SURGERY OF THE LUNG Since the World War the surgery of the lung has made great strides, and in all countries is engaging the attention of active workers. While differential pressure anaesthesia of some kind is still advisable, the introduction of intra-tracheal insufflation has enabled the elaborate and costly pressure chambers to be dis pensed with. For many types of operation ordinary inhalation anaesthesia, especially by nitrous oxide and oxygen, suffices. Local infiltration anaesthesia, combined with nerve blocking by novo cain or some similar drug, is largely used, and for some operations is essential. It is being combined with light analgesia by nitrous oxide and oxygen, or even ether by some surgeons in the case of nervous patients, for whom deep general anaesthesia is inadvis able (see ANAESTHESIA AND ANAESTHETICS).
Surgical Treatment of Pulmonary Tuberculosis.—Direct operations on the tuberculous lung, either by drainage of tuber culous cavities or the resection of one or more lobes of the lung, have been abandoned by the majority of thoracic surgeons. The great advance in latter years has been in devising methods of collapsing the affected lung either temporarily or permanently.
In all other parts of the body it is found that rest of the affected part is beneficial, but in the case of the lung the respiratory movements, exaggerated by coughing, continue unless the lung is compressed. By collapse, stasis in the lymphatic vessels occurs, preventing spread of tuber cle bacilli to other parts of the lung and diminishing the entrance of toxins into the general circulation with consequent improvement of the general resistance of the body. Congestion of the collapsed lung with blood appears to occur, favouring the formation of fibrous tissue and healing of the lesions. Mechanically, the effect is to allow the retraction of the new formed fibrous tissue and to collapse cavities and dilated bronchi. This prevents the retention of secretions, which often become secondarily infected with other organisms, and allows the walls of the cavities to come in contact and so to heal. This retraction occurs normally to a limited extent by the pulling up of the diaphragm, the pulling over of the medias tinum, and the assumption of the expiratory position by the ribs, but falls far short of that necessary for complete obliteration of the cavities.
Artificial pneumothorax was first proposed by James Carson, of Liverpool, in 1821, but was introduced into practice by Forlanini, of Pavia, in 1882 (Ganz. d. Osp., 1882). It is now extensively practised by physicians all over the world. By the introduction of air, oxygen or nitrogen through a hollow needle into the pleural cavity the lung may be more completely collapsed than by any other method. As this method is simple and satisfactory it is the method of choice, and other operations are only undertaken when this is impossible, through the presence of adhesions binding the two layers of the pleura together (see PNEUMOTHORAX).
Where the adhesions are few and bandlike, so that a partial collapse only can be obtained, it is necessary to divide them. The operation of thoracotomy and division of the bands by direct vision is unnecessarily severe. Jacobaeus, of Stockholm, in 1913 devised an instrument similar to a cystoscope, which he calls a thoracoscope. After the induction of a pneumothorax this is introduced under novocain anaesthesia through a canula. Through a smaller canula a galvanocautery is introduced. Thus the adhesions may be burnt through under the vision of the operator without opening the chest cavity (H. C. Jacobaeus, Proc. Roy. Soc. Med., 1922-23, V01.16, p. 45). By using the cautery at a red heat only, haemorrhage is avoided. The adhesions often pull out a cone of lung substance in which may be a prolongation of a lung cavity, so that it is important to burn the adhesions through as near the chest wall as possible.
Stuertz first proposed this operation by division of the phrenic nerve in the neck, which was independently devised by Sauerbruch. The result of depriving the diaphragm on one side of its motor innervation is that it rises in the thorax as much as 21 to 3in., thus allowing the lower lobe partially to collapse and putting it at rest. The operation is easily done in a few minutes under local anaesthesia by novocain, the nerve being found running obliquely across the scalenus anticus muscle in the neck. At first the nerve was simply divided, but it was found that accessory fibres joined it below the point of section in 20-30% of individuals. W. Felix's operation of "Exairesis" (Deutsch. Ztsch. f. Chir., No. 171, p. 283, 1922) has gained favour. In this modification the lower end of the divided nerve is seized in forceps and gradually drawn out of the thorax. Sometimes the whole length of the nerve as far as the diaphragm is successfully extracted, but in any case the collaterals which join it in its upper part are also severed so that the paralysis is com plete. The operation is used where basal adhesions are preventing full collapse in pneumothorax, as an addition to thoracoplasty, in some cases of early tuberculosis of the lower lobe only and for the relief of pain in the region of the diaphragm on coughing.
The operation consists in sep arating the parietal layer of the pleura from the chest wall over a limited area and filling the space thus formed with some material which is not absorbed, thereby compressing the lung beneath. A portion of one rib is resected and the posterior periosteum and endothoracic fascia are carefully incised. The gloved finger then separates the outer surface of the parietal pleura from the inner surface of the endothoracic fascia. As the air which enters the cavity thus formed is rapidly absorbed it is necessary to provide some filling. Tuffier, in 1910, first used fat obtained from omen tum or a lipoma. This has become one of the favourite methods, the fat being obtained from the patient's thigh (Tuffier, Bull, et. mem. Soc. de Chir. de Paris, vol. 49, 1249, 1923). If a very careful aseptic technique is not followed the fat may be extruded. Owing to the difficulty of obtaining enough fat, Baer, in 1913, used a paraffin filling (H. Baer, Munch. med. Wochenschr., vol. 68, 1921) . This is readily available but is heavy, and tends to be extruded later in many cases. E. W. Archibald, of Montreal (Am. Rev. of Tuberc., vol. 4, p. 828, 1921), has used a pedicled muscle graft obtained by detaching the pectoral muscle.
The operation is almost confined to apical lesions and is used either alone, or following thoracoplasty, in cases where the apex of the lung is incompletely collapsed. It may also be of service where the apex alone is adherent and a satisfactory pneumothorax has collapsed the lower part of the lung.
