system of anaesthesia using d …anaesthesia is playing its part in these advances and materially...

514 POST GRADUATE MEDICAL JOURNAL October I948

all round sense to other methods but even in itsmost refined standards it is doubtful whether,alone, it serves fully the requirements of the longand severe operations now carried out in theabdomen. Success with inhalational anaesthesiademands a much higher degree of technical dex-terity and more fundamental physiological andpharmacological knowledge on the part of theadministrator than ever before. In the hands ofthe. inexperienced there are many things that may

go wrong and create dangers that are just as great,if not greater because they are more insidiousthan those associated with the older, and simplermethods.The observation so often made in the past that

the choice of the anaesthetist is more importantthan the choice of anaesthetic is indeed truertoday than ever for the scope for unintentionalfoolishness and possible disaster has widenedconsiderably.

A SYSTEM OF ANAESTHESIA USINGD-TUBOCURARINE CHLORIDE FOR CHEST SURGERY

By T. CECIL GRAY, M.D., D.A., F.F.A., R.C.S.e -t

Reader in Anaesthesia, University of Liverpool ; Atiaesthetist, Liverpool Chest Surgical Centre

The exciting and exploratory spirit which hasbecome apparent of recent years in surgery wouldhave been frustrated were it not that anaesthesiaadvanced contemporaneously. In no field has thisspirit in surgery and this progress in anaesthesiabeen more in evidence than in the radical treat-ment of disease of the thoracic viscera. Thepioneer work of Sauerbruch (I904) in Germanyand the modem developments in America andGreat Britain have produced an era in whichsurgical procedures of a gravity and extent hithertoconsidered impossible have become everydayevents. The total or partial removal of a lung isnow a rather less hazardous proposition than amajor abdominal operation. Intra-cardiac surgeryand the operative treatment of congenitallyabnormal vascular channels are possible and newhope has been given to many patients hithertodoomed to starvation by removal and reconsti-tution of the diseased oesophagus. Moreover thesurgery of tiiberculous disease of the lungs hasprogressed far since the first thoracoplasty wasperformed in this country by Mr. H. MorristonDavies in 1912. It is the purpose of this paper toshow how one of the most recent discoveries inanaesthesia is playing its part in these advancesand materially contributing to successful surgerywithin the thorax. It is necessary first, however,to consider how the upset to a patient consequentupon the creation of an open pneumothorax canbe offset by the anaesthetist.

Controlled resiration. In the presence of anopen pneumothorax or when the pleura has beenfreed from the chest wall in thoracoplasty, certain

mechanical disorders in the respiration are likelyto occur. On the affected side the lung will collapseon inspiration and expand on expiration. Thisphenomenon has been described as 'paradoxicalrespiration' and it results in a certain amount ofvitiated air passing from the collapsed to thenormally expanded lung on each inspiration, and,if there is a sufficiently big respiratory excursion,it may lead to the spread of infected secretion intothe bronchial tree and so from the diseased to thesound lung. Paradoxical movement of this kindwill cause the mediastinum, if it is mobile, toswing away from the open side on inspiration andback on expiration. This ' flap' may interferewith the normal inspiratory filling of the oppositelung. and by reducing the venous return to theheart result in sudden circulatory collapse.

For these reasons it is advisable during a thora-coplasty under general anaesthesia and essential inthe presence of an open thorax, to control the res-piration and avoid such irregular movements.Sauerbruch (1904) devised two methods ofcounteracting these undesirable effects both ofwhich depend upon the production of a pressuregradient between, on the one hand, the atmospherebreathed by the patient and, on the other, theexposed lungs. In his' Unterdruck Kammer' thehead of the patient was occluded by an airtightrubber diaphragm from a room in which theremainder of his body together with the surgeonand his assistants were subjected to a pressurelower than atmospheric. The patient continued tobreathe air at atmospheric pressure. Thus whenthe chest was opened there was no increase of

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October I948 GRAY: d-Tubocurarine Chloride for Chest Surgery 5I5

pressure on the lungs and the normal respiratorypressure difference was maintained. Converselythe same effect was achieved by Sauerbruch'salternative method in which the patient's head wasenclosed in an apparatus, the ' UeberdriickApparat,' in which the pressure was slightly aboveatmospheric. These original methods, however,were not altogether satisfactory and involved theuse of complex and bulky apparatus. Meltzer(I909) and later Beecher (I940) achieved the sameresult by the continuous intra-tracheal insufflationof air and anaesthetic gases under a pressuresufficient to prevent collapse of the lung when thechest was opened. But this procedure facilitatesthe spread of infected material to healthy areas ofthe lungs and, according to Crafoord (1938), mayresult in a steadily increasing alveolar carbondioxide tension.The advent of closed circuit anaesthesia lead to

the development of a method whereby the anaes-thetist achieved perfect control of the respiration.The normal respiratory movements of the patientare completely abolished and the lungs are arti-ficially inflated either by mechanical means as inCrafoord's spiro-pulsator, or by manual compres-sion of the rebreathing bag of the anaestheticapparatus. In this way the lungs are inflated anddeflated rhytihmically and paradoxical respirationwhich depends on active respiratory movementcan no longer occur. An added advantage of thismethod of controlled respiration is that the move-ments of the lungs can be adapted to the require-ments of the surgeon. Even this maneouvre, how-ever, is not without disadvantages for it may pro-duce certain undesirable physiological effects.During apnoea the absence of a negative pressure

within the thorax removes the respiratory venouspump mechanism and may lead to a deficientfilling of the heart during diastole. Perhaps moreimportant is the fact that the normal relationshipbetween the respiration and the intra-pulmonaryblood circulation is disturbed. In normal inspira-tion the alveolar blood capillaries are dilated bythe negative intra-thoracic pressure and an effectiveand efficient interchange of gases between theblood and alveolar air is thus facilitated. Whenthere is positive pressure on inspiration, as incomplete control of the respiration with apnoea,these capillaries are flattened and many may beemptied. These effects have been investigated onanimals by Humphries and his colleagues (1938)and they have shown that under similar conditionssignificant changes may result in both the cardiacoutput and pulmonary artery pressure. It is pos-sible that circulatory changes brought about inthis way may have an important bearing on theoutcome of a critical case when there is only asmall circulatory reserve.

It is, however, not always necessary to producecomplete apnoea and paradoxical movement canbe prevented in quiet respiration by exertingslight positive pressure on the rebreathing bagduring inspiration. It seems likely that this degreeof positive pressure will not balance completely theintra-thoracic negative pressure produced byinspiration, particularly on that side of the chestwhich remains closed and, therefore, the physio-logical upset will be less than when there are noactive respiratory movements. This modified con-trol of the respiration has been preferred except,as will be amplified later, when complete apnoea isdesirable to assist the operative technique.

Inaccuracy in terminology is not uncommonand this latter maneouvre has been called by some' assisted respiration.' However, in ordinaryassisted respiration there is no attempt by theanaesthetist to control the respiratory movements;they are simply augmented in order to overcomethe depressant effects of, for example, Cyclopro-pane or d-Tubocurarine Chloride.

