786

PREGNANCY AFTER PULMONARY

LOBECTOMY

A. GRAHAM BRYCEM D MANC., F R C S

EMS CONSULTANT IN

THORACIC SURGERY

ELEANOR M. MILLSM B MANC., F R C S, M R C O GCHIEF ASST, SURGICAL

UNIT, ROYAL INFIRMARY

Manchester Coõrdinated Thoracic Surgery ServiceTHERE are now doubtless many women who have

surmounted the trials of pregnancy and labour afterbeing subjected to resection of the lung, but we havebeen able to find only one record of such a sequence.Tyson (1943) mentions a patient who was delivered ofa healthy child after right upper lobectomy for a giantpulmonary cyst. The following case therefore seemsworthy of record.

CASE-HISTORY

A woman of 23 developed a slight cough after tonsillectomyin January, 1937. A month later there was severe pain onthe left side of the chest. In March, 1937, haemoptysis wasfollowed by the expectoration of putrid pus. The symptomscontinued and the patient was admitted to the ManchesterRoyal Infirmary under the care of Dr. T. H. Oliver in August,1937. Bronchograms showed a localised bronchiectasis ofthe left lower lobe. On Dec. 4, 1937, the left lower lobe wasremoved by the Brunn-Shenstone (tourniquet) _method, aprocedure which is nowadays perhaps best described as thesubtotal operation. A bronchial fistula persisted for somemonths but eventually closed.On Oct. 30, 1942, she was again referred to the department

of thoracic surgery from St. Mary’s Hospital, where she hadattended the antenatal clinic. At that time she was in theseventh month of her first pregnancy and the desirability ofterminating it came into question. This course was not advised,since apart from a little dyspnoea she was entirely free fromsymptoms referable to her chest. She went into labourspontaneously at term on Jan. 3, 1943, and was admitted toSt. Mary’s Hospital. The foetus was presenting by the vertexin the left occipito-anterior position. The first stage con-tinued for 48 hours. After the second stage had lasted for 2hours, the fœtus showed signs of distress. Under ether anoes-thesia a mid-forceps extraction was carried out and a livingfemale child was delivered, an episiotomy being necessary.Throughout the long labour the patient showed no cardiacor respiratory embarrassment. She went home on the 16th

day and was able to continue breast-feeding for 8 months, atthe same time carrying out all her household duties.

Follow-up bronchograms, made in August, 1943, demon-strated the entire freedom from bronchiectasis of the rightlung and the remaining left upper lobe.1

DISCUSSION

Cases of this kind are important in these days, whenlobectomy and pneumonectomy have attained an estab-lished position in the treatment of bronchiectasis andother pathological conditions of the lung.

Longacre and his colleagues (1937), Longacre and Johans-mann (1940) and Bremer (1937) have studied experimentallythe physiological and histological changes which occur in theremaining lung after total pneumonectomy. As might beexpected the functional disability is less in young than inadult animals. While kittens and puppies appeared to havethe power of true regeneration of lung tissue, the changes inthe remaining lungs of adult animals were more like thoseseen in pulmonary emphysema. Graham (1940) removed,in stages, the right lower and middle lobes and the left lowerlobe and lingular process of a boy aged 14. The patient wassubsequently able to indulge in all activities usual at his age.

Lester and others (1942) have studied the pulmonary functionof three children 1-3 years after the operation of total pneu-monectomy. They found that persistent compensatoryoverdistension of the remaining lung was the factor whichmost impaired respiratory efficiency. Such overdistensionis not likely to be severe when only a portion of one lung hasbeen removed.A number of cases of pregnancy after thoracoplasty

have been reported. While this operation does notinvolve the ablation of any of the functional diffusing1. Since this record was written a multipara, aged 34, in her sixth

pregnancy, has been delivered of a 5¼ Ib. child in the 37th weekof pregnancy. The mother had undergone a left lower lobec-tomy for bronchiectasis 20 months before the confinement.The baby died when it was 15 days old. Delivery was bynatural forces and the puerperium was normal.

