing FIG. 3.-Bronchogram of child aged 6j with a large infected cyst of the left lower lobe. Anaesthesia is more disastrous than the failure of an occlusion for the bronchogram was with thiopentone and upon which reliance has been placed. Perhaps the d-tubocurarine chloride. method of blind bronchial intubation described by Halton (I943) in which the balloon is held rigidly in position offers the most hope of a success- There remain, however, a limited number of ful answer to this problem. It would, however, cases for which these simple measures are inade- seem more prudent generally to depend on posture quate. In the presence of a bronchopleural fistula to prevent spill over and spread of infected positive pressure and controlled respiration is material, and in cases with considerable secretion impossible as the inflated air simply passes into clamping of the bronchus by the surgeon at an the pleural cavity. A similar difficulty may be early stage before the lobe is lifted will be of great encountered where a congenital cystic condition assistance. is associated with a non-return valve mechanism, The majority of cases can be controlled by good (Gray and Edwards 1948). In these cases some Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

October J948 GRAY: d-Tubocurarine Chloride for Chest Surgery 523 form of endobronchial anaesthesia or occlusion is gitation of fluid may occur from the stomach and essential for satisfactory anaesthesia. be inhaled. Trans-thoracic resections of the stomdch and The surgical treatment of patients with heart oesophagus call for minor modifications in tech- disease has been made practicable by the nvork of nique. When the lesion is in the oesophagus, after Blalock in the United States and Brock in this the induction of anaesthesia an oesophagoscope is country, and this paper would be incomplete passed and oesophageal toilet carried out. During without some reference to the technique of anaes- this procedure oxygen is continuously administered thesia for this work. The general principles which into the trachea through a gum elastic catheter in have been postulated still hold and d-tubocurarine the manner already described. After completely chloride is of the same value here as elsewhere. clearing the oesophagus of food debris and sec- It has no action on the heart and it permits a very retions penicillin powder is insufflated. A light plane of anaesthesia to be maintained easily 'Tampax' pack (attached to a long thread) is and with minimal concentrations of drugs which inserted to prevent the regurgitation of stomach in higher concentration may have a detrimental and intestinal contents when continuity has been effect on the myocardium and conducting mech- established between the oesophagus and stomach anism. It has been stated by many authorities that or jejunum. It may be possible to insert the cuffed cyclopropane is contra-indicated because of the endotracheal tube over the gum elastic catheter severe and frequent cardiac arrhythmias which are and thus avoid the need for another laryngoscopy likely to occur when it is used. It is probable, which will require a deepening of the anaesthesia. however, that such irregularities are more frequent The induction and maintenance of anaesthesia when cyclopropane is the sole agent and used in a is carried out in the standard manner. A trace of concentration sufficient to depress the respiration. ether has been found of great value in these cases Undue irritability of the 'heart has not been to reduce the amount of barbiturate which will be observed when it has been employed with tubo- required. Ether has a curare-like action and when curarine and a recent report (Rink 1948) suggests using it with d-tubocurarine chloride it should be that used in this way it is the most suitable anaes- remembered that there is a summation of both thetic agent for the operative treatment of the copyright. their effects at the myoneural junction. For this tetralogy of Fallot. Some cardiac irregularities reason it is stated by some writers (Cullen i944) will always occur during manipulation of the heart that only i of the dosage of tubocurarine should and. only if the arrhythmia becomes of threatening be injected when ether is the anaesthetic. Ether, significance is it necessary to abandon cyclopropane however, is a toxic drug whereas d-tubocurarine and use ether. There is little doubt-that the intra- is not, and theoretically it would seem more venous injection of 3-5 ml. of i per cent. procaine feasible and in practice it is conducive to better or the application of a i per cent. solution to the results to reduce the amount of ether and give the surface of the heart renders the organ less sensitive to mechanical stimulation. same dose of tubocurarine. The smallest con- http://pmj.bmj.com/ centration of ether which will give an 'ethereal' Thiopentone or kemithal must be used with smell to the mixture should be