The use of d-Tubocurarine Chloride to providerespiratory control. In the past the impaired andquiet respiration necessary for control has beenachieved by depression of the respiratory centrewith heavy premedication and- large doses ofanaesthetic agents. Unfortunately, this resultedalso in depression of the other medullary centreswhich are concerned with the maintenance of thecirculation. Such ' depression anaesthesia' pre-disposes to shock and not infrequently resulted intoxic sequelae and prolonged periods of post-operative prostration. The same diminution ofrespiratory movement can be achieved by the useof very light narcosis and judicious doses of d-tubocurarine chloride.

d-Tubocurarine chloride is a pure alkaloidextracted from a tropical vine, the chondodendrontomentosum, which is found in the Amazonianjungles. For centuries Curare, the name given toextracts of this vine, was known only as a potentarrow poison and not until the time of ClaudeBemard was its action scientifically investigated.Isolation of the pure alkaloid by King in I935made possible accurate pharmacological researchinto the properties of the drug and ultimatelymade safe its clinical application. d-Tubocurarinechloride produces paralysis of the voluntarystriated muscles. This paralysis is peripheral inorigin and is due to an interference at the neuro-muscular junction with the conduction of thenerve impulse from the nerve to its muscle. Themuscles of respiration being striated are affected.It is important to appreciate that paralysis is theonly significant effect of an injection of d-tubo-curarine chloride when it is administered inclinical dosage. It is therefore in a sense non-toxic,



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for the heart, liver, kidneys and other organs areunaffected. After the intravenous injection ofnormal doses the maximum effect is developed intwo to three minutes and it diminishes in intensityafter twenty to thirty minutes. There is a cum-ulative effect, in that, after an initial dose, smallincrements will produce a marked effect.The use of this substance to produce relaxation

during anaesthesia for general surgery is now wellestablished. Its application to chest anaesthesiaalthough less apparent is no less fundamental andproduces equally gratifying results. In thoracicsurgery it permits the chest to be opened and thelung to be handled under light anaesthesia. Thelaryngeal and cough reflexes are depressed and therespiratory movements can be quietened and ifnecessary completely abolished. Because of thefreedom from respiratory spasm very light anaes-thesia can be maintained easily while ideal operat-ing conditions are ensured. The principle ofminimal narcotization with adequate curarizationis the basis of the techniques which are to be des-cribed and which have been used in the AnaestheticSection of the Liverpool Chest Surgical Centreduring the past three years.

Action of physostigmine and neostigmine as anti-dotes to d-tubocurarine chloride. d-Tubocurarinechloride is a powerful drug and its use is onlyjustified if an equally powerful antidote is immed-iately available. Fortunately we have in physo-stigmine and neostigmine that antidote. Theaction of physostigmine was first observed by Pall(I900) who noted that normal respiration wasresumed in curarized dogs after the intravenousadministration of physostigmine salicylate.Koppanyi and Viveno (i944) showed that neo-stigmine methylsuphate (Prostigmine) had a similaranti-curare effect and was, in fact, dose for dose,twice as effective as physostigmine. The recentwork of Burke, Linegar, Frank and McIntyre(1948) has confirmed these findings and placedbeyond all doubt that up to the present neostig-mine is the most effective drug in this respect. Inthe light of the humoral theory of neuro-musculartransmission physostigmine and prostigmineinhibit the action of cholinesterase and permit anunusually large concentration of acetylcholene atthe myoneural junction. This may succeed inovercoming the inhibition by tubocurarine of thereceptive substance of the muscle. A more recentobservation is that these drugs cause a rise inexcitability of the muscle by some other actionand there appears to be good evidence that theyprolong the action of a nerve volley on muscle organglion cells (Lloyd I946). When curarizationis complete neostigmine is less effective as anantidote and Trevan of the Wellcome ResearchInstitute has shown by experiments on the rat's

isolated phrenic nerve diaphragm* preparationthat after paralysis of the muscle with large dosesof d-tubocurarine chloride its excitability toindirect stimulation cannot be restored by neo-stigmine in any dosage.

In clinical practice neostigmine is a very effec-tive antidote to partial curarization and has beenmost useful in the work under consideration. Thereason for the dissatisfaction shown by Americanwriters with the effectiveness of this substance hasbeen that they have used it in inadequate dosage.The dose of neostigmine which has been foundmost effectual is 3-5 mgm. administered withatropine gr. i/iooth to 1/5oth (o.65 mg.-I.3 mg.).The atropine is given to neutralize the undesirableparasympathomimetic effects. Whenever there isthe slightest doubt concerning the completerecovery of the patient from the effects of tubo-curarine, the anaesthetist should not hesitate toadminister neostigmine, and, in fact, it is advisableas a routine following chest operations.

The preparation of the patient for operation.The adequate preparation of the patient before athoracic operation plays a most vital part inensuring a successful result. It is hardly necessaryto stress that the patient must be seen beforeoperation and the anaesthetist ensure that hispreparation has been efficiently carried out andthat he himself is fully acquainted with the par-ticular pr'oblem on hand.A very full and complete investigation of the

cardiorespiratory function of the patient shouldbe a routine in every major case and it shouldinclude a blood count, vital capacity and exercisetolerance estimations. Although not absolutelynecessary a routine electro-cardiograph in patientsover thirty years of age will provide occasionalsurprises and prevent some avoidable accidents.The paramount features of the pre-operativepreparation can best be considered in relation tothose types of major cases with which the thoracicanaesthetist is concerned.

Cases undergoing lung surgery have pulmonarydisease requiring complete pneumonectomy,lobectomy, segmental resection of a lobe or someform of thoracoplasty. They are not infrequentlyin poor condition as a result of toxaemia andinfection and may be producing large quantities ofsputum. In such cases adequate physio-thera-peutic preparation is of importance and shouldinclude the education of the patient in the art ofbreathing. Frequent vital capacity estimationsshould be made in order to assess improvement.If there is sputum production, a morning andevening postural drainage routine must be carriedout and the quantity of sputum produced everytwenty-four hours charted. In those cases whichdo not respond to postural drainage a course of



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penicillin inhalation is often very helpful. Com-plete otolaryngological toilet is necessary and afinal careful check up should be made immediatelyprior to operation as to the presence of any acutenaso-respiratory infection. In cases for thoraco-plasty it is wise to make a radiological examinationtwenty-four hours prior to operation, in order toensure that there has not been any unsuspectedspread (Langton Hewer I948).

Cases for cardiac surgery frequently have avery poor circulatory reserve. In the presence ofactual decompensation the cardiac function mustbe improved as much as possible by rest in bed andadequate digitalization where it is required.Oedema may be a very prominent feature and incases of constrictive pericarditis there may be,besides oedema, massive ascites and extensivepleural effusions. The effusions should be treatedby repeated aspiration and a course of one of themercurial diuretics before operation will oftengreatly improve the clinical picture. It is importantto ensure that the chest is free from fluid on theday of operation as in these cases a rapid overnightaccumulation may occur. Coincident bronchitisis common and should be treated by breathingexercises and if necessary penicillin. Arithmeticalestimations of the cardiac efficiency such as thatdevised by Moot serve no useful purpose in thesecases. Furthermore, exercise is often toleratedextremely badly by patients who are very suitablefor and must undergo cardiac surgery. Perhapsthe breath holding test of Sebrasez gives the bestindication to the anaesthetist of the patient'scardiac reserve. The patient resting in bed takesa deep inspiration and holds it for as long as pos-sible. Normally this period is thirty seconds, butanything less than fifteen seconds indicates amarked reduction in the cardiac or respiratoryreserve. In dealing with these patients, however,no test can replace a good clinical acumen and ajudgment based upon observation of the patientas a whole.