respiratory area, it does impair the capacity of the lungon the operated side to act as an organ of respiration, inproportion to the extent of the rib resection. Hartung(1938) describes the case of a woman who was success-fully confined after a total thoracoplasty for tuberculousempyema. Severe collapse developed 3 hours afterlabour, but the patient was resuscitated by an intra-venous injection of glucose-saline solution. Seeley et al.(1940) record 13 pregnancies in 10 of their patients after - --

thoracoplasty for tuberculosis ; 8 pregnancies went toterm and the patients were well. The unfortunate out-come in some of their cases seems to have been due notso much to the operation as to the deleterious effectwhich pregnancy is well known to have on the courseof pulmonary tuberculosis. They collected 20 additionalcases from published work. On the whole, they con-sider that the fear of respiratory difficulty during preg-nancy and labour is not borne out by their case-records,though there have been some reports of considerableand occasionally serious dyspnoea during labour.The question of inducing therapeutic abortion after

resection of the lung must be determined in each case.We advised interruption in the case of a woman aged 36,in her second pregnancy, who had undergone a left lowerlobectomy and subsequently a lingulectomy for bronchi-ectasis and who still had a discharging bronchial fistula..In her case, the presence of a persistent septic focus andthe possible danger of an abdominal hysterotomy, ifit should have proved necessary in the later months ofpregnancy, were held to ’justify emptying the uterusat the end of the third month. We should not, however,regard the mere fact of a successful lobectomy (or evena total pneumonectomy) as a sufficient reason for ter-minating pregnancy in an otherwise fit woman.We desire to thank Dr. T. H. Oliver, Dr. W. R. Addis, and

Dr. C. P. Brentnall for allowing us access to their case-

records.REFERENCES

Bremer. J. L. (1937) J. thorac. Surg. 6, 336.Graham, E. A. (1940) Surgery, 8, 239.Hartung, H. (1938) Zbl. Gynäk. 62, 2865.Lester, C.W., Courland, A., Riley, R. L. (1942) J. thorac. Surg. 11, 529.Longacre, J. J., Carter, B. N., Quill, L. McG. (1937) Ibid, 6, 237.Longacre, J. J., Johansmann, R. (1940) Ibid, 10, 181.Seeley, W. F. Siddall, R. S., Balzar, W. J. (1940) Amer. J. Obstet.

Gynec. 39, 51.Tyson, M. D. (1943) Ann. Surg. 118, 50.

Medical Societies

ROYAL SOCIETY OF MEDICINEAT a meeting of the section of medicine on Nov. 28,

with Dr. GEOFFREY EVANS in the chair, a discussion on

Nutritional Factors in Liver Diseasewas opened by Prof. H. P. HIMSWORTH. - Dieteticlesions in the liver, he said, are of two kinds : massiveacute necrosis, either killing or causing scarring andnodular hyperplasia ; and diffuse hepatic fibrosisresembling portal cirrhosis. Because both lead tofibrosis of the liver they have been confiised under theterm " dietary cirrhosis." The development of massiveacute necrosis depends, he has been able to show, on theamount of protein eaten. The amounts of vitamin,choline, fat and carbohydrate in the diet have no effecton this lesion. Different proteins vary in their abilityto prevent the appearance of necrosis ; thus, smallamounts of casein are effective, while large amounts ofyeast protein are ineffective. Casein differs from yeastin beingrich in the amino-acid methionine, and yeastenriched with methionine protects as effectively as casein.Rats fed on a diet low in protein seem to remain wellfor some weeks ; then without warning they fall ill,sometimes dying in a few hours from massive necrosis ofthe liver, and sometimes surviving to develop nodular .hyperplasia, with jaundice, ascites, and oedema. Pro-fessor Himsworth specially noted that the latent periodis long, that the liver looks normal until the suddenonset of necrosis, and that it is always scarred if theanimals survive. A variant of the condition is partialhepatic necrosis, in which only the left half of the liveris affected. This appears in rats receiving just sufficientprotein to protect them against generalised hepaticnecrosis. The blood from the superior mesenteric veingoes mainly to the right half of the liver, while that from

787

the splenic vein goes mainly to the left half. The

products of protein digestion are carried by the blood inthe superior mesenteric vein, so that the right half ofthe liver suffers less from protein deficiency than theleft half, which receives the impoverished blood from thesplenic vein. The diets causing the second type of liverlesion-difflise hepatic fibrosis-are either rich in fat ordeficient in lipotropic factors, and all produce fattyinfiltration of the liver. Unlike massive necrosis, whichappears after a period of weeks, this condition takesmonths to develop ; health gradually deteriorateswithout any acute stage and the changes in the liveralso develop gradually. Necrosis is- absent, but fattyinfiltration precedes and accompanies the fibrosis.

