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"HEART AND LUNG SURGERY. - In recent years notable advances have been made in the surgery of the heart and lung.

I. HE:1RT.-It has been proved experimentally and verified by actual experience of operations in man that the heart may be safely handled, incised, and sutured; and cardiac surgery, thought to be impossible 30 years ago, had by 1921 achieved many striking successes. Operation on the pericardium and heart is undertaken (1) for the relief of pericardial effusion, serous, purulent or haemorrhagic; (2) for releasing pericardial adhesions; (3) for injuries and the removal of foreign bodies; (4) for the reanimation of a heart which has ceased to beat. (5) It has been proposed and attempted for the relief of certain valvular lesions, and for (6) tumours of the heart.

Pericardial effusion

When it is decided to evacuate the contents of the pericardium it should be exposed and a sufficient incision made in it; paracentesis of the pericardium is uncertain and dangerous; as an operation it should be abandoned, though the cautious use of an exploring needle fOr diagnostic purposes may occasionally be desirable. Especially when the effusion is purulent every endeavour should be made to avoid opening a healthy pleura. The extent to which the pericardium is overlapped by the pleura varies considerably, but, according to Voinitch, there is invariably a triangular area of safety at the inner end of the 6th and 7th left costal cartilages. Pericardial effusion by no means always displaces the reflection of the pleura, but the surgeon can generally recognize the pleura and push it aside.

The lower the opening in the pericardium the better the drainage. Mintz (Zentralblatt far Clair., 1904, p. 59) opened the pericardium in a case of suppurative pericarditis after resecting the 5th costal cartilage, and at once decided to drain it from below. He made an incision along the lower border of the 7th cartilage, separated the attachments of the abdominal muscles and of the diaphragm and continued blunt dissection until he reached the pericardium, which he then incised on a probe introduced through the upper wound. In the operation he subsequently advised the patient is placed with the chest somewhat raised; the surgeon, standing on the right, makes an incision along the lower border of the left 7th costal cartilage extending 7 or 8 cm. outwards from the costo-ziphoid angle. The abdominal muscles are disinserted and the cartilage divided at each end of the wound, the diaphragm is next disinserted and the cartilage and skin retracted upwards. The prolongation of the internal mammary artery is seen and tied or displaced. The anterior inferior angle of the pleura is identified and avoided, and, nearer the median line, the pericardium is defined and incised.

In the operation recommended by Voinitch the left 6th and 7th cartilages and the adjoining edge of the sternum are resected.

Delorme and Mignon (Rev. de Chi., 1895) give the following directions for opening the pericardium: - (1) 1?Iake a vertical incision i cm. external to the left border of the sternum from the lower border of the 7th to the upper border of the 4th costal cartilage. (2) Dissect off soft parts from ribs and cartilages for i cm. towards middle line and for two fingers breadth outwards. (3) Disarticulate and resect a piece of 5th and of 6th cartilage. (4) Carry the incision through intercostal muscles and perichondrium down to triangularis sterni. (5) With a director worked parallel to posterior surface of sternum detach insertions of triangularis sterni, introduce finger and completely detach soft parts from posterior surface of sternum, seek the pericardium just above the insertion of the cartilages into the sternum and separate it with the finger from the cellular tissue which covers it, then, when its opaque surface is clearly exposed and its transverse fibres recognized, continue the separation through the whole extent of the wound. Thus the pleura and the internal mammary artery are displaced outwards and are not seen. (6) Pick up the pericardium with forceps and incise it. These methods or some modification of them are those recommended for the surgical treatment of pericardial effusion, but they are not suitable as the first stage of operation on the heart itself.

Cardiolysis

Intra-pericardial separation of adhesions (endopericardial cardiolysis) has been suggested, but its possible utility is not apparent. Extra-pericardial cardiolysis in which adhesions between the pericardium and the mediastinal tissues are separated is more likely to be useful. It has been proposed to introduce a graft of fat or of fascia lata to prevent fresh adhesions.