Cases for transthoracic gastric or oesophagealresection are not infrequently elderly andemaciated. A full investigation of their respiratoryand cardio-vascular systems must always be car-ried out and an effort made to restore their con-stitution to a state approaching normal. A con-sideration of their plasma protein and blood countin conjunction with the haematocrit value willensure control of the fluid and protein adminis-tration. It is necessary to stress that the haema-tocrit value should always be considered in deter-mining the fluids to be administered, as in thepresence of haemoconcentration, an anaemia maynot be apparent and the fact not appreciated thatwhole blood rather than saline or plasma is thecorrect transfusion. If the patient can swallow

fluids the preparation is easier, but if adequateoral fluid replacement is not possible, a rectal orintravenous routine must be adopted. In com-plete obstruction an attempt should always bemade to dilate the stricture under anaesthesiasufficiently to take a Souttar's tube or allow aRyle's tube to be passed so that a high proteinfluid diet of ' fortified milk' can be given.The anaesthetist must not allow himself to be

too depressed by the pre-operative condition ofthese patients. Although by all the ordinarystandards they would appear to have little chanceof survival they not infrequently tolerate longoperations remarkably well. It is a grave decisionto refuse to give the only possible chance to onedoomed to slow death by starvation.

Pre-medication. The rationale for pre-medica-tion is that certain drugs are administered toprevent bronchial and salivary secretions duringanaesthesia and to reduce the quantity of anaes-thetic required. Atropinization is very importantespecially when d-tubocurarine chloride is to beused. If atropine is omitted, or if it is given toolate for it to be effective before the induction ofanaesthesia, the injection of tubocurarine mayresult in the production of large amounts of asticky, glairy salivary secretion. This may causelaryngeal spasm and result in a critical situation.The second purpose of premedication is achievedby the administration of sedatives which allayapprehension, relieve pain and thus reduce themetabolism of the patient (Guedel I937). Sedativedrugs, such as morphia and scopolamine have alsoan action on the medulla and the reduction oftheexcitability of the respiratory centre by large dosesof omnopon and scopolamine have in the pastbeen an important part of the technique of con-trolled respiration. This depression is likely to beprolonged into the immediate post-operativeperiod at which time it is most desirable to have afull respiratory function and active cough reflexes.Control of the respiration can now be achievedwithout such depression and heavy sedation is notnecessary and is in fact definitely harmful. InCentres where an intravenous induc.tion of an-aesthesia is routine, patients, even quite smallchildren, have little pre-anaesthetic apprehension.Very light premedication is desirable and is an im-portant part of the technique advocated in thispaper. For adults, morphia, gns. k i i mg.) andatropine gr. T o (0.4 mg.) is given at leastone hour prior to the induction of anaesthesia.The dosage of atropine is the same for children,but that of morphia is modified according to age.If it is impossible to give the premedication at theproper time it should be given intravenously inthe anaesthetic room. In such circumstancessedation is obviously not part of the function of



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Si8 POST GRADUATE MEDICAL JOURNAL October 1948

the injection, but the morphia assists in reducingthe amount of anaesthetic required and serves auseful purpose in a balanced technique of anaes-thesia. On those occasions when a child hasproved unco-operative and excited, rectal thio-pentone (o.i g. per year) has been administeredand given a most satisfactory and transientsedation.

Technique of anaesthesia. A standard anaestheticarrangement and procedure for induction is usedand slightly modified to suit the different types ofoperation. As the anaesthesia is mainly intra-venous it is important to have a reliable anddependable method of making the injections andfor these the three way tap originally describedby Gray and Halton (1946) and its recent modi-fication by Halton as described below have beenfound invaluable.The tap (Figure i) is mounted on a small base

moulded to the curve of the forearm and is easilystrapped in position. The male end connectsdirectly to a serum needle, size ten, and an intra-venous drip is led to one of the two female inlets,the other being used to inject the solutions. Thetap can be used either after the manner of a Gordhneedle (Torston Gordh 1945) or in associationwith a continuous intravenous transfusion. Inthe former case when the tap is turned off betweeninjections there can be no reflux of blood into theneedle and blockage by clot is thus prevented.For longer procedures when a continuous drip ofsaline or blood should be used the arm is splintedbefore the apparatus is fixed in position. For con-venience the arm opposite to the side of operationis the most suitable choice.

Induction of anaesthesia is carried out with d-tubocurarine chloride and thiopentone. The doseof d-tubocurarine chloride is 15 mgm. for adultsand 0.3 mgm. per kilo body weight for childrenand that of thiopentone 0.5 gm. for healthy adultswith suitable reductions for children, the elderlyand those with a poor cardiac reserve.A test dose of d-tubocurarine chloride is first

injected in order to detect any hypersensitivity tothis substance (Gray and Halton I948). In adultsthis is usually 5 mg. i.e. i of the calculatedinduction dose. If after two minutes there is nosign of an unusual reaction, the remaining iomgm. is injected followed by the thiopentone.Following this injection the lungs are immediatelyinflated two or three times with oxygen and apharyngeal airway or endotracheal tube is intro-duced. Oral intubation is invariably performedwith ease if the injections are given in this orderand when a Macintosh laryngoscope is used.When the d-tubocurarine chloride is given beforethe thiopentone the maximum effects of bothdrugs are synchronized and provide excellent

relaxation. The Macintosh laryngoscope facilitatesthe introduction of the tube by avoiding stimu-lation of that most sensitive area of the larynx, theposterior part of the epiglottis. The cheeks arepacked with gauze to ensure a close and airtightfit of the anaesthetic facepiece. Where an endo-tracheal tube is employed the firmness of the lipsand cheeks ensured by this pack enables the tubeto be fixed in position by a piece of soft tubber tapepassed round the occiput. (Figure 2). It is betterto leave the connection between the endotrachealtube and the absorption canister free for if it isfixed, as for example by Hudson's harness, theendotracheal tube is apt to become kinked whenthe head is moved.