Possibly when the liver cells are choked with fat the flowthrough the tortuous sinusoids may be so much retardedthat by the time the blood reaches the centre of thelobule it is largely depleted of nutriment. CeÍls in thecentre may therefore be dying off unobtrusively all thetime; and repeated attacks of centrilobular necrosisare known to lead eventually to portal, cirrhosis.

In man massive necrosis can be produced eitherby poisons (toxipathic hepatitis) or by dietary defici-ency (trophopathic hepatitis). lit toxipathic hepatisisthere is transient zonal necrosis ; in trophopathichepatitis massive necrosis leads to scarring and nodularhyperplasia. In temperate climates, massive necrosisis only seen in association with pregnancy, or afterinfective hepatitis, or after exposure to poisons such asTNT. In pregnancy, the mother’s nutrition may sufferto meet the needs of the foetus. The mortality fromjaundice following yellow fever vaccine (which is relatedto infective hepatitis) was only 0-2% among well-fedAmerican troops, but 2-5% among ill-fed Brazilians.An isomer of TNT is- known to combine with someamino-acids, and may thus make them inaccessible foruse by the body. Massive’necrosis may develop as acomplication of zonal necrosis, because in the tenseand swollen liver the circulation is impeded. If theblood is poor in protein, the slow rate of flow mayprevent the liver cells from getting enough nutrimentto survive. From the tropics outbreaks of " yellowfever " are sometimes reported which prove on in-

vestigation to be epidemics of massive hepatic necrosis.Such outbreaks are only seen among peoples livingon diets grossly deficient in protein. ProfessorHimsworth quoted other examples of liver ’ necrosisand fibrosis in tropical countries, all associated withsome dietary deficiency, either direct or produced bydisease. He recalled that portal cirrhosis in westerncountries is traditionally associated with alcoholism;but recent investigations, he said, suggest that alcoholis at most a contributory factor. In the East cirrhosisoccurs among people who take no alcohol. Long-standing fatty infiltration of tha liver is an essentialprecursor of experimental portal cirrhosis, and there isgood clinical evidence that it also precedes such cirrhosisin man. 1B lcohol contains no lipotropic factors; inexcess it impairs appetite and thus limits the addict’sintake of protective foods. Fatty infiltration of theliver is thus favoured. Proteins and alcohol are bothexpensive, and he who can afford to buy good food aswell as much drink may escape cirrhosis : the conditionis thus commoner in the poor alcoholic. In the East agross fatty infiltration occurs in native races, apparentlyas the direct result of a poor diet, and among themportal cirrhosis is common.

Dr. L. E. GLYNN showed lantern slides illustrating thepathological states of the liver in man and rats discussedby Professor Himsworth. Massive acute necrosis of therat’s liver resulting from a methionine-deficient diet wascompared with human acute yellow atrophy at all stagesfrom the onset of necrosis to -that of postnecrotic scarringwith nodular hyperplasia. The points of similarity inthe acute stage which were particularly emphasied werethe massive character of the necroses with relativelylittle hemorrhage, and the haphazard distribution ofthe surviving liver cells. Attention was also drawn inboth species to the rapid removal of the necrotic livercells followed by intense infiltration with lymphocytesand macrophages, the latter apparently derived fromthe Kupffer cells; the often considerable proliferation ofbile-ducts ; and finally the regeneration of nodules ofliver cells from the irregularly distributed survivors,

which together with the development of scar tissue inthe areas of histiocytic infiltration, results in thecharacteristically coarsely nodular scarred liver ofso-called toxic cirrhosis. The remarkable tendency,both in man and rats, towards localisation of the lesionsto the left half of the liver in the less acute cases was alsoillustrated. Slides were then shown of various stages inthe development of diffuse hepatic fibrosis in the rat’sliver consequent on prolonged fatty infiltration due todiets deficient in lipotropic factors. Correspondingstages in the evolution of human portal cirrhosis werealso shown-intense fatty infiltration, progressive in-crease of portal-tract connective tissue, subsequentinvasion of the individual lobules by this tissue resultingin the ensnaring of groups of liver cells, and finallynodular regeneration in these ensnared groups causinga finely granular organ with complete loss of its normalregular lobular pattern.

