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Toracoplastia bilateral
February I938
TUBERCLE
notes on the skin the position at w h i c h the puncture should be made and the direction to bc taken by the needle. A spinal needle is used for anaesthetlzlng skin and underlying tissues, and when the needle is felt to have entered the cavity, the syringe isremoved, the trocar replaced, and the patient again fluoroscoped to make sure that the point of the needle has entered the cavity. When this has been verified, -', c.c. of colloidal copper morrhuate are injected through the needle, subsequent injections being from Io to .'2o c.c., the increase depending on whether the preceding dose was well tolerated. Immediately after the injection the patient is placed in the headelevated position on the fluoroscope table and kept there for ten minutes. In only one case was there any notable reaction--increased temperature, cough, and expectoration over a period of four d a y s - - b u t fluoroscopically no alteration in the pathology was noted. The writers give two illustrative case reports, pointing out in conclusion that although the technique is not difficult, the method does require expert fluoroscopic guidance.
A REVIEW O F ~oo C O N S E C U T I V E T I I O R A C O P L A S T I I g S . By R. G. URQUIIART. Amer. Rev. Tuberc., t937, xxxv. 443. T h e w r i t e r stresses the importance of transferring prospective thoracoplastic cases to a surgical ward for a preliminary period of observation. The general condition ofthe patient should be the first consideration, pcrslstently raised temperature and pulse being looked on as warning signs, putting the surgeon on his guard. Blood, serological, and repeated X-ray examinations are also necessary. With regard to age, the best results are obtalncd between the ages of _'20 and 4 0 ; in children under zo or x5 the operation should be performed only under exceptional circumstances. The most important pre-operative requislte in the writer's opinion is a fixed mediastinum, Which actually means a stiffening of the mediastinal pleura. The most constant indication of this is the displacement of the trachea towards tim cffccted side as sccn by X-rays. Reinoval of the ribs in the absence of a fixed mediastinum is fiequcntly attcndcd by paradoxical movement of the underlying lung, which results in mediastlnal flutter. Chronicity of the disease as a guide to the choice of cases for thoracoplasty should be determined more by the appearance of fibrosis than by the actual length of history. T h e 2oo cases reported in this series are divided into thrce groups, as advocated by
230"
Archibald : (1) favourable, uncomplicated and good chronic cases ; (2) doubtful or conditionally favourable cases; and (3) definitely unfavourable cases. O f 115 in group I, 87 are apparently arrested, z9 improved, 4 not improved ; 5 dead. Group _'2, with 54 cases, gives -"4, 2o, ~, and 6 respectively. Group 3, with 3 I cases, shows 8.9, o, and t 4 respectively. T h a t is, ofthe total ~oo cases, 59"5 per cent are apparently arrested ; 24 per cent improved ; 4 per cent not i m p r o v e d ; I.'2"5 per cent dead. For the past four years it has been the writer's practice to fit the patient with a two-lnch thick sponge-rubber jacket, held in place by a snugly-fittlng binder with shoulder-straps. In addition, sandbags up to 15 pounds are used for tim first three months, after which the patient is allowed up, but continues to wear the jacket for another three months. This jacket is applied after the wound has healed. An analysis of the ~5 deaths accurring in this series brings out the importance of the proper selection of cases, and also demonstrates the difficulty of accurately forecasting the reaction of each patient to thoracoplasty. With regard to partial thoracoplasty, the writer believes that this operation is the most satisfactory that there is for treating apical disease and apical cavities. There were 4t partial thoracoplastles in this series, with the removal of from four to eight ribs.