Anaesthesia is maintained with a mixture of70 per cent. to 50 per cent. of nitrous oxide inoxygen, occasional injections of a 5 per cent.solution of Kemithal (I.C.I.) and increments ofd-tubocurarine chloride as required. Kemithal ispreferable for maintenance having a less depres-sant effect on the respiration and giving morerapid recovery than thiopentone (Halton). AWater's to and fro circuit is always employed.This apparatus is more reliable and has less pos-sibility of leaks than the circle type of absorber.It permits a sensation of closer contact betweenthe administrator and the patient which is mostimportant when the depth of anaesthesia and thefreedom of the airway must be assessed mainlyby the feel of the rebreathing bag. A long exten-sion tube between the distal side of the absorptioncanister and the bag affords greater freedom ofmovement to the anaesthetist and provides lessrisk of disturbing the apparatus during the opera-tion. Once the patient has been turned into thelateral position, for greater security the absorptioncanister may be fixed to the table.To employ this technique successfully the

anaesthetist should make a mental resolution toadminister further doses of anaesthetic only whenit is absolutely essential. After induction it isseldom necessary to inject more barbiturate untilthe surgeon is about to make his incision and thenas little as 0.2 gm. of Kemithal will produce aquiet and relaxed patient. A further io mg. ofd-tubocurarine chloride will be required to controlthe respiratory movements before the chest isopened and after that control can be maintainedby further doses of 2-5 mg. as required. New-comers to this method of anaesthesia often havedifficulty in deciding between the indications forthe administrations of barbiturate and d-tubo-curarine chloride, and there is no doubt thatsuccess depends largely upon a correct decisionin this respect. d-Tubocurarine chloride providesrespiratory control and relaxation. If the patientis resistant to inflation of the lungs, is straining,



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FIG. i.-Halton's modification of three way tap.

coughing, or there are ' bumpy ' respiratory move-ments when the chest is opened, an injection ofd-tubocurarine chloride will restore the situation.On the other hand more barbiturate is indicatedwhen there is inadequate anaesthesia as evidenceddirectly by a slight movement of a limb or of thefacial muscles and reflexly by a rising pulse rate.With experience and practice the discriminationis not difficult and niceness of decision will amplyrepay the careful observation of the patient whichis necessary.The indications for endotracheal intubation and

bronchial tamponage or occlusion will be discussedwhen the particular technique for pulmonaryoperations is described, but a word must be saidon the dangers of ' mechanic-al respiration.'Mechanical aids to assist or control respiration arepopular in Scandinavia. Crafoord's (1938) modi-fication of the Franckner Spiropulsator andMerck's Spiropulsator (1948) undoubtedly relievethe anaesthetist of a great deal of what might beconsidered monotonous work. It may be tediousto have to compress rhythmically a rebreathingbag for five hours and these machines free theanaesthetist to perform other useful functions,but they cannot replace trained hands. Auto-matic devices have no feeling or discrimination.A case was recently observed in which a patientundergoing thoracoplasty was artificially ventilatedby mechanical means. Not only was the apexcomparatively uncontrolled but an unsuspected§pill over occurred and resulted in a spread of thedisease. A disaster of this nature persuades onethat these interesting mechanical achievementsrequire much greater refinement before they can

begin to compete with the interpretation of thepressure sensations by the human hands. The feelof the rebreathing bag helps the anaesthetist todetermine not only the depth of anaesthesia anddegree of curarization, but also the efficiency andfreedom of the airway. It gives him warning ofthe collection within the bronchi of any sputumwhich requires removal by suction and enableshim to adjust the movements of the lungs to themanipulations of the surgeon.

Before considering details there is one furtherpoint of principle which needs to be emphasized.In long traumatic and potentially shocking opera-tions the circulatory blood volume should bemaintained as it is lost, drop for drop. Under nocircumstances should a blood transfusion be with-held until there is evidence of impending circu-latory collapse. Neither is it advisable to dependupon the transfusions set up in the arm for bloodreplacement and a cannula should be inserted intothe leg vein as soon as anaesthesia has been induced.The standard technique which has been des-

cribed has been adapted to all types of operationsand the points peculiar and special to the individualthoracic procedures must now be discussed.

Endoscopy. Both oesophagoscopy and broncho-scopy can be performed under local surface anal-gesia. Even with adequate premedication, how-ever, this is usually a very unpleasant experiencefor the patient. The administration of a smalldose of thiopentone removes this objection, butwhen there is a long list, anaesthesia with d-tubo-curarine chloride and thiopentone alone givesexcellent results and is less time consuming.The procedure and dosage is exactly that which

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520 POST GRADUATE MEDICAL JOURNAL October 1948has been de2scribed for the induction of anaesthesiausing the three way tap after the manner of aGordh needle. There are a few points of detail inrespect of oesophagoscopy and bronchoscopywhich are important. Patients for oesophagoscopyare often poor risks and for the aged and cachectica 2.5 per cent. solution of thiopentone should beused and the dosage reduced to 0.25 gm. with iomg. of tubocurarine. A gum elastic catheterthrough which oxygen is continuously insufflatedshould be introduced into the trachea as the oeso-phagoscope is passed. It is not uncommon toencounter some resistance due to spasm of theinferior constrictor of the pharynx. This willusually relax after a few moments, but if it doesnot a small increment of thiopentone will enablethe instrument to be passed with ease.

During bronchoscopy oxygen should be in-sufflated down the side tube of the bronchoscope.From the surgeon's point of view the conditionsduring the examination are usually ideal. A resis-tant patient may cough and strain a little but satis-factory control can be regained with a furthersmall dose of thiopentone. When there is a greatdeal of sputum or blood in the bronchial tree itshould be aspirated before the bronchoscope iswithdrawn, following which the patient is turnedat once on to the same side as his lesion with thehead of the table lowered.Under general anaesthesia patients with a con-

siderable amount of sputum or a tendency tohaemoptysis should be bronchoscoped in thehead down position. If it is proposed to remove aforeign body or tumour endoscopically it is likelythat a quantity of pent up secretion will be liberatedand the head down position should be adoptedbefore the endobronchial manipulation is started.A patient cannot drown in this position, but hemay easily do so in the usual decubitus position.An intense laryngeal and bronchial spasm may

develop when the bronchoscope is withdrawn.This is most likely to occur when the premedicationhas been given late and when the endobronchialreflexes have been depressed insufficiently by theanaesthesia. Further small doses of thiopentone,should, therefore, not be witheld if the patient istoo light. The most effective treatment for spasmonce it has developed has been the injection of asmall dose of thiopentone and inflation of thelungs with oxygen. Endotracheal intubation shouldnot be performed unless absolutely necessary, asthe presence of an endotracheal tube in the tracheatends to set up further respiratory spasm.

Anaesthesia for bronchography in childrenpresents problems which have not been satis-factorily solved by any of the methods usuallyemployed. The method at present under con-sideration has many advantages. It gives a smooth

and pleasant induction permitting quiet and coughfree respiration at the time the bronchogram isbeing taken and, most important, results ih a quickrecovery. The dose of tubocurarine suitable forthe child (0.3 mg. per kilo) is injected intraven-ously a test dose being fir'st given in the mannerwhich has been described. This is followed byan injection of thiopentone of the order of 0.25 to0.4 gm. the actual dose depending on the age andphysique of the patient. After a bronchoscopy,during which excessive secretions and sputum canbe removed by suction, a catheter is passed downthe bronchoscope and left in situ while the instru-ment is withdrawn. Oxygen is continuouslyinsufflated down the catheter as the child is takento the X-ray room. When all is ready the anaes-thesia is momentarily deepened with a furthersmall amount of thiopentone and the lipiodolinjected down the catheter. Once the photographhas been taken the child must be turned at onceinto the semiprone position, the head lowered andthe catheter used again to insufflate oxygen. Ifthere should be any respiratory depression orimpairment of the cough reflex 1.0-2.5 mg. ofneostigmine and atropine o.65 mg. should beinjected intravenously. Figure 3 shows a broncho-gram taken using this type of anaesthesia.