Pericardial thoracolysis, in which adhesions between the pericardium and the chest wall are separated and portions of ribs or costal cartilages excised, is an operation designed to free the heart from the rigid chest wall in front and to relieve an enlarging heart from compression in a too confined space. Good results have been obtained. The first operations of this kind were done in 1902 by Peterson and Simon at the suggestion of Brauer. Thorburn of Manchester (Brit. Med. Journ., 1910, vol. i., p. 10) discusses the question and gives a table of 15 cases collected from literature. He relates one case done by himself and refers to two other operations by Stabb at the suggestion of Alexr. Morrison.

Heart Wounds

The course and symptoms of heart wounds vary considerably. Instantaneous death may result from a quite small wound, and extensive injuries may be brought for treatment. Under war conditions most cases die on the field of battle with the symptoms so long ago described by Celsus (V. 26.8.):" When the heart is wounded much blood is poured out, the pulse fails, pallor becomes extreme, the body is bedewed with cold and ill-smelling sweat, the extremities become chilled and speedy death ensues."When seen the diagnosis may be obvious, or difficult and uncertain. The symptoms may be severe and the injury to the heart nil; thus Tuffier remarks," the case in which the diagnosis of wound of the heart seemed to us the most obvious and the most clearly demonstrated by the situation of the wound and the grave condition of the patient was that of a woman in whom the revolver bullet had not even penetrated the thorax."This was probably an instance of contusion of the heart and analogous to the phenomenon of arterial paralysis. When the initial symptoms have subsided and the external haemorrhage has ceased the diagnosis is based upon the history of the case, the situation of the external wound and the signs of haemo-pericardium or haemothorax, or of a foreign body.

The classical signs of pericardial effusion are: the cardiac impulse and sounds are feeble or imperceptible and the area of cardiac dullness is enlarged; sometimes abnormal (pericardial) sounds can be heard, of these that known as the mill-wheel sound (bruit de moulin) has been much discussed; it is chiefly associated with air and fluid in the pericardium and was for a time thought to be pathognomic. It is thus described in a work by Stokes published in 1854:" They were not the rasping sounds of indurated lymph, or the leather creak of Collin, nor those proceeding from pericarditis with valvular murmur, but a mixture of the various attrition murmurs with a large crepitating and gurgling sound, while to all these phenomena was added a distinct metallic character."Sudden distension of the pericardium with blood is a great surgical emergency. The auricles are compressed and signs of venous obstruction appear; there is great dyspnoea with cyanosis. The respiration is laboured and shallow and the pulse small, rapid and of low tension. It is urgent freely to open the pericardium and to decompress the heart.

In purulent pericarditis the upper segments of both recti may be rigid, and there may be a narrow band of oedema round the front and left side of the trunk about the level of the 5th interspace. The present writer has seen this band of oedema and has known suppurative pericarditis to be mistaken for inflammation below the diaphragm. Absence of diaphragmatic movement suggests pus in contact with the diaphragm. In pericarditis with effusion the right lobe of the liver is low; in dilatation of the heart the right lobe of the liver is not depressed. Many observers have found a small area of dullness in the left back just internal to the angle of the scapula, a purulent pericardial effusion has been tapped from the back in mistake for an empyema. The early diagnosis of purulent pericarditis is greatly assisted by X-ray examination and by the bloodcount. These should never be omitted.

Bullets and other foreign bodies may lodge in the pericardium or in the heart muscle or in one of the cavities, in which it may become fixed or remain freely movable. Sometimes few or no symptoms are observed, and their presence is only demonstrated by radiography; sometimes they cause more or less frequent and severe attacks of pain and syncope, and give rise to abnormal sounds. Only by radiography can an accurate diagnosis be made.

The story of the wanderings of bullets and other foreign bodies in the vascular system of man is very remarkable. A bullet may perforate the heart or aorta without causing fatal haemorrhage.

