Document 2jeewLgkKkB58ZzYN5a7KGjqb

FILE NAME: Smoking (SMOK) DATE: 1965 Oct DOC#: SMOK053 DOCUMENT DESCRIPTION: Journal Article - Pleurectomy VOL 194, NO 3 Cj Z^ Ht UAVI L MEMORIAL MERCAL UBRAW OCTOBER 18, 1965 