Thoracoplasty. There has been a great deal ofdiscussion concerning the relative merits of localand general anaesthesia for this operation. Manyof the objections to general anaesthesia, whichhave been raised, no longer apply. The perform-ance of a nerve block of the chest wall is a lengthyprocedure and entails no little discomfort for thepatient. Very heavy pre-operative sedation withlong acting drugs is required and the protectivereflexes are thereby rendered less active for anindefinite period. Moreover, for second andthird stage operations, the analgesia is difficult toproduce and is not always satisfactory. It has tobe helped out not infrequently by ' chloroformanalgesia.'The presence of the cough reflex throughout

the operation has been postulated as an advantageof local anaesthesia; yet illogically it is suggestedthat the vagus should be blocked to diminish this.same reflex (Joan Miller 1948). Coughing producestwo effects. It is expulsive, but it also producesperipheral spread as can easily be demonstrated bya study of bronchograms taken after coughing.In the absence of a rigid chest wall during thora-coplasty the expulsive function of the cough islost, but the peripheral spread remains and maydo irreparable damage. The surgeon may manuallycontrol the apex when he tells the patient to cough,but such control can only be partially effectiveand an involuntary and unexpected cough is notinfrequent and cannot be anticipated.



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October 1948 GRAY: d-Tubocurarine Chloride for Chest Surgery 521

Patients who are anaesthetized with barbiturate,nitrous oxide and tubocurarine have all theirreflexes fully active at the end of the operation andmost of them are able to talk before they leave thetheatre. They have a cough reflex which isimmediately effective. Their convalescence is astrouble free as any who are given a full local block.

In these cases the routine procedure for induc-tion and maintenance of anaesthesia which hasbeen described is adopted. Except where there isa large cavity and much sputum production anendotracheal tube should not be used for its intro-duction may result in slight trauma and the pos-sible appearance of a new tuberculous focus in thelarynx. In ' wet' cases, however, intubation andsuction drainage must be the rule and the operationcarried out in the Trendelenburg position.When a pharyngeal airway only is used the prop

originally described by Moreland Smith (i944)will support the jaw and be of great assistance.It is held in position by a Clausen's harness and,provided that the artificial airway is of adequatesize and a good shape, perfectly satisfactory aera-tion can be maintained. After the induction ofanaesthesia the line of incision is infiltrated with aI.2000 solution of'amethocaine and, as the neuro-muscular bundles are exposed, an intercostal blockis performed with the same solution. This is ofundoubted assistance ag it allows the'wound to bestitched at the end of the operation under extremelylight narcosis and may reduce the operative shock.The respiration must be controlled from the

time that the parietal pleura of the apex has beenfreed from the chest wall. Complete apnoea isseldom required and a modified controlled res-piration with a constant slight positive pressure(of the order of 4 mm. of mercury) will keep thelung steady and greatly facilitate the work of thesurgeon. The responsibility of the anaesthetistduring these operations is very great indeed andnothing can do more tragic harm than a badgeneral anaesthetic. At no time nust he lose a gripof the situation either in regard to the depth ofanaesthesia or as to control of the lung. Too deepan anaesthesia may result in atelectasis of thelower lobe due to stagnation of secretion and un-controlled movement of the apex may lead tospread of infected material to non-infected areasof the lung. The doses of the anaesthetic agentswill depend on the type of case. As an indicationof the maximum dosage which will be required indealing with ex-servicemen the average for a firststage thoracoplasty has been of the order of 0.5 gm.of thiopentone, 0.25-0.5 gm. of kemithal and 20-45 mgm. of d-tubocurarine chloride.

Lobectomy and pneumonectomy. Although localanalgesia has its advocates for thoracoplasty,general anaesthesia has become the accepted

method for lung resection. Cyclopropane isgenerally considered the anaesthetic agent ofchoice for maintenance in these cases and it wasundoubtedly this agent which first opened thedoor to modem thoracic surgery. Cyclopropanehas many desirable properties from the point ofview of the thoracic anaesthetist. It is non-irritant, controllable, and capable of producinganaesthesia in a very high concentration of oxygen.Furthermore the depression of respiration whichaccompanies its administration is of great assistancewhen the respiration has to be controlled. Butthe disadvantages of cyclopropane should makethe anaesthetist welcome an alternative. Itsexplosibility and tendency to cause troublesomeoozing in the wound no matter how efficient theventilation are minor and tolerable defects, butmore serious are its effects on the circulation.Recent studies in America (Dripps I947) havelent authority to a clinical impression that cylco-propane is apt to give a false sense of security inregard to the circulatory condition of the patient.The blood pressure, pulse, colour and generalcondition of the patient may be perfectly satis-factory until the anaesthetic mask is removed atthe end of the operation, when the patient maycollapse suddenly with all the signs of ' shock' orgradually, over a period of half an hour, pass intoa state of hypotension. This phenomenon hasvariously been attributed to a specific effect ofcyclopropane, to the respiratory depression whichattends its administration with consequent carbondioxide retention and acidosis, and to closed circuitanaesthesia itself. But whatever its aetiology' cyclopropane shock' is a very real entity. Forthese reasons the agent has been used ony rarelyand sparingly in the technique under consideration.For routine intra-thoracic procedures d-tubocura-rine chloride with a barbiturate and nitrous oxidegives very satisfactory anaesthesia. The anaestheticis controllable and permits of the use of the cauteryin the chest. Furthermore the condition of thepatient does not deteriorate at the close of theoperation. It is usual to maintain the 50 per cent.mixture of nitrous oxide and oxygen by runningin 500-600 ml. of each,gas per minute. Thisdemands a certain small ' escape ' from the closedcircuit a feature which helps to avoid undue carbondioxide retention (Dripps 1947). Cyclopropane isused only when it is considered that barbiturateswill be tolerated badly, as in small children, thevery elderly and those with evidence of myocardialweakness. There are occasions too when theadministrator is unable to obtain just the perfectconditions which he requires and a little cyclo-propane will tide him over a difficulty. When thebronchus is opened for example, prior to ligaturing,a few minutes of overventilation will usually pro-



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522 POST GRADUATE MEDICAL JOURNAL October i948

duce complete quietude ; but if this fails, it is oftenbetter to use a little cyclopropane than to givemore tubocurarine, as the operation is generallynearing completion.