A bullet may enter the hepatic vein or vena cava and pa.os on into the right ventricle, or enter a pulmonary vein and lodge in the left ventricle. Or it may enter the inferior vena cava and be carried by gravity against the blood current and be arrested in an iliac vein, or again a bullet may be expelled from the left ventricle into the aorta and travel with the blood current and be arrested in an artery, or from the right ventricle may be ejected into the pulmonary artery. In several cases during the World War the course of the projectile has been followed by radiography, and removed by operation from the vessel in which it became arrested.

Operations for injury and the removal of foreign bodies

The operation must be so planned that free access to the heart is obtained and that any required operation on it can be carried out. We have to consider (a) the exposure of the heart; ( b) the surgical manipulation of the heart; ( c) the control of haemorrhage; ( d) drainage of the pericardium.

The chief methods of opening the chest for exposure of the heart which have been successfully utilized are as follows: 1. The various forms of flap operation of which the DelormeMignon-Kocher operation may be taken as a type: a vertical incision is made down the middle of the sternum from the level of the 3rd to that of the 5th cartilage; the upper end of the incision is then continued towards the left along the line of the 3rd cartilage and the lower end of the vertical incision is carried downwards and towards the left along the line of the 6th cartilage. The musculocutaneous flap is raised and turned outwards, the 4th, 5th, and 6th cartilages are removed, the internal mammary vessels are tied and divided (which is best done after removal of the 6th cartilage), triangularis sterni is cut through and displaced, the pleural edge being carefully avoided, and the pleura displaced by gauze pressure.

2. The Duval-Barasty operation. This operation opens both thorax and abdomen but does not divide ribs; it gives free exposure of the heart without opening the pleura but demands good vitality in the patient and seems unsuitable for possibly septic cases. It was used in several successful cases by French surgeons in the World War. It is thus carried out: (1) Make a median incision from the level of the 3rd cartilage to the mid-point between xiphoid and umbilicus. (2) Separate the attachments of the muscles to the xiphoid and insinuate two fingers of the left hand behind the sternum, so as to protect the pericardium and the anterior margins of the pleura. (3) Divide the sternum transversely opposite the 3rd cartilage, and below the section split the gladiolus and xiphoid longitudinally. (4) Open the peritoneum along the line of the median incision in the upper abdomen. Open the pericardium in the middle line then divide the diaphragm between the two halves of the xiphoid cartilage, one blade of the scissors being within the pericardium and one in the abdominal cavity. While this cut is being made the heart must be gently lifted out of the way. The diaphragm is divided as far back as the coronary ligament. (5) The halves of the sternum can now be widely separated and" the whole contents of the pericardium are an open book to the surgeon. We have by this operation removed a bullet from the intra-pericardial portion of the vena cava inferior."(Bull. et Mem. de la Soc. de Chi., Paris, June 1918.) (6) At the close of the operation the reconstitution of the divided structures is perfect. The incisions in the diaphragm and pericardium are sutured. The sections of the sternum fall together and do not require suture.

3. The Spangaro operation. Spangaro makes a long incision in an intercostal space, generally the 4th, and then divides or disarticulates the 4th and 5th costal cartilages at their union with the sternum, and in some cases the 3rd and 6th cartilages may also be divided. The 4th and 5th ribs are then forcibly drawn apart by a rib-spreader and a fine view is obtained.