used, for more great caution when there is an impaired myocar- than this will result in a prolonged recovery time. dium. There is evidence that these substances are During these operations there is not infrequently direct myocardial depressants, and whilst cases some deterioration in the patient's condition with a patent ductus arteriosus may tolerate shortly after the chest has been opened. The blood them well, a normal dose would certainly prove pressure falls and the visible heart action appears fatal in a case of constrictive pericarditis. weak. At this point it has been found of advantage Patients with constrictive pericarditis have a on October 1, 2021 by guest. Protected to start an adrenalin drip as originally described feeble, thin and atrophic myocardium. They are by Frankis Evans (I944). Although a single injec- usually oedematous and have enlargment of the tion of methedrine may produce a similar result liver, ascites and pleural effusions. They may adrenalin is preferable in that its effects are have a marked degree of cyanosis and are. freq- transient and, therefore, more controllable. After uently orthopnoeic. Patients in this condition a short period it is usually possible to stop the would call for a modification of most techniques.' adrenalin. The following procedure has been found useful. A feature of this method of anaesthesia is that After premedication with morphia and atropine, no matter what the length of the operation the oxygen is administered through the anaesthetic patient is never deeply anaesthetized and, as a mask for a few minutes prior to the induction of result, is able in the majority of cases to talk before anaesthesia. Cyclopropane is then introduced at leaving the operating theatre. This state of con- 400 ml. per minute with 500 ml. of oxygen until sciousness is highly desirable as the action of the the patient is asleep. The usual test dose of d- cardiac sphincter has been removed, and regur- tubocurarine is given, after a pause it is followed Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

524 POST GRADUATE M'EDICAL JOURNAL October 1948 by the injection of the remainder of the induction retention of urine when d-tubocurarine has been dose. Assisted respiration must be instituted at employed (Gray 1948). In the present series this once to build up a good oxygen reserve which will has not been unduly troublesome and the retention allow for the quick introduction of an endotracheal has usually responded to injections of carbachol. tube. Anaesthesia is maintained with minimal One patient, however, did not micturate naturally quantities of cyclopropane or ether with incre- for seven days following a lobectomy. ments of d-tubocurarine given as necessary to During I945 and 1946 a sufficient number of assist control of the respiration. In the less severe operations for thoracoplasty were performed to cases of decompensation it is possible to induce permit numerical comparison with other series. anaesthesia with 4-6 ml. of a 2.5 per eent. solution In the following analysis the results will be com- of thiopentone but great caution is necessary and pared with the figures quoted by Joan Miller (I948) full oxygenation before and during the injection for a very comparable series of cases in which local should be ensured. analgesia was used (Table I). There have been Post-Operative Results TABLE It is becoming widely recognized that given *st 2nd 3rd Apico- good anaesthesia the results following any surgical Cases stage stage Ant. lysis procedure depend less upon the technique or agent stage Rev. used than was at one time considered probable. Parenc/zvmatouts In thoracic work the efficiency of the pre-operative disease 153 148 138 26 I I 12 ii6 78% physiotherapy, medical preparation and the Basal standard of post-operative nursing are variable operatiotis ..... 5 I1 5 5 5 factors making it difficult to compare the results Eip3ema .. 9 9 8 obtained in different centres. Even the degree of humidity of the atmosphere in the wards may Comparative influence the post-operative convalescence of these series (Joan Miller 1948) 204 i8o 172 8 13 153 85°o patients. copyright. The essential prerequisites of any anaesthesia Particulars of thoracoplasty operations performed 1945-1946. for this work are that it should permit control of The comparative series is that quoted by Joan Miller (1948) the respiration, result in as little toxic upset of the carried out under local analgesia. patient as possible and permit a patient at the end in this series six deaths within three months of of the operation to be co-operative and able to operation giving an operative mortality of 3.6 cough and breathe efficiently. When small doses per cent. This compares well with the series of the anaesthetic agents are combined with ade- under local analgesia in which twelve deaths in a quate dosage of d-tubocurarine in the manner similar period gave a mortalitv of 5.3 per cent.