Control of the respiration, is, of course, essentialfrom the time the pleura has been opened. Thetechnique of this manoeuvre has been discussedbut it should be pointed out that complete apnoeais required only during the dissection of anunusually difficult hilum or in freeing adhesionsof the lung to the diaphragm. At other times it isbetter to maintain some respiratory movement.Some positive pressure should be maintainedduring inspiration until the chest has been closedso that the lung is kept fully expanded. Intercostaldrainage is usual and after the chest has beenclosed the spigot should be inserted into the tubejust after inspiration while positive pressure isexerted on the rebreathing bag. In this wayexpansion of the remaining lobe is ensured.The control of secretion in 'wet' cases can be

a difficult problem and the search for a satisfactorysolution has fascinated every anaesthetist who hashad to deal with such cases. There can be no rou-tine, for every patient is a distinct and individualproblem. Furthermore at a recent meeting at whichthis matter was discussed a speaker of some ex-perience (Organe I948) stated that he had yet tosee an atraumatic bronchial occlusion, and with allthe methods usually advocated this trauma is afactor which cannot lightly be dismissed.

Endobronchial anaesthesia can be used forpneumonectomies but it is debatable whether onelung anaesthesia is really desirable for this opera-tion. It is rational to conserve the function of theuseful part of the diseased lung as long as possible.The extra aerating surface thus maintained maywell help to tide the patient over a long operation.In lobectomy on the other hand it would seemideal to block off the diseased lobe, but none ofthe methods of bronchial occlusion are com-pletely reliable and satisfactory. The Thompsontype of suction occluder is very apt to slip out ofposition. More than once the balloon has beenknown to collapse during an operation and nothingis more disastrous than the failure of an occlusionupon which reliance has been placed. Perhaps themethod of blind bronchial intubation describedby Halton (I943) in which the balloon is heldrigidly in position offers the most hope of a success-ful answer to this problem. It would, however,seem more prudent generally to depend on postureto prevent spill over and spread of infectedmaterial, and in cases with considerable secretionclamping of the bronchus by the surgeon at anearly stage before the lobe is lifted will be of greatassistance.The majority of cases can be controlled by good

physiotherapeutic preparation and during theoperation suction drainage with 350 of Trendelen-burg. A plain endotracheal tube can be led outthrough a rubber diaphragm fitted in the facepieceand the secretion allowed to pass up the trachearound the tube into the facepiece as described byBeecher (Beecher, H. K., 1940), but it is easier andmore satisfactory to use a cuffed endotracheal tubewith a Magill's T-piece and pass a suction catheterthrough the rubber cap. In this case care must betaken to ensure that the rebreathing bag is keptinflated during suction otherwise there is a dangerof collapse of the lung. Where there is a largeabscess cavity containing a fluid collection whichhas not been completely controlled by the pre-liminary postural drainage, pre-operative broncho-scopy and suction has been found most useful.Figure 3 shows such a cavity in a child aged 61years. The diseased lung was successfully removedusing simple postural and suction drainage after apre-operative bronchoscopy and toilet.

FIG. 3.-Bronchogram of child aged 6j with a largeinfected cyst of the left lower lobe. Anaesthesiafor the bronchogram was with thiopentone andd-tubocurarine chloride.

There remain, however, a limited number ofcases for which these simple measures are inade-quate. In the presence of a bronchopleural fistulapositive pressure and controlled respiration isimpossible as the inflated air simply passes intothe pleural cavity. A similar difficulty may beencountered where a congenital cystic conditionis associated with a non-return valve mechanism,(Gray and Edwards 1948). In these cases some



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October J948 GRAY: d-Tubocurarine Chloride for Chest Surgery 523

form of endobronchial anaesthesia or occlusion isessential for satisfactory anaesthesia.

Trans-thoracic resections of the stomdch andoesophagus call for minor modifications in tech-nique. When the lesion is in the oesophagus, afterthe induction of anaesthesia an oesophagoscope ispassed and oesophageal toilet carried out. Duringthis procedure oxygen is continuously administeredinto the trachea through a gum elastic catheter inthe manner already described. After completelyclearing the oesophagus of food debris and sec-retions penicillin powder is insufflated. A'Tampax' pack (attached to a long thread) isinserted to prevent the regurgitation of stomachand intestinal contents when continuity has beenestablished between the oesophagus and stomachor jejunum. It may be possible to insert the cuffedendotracheal tube over the gum elastic catheterand thus avoid the need for another laryngoscopywhich will require a deepening of the anaesthesia.The induction and maintenance of anaesthesia

is carried out in the standard manner. A trace ofether has been found of great value in these casesto reduce the amount of barbiturate which will berequired. Ether has a curare-like action and whenusing it with d-tubocurarine chloride it should beremembered that there is a summation of boththeir effects at the myoneural junction. For thisreason it is stated by some writers (Cullen i944)that only i of the dosage of tubocurarine shouldbe injected when ether is the anaesthetic. Ether,however, is a toxic drug whereas d-tubocurarineis not, and theoretically it would seem morefeasible and in practice it is conducive to betterresults to reduce the amount of ether and give thesame dose of tubocurarine. The smallest con-centration of ether which will give an 'ethereal'smell to the mixture should be used, for morethan this will result in a prolonged recovery time.

During these operations there is not infrequentlysome deterioration in the patient's conditionshortly after the chest has been opened. The bloodpressure falls and the visible heart action appearsweak. At this point it has been found of advantageto start an adrenalin drip as originally describedby Frankis Evans (I944). Although a single injec-tion of methedrine may produce a similar resultadrenalin is preferable in that its effects aretransient and, therefore, more controllable. Aftera short period it is usually possible to stop theadrenalin.A feature of this method of anaesthesia is that

no matter what the length of the operation thepatient is never deeply anaesthetized and, as aresult, is able in the majority of cases to talk beforeleaving the operating theatre. This state of con-sciousness is highly desirable as the action of thecardiac sphincter has been removed, and regur-

gitation of fluid may occur from the stomach andbe inhaled.The surgical treatment of patients with heart

disease has been made practicable by the nvork ofBlalock in the United States and Brock in thiscountry, and this paper would be incompletewithout some reference to the technique of anaes-thesia for this work. The general principles whichhave been postulated still hold and d-tubocurarinechloride is of the same value here as elsewhere.It has no action on the heart and it permits a verylight plane of anaesthesia to be maintained easilyand with minimal concentrations of drugs whichin higher concentration may have a detrimentaleffect on the myocardium and conducting mech-anism. It has been stated by many authorities thatcyclopropane is contra-indicated because of thesevere and frequent cardiac arrhythmias which arelikely to occur when it is used. It is probable,however, that such irregularities are more frequentwhen cyclopropane is the sole agent and used in aconcentration sufficient to depress the respiration.Undue irritability of the 'heart has not beenobserved when it has been employed with tubo-curarine and a recent report (Rink 1948) suggeststhat used in this way it is the most suitable anaes-thetic agent for the operative treatment of thetetralogy of Fallot. Some cardiac irregularitieswill always occur during manipulation of the heartand. only if the arrhythmia becomes of threateningsignificance is it necessary to abandon cyclopropaneand use ether. There is little doubt-that the intra-venous injection of 3-5 ml. of i per cent. procaineor the application of a i per cent. solution to thesurface of the heart renders the organ less sensitiveto mechanical stimulation.

Thiopentone or kemithal must be used withgreat caution when there is an impaired myocar-dium. There is evidence that these substances aredirect myocardial depressants, and whilst caseswith a patent ductus arteriosus may toleratethem well, a normal dose would certainly provefatal in a case of constrictive pericarditis.