4. The method of Duval as modified by Moynihan." An incision is made exactly in the line of a rib following its curve from the edge of the sternum for about five inches outwards, down to the pectoralis major muscle a pair of forceps is pushed through the muscle until it touches the rib, the blades are opened and the muscle is split, and the separation carried from end to end of the incision. All bleeding vessels are ligated. The rib and costal cartilage are cleared. Two incisions are made through the periosteum close to the upper and lower edges of the rib, and from them the periosteum is stripped upwards and downwards and from the posterior surface. The periosteum which lies between the two incisions is left attached to the rib throughout the operation. As soon as the periosteum is freed from the posterior surface for half an inch the periosteal elevator of Doyen is slipped round the rib and pushed backwards towards the axilla and forwards to and along the costal cartilage until a length of about 5 in. is cleared. Here and there a little help may be needed with the knife or scissors to make the way easy for the instrument. The costal cartilage is now divided by two incisions meeting at a point, this allows the divided ends to dovetail together when the operation is nearing completion. When the cartilage is divided a gauze strip is passed underneath the rib, which is lifted gently upwards and outwards. In young patients the elasticity and suppleness of the rib are remarkable. It is quite easy to raise the bone out of the way throughout the operation and then to replace it.

"When the rib is elevated the periosteum is seen as a thickening of the pleura exposed in the wound. Through periosteum and pleura a small incision is made with the result that in the absence of adhesions air slowly enters the pleural cavity and the lung begins to collapse. The incision in the pleura is then lengthened always along the line of the periosteum, until there is room for the hand to pass through it. The rib-spreader is then introduced" (Sir B. Moynihan, Brit. Journ. of Surgery, vol. vii., 457). At the conclusion of the operation the rib is replaced and fixed by a suture.

5. Tuffier's method. Transverse sterno-thoracotomy. Transverse incision in the 4th intercostal space, prolonged over the sternum to the right side, opening the intercostal space, division of the sternum by Lister's forceps, retraction of the divided sternum to the maximum.

In many cases of injury to the heart the pleura has also been wounded, and in these the Spangaro or Duval operation has the advantage that the pleura and lung can also be examined. The dangers of pneumo-thorax on one side seem to have been exaggerated, and experience has shown that a differential pressure apparatus formerly considered essential is not necessary.

The danger of opening the pleura is not respiratory difficulty but infection. Moynihan lays stress on the patient being deeply anaesthetized before the pleura is opened, and on the opening in the pleura being made small at first so that the lung may slowly collapse.

6. The method of Petit de la Villeon. This operation is carried out under the guidance of the X rays; a small incision is made in an intercostal space and a special forceps thrust through it and pushed on closed until its shadow on the screen touches that of the foreign body; the forceps are then opened, the foreign body grasped, mobilized and pulled out. The method was elaborated by its author for removing foreign bodies from the lung, and has been applied by him to 15 cases of foreign body in the wall of the heart. Manipulation of the heart. - The pericardium having been widely opened the heart may be safely palpated and grasped in the gloved hand; it feels like a live fish, and it may be steadied and drawn forwards and upwards by a fixation suture passed through the apex. The specially dangerous regions of the heart are (1) The coronary arteries between their origin from the aorta and their bifurcation. A wound or ligature in this situation is fatal: the heart becomes arrested in diastole from the failure of its own mitrition. Domenici, from experiments on dogs, concluded that the prognosis is more favourable when both artery and vein are ligatured than when the artery alone is tied ( Policlinico Romana, 1916, p. 155). Sir G. H. Makins made the same observation respecting the femoral artery and vein. A branch of the coronary artery may be tied without ill effects.

(2) The inter-auricular septum and the cardiac ganglia and nerve plexuses which are found chiefly at the base of the right auricle and along the auriculo-ventricular groove. Kr< necker and Schurey (quoted from Tuffier) have described a ganglion centre at the level of the auriculo-ventricular septum near the left border of the heart, a wound of which causes immediate arrest of the heart.

(3) The bundle of His. Carrel and Tuffier say "the starting point of the cardiac contractions is at the opening of the vena cava at the base of the right auricle, the fibres of the auriculo-ventricular bundle of His, which transmit the auricular excitation to the ventricles, traverse the inter-auricular septum, then the inter-ventricular septum and bifurcate and anastomose with the ventricular fibres." A sudden lesion of the bundle of His produces irregularity of contraction and dissociation of function of the two sides of the heart.