which has been described the patients are routinely The cause of death in the following series of cases http://pmj.bmj.com/ awake at the close of the operation and not in- was as follows:- frequently they have been able to converse intel- (i) Pulmonary embolus. This patient developed ligently as they leave the theatre perhaps following a femoral thrombosis four weeks after a a five-hour oesophagectomv. Such co-operation second stage operation and died in the materially facilitates the post-operative nursing and seventh week. The presence of a large pul- removes the danger of the aspiration of vomit or monary embolus was confirmed at post secretion. There need be no apprehension that mortem. the respiration will be depressed after tubocurarine (2) Acute tuberculous pneumonia of the same on October 1, 2021 by guest. Protected when it is used in reasonable dosage and added without safety is provided by the routine injection of an side following a first stage apicoly- adequate dose of neostigmine. sis. The cause of death was confirmed at Nausea and vomiting has been rare following autopsy. thoracotomy but it still occurs after thoracoplasty. (3) Acute bilateral tuberculous broncho-pneu- It is of interst that vomiting persists even when monia, six days after a first stage operation local analgesia is used (Joan Miller 1948). The with apicolysis. Confirmed at autopsy. vomiting has been attributed to the morphia given This was the only case of contra-lateral in premedication but this seems an unlikely spread in the present series. explanation in view of its comparative infrequency (4) Coronary thrombosis. This patient col- after other thoracic procedures. It may well be due lapsed and died eight hours after a first stage to some vagal imbalance resulting from collapse of operation with apicolysis. Confirmed at the chest wall. autopsy. There is possibly an increased frequency of (5) Cardiac failure, in a patient who had had a Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

October 1948 GRAY: d-Tubocurarine Chloride {or Chest Surgery 525

I3 years history of tubercle. She made a TABLE 4 good recovery after a first stage thoraco- MORBIDITY AFTER SECOND STAGE OPERATIONS TABLE 2 rA4il re-aerated but Atelectasis of lower lobe .. 5 apicolysis moist sounds still MORBIDITY AFTER FIRST STAGE THORACOPLASTY SUFFICIENT TO I non-apicolysis Lpersist. CAU1SE DELAY OF SECOND STAGE Post-operative shock I Haemothorax I Haematom...... I Delay 2 wveeks 4 wveeks 4 weeks + Indefinite Nephritis. .... I A. N.A.lA. N.A. A. ' N.A. A. N.A.4. Superficial wourd sepsis .. 3 Contralateral exacerbatiors .. I three months after, small. I two months after a contralatera Poor general condition 4 A.P. small. Bronchitis I 1 due to haemoptysis, snall. Consolidation base 3 Extra fascial space infections 4 Atelectasis. . . 2 1 2 3 i Emp. (Bro nchiectasis I) Haemothorax ...... 3 Tachycardia 2.. lobe following thoracoplasty in this series and 21 Superficial sepsis 1 2 I Coryza .. .. l (5.5 per cent.) in the series done under local anal- Thrombosis axillary gesia. Seven (4.4 per cent.) of the cases under vein 2 Haemoptysis .. I general anaesthesia followed first stage operations Old rheumatic heart Pyrexia ? cause .. and 6 (4.0 per cent.) occurred after second stages. Nephrosis X Following local analgesia 9 (5.9 per cent.) occurred after upper stages and I2 after second stages. The 35 delayed out of 158 first stages-22",,-7 in non-apicolysis and 28 in apicolysis. number of secoDd stages in the latter series is not A-apicolysis. NA.A.