The principles and practice of modern surgery

by Roswell Park

This procedure may be modified to suit the indications of any given case, and simply includes what may be done in extreme cases. The surgeon who thus for the first time uncovers such a cavity will be surprised at its interior appearance, and at the shreds of tissue and debris which hang from its walls. The measure thus described provides for collapse of the chest wall. Fowler and others have shown, however, that even now the principal obstacle to expansion of the lung is not removed, and have suggested what Fowler has aptly described as decortication of the lung—namely, a removal of its thickened pleura by a process of dissection and stripping, which may be made partial or complete, as circumstances permit. In some respects this adds to the gravity of the case and will perhaps better be done at a second operation. Should it, however, be justified by the condition of the patient it is best done in connection with the resection of the chest wall.

When decortication cannot be practised Fowler has advised that a series of incisions be made, and that by thus gridironing the thickened membrane it may be weakened or caused to lose its inelasticity and thus a mild degree of similar effect secured. [Fig. 521] illustrates the end result of such an extensive thoracoplasty.

Fig. 521

End result of an extensive thoracoplasty. (Park.)

Pneumotomy.

—This is a term applied to an attack upon the lung itself, it having been exposed by a thoracotomy. It is necessary in cases of gangrene, abscess, hydatid cyst, and occasionally in large bronchiectatic cavities. It is not ordinarily a difficult procedure when the lung has attached itself to the chest wall in the course of the disease process. Here the lesion having been located a part of one or more ribs is removed, as may be needed, thus exposing the lung surface, the cavity is then opened either with a knife or by dilatation with the blades of a forceps, or preferably with the thermocautery blade, by which hemorrhage is better controlled and possibilities of absorption reduced. If such a cavity can be located it may be opened with a large trocar and cannula, which should be introduced with great care, lest it be thrust too far, the method by incision being therefore preferable. If after opening the chest the lung be found non-adherent, it depends on the character of the lesion whether adhesion should be provoked or the cavity itself attacked. In the former case adhesions may be produced by stitching the exposed lung surface to the margins of the wound, and waiting for sufficient exudate to be poured out to ensure that the pleural cavity has been hermetically sealed. The same result may be obtained more crudely by packing gauze around the opening.

In case of urgency it would probably be best to attach the lung to the chest wall with sutures and secure it there. This is a comparatively safe method in dealing with hydatid cysts, and will give a fair measure of success in many other instances. The suppurating or gangrenous cavity being opened its contents should be removed, dead or sloughing tissue excised, and the cavity then packed for drainage purposes, the external wound being kept open until it can be safely allowed to close.

Pneumonectomy, that is, removal of a portion of the lung substance, may be done with comparative safety upon animals, but rarely upon human patients. It is occasionally required in connection with the removal of malignant tumors of the chest wall, to which the lung has affixed itself. In exceedingly rare instances it may be justified for localized tumors of the lung itself. It would be equally valuable for circumscribed, primary tuberculosis of the lung, were it possible to recognize this in time. This an Italian surgeon once thought that he had done, in the case of his fiancée, and proceeded to resect the upper lobe of one of her lungs. His lack of success quickly led to his own suicide a few days later.

The lung is exceedingly vascular and at the same time bears sutures well. The suturing, however, should be accurate in order to prevent secondary hemorrhage and favor the process of repair.