A case published by Keith and Miller (Lancet 1906. II. 1429), in which the commencement and upper half of the main auriculoventricular bundle was destroyed by a gumma and the coronary arteries were partially obliterated, shows that the normal mechanism of the heart may be profoundly changed without a great disturbance of function, provided that these changes are not brought about too suddenly. The bundle of His is fully described by Keith and Flack ( Lancet 1906. II. 359).

The control of haemorrhage

Free haemorrhage from a wound in the heart is a great and imposing emergency: the heart, relieved from compression by the incision in the pericardium, contracts tumultuously, the field is obscured by the escaping blood, the bloodpressure is rapidly falling and death is imminent. Rapid, precise, and correct action can alone save life. The surgeon, just as in a case of ruptured spleen or of ruptured tubal gestation he plunges his hand into the abdomen through a mass of blood and seizes the bleeding vessel, so he must now plunge his hand into the pericardium, grasp the heart and by digital compression control the bleeding, and proceed to suture the wound. Suture is the method by which haemorrhage from the heart is permanently controlled, though ligature has been used in a wound of an auricular appendage. The vena cava may be compressed digitally or with suitable forceps as an aid in the arrest of haemorrhage.

When an incision is to be made into an unwounded heart, the sutures should be placed, and the loops drawn out of the way before the incision is made; tightening the sutures arrests the bleeding. In experimental work on the heart the effect of compression of the great vessels has been tried. Carrel and Tuffier found that the entire vascular pedicle could be compressed for 45 seconds, the pulmonary artery for 10 minutes, the aorta for 6 minutes, the two venae cavae for 3z minutes, which could be prolonged to 10 minutes if an oxygenated solution were injected into the carotids; compression of the four pulmonary veins was rapidly fatal, but isolated compression of one pulmonary vein was of no gravity. The times would probably not apply to the human heart; Trendelenburg found that the aorta and pulmonary artery must not be obstructed for more than a minute and a half.

Drainage of the pericardium

In clean wounds this is unnecessary and even harmful; in infective pericarditis efficient drainage is a necessity, but is by no means easy to carry out. As fluid collects in the pericardium it accumulates mainly in the two postero-lateral pouches of the pericardium on each side of the partition formed by the projection of the two venae cavae and the right auricle, and in the dome-shaped space above, the heart is pushed forwards, approaching the chest wall more closely as the tension of the fluid increases, and the pouches formed by the reflexion of the pericardium on to the great vessels become distended. The chief of these recesses is that described by French anatomists as the cul-de-sac of Haller, in English works as the oblique sinus, and by Prof. Keith as the bursa of the left auricle. It is situated behind the left auricle and extends upwards between the right and left pulmonary veins and arteries to the upper border of the left auricle and towards the right as far as the superior vena cava. It is 4 to 5 cm. in depth and behind it is the oesophagus. The lower end is widely open below at the level of the groove on the posterior surface of the heart between the left auricle and ventricle. The right border of the opening is on a lower level than the left and reaches as far downwards as the inferior vena cava. The opening faces downwards, forwards, and to the left.

In a distended pericardium the apex of the heart is carried forwards and the contents of the oblique sinus can escape, but with the emptying of the pericardium the ventricles and apex drop backwards and downwards and shut off the oblique sinus from the rest of the pericardial cavity so that it cannot drain through an anterior incision in the pericardium.

Failure to drain this recess properly was, in the writer's opinion, a cardinal factor in the fatal termination of a case of his own.

A left postero-lateral incision would drain this space, and can be made when the trans-pleural route is adopted. Rubber tissue is the best drainage material. The pericardium differs from the pleura and peritoneum in that it cannot be completely inspected and cleansed even if the apex and ventricles are pulled forward so as to expose the mouth of the oblique sinus, this is a cause of difficulty in deciding for or against drainage.