TORACOPLASTIA BILATERAI. By R. FRANClnETTO. Arch. Arg. I'nferm, Apar. Resp. Tub., I937, v. x. This paper contains a summat T of five cases of bilateral thoracoplasty in patients age d from o0 to 47 respectively, by Alien, Gravesen, Jessen (two cases), and Magri. T h e writer's conclusions are as follows. Bilateral thoracoplasty has been employed in relatively stationary cases, as well as in those relatively progressive. In all the cases pulmonary cavities were present, and without operation no improvement, much less recovery could have been expected. In all tile cases in which tile operation was performed the active lesions wcre above the level of tile fifth ribs. It was deeidcd to carry out the operation first on the side which was most affected. In one case there was only a short interval of a few weeks between the first and second operation, while in Allen's case and in one of Jesscn's cases, the contralatcral side was not dealt with until the lesions on that side were found to be active. T h e amount of rcscction carried out in bilateral thoracoplasty was the same as if it had been a simple
234
TUBERCLE
unilateral operation. The subsequent course and results of the cases are sufficiently encouraging to warrant the use of bilateral thoracoplasty in desperate cases. THE EFFECT OF Tt IORACOPLASTY AND PHRENIC PARALYSIS ON THE TOTAL V O I ~ U M E O F T H E L U N G A N D ITS C O M P O N E N T P A R T S . By G. E. Lt.~nsno(: and I. FRIEDMAN. Amer. Rev. Tub., 1936 , xxxtv. 5o5 . The writcrs describe in this paper studies that were made on the lung-volumc of ten paticnts with puhnonary tubcrculosis, of whom thrcc werc subjcctcd to thoracoplasty in two or threc stages, and thc rcmalning scvcn to phrcnic cxalrcsis or crushing. Thc technique followed for dctcrmining thc sub-tidal lung volumc was that describcd by Ghristic (Journ. Clin. hwest., 1932, t t. xo99 ). Thc protocols in thc scvcn cases in which phrcnic paralysis was carrlcd out showed in all but one a fall in sub-tidal volumc on the first post-operativc day, the dccrcasc ranging from I~o to -3 ~ c.c., with a mean of t7o. In three of these cases filrthcr determinations made on thc sixth to cighth post-operativc days showcd rcductlons of 155 to 3xo c.c. from thc pre-opcratlon values, the mcan bcing ~ All seven padcnts showed a dccrcasc in vital capacity on thc first post-opcratlvc day, varying from 60 to 77o c.c., with a mcan of 395- In four cascs, detcrminations rcpcatcd a wcck later showcd a return towards the prc-opcrationvalucs averaging xgo c.c. T h c rcduction in vital capacity occurred chicfly at the cxpensc of the complementary and reservc fractions, which together rcprescnt thc volume of air available for unusual respiratory demands. T h c r c appearcd to bc no constant rclatlonship between thc volume dccrcasc in sub-tidal air and vital capacity. An analysis of thc data in thc three cases of gradcd thoracoplasty showed that the maximal reduction in sub-tidal volumc occurred after thc first stagc, which involved rcscction of thc uppcr three or four ribs. O n thc scvcnth or eighth day aftcr the first stage, the obscrvcd dccreascs wcrc all over 5oo c.c., cxcccding by far any diminutions notcd after the lapse of a similar timc-interval following the sccond-stagc operation. In two patients who had third-stagc procedurcs, thc furthcr dccrcascs werc only 50 and t3o c.c., rcspcctivcly. T h e writcrs add that thc rcduclion in lung volume induccd by collapse is probably obscurcd to a varlablc cxtcnt by subscqucnt compcnsatory changes in thc uncollapsed, and particularly in the contralatcral, lung ficld.
February I938
L'APICOLYSE AVEC PLOMIIAGE P A R A F F I N E D A N S LE T R A I T I ' : M E N T DE LA T U B E R C U L O S I ~ P U L M O N A I I C By A. BIDERMANN ~-~ A. AI.IBERT. Rev. M6d. Franc., x937, xvm. 3.o3. The principle on which apicolysls is based is that of all methods of collapse therapy--not that of compressing the lung, but only of freeing it fi'om the thoracic wall so that it may effect a cieatricial retraction. After- discussing the technique usually adopted, the writers set out the possible complications that may be met with. The immediate complications amy include injuries to pleura or lung, which, being the result of force, are avoidable ; extrapleural haemorrhagic or sero-haemorrhagic effusions, which are also exceptional and can be avoided by careful technique ; early suppuration--not that due to defective asepsis, but an aseptic suppuration due to irritation from the mass of paraffin introduced. In the three cases in which the writers met whh this complication, removal of the plombage immediately put an end to it ; the operation wound cicatrized without a fistula. Another possible complication is that of leakage of the paraffin outside the pocket. This occurrence, which is of little importance, may be obviated by avoiding too early movements. The wrhers immobilize the arm for some days for this reason. Late complications include (I) late suppairation, usually aseptic, which can be speedily cured by removal of the plombage ; ('2) elimination of the paraffin through the bronchi. This complication may occur several years after the operation ; its evolution is insidious a n d - - c o n t r a r y to what might be expected--relatively benign. The prognosis depends essentially on the underlying pulmonary lesions. O f o 4 cases operated on between April, I932 and December, i935, ~2 are alive, of whom Ill are working and have negative sputum. T w o are dead, one from an intcrcurrent disease, seven months after the operation, the other fi'om a tuberculous bilateralisation after a period of apparent cure for two years. While the writers do not pit apicolysis against thoracoplasty, they urge that the p r o c e d u r e - - i n view of its simple technique, absence of operative shock and of deaths due to the operation--should not be confined to cases in which thoracoplasty is contraindicated owing to the age of the patient, bad general condition, or the state of the other lung. They believe that in certain well defined cases (cavities exclusively apical) apicolysis can give, with the minimum of risk, results fully as satisfactory as those obtained from thoracoplasty.