-non-apicolysis. known as the figure given (I72) combines second and third stage operations. plasty. After her second stage she left the This present series and that with which it is theatre in good condition and recovered compared are not large in numbers but they are from her anaesthetic. Three hours later she comparable, in that similar operations were per- collapsed suddenly and died with all the formed under conditions which were not dis- signs of cardiac failure. There was no post similar. copyright. mortem examination. These results would seem to indicate fairly (6) Unkrnown cause. This man developed res- clearly that light general anaesthesia with d- piratory distress for no apparent reason tubocurarine chloride is as safe as local analgesia towards the end of a first stage operation for thoracoplasty operations. It-is certainly more with apicolysis. The respirations were pleasant for the patient and the surgeon, and less gasping in type and continued so for six time consuming for the anaesthetist. hours when he died. His blood pressure Results following lung resection. The details of at the close of the operation was I75/100 the lung resections which have been performed in

and he had a very forcible bounding pulse the years 1946-1947 at the Liverpool Chest http://pmj.bmj.com/ of eightv beats per minute, which was sug- Surgical Centre under this form of anaesthesia are gestive of a cerebral lesiop. Nothing was shown in Table 5. found at autopsy. Following these i I6 operations there have been A useful indication of the morbidity following five deaths within four months giving a case thoracoplasty is afforded by the number of patients mortality of 4.3 per cent. who are fit for their subsequent stages within the usual period of two weeks. Tables 2 and 3 show TABLE s the number of cases which had to be delayed after LUNG RESECTIONS 1946 - 1947 on October 1, 2021 by guest. Protected their first and second Table shows the stages. 4 Lobectomy: Bronchiectasis .. 82 total morbidity after second stage operations. Carcinoma .. Cyst of lung 2 Atelectasis following thoracoplasty. There were Abscess .. . I I3 (3.6 per cent.) cases of atelectasis of the lower Tuberculosis . 3 Adenoma .. I TABLE 3 92 MORBIDITY AFTER SECONDr SiTAGE THORACOPLASTY SUFFICIENT To Pneitmonectonij: Bronchiectasls 1 3 CAUSE DELAY OF THIRD STAGE Carcinoma .. Io Adenoma .. Delay wtoeeks 4 wreeks 4 weeks + Indefinite A. N.A. A. N.A. A. N.A. A. N.A. 24

Pyrexia .. .. Sepsis .. .. J (I) Pulmonary oedema. This man aged forty- Poor general condition i three was in poor condition before his Haematoma l (Basal) operation and died 29 hours after a difficult pneumonectomy for carcinoma. Postgrad Med J: first published as 10.1136/pgmj.24.276.514 on 1 October 1948. Downloaded from

526 POST GRADUATE MEDICAL JOURNAL October I948 Shortly after his operation he showed signs TABLE 6 of oedema of the remaining lung aid his OTHER OPERATIONS PERFORMED AT THE LIVERPOOL CHEST SURGICAL condition gradually deteriorated. A sub- CENTRE, I946-I947 sequent section of the removed lung re- Oesophagectomy 5 Oesophago-gastrectomy...... 5 vealed that he had tubercle in addition to Thoracotomy ...... 75 Decortication ...... g9 carcinoma. Pericardectomy...... 5 (2) Cerebral catastrophe. This patient aged Patent ductus 3...... 3 Splanchnicectomy ...... Z9 sixty-five years, died following pneumonec- Laparotomy ...... 7 tomy for carcinoma. His condition was For lung abscess...... 28 Intrathoracic goitre 3...... 3 poor at the end of the operation which was Minor operations...... 328 difficult and prolonged. The next day he was found to have hemiplegia and, he col- 497 lapsed suddenly and died on the evening of the second day after operation. There was Summary no post-mortem. The methods of controlled respiration are (3) Surgical emphysema which developed reviewed and the role of d-tubocurarine chloride 24 hours after a pneumonectomy for in thoracic surgery is discussed. The preparation bronchiectasis. The chest, arms, neck and anaesthetization of patients for various thoracic and possibly the mediastinum were involved procedures is detailed and the results following and despite the repeated aspiration of air 363 thoracoplasties discussed in detail