Reanimation of an arrested heart

An epigastric incision is the quickest route though the trans-costal route has been used. The heart is reached through an incision in the diaphragm, grasped directly near the apex by the thumb and forefinger and the ventricles compressed rhythmically 30-40 times a minute. Some surgeons have massaged the heart from the abdomen without incising the diaphragm.

Speed is an essential factor; massage must be commenced without any delay. The circulation has, indeed, been restored after a considerable interval, but recovery is not possible unless the organs are in a condition to benefit from the influx of blood; the nervous system suffers irreparable damage from cessation of circulation in about 15 minutes. The heart muscle retains its power of contraction a long time; according to Kuliabko (quoted from L. Wrede Arch. f. kl. Chi. Bd. 101 (1913) S. 835) contraction can be induced in the isolated human heart by passing through it a stream of warm oxygenated fluid even 24 hours after death.

Intra-cardiac injection of excitant substances such as strophanthin, adrenalin, and caffeine has been used either alone or in conjunction with massage, as also injection of saline solution or defibrinated blood, either intravenously or into the heart; with a view to rapid restoration of circulation through the coronary arteries injection through the carotid towards the heart has been suggested. Pieri reported 76 cases of heart massage. In 19 success was complete and permanent, in 16 partial and temporary, and in 41 failure was complete. In the successful cases the interval between cessation of the heart's action and the start of massage was from 2 to 15 minutes (Revista Ospedalera, April 15 1913, vol. iii., No. 7).

Wrede, in order to decide whether massage of the heart effected an artificial circulation of the blood and not a mere to and fro movement in which the pressure in veins and arteries was equal, injected colouring matter into the external jugular vein after death and then massaged the heart. He found the colouring matter had penetrated into the vessels of the portal circulation, and this he considered proved that capillary resistance had been overcome, but that it was conceivable that it was in the reverse direction.

Proposed operations for certain valvular lesions

Sir Lauder Brunton (Lancet, 1902), witnessing the autopsy on a young girl who had died from uncomplicated mitral obstruction was led to reflect on the possibility of surgical relief in similar cases, and made experiments bearing on the subject. Carrel and Tuffier pursued the enquiry further ( Presse Medicale mars 1914) and concluded that pure mitral stenosis, certain forms of stenosis of the aortic orifice and of the pulmonary artery, might derive benefit from surgical intervention. Schepelman ( Arch. f. kl. chi., 1912, vol. 97) suggested that congenital tricuspid stenosis might be amenable to operation.

The following operations were experimentally performed by Carrel and Tuffier: - Internal valvulotomy, external valvulotomy, auriculo-ventricular anastomosis, arterio-ventricular anastomosis, section of the mitral valve indirectly through the carotid artery after the manner of an internal urethrotomy, resection of valves. They effected derivation of the blood current by means of a piece of vein with the formation of an artificial valve. An ingenious method which they term "patching" was tried: a square piece of vein is sutured along three sides of its sides over the site of the arterial opening it is desired to enlarge, a small knife is insinuated beneath the patch at the unsewn edge, the vessel beneath incised, and the suture of the patch completed.

The only reference to operations for valvular disease in man which the writer has seen is by Tuffier, who mentions two cases (Fifth Congress of Int. Soc. of Surgery, Brussels, July 1920): - "I observed, in a young man, a grave and rapidly progressive aortic stenosis. On the repeated request of his physician I decided to explore it. The vibration was intense: I reached the stenosis and very easily carried out a gradual dilutation by slowly introducing the little finger into the strictured ring, the vibrations under the finger being intense; I abstained from trying to divide the stricture as I did not consider experimental enquiry sufficiently advanced. I did not expect to attain any result. The patient was well in a few days; he improved temporarily and is still alive. I saw him three months ago." Doyen attempted cardiotomy on a patient believed to be suffering from mitral stenosis; at the operation an inter-ventricular communication was found and the patient died in a few minutes.