Prof. JOHN BEATTIE discussed the possibility thatoutbreaks of infective hepatitis and postarsphenaminejaundice were related to deficiencies of protein in thediet.. He mentioned the high incidence of hepatitisamong Army recruits from some African tribes whichtake a diet poor in protein, and the low incidence among- others who are meat-eaters. The severity of hepatitisoccurring in burn cases, in pregnant women, and insurgical cases where there is a history of undernutritionalso supports this view. Yet Pickles’s report of theWensleydale outbreak of hepatitis contained no sugges-tion of dietary factors, and in, fact the protein intake ofthose patients was rich and high. The virulence of theinfective organism must, he thought, be taken intoaccount. In his study of postarsphenamine jaundice hewas also unable to obtain anything more than a verygeneral correlation between the occurrence of the diseaseand the dietary background of the cases. Experimentson the protective value of methionine in preventingjaundice in such cases suggested that 3 grainmes ofmethionine daily, whether as supplement or containedin food, materially reduced the severity of jaundice anddelayed its appearance, but probably did not reduce itsincidence. In the cure of-jaundice much larger doses ofmethionine are required to obtain an effect. In verysevere cases 10 g. may be given intravenously at intervalsof a few days-but this method of treatment maynot be without danger in some exceptional cases. Theeffect of methionine on the hepatic condition in alreadyjaundiced patients may be considerable but methioninealone cannot cure the illness. Unless adequate dietaryprotein is available at this stage relapse may follow or atleast a very long period of convalescence. Two seriesof cases had been observed. In one the availableprotein was less than 120 g. daily. In the other therewas unlimited protein available and the individualconsumption was never less than 150 g. While weightlosses were common in the first group, large weightincreases were- the rule in the second group. Theaverage stay in hospital for cases of comparable severityin the first group was 14 days longer than in the secondgroup. Prof. Beattie emphasised the importance ofproviding adequate protein food during the recoveryphase when attempting to assess the value of methionineas a therapeutic agent in cases of hepatitis. In somecases this might only be optimal when the food provided300 g. of protein daily. ’

’

Major CLIFFORD WILSON was not convinced by theevidence that dietetic factors have any influence on thecourse of infective hepatitis as seen in this country. Hehad conducted methionine trials in 100 soldiers withinfective hepatitis admitted to hospital at Cambridgeduring the past year ; alternate cases were used ascontrols. - Methionine, 5 grammes daily, was given bymouth from the time of admission until 5 days after bilehad disappeared from the urine ; diet was not restricted.Since most of these cases are recovering when they cometo hospital, he said, it is difficult to assess results, but hehas used the following criteria : duration of jaundice andof liver tenderness ; time in hospital ; duration ofbiliuria ; the days taken for the serum bilirubin to fallto 2 mg. ; the maximum serum bilirubin ; and the levelof hippuric acid at the end of treatment. There was aslight difference in favour of the treated group through-out, but it was not statistically significant in respect of anysingle factor. All he could say was that if the methionine

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in the diet was increased to twice the normal intake therewas no observable effect as judged by these criteria.

-

Dr. H. W. ALLEN mentioned some results of anti-syphilitic treatment in French workers. The higherthe dose of NAB the greater, he found, was the like-lihood of jaundice ; and the underfed were more likelyto suffer than the well fed. He pointed out thatstarvation alone can produce jaundice in dogs, and thatalcoholism predisposes to arsenobenzene jaundice. Hethought it doubtful whether methionine is more valuableas a protection than an ordinary good diet.

Professor H]IMSWORTH. in replying to questions,stressed two points. First, that his results did not provethat massive hepatic necrosis was directly due tomethionine deficiency : to prove this, experiments inwhich amino-acids provided the only source of dietarynitrogen were needed. What had been shown was thatthis lesion was produced by a low-protein diet, particu-larly one deficient in sulphur amino-acids, and that itwas prevented by methionine. Secondly, he said, theresults gave no indication that the incidence of hepatitisdue to poisons or viruses could be influenced by diet,though they did suggest that a high-protein diet, or

methionine, might prevent such cases developing thecomplication, massive hepatic necrosis. ’

Reviews of Books

Year Book of Dermatology and Syphilology, 1943MARION B. SULZBERGER, MD ; RUDOLF L. BAER, MD.(Year Book Publishers; Lewis. Pp. 584. 19s.)

As usual the Year Book consists of abstracts of all theimportant published work of the year and is well up tostandard. The customary original article at the begin-ning is on skin-tests and is specially well-timed nowthat dermatitis has at last been recognised as ’one ofthe most important and serious of industrial hazards.Industrial skin disease appears to be on the increase,possibly owing to the growing number of complexchemical substances in use in industry. The editors donot confine themselves to industrial irritants, however,but include almost every known substance which cancause a reaction in the skin. They keep skin-testingin its proper perspective, pointing out that withoutproper history-taking and study of the case such testsmay prove valueless. Careful instructions about tech-nique and interpretation are given, and anyone taking upskin-testing for the first time will do well to follow theplan outlined.