together from his chest his condition gradually with the operative mortality- in i I6 lung re- deteriorated. Permission was not granted sections. for a post-mortem examination. I am most grateful to Mr. H. Morriston Davies, (4) Caseous tuberculous pneumonitis in associa- F.R.C.S., for his unfailing help and encourage- tion with renal and cardiac failure. This ment and to Mr. F. Ronald Edwards, F.R.C.S., man aged forty-nine years, had undergone for much advice and assistance with this papercopyright. a left upper lobectomy for a lesion con- and for the detailed results following thoracoplasty. sidered to be a tuberculoma, however, he The skill and originality of my colleague anaes- had much more extensive disease than had thetists at the Liverpool Chest Surgical Centre, been thought and after his operation he Dr. John Halton and Dr. Joseph E. Esplen, and developed tuberculous pneumonitis of the their permission to include cases anaesthetized by lower lobe and later an acute form of neph- them have ma5e this paper worthwhile. ritis and cardiac failure. He died four Lastly I owe a special word of gratitude to Miss months after operation. E. S. N. Fenton, my registrar, for statistical re- (5) Anoxia due to a sudden intra-bronchial search. haemorrhage and spill-over of thick tenac- http://pmj.bmj.com/ ious sputum. This patient suffered from BIBLIOGRAPHY BEECHER, H. K. (1940), J. of Thoracic Surgery, IO, 202. recurrent haemoptyses and had a chronic BURKE, J. C., LINEGAR, C. R., FRANK, M. N., McINTYRE, abscess of the right lower lobe. During the A. R. (1948), Anesthesiology, 9, 251. CRAFOORD, C. (1938), On the Technique ofPneumonectomy in Man. early manipulation and freeing of the lobe Stockholm. 6I. Tryckeri Aktiebol4get Thule also Asta Chirurg. Scand. 54. (Supplement). haemorrhage into the bronchus occurred CULLEN, S. C. (1944), Anesthesiology, S, x66. and a great deal of tenacious secretion spilt DRIPPS, R. D. (1947), Anesthesiology, 8, x5. EVANS, Frankis (i944), Lancet, I, is. over into the bronchial tree. Despite GORDH, T. (I945), Anesthesiology, 6, 258. the GRAY, T. C. and EDWARDS, F. R. E. (I948), Thorax. In the press. on October 1, 2021 by guest. Protected immediate bronchoscopy and suction GRAY, T. C. and HALTON, J. (I946), B.M.J., 2, 293. patient succumbed. The use of a suitable GRAY, T. C. and HALTON, J. (I948), B.M.J., I, 784. GRAY, T. C. (1948), Proc. Roy. Soc. of Med., 41, 559. and reliable bronchial occluder would prob- GUEDEL, A. E. (I937), 'Inhalation Anaesthesia.' Macmillan. A New York, p. 6i. ably have avoided this accident. pre- HALTON, J. (I943), Lancet, I, 12. operative bronchoscopy, however, was not HEWER, C. Langton (I948), Annals of the Roy. Coll. of Surgeons, 2, 314- performed and it seems likely that the HUMPHRIES, G. H., MOORE, R. L., MAIER, H. C. and not out in the head APGAR, V. (1938), 7. of Thoracic Surgery, 7, 438. operation was carried KING, H. (I935),Y. Ch. Soc. Pt. 2, 138I. down position. KOPPANYI, T. and VIVINO, A. E. (I944), Science, 100:474. LLOYD, D. P. C. (x946), In Howell's Textbook of Physiology rev. Owing to the many factors involved it is difficult by Fulton, Saunders, p. 133. MELTZER (I909), Journ. of Eixper. Med., 2, 622. to obtain a reliable assessment of the results follow- MILLER, J. (I948), Tubercle, 29, 12I. are MORCH, E. T. (I948), Anaesthesia, 3, 4. ing lung resection and figures for comparison ORGANE, G. (I948), Brit. Med. Journ., I, 9I. not easy to find. It Is hoped that such an analysis PALE, J. (I900), Centralbl. f. Physiol., io. RINK (1948), Brit. Med. 3ourn., I, 9I. together with the results which have been obtained SAUERBRUCH (1904), Mittheilungen aus den Grenzegebieten der Medizin und Chirurgie, 13, 399. in other types of thoracic procedures (Table 6) SMITH, J M. (I944), Brit. Med. 7., 2, 820. will be the subject of a later communication. TREVAN, J. (1946), Personal communication.