Tumours of the heart and paracardiac tumours

A primary tumour of the heart has not yet been diagnosed during life, and the symptoms to which they give rise having been referred to valvular lesions or to angina pectoris, but some forms of benign tumour are anatomically operable. Certain paracardiac tumours, mediastinal dermoids among others, adhere intimately to the pericardium and cause cardiac embarrassment.

Tuffier has successfully operated on one such case. Removal of the 2nd and 3rd costal cartilages disclosed a dermoid cyst as large as two fists filled with sebaceous matter, it was totally adherent and within it the aorta, the auricle and ventricle could be seen beating, and formed part of the wall without the interposition of the pericardium, part of the wall was calcareous and constricted the left half of the vascular pedicle. The cyst was drained, and six months later the calcified portion of its wall was broken up piecemeal. The patient recovered. Clerc and Duval (Bull. et Mem. de la Soc. de Chi. vol. xlvii., 1921, p. 200) published a successful case in which a dermoid cyst was completely removed from the mediastinum; the pleura was closed without drainage. On the second day after operation 500 c.c. of sterile fluid were removed by aspiration, after which there was no further complication.

Literature and statistics

The paper by Fisher in Langenbecks Archiv., vol. ix., (1868) and the article by Matas in Keen's Surgery (1909) give a full account of the subject and its literature as known at the respective dates; by contrasting them the great advance of knowledge will be evident. In Sir Charles Ballance's Bradshaw Lecture, 1919, a table is given of 152 cases of operation on the heart and pericardium subsequent to 1912 (with references) collected from literature; of these 104 recovered and 48 died, showing a mortality of 3 1.57%. In 1920 Tuffier, in a paper at the Fifth Int. Cong. of Surgery at Brussels, referred to 305 cases with a mortality of 49.6 °%. Statistics give some idea of the amount of work that has been done, but so many different conditions are present and the probability that many unsuccessful cases are not recorded is so great, that they are not reliable in estimating the risks of operation. In the Lancet of May 7 1921 a case is quoted from the Journal of the American Med. Assn. of Feb. 19 1921 in which E. M. Freeze successfully sutured a wound of both ventricles.

II. Lungs And Pleurae. - It was until recently believed that opening the pleural cavity without the aid of differential pressure might be fatal, and that incision or even handling of the lung would cause severe haemorrhage; these fears long retarded the progress of intra-thoracic surgery. Experience has shown that an open pneumothorax on one side is without grave danger, that the once-dreaded pulmonary collapse is an assistance rather than otherwise to the surgeon, and that bleeding from the lung is readily arrested by suture. The scope of intra-pleural surgery has been considerably extended, not so much by any new discovery as by the application of the general principles of surgery. Operations on the lung and pleura are now undertaken (a) for injuries, ( b ) for certain diseases. The pleural cavity is opened and the lung exposed by resection of a rib or ribs or by ribspreading with, or sometimes without, division of one or more ribs or cartilages. Osteo-plastic flaps are mostly abandoned.

Injuries

The experience of the World War has shown that the ideal treatment of a wound (gunshot or other) is mechanical cleansing, removal of all foreign bodies and devitalized tissue, and repair by suture. This should be the aim of the surgeon in dealing with wounds of the lung, and the complete operation for this condition would be excision of the parietal wound, removal of all blood and clots from the pleura, exposure of the lung, removal of any foreign body, cleansing and repair of the pulmonary wound and closure of the thorax.