Collapsing operations on the chest wall were suggested as long ago as 1888 (Quincke) and 1890 (Spengler). In 1907 Brauer and Friedreich removed large portions of the ribs in their lateral portions. Wilms, in 1911, removed portions both posteriorly and anteriorly. The modern operation of paravertebral thoracoplasty is due to Sauerbruch and the Scandinavians : Bull, of Oslo ; Saugman, of Veilefiord; Jacobaeus and Key, of Stockholm. The operation may be done in one, two or more stages and consists essentially in resetting a portion of the first to the loth or 11th ribs posteriorly through a long incision posterior to the scapula and turning forwards along the Loth rib. The muscles attached to the scapula are divid ed and the scapula is turned forwards. It is essential that the ribs should be resected as far back as the tips of the transverse processes of the vertebrae. The length of rib removed varies from fin. of the first rib to 7 or Bin. of the middle and lower ones. The operation is a severe one, but the mortality, which was at first about 8%, has been reduced by proper selection of cases to about 2% in the hands of experienced operators. Many operators still prefer a local anaesthesia by novocain, but the tendency now, except in cases with profuse sputum, is to operate under general anaesthesia by nitrous oxide and oxygen preceded by an injection of morphine and hyoscine. The results of these operations have shown that in cases of unilateral or mainly unilateral pulmonary tuberculosis which are not improving under sanatorium treat ment a new field of hope is opening out. F. Sauerbruch (Chir. der Brustorgane, 192o), H. C. Jacobaeus and E. Key (Acta. Chir. Scand., 1923) ; P. Bull (Proc. Roy. Soc. Med., 1924, vol. 17, p. I) ; J. Alexander (Surg. of Pulmon. Tub., 1925); J. Gravesen (Surg. Treat. of Pulmon. and Pleur. Tub., 1925).
Three types of operation are used in the treatment of this distressing condition :
Drainage operations, (2) operations to collapse the lungs, (3) radical excision of the affected part of the lung. (I) Drainage operations are palliative only and aim either at drainage of abscess cavities or, by making a permanent bronchial fistula, at reducing the amount of sputum. (2) All the forms of collapsing operations which are in use for pulmonary tuberculosis have their place in the treatment of bronchiectasis. They are phrenicotomy, pneumothorax, extra pleural pneumolysis and extrapleural thoracoplasty. The principles involved are, firstly, that the spaces in which secretions collect and decompose are obliterated by the collapse of the lung, and secondly that the new formed fibrous tissue in its contraction no longer pulls open the walls of the bronchi softened by inflam mation, but can now pull inward the mobilised walls of the thorax. (3) In certain types of bronchiectasis the results of col lapsing operations are not satisfactory, and in consequence ampu tation of the affected lobe or lobes of the lung has been performed. This procedure has produced real cures but the mortality of the operation is high. The longest series of cases is that published by H. Lilienthal, of New York (Arch. of Surg., vol. 8, 1924), whose mortality is nearly 5o%. Many of his patients were, how ever, desperately ill. Evarts A. Graham (Arch. of Surg., vol. Io, p. 392, 1925) has practised pneumectomy by the actual cautery, in one or several stages, on 20 patients. Of these, 5o% were cured, 3o% improved and 2o% died.
Innocent intrathoracic tumours are being diagnosed with greater frequency owing to the increas ing use of X-rays. H. C. Jacobaeus and E. Key (Acta Chir. Scand., vol. 53, p. 575, 1921) have successfully removed four fibromata by the transpleural route. T. P. Dunhill (Br. Jour. of Slug., 19 2 2) removed a fibroma by Gask's modified sternum split ting operation. J. E. H. Roberts (Tr. Roy. Soc. Med., 1926) has removed f our innocent tumours, two fibromas, an encapsuled endothelioma and a dermoid cyst, three by the transpleural route and one by sternum splitting.
Radical operations for the removal of carcinomata of the lung are rarely possible owing to the later stage at which patients come under observation. F. Sauerbruch (Chir. der Brustorgane) has operated in five cases: One with a carcinoma of the lower lobe the size of a small fist, was alive five years later ; another was alive after three years. Sauerbruch advises a two-stage operation or three-stage operation, ligature of the branch of the pulmonary artery to the affected lobe being done as a preliminary followed by thoracoplasty and resec tion of lung.
Palliative operations often give great relief from distressing symptoms and prolong life for many months ; they are (I) drain age of a secondary lung abscess or empyema, (2) drainage of a sterile abscess due to necrosis of growth, (3) exposure of the growth for the insertion of radium, (4) treatment by X-rays.
BIBLIOGRAPHY.-F. Sauerbruch's monumental work, Chirurgie der Bibliography.-F. Sauerbruch's monumental work, Chirurgie der Brustorgane (192o and 1925) ; L. Guibal, Traitemeni chirurgical de la dilatation bronchique (1924) ; D. S. Allen, "Intracardiac Surgery," Arch. Surg., vol. viii., 317-25 (Jan. 1924) ; J. Alexander, Surgery of Pulmonary Tuberculosis (1925) ; J. Gravesen, Surgical Treatment of Pulmonary and Pleural Tuberculosis (1925) ; D. S. Maguire, "Success ful Cardiorrhaphy," Surg., Gynec. & Obst., 4o, 623-5 (May, 1925) ; C. S. Beck and R. L. Moore, "Significance of Pericardium in Relation to Surgery of the Heart," Arch. Surg., 11. 550-77 (Oct., 1925) ; J. H. Long, "Cardiorrhaphy," Boston, M. and S. J. (Dec. 24, 1925) ; H. Lilienthal, Thoracic Surgery (1925) . (J. E. H. R.)