TUBERCLE
notes on the skin the position at w h i c h the puncture should be made and the direction to bc taken by the needle. A spinal needle is used for anaesthetlzlng skin and underlying tissues, and when the needle is felt to have entered the cavity, the syringe isremoved, the trocar replaced, and the patient again fluoroscoped to make sure that the point of the needle has entered the cavity. When this has been verified, -', c.c. of colloidal copper morrhuate are injected through the needle, subsequent injections being from Io to .'2o c.c., the increase depending on whether the preceding dose was well tolerated. Immediately after the injection the patient is placed in the headelevated position on the fluoroscope table and kept there for ten minutes. In only one case was there any notable reaction--increased temperature, cough, and expectoration over a period of four d a y s - - b u t fluoroscopically no alteration in the pathology was noted. The writers give two illustrative case reports, pointing out in conclusion that although the technique is not difficult, the method does require expert fluoroscopic guidance.
A REVIEW O F ~oo C O N S E C U T I V E T I I O R A C O P L A S T I I g S . By R. G. URQUIIART. Amer. Rev. Tuberc., t937, xxxv. 443. T h e w r i t e r stresses the importance of transferring prospective thoracoplastic cases to a surgical ward for a preliminary period of observation. The general condition ofthe patient should be the first consideration, pcrslstently raised temperature and pulse being looked on as warning signs, putting the surgeon on his guard. Blood, serological, and repeated X-ray examinations are also necessary. With regard to age, the best results are obtalncd between the ages of _'20 and 4 0 ; in children under zo or x5 the operation should be performed only under exceptional circumstances. The most important pre-operative requislte in the writer's opinion is a fixed mediastinum, Which actually means a stiffening of the mediastinal pleura. The most constant indication of this is the displacement of the trachea towards tim cffccted side as sccn by X-rays. Reinoval of the ribs in the absence of a fixed mediastinum is fiequcntly attcndcd by paradoxical movement of the underlying lung, which results in mediastlnal flutter. Chronicity of the disease as a guide to the choice of cases for thoracoplasty should be determined more by the appearance of fibrosis than by the actual length of history. T h e 2oo cases reported in this series are divided into thrce groups, as advocated by
230"
Archibald : (1) favourable, uncomplicated and good chronic cases ; (2) doubtful or conditionally favourable cases; and (3) definitely unfavourable cases. O f 115 in group I, 87 are apparently arrested, z9 improved, 4 not improved ; 5 dead. Group _'2, with 54 cases, gives -"4, 2o, ~, and 6 respectively. Group 3, with 3 I cases, shows 8.9, o, and t 4 respectively. T h a t is, ofthe total ~oo cases, 59"5 per cent are apparently arrested ; 24 per cent improved ; 4 per cent not i m p r o v e d ; I.'2"5 per cent dead. For the past four years it has been the writer's practice to fit the patient with a two-lnch thick sponge-rubber jacket, held in place by a snugly-fittlng binder with shoulder-straps. In addition, sandbags up to 15 pounds are used for tim first three months, after which the patient is allowed up, but continues to wear the jacket for another three months. This jacket is applied after the wound has healed. An analysis of the ~5 deaths accurring in this series brings out the importance of the proper selection of cases, and also demonstrates the difficulty of accurately forecasting the reaction of each patient to thoracoplasty. With regard to partial thoracoplasty, the writer believes that this operation is the most satisfactory that there is for treating apical disease and apical cavities. There were 4t partial thoracoplastles in this series, with the removal of from four to eight ribs.