Operation for retained projectiles in the lung is fully described and discussed in a paper by Sir B. Moynihan in the Brit. Journ. of Surgery, April 1920. He recommends the open method of Duval and the separation of all adhesions, however dense, as the first step of the intra-pleural operation. Duval's lung forceps are used for fixing the lung and bringing the area of incision to the surface. The specially dangerous region is the root of the lung "the number of vessels is great and their size formidable. A wound of the root of the lung should be inflicted with extreme caution, for if a vessel is wounded it is exceedingly difficult to arrest the haemorrhage. It is almost impossible to secure the vessel and to ligate it in the ordinary manner. If a suture is passed round the vessel it is likely that other vessels will be wounded by it. For this reason many of the French surgeons advise plugging the wound with gauze, which is left in position for two or three days. The root of the lung is almost immobile. The operator must go down to it; he cannot bring the parts nearer to him. All the steps of the operation can, and should, be visible to the surgeon - nothing need be done in the dark; but the remoteness and the immobility render all manipulations much more difficult than they are elsewhere. All technical procedures at the root of the lung are made easier if the parts near the hilum are fixed by the special light forceps of Duval. They not only withdraw the lung from the path of the surgeon, but give a stable field in which to work." Another point emphasized by Moynihan is the "mimicry of a projectile by the hard rounded but irregular condition of a bronchus." Most foreign bodies which have entered a bronchus by the mouth can now be removed by bronchoscopy, and unless they have caused abscess would rarely call for the trans-pleural operation.

Disease

Operations on the lung and pleura for disease have for their object: (i) The removal of morbid products from the lung by incision and drainage or by excision of portions of lung. (2) The induction of collapse of the lung for the arrest of haemoptysis or to give it rest and assist in recovery from tuberculous disease or to allow a cavity to close. (3) The removal of morbid products from the pleura and the separation of adhesions.

1. Incision of lung and drainage have been carried out (a) for hydatid cyst of lung; the cyst is incised, its contents evacuated, and the adventitious cyst wall left in place, either marsupialised and drained or sutured; (b ) for gangrene and abscess of lung; (c ) for tuberculous cavities.

Excision of portions of lung for tuberculous disease has been performed; in one case with survival for seven years. But Tuffier and Martin wrote in 1910: - "Pneumotomy for tuberculous cavities has now fallen into disfavour, as likewise pneuinectomy for early tuberculosis." 2. Collapse of lung is induced either by opening the pleura and admitting air, by injecting nitrogen, or by incising the chest wall down to the pleura, with or without resection of rib, detaching the parietal pleura and plugging the resulting cavity with gauze so as to bring about an extra-pleural pneumo-thorax.

3. Fluid is removed from the pleura by aspiration or by`incision. Aspiration is employed for serous effusions and sometimes for haemothorax. Incision with excision of a portion of one or more ribs is the current treatment for acute empyema, though some cases have been cured by aspiration only.

Recent experience seems to show that a wider opening into the pleural cavity than that usually made is desirable in empyema, so that the cavity can be inspected, the hand introduced, and all adhesions separated and false membranes and lymph removed. This is the only sure way to detect an inter-lobar abscess, and to secure expansion of the lung.

Immediate suture, after complete evacuation of the pus, has been carried out, but unless done very early does not seem likely to succeed. It has been suggested the pus should be removed as completely as possible by aspiration, and then 20-60 c.c. of a 2% solution of formalin in glycerine injected into the pleura. Chronic empyema in which the lung fails to expand and a persistent sinus has resulted has until recently been dealt with by extensive thoracotomy such as Estlander's operation with the object of making the chest contract down to the level of the contracted lung; the more recent operation has for its object the expansion of the lung. A free opening is made in the chest by the method of Duval or some analagous method, and the false membranes, often of considerable density, which bind down the lung are stripped off, and the pleural cavity closed.

Of the various antra-thoracic operations that have been suggested and tried, some will doubtless be abandoned while others will be developed and pass into current surgical practice. The war demanded new methods of diagnosis and treatment, and these were evolved and perfected amid stress and strain.

It was found that the chest cavity hitherto treated with undue deference could be opened and its contents inspected, palpated and dealt with as readily and as safely as the contents of the abdomen. This knowledge, won at the cost of so much suffering, has now to be applied to civil surgery, and when this is done even more successful results may be expected. Mr. G. E. Gask, in his Lettsomian lectures for 1921 gave an able exposition of the surgery of the lung and pleura as influenced by the experience of the World War; these lectures have been published in the Transactions of the Medical Society of London. (C. A. B.)