Patients with constrictive pericarditis have afeeble, thin and atrophic myocardium. They areusually oedematous and have enlargment of theliver, ascites and pleural effusions. They mayhave a marked degree of cyanosis and are. freq-uently orthopnoeic. Patients in this conditionwould call for a modification of most techniques.'The following procedure has been found useful.After premedication with morphia and atropine,oxygen is administered through the anaestheticmask for a few minutes prior to the induction ofanaesthesia. Cyclopropane is then introduced at400 ml. per minute with 500 ml. of oxygen untilthe patient is asleep. The usual test dose of d-tubocurarine is given, after a pause it is followed



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524 POST GRADUATE M'EDICAL JOURNAL October 1948

by the injection of the remainder of the inductiondose. Assisted respiration must be instituted atonce to build up a good oxygen reserve which willallow for the quick introduction of an endotrachealtube. Anaesthesia is maintained with minimalquantities of cyclopropane or ether with incre-ments of d-tubocurarine given as necessary toassist control of the respiration. In the less severecases of decompensation it is possible to induceanaesthesia with 4-6 ml. of a 2.5 per eent. solutionof thiopentone but great caution is necessary andfull oxygenation before and during the injectionshould be ensured.

Post-Operative ResultsIt is becoming widely recognized that given

good anaesthesia the results following any surgicalprocedure depend less upon the technique or agentused than was at one time considered probable.In thoracic work the efficiency of the pre-operativephysiotherapy, medical preparation and thestandard of post-operative nursing are variablefactors making it difficult to compare the resultsobtained in different centres. Even the degree ofhumidity of the atmosphere in the wards mayinfluence the post-operative convalescence of thesepatients.The essential prerequisites of any anaesthesia

for this work are that it should permit control ofthe respiration, result in as little toxic upset of thepatient as possible and permit a patient at the endof the operation to be co-operative and able tocough and breathe efficiently. When small dosesof the anaesthetic agents are combined with ade-quate dosage of d-tubocurarine in the mannerwhich has been described the patients are routinelyawake at the close of the operation and not in-frequently they have been able to converse intel-ligently as they leave the theatre perhaps followinga five-hour oesophagectomv. Such co-operationmaterially facilitates the post-operative nursing andremoves the danger of the aspiration of vomit orsecretion. There need be no apprehension thatthe respiration will be depressed after tubocurarinewhen it is used in reasonable dosage and addedsafety is provided by the routine injection of anadequate dose of neostigmine.

Nausea and vomiting has been rare followingthoracotomy but it still occurs after thoracoplasty.It is of interst that vomiting persists even whenlocal analgesia is used (Joan Miller 1948). Thevomiting has been attributed to the morphia givenin premedication but this seems an unlikelyexplanation in view of its comparative infrequencyafter other thoracic procedures. It may well be dueto some vagal imbalance resulting from collapse ofthe chest wall.There is possibly an increased frequency of

retention of urine when d-tubocurarine has beenemployed (Gray 1948). In the present series thishas not been unduly troublesome and the retentionhas usually responded to injections of carbachol.One patient, however, did not micturate naturallyfor seven days following a lobectomy.

During I945 and 1946 a sufficient number ofoperations for thoracoplasty were performed topermit numerical comparison with other series.In the following analysis the results will be com-pared with the figures quoted by Joan Miller (I948)for a very comparable series of cases in which localanalgesia was used (Table I). There have been

TABLE

*st 2nd 3rd Apico-Cases stage stage stage Ant. Rev. lysis

Parenc/zvmatoutsdisease 153 148 138 26 I I 12 ii6 78%

Basaloperatiotis ..... 5 I1 5 5 5

Eip3ema .. 9 9 8

Comparativeseries (JoanMiller 1948) 204 i8o 172 8 13 153 85°o

Particulars of thoracoplasty operations performed 1945-1946.The comparative series is that quoted by Joan Miller (1948)

carried out under local analgesia.

in this series six deaths within three months ofoperation giving an operative mortality of 3.6per cent. This compares well with the seriesunder local analgesia in which twelve deaths in asimilar period gave a mortalitv of 5.3 per cent.The cause of death in the following series of caseswas as follows:-

(i) Pulmonary embolus. This patient developeda femoral thrombosis four weeks after asecond stage operation and died in theseventh week. The presence of a large pul-monary embolus was confirmed at postmortem.

(2) Acute tuberculous pneumonia of the sameside following a first stage without apicoly-sis. The cause of death was confirmed atautopsy.

(3) Acute bilateral tuberculous broncho-pneu-monia, six days after a first stage operationwith apicolysis. Confirmed at autopsy.This was the only case of contra-lateralspread in the present series.

(4) Coronary thrombosis. This patient col-lapsed and died eight hours after a first stageoperation with apicolysis. Confirmed atautopsy.

(5) Cardiac failure, in a patient who had had a



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

I3 years history of tubercle. She made agood recovery after a first stage thoraco-

TABLE 2MORBIDITY AFTER FIRST STAGE THORACOPLASTY SUFFICIENT TO

CAU1SE DELAY OF SECOND STAGE

Delay 2 wveeks 4 wveeks 4 weeks + IndefiniteA. N.A.lA. N.A. A. ' N.A. A. N.A.4.

Poor general condition 4Bronchitis IConsolidation base 3Atelectasis. . . 2 1 2 3 i Emp.

(Bro nchiectasis I)Haemothorax ........ 3Tachycardia 2..Superficial sepsis 1 2 ICoryza . . .. lThrombosis axillary

vein 2Haemoptysis .. IOld rheumatic heartPyrexia ? cause ..Nephrosis X

35 delayed out of 158 first stages-22",,-7 in non-apicolysis and28 in apicolysis.

A-apicolysis. NA.A.-non-apicolysis.

plasty. After her second stage she left thetheatre in good condition and recoveredfrom her anaesthetic. Three hours later shecollapsed suddenly and died with all thesigns of cardiac failure. There was no postmortem examination.

(6) Unkrnown cause. This man developed res-piratory distress for no apparent reasontowards the end of a first stage operationwith apicolysis. The respirations weregasping in type and continued so for sixhours when he died. His blood pressureat the close of the operation was I75/100and he had a very forcible bounding pulseof eightv beats per minute, which was sug-gestive of a cerebral lesiop. Nothing wasfound at autopsy.

A useful indication of the morbidity followingthoracoplasty is afforded by the number of patientswho are fit for their subsequent stages within theusual period of two weeks. Tables 2 and 3 showthe number of cases which had to be delayed aftertheir first and second stages. Table 4 shows thetotal morbidity after second stage operations.

Atelectasis following thoracoplasty. There wereI3 (3.6 per cent.) cases of atelectasis of the lower

TABLE 3MORBIDITY AFTER SECONDr SiTAGE THORACOPLASTY SUFFICIENT To

CAUSE DELAY OF THIRD STAGE

Delay wtoeeks 4 wreeks 4 weeks + IndefiniteA. N.A. A. N.A. A. N.A. A. N.A.