TORACOPLASTIA BILATERAI. By R. FRANClnETTO. Arch. Arg. I'nferm, Apar. Resp. Tub., I937, v. x. This paper contains a summat T of five cases of bilateral thoracoplasty in patients age d from o0 to 47 respectively, by Alien, Gravesen, Jessen (two cases), and Magri. T h e writer's conclusions are as follows. Bilateral thoracoplasty has been employed in relatively stationary cases, as well as in those relatively progressive. In all the cases pulmonary cavities were present, and without operation no improvement, much less recovery could have been expected. In all tile cases in which tile operation was performed the active lesions wcre above the level of tile fifth ribs. It was deeidcd to carry out the operation first on the side which was most affected. In one case there was only a short interval of a few weeks between the first and second operation, while in Allen's case and in one of Jesscn's cases, the contralatcral side was not dealt with until the lesions on that side were found to be active. T h e amount of rcscction carried out in bilateral thoracoplasty was the same as if it had been a simple
234
TUBERCLE
unilateral operation. The subsequent course and results of the cases are sufficiently encouraging to warrant the use of bilateral thoracoplasty in desperate cases. THE EFFECT OF Tt IORACOPLASTY AND PHRENIC PARALYSIS ON THE TOTAL V O I ~ U M E O F T H E L U N G A N D ITS C O M P O N E N T P A R T S . By G. E. Lt.~nsno(: and I. FRIEDMAN. Amer. Rev. Tub., 1936 , xxxtv. 5o5 . The writcrs describe in this paper studies that were made on the lung-volumc of ten paticnts with puhnonary tubcrculosis, of whom thrcc werc subjcctcd to thoracoplasty in two or threc stages, and thc rcmalning scvcn to phrcnic cxalrcsis or crushing. Thc technique followed for dctcrmining thc sub-tidal lung volumc was that describcd by Ghristic (Journ. Clin. hwest., 1932, t t. xo99 ). Thc protocols in thc scvcn cases in which phrcnic paralysis was carrlcd out showed in all but one a fall in sub-tidal volumc on the first post-operativc day, the dccrcasc ranging from I~o to -3 ~ c.c., with a mean of t7o. In three of these cases filrthcr determinations made on thc sixth to cighth post-operativc days showcd rcductlons of 155 to 3xo c.c. from thc pre-opcratlon values, the mcan bcing ~ All seven padcnts showed a dccrcasc in vital capacity on thc first post-opcratlvc day, varying from 60 to 77o c.c., with a mcan of 395- In four cascs, detcrminations rcpcatcd a wcck later showcd a return towards the prc-opcrationvalucs averaging xgo c.c. T h c rcduction in vital capacity occurred chicfly at the cxpensc of the complementary and reservc fractions, which together rcprescnt thc volume of air available for unusual respiratory demands. T h c r c appearcd to bc no constant rclatlonship between thc volume dccrcasc in sub-tidal air and vital capacity. An analysis of thc data in thc three cases of gradcd thoracoplasty showed that the maximal reduction in sub-tidal volumc occurred after thc first stagc, which involved rcscction of thc uppcr three or four ribs. O n thc scvcnth or eighth day aftcr the first stage, the obscrvcd dccreascs wcrc all over 5oo c.c., cxcccding by far any diminutions notcd after the lapse of a similar timc-interval following the sccond-stagc operation. In two patients who had third-stagc procedurcs, thc furthcr dccrcascs werc only 50 and t3o c.c., rcspcctivcly. T h e writcrs add that thc rcduclion in lung volume induccd by collapse is probably obscurcd to a varlablc cxtcnt by subscqucnt compcnsatory changes in thc uncollapsed, and particularly in the contralatcral, lung ficld.
February I938
L'APICOLYSE AVEC PLOMIIAGE P A R A F F I N E D A N S LE T R A I T I ' : M E N T DE LA T U B E R C U L O S I ~ P U L M O N A I I C By A. BIDERMANN ~-~ A. AI.IBERT. Rev. M6d. Franc., x937, xvm. 3.o3. The principle on which apicolysls is based is that of all methods of collapse therapy--not that of compressing the lung, but only of freeing it fi'om the thoracic wall so that it may effect a cieatricial retraction. After- discussing the technique usually adopted, the writers set out the possible complications that may be met with. The immediate complications amy include injuries to pleura or lung, which, being the result of force, are avoidable ; extrapleural haemorrhagic or sero-haemorrhagic effusions, which are also exceptional and can be avoided by careful technique ; early suppuration--not that due to defective asepsis, but an aseptic suppuration due to irritation from the mass of paraffin introduced. In the three cases in which the writers met whh this complication, removal of the plombage immediately put an end to it ; the operation wound cicatrized without a fistula. Another possible complication is that of leakage of the paraffin outside the pocket. This occurrence, which is of little importance, may be obviated by avoiding too early movements. The wrhers immobilize the arm for some days for this reason. Late complications include (I) late suppairation, usually aseptic, which can be speedily cured by removal of the plombage ; ('2) elimination of the paraffin through the bronchi. This complication may occur several years after the operation ; its evolution is insidious a n d - - c o n t r a r y to what might be expected--relatively benign. The prognosis depends essentially on the underlying pulmonary lesions. O f o 4 cases operated on between April, I932 and December, i935, ~2 are alive, of whom Ill are working and have negative sputum. T w o are dead, one from an intcrcurrent disease, seven months after the operation, the other fi'om a tuberculous bilateralisation after a period of apparent cure for two years. While the writers do not pit apicolysis against thoracoplasty, they urge that the p r o c e d u r e - - i n view of its simple technique, absence of operative shock and of deaths due to the operation--should not be confined to cases in which thoracoplasty is contraindicated owing to the age of the patient, bad general condition, or the state of the other lung. They believe that in certain well defined cases (cavities exclusively apical) apicolysis can give, with the minimum of risk, results fully as satisfactory as those obtained from thoracoplasty.