Invisible AnatomyA Study of Nerres, Hysteria and Sex. E. GRAHAM HowE,mB LOND., DPM. (Faber.Pp. 333. IOs.6d.)

THERE is nothing in common between conventionalmedical psychology and the theme of Dr. GrahamHowe’s hortatory and expository manual, with itspervading appeal to the " ancient wisdom of the East."He assumes the r6le of the teacher, the " student of theunseen Laws " who wishes to bring together the Easternand the Western standpoints ; only those are likely toappreciate him who find meaning and help in theesoteric doctrines of Buddhism-or what passes for thesein our time and country. In many passages the influenceof C. G. Jung and of Rudolf Steiner is apparent. Psycho-logy here becomes a matter not of scientific study anddemonstration but of occult speculation and intuition.

Advances in Enzymology and Related Subjects of

Biochemistry ‘

(Vol. IV.) Editors : F. F. NORD, Fordham University,New York, NY ; C. H. WERKMAN, Iowa State College.(Interscience Publishers. Pp. 332.$5.50.)

THE need for books in English on this subject has beenrecognised for some time and this work meets the needwell. The fourth volume, like its forerunners, helps thebiochemist to keep pace with advances in a wide field,and the contributors deal with a number of biochemicalproblems from the point of view of the enzymologist. Theirreviews are well written and brief; critical discussionhas been curtailed and only modern findings are givenat length. The book makes good reading for the advancedstudent. The bibliography is extensive and stresses theneed for a volume of the Advances on this subject.

New Inventions

BOARD FOR CUTTING SKIN GRAFTS OFDEFINITE WIDTH

WHEN a skin-graft is being cut freehand, a woodenboard is usually employed to flatten the skin in frontof the knife,! so that the knife will have an even surfaceto work.on. Kilner 2 devised a skin-stretching apparatusfor this purpose, and Blair 3 used- a suction-box. Withthe usual board the width of the graft cut depends onthe width of the flat surface in front of the knife-it isnot possible to cut a narrow graft from a broad thigh,and there is no other way of controlling the width of thegraft than by choosing an appropriate donor area. TheBlair suction-box permits definite control of the width

Fig. I-Stainless steel board..

of the graft, but it is necessary to have a different boxfor each width, and a good suction apparatus is notalways available. In practice the wooden board ismost used because of its simplicity, but with a board itis not easy to cut a skin-graft freehand from such excel-lent donor areas as the abdomen, the chest or the back.

I have overcome these difficulties by devising a simpleboard made of stainless steel (fig. 1) to determine thewidth of surface for the knife to cut. It has four notchesof different sizes-2, 2, 3 and 4 in.-and whenpressed down on the donor area produces a flattenedsalient the same width as the notch (fig. 2) ; the widthof graft obtained is about half an.inch less. It is neces-sary to hold the metal board more nearly perpendicular

Fig. 2-(a) Flat surface obtained with the ordinary wooden board applied toalimb. The width of the graft depends on width of donor area. (b) Surface- -

obtained with the new board applied to same limb. There is a flattenedsalient of a definite width which is independent of width of donor area.

to the surface than the usual board, and to apply slightlymore pressure, but this adjustment is simple in practice.

This board has been employed, with satisfactory results,-for over two years, using the Blair or Humby knife, orthe old amputation knives (which I should recommend).With the Humby knife, which allows one to control thethickness of the graft cut, and this board, which controlsits width, it has been possible to cut, free-hand, graftsof any width and thickness not only from the classicaldonor areas-the inner side of the arms and thighs-butalso from the buttocks, chest, back and abdomen. Theboard is made to my design by Messrs. C. F. Thackray Ltd..01 -London. P. GABARRO, M D BARCELONA,

Plastic surgeon at an EMS Hospital.1. McIndoe, A. H. In Hamilton Bailey’s Surgery of Modern Warfare,

Edinburgh, 1941, p. 155.2. Kilner, R. Plastic Surgery. Part 19 of Maingot’s Post-Graduate

Surgery, London, 1937, vol. III.3. See Fomon’s Surgery of Injury and Plastic Repair, Baltimore ,

1939, fig. 66, p. 134.