Pyrexia .. ..Sepsis .. .. JPoor general condition iHaematoma l

(Basal)

TABLE 4

MORBIDITY AFTER SECOND STAGE OPERATIONS

rA4il re-aerated butAtelectasis of lower lobe .. 5 apicolysis moist sounds still

I non-apicolysis Lpersist.Post-operative shock IHaemothorax IHaematom.. .. ...INephritis. .... ISuperficial wourd sepsis .. 3Contralateral exacerbatiors .. I three months after, small.

I two months after a contralateraA.P. small.

1 due to haemoptysis, snall.Extra fascial space infections 4

lobe following thoracoplasty in this series and 21(5.5 per cent.) in the series done under local anal-gesia. Seven (4.4 per cent.) of the cases undergeneral anaesthesia followed first stage operationsand 6 (4.0 per cent.) occurred after second stages.Following local analgesia 9 (5.9 per cent.) occurredafter upper stages and I2 after second stages. Thenumber of secoDd stages in the latter series is notknown as the figure given (I72) combines secondand third stage operations.

This present series and that with which it iscompared are not large in numbers but they arecomparable, in that similar operations were per-formed under conditions which were not dis-similar.These results would seem to indicate fairly

clearly that light general anaesthesia with d-tubocurarine chloride is as safe as local analgesiafor thoracoplasty operations. It-is certainly morepleasant for the patient and the surgeon, and lesstime consuming for the anaesthetist.

Results following lung resection. The details ofthe lung resections which have been performed inthe years 1946-1947 at the Liverpool ChestSurgical Centre under this form of anaesthesia areshown in Table 5.

Following these i I6 operations there have beenfive deaths within four months giving a casemortality of 4.3 per cent.

TABLE s

LUNG RESECTIONS 1946 - 1947

Lobectomy: Bronchiectasis .. 82Carcinoma ..Cyst of lung 2Abscess .. . ITuberculosis . 3Adenoma .. I

92

Pneitmonectonij: Bronchiectasls 1 3Carcinoma .. IoAdenoma ..

24

(I) Pulmonary oedema. This man aged forty-three was in poor condition before hisoperation and died 29 hours after adifficult pneumonectomy for carcinoma.



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526 POST GRADUATE MEDICAL JOURNAL October I948Shortly after his operation he showed signsof oedema of the remaining lung aid hiscondition gradually deteriorated. A sub-sequent section of the removed lung re-vealed that he had tubercle in addition tocarcinoma.

(2) Cerebral catastrophe. This patient agedsixty-five years, died following pneumonec-tomy for carcinoma. His condition waspoor at the end of the operation which wasdifficult and prolonged. The next day hewas found to have hemiplegia and, he col-lapsed suddenly and died on the evening ofthe second day after operation. There wasno post-mortem.

(3) Surgical emphysema which developed24 hours after a pneumonectomy forbronchiectasis. The chest, arms, neckand possibly the mediastinum were involvedand despite the repeated aspiration of airfrom his chest his condition graduallydeteriorated. Permission was not grantedfor a post-mortem examination.

(4) Caseous tuberculous pneumonitis in associa-tion with renal and cardiac failure. Thisman aged forty-nine years, had undergonea left upper lobectomy for a lesion con-sidered to be a tuberculoma, however, hehad much more extensive disease than hadbeen thought and after his operation hedeveloped tuberculous pneumonitis of thelower lobe and later an acute form of neph-ritis and cardiac failure. He died fourmonths after operation.

(5) Anoxia due to a sudden intra-bronchialhaemorrhage and spill-over of thick tenac-ious sputum. This patient suffered fromrecurrent haemoptyses and had a chronicabscess of the right lower lobe. During theearly manipulation and freeing of the lobehaemorrhage into the bronchus occurredand a great deal of tenacious secretion spiltover into the bronchial tree. Despiteimmediate bronchoscopy and suction thepatient succumbed. The use of a suitableand reliable bronchial occluder would prob-ably have avoided this accident. A pre-operative bronchoscopy, however, was notperformed and it seems likely that theoperation was not carried out in the headdown position.

Owing to the many factors involved it is difficultto obtain a reliable assessment of the results follow-ing lung resection and figures for comparison arenot easy to find. It Is hoped that such an analysistogether with the results which have been obtainedin other types of thoracic procedures (Table 6)will be the subject of a later communication.

TABLE 6

OTHER OPERATIONS PERFORMED AT THE LIVERPOOL CHEST SURGICALCENTRE, I946-I947

Oesophagectomy 5Oesophago-gastrectomy.................5Thoracotomy ...................... 75Decortication ..................... g9Pericardectomy. ............. .. ...5Patent ductus 3........ .............3Splanchnicectomy ... ......Z9Laparotomy ......7For lung abscess............. ....28Intrathoracic goitre 3........3Minor operations.... ...... 328

497

SummaryThe methods of controlled respiration are

reviewed and the role of d-tubocurarine chloridein thoracic surgery is discussed. The preparationand anaesthetization of patients for various thoracicprocedures is detailed and the results following363 thoracoplasties discussed in detail togetherwith the operative mortality- in i I6 lung re-sections.

I am most grateful to Mr. H. Morriston Davies,F.R.C.S., for his unfailing help and encourage-ment and to Mr. F. Ronald Edwards, F.R.C.S.,for much advice and assistance with this paperand for the detailed results following thoracoplasty.The skill and originality of my colleague anaes-

thetists at the Liverpool Chest Surgical Centre,Dr. John Halton and Dr. Joseph E. Esplen, andtheir permission to include cases anaesthetized bythem have ma5e this paper worthwhile.

Lastly I owe a special word of gratitude to MissE. S. N. Fenton, my registrar, for statistical re-search.

BIBLIOGRAPHYBEECHER, H. K. (1940), J. of Thoracic Surgery, IO, 202.BURKE, J. C., LINEGAR, C. R., FRANK, M. N., McINTYRE,

A. R. (1948), Anesthesiology, 9, 251.CRAFOORD, C. (1938), On the Technique ofPneumonectomy in Man.

Stockholm. 6I. Tryckeri Aktiebol4get Thule also Asta Chirurg.Scand. 54. (Supplement).

CULLEN, S. C. (1944), Anesthesiology, S, x66.DRIPPS, R. D. (1947), Anesthesiology, 8, x5.EVANS, Frankis (i944), Lancet, I, is.GORDH, T. (I945), Anesthesiology, 6, 258.GRAY, T. C. and EDWARDS, F. R. E. (I948), Thorax. In the press.GRAY, T. C. and HALTON, J. (I946), B.M.J., 2, 293.GRAY, T. C. and HALTON, J. (I948), B.M.J., I, 784.GRAY, T. C. (1948), Proc. Roy. Soc. of Med., 41, 559.GUEDEL, A. E. (I937), 'Inhalation Anaesthesia.' Macmillan.

New York, p. 6i.HALTON, J. (I943), Lancet, I, 12.HEWER, C. Langton (I948), Annals of the Roy. Coll. of Surgeons,

2, 314-HUMPHRIES, G. H., MOORE, R. L., MAIER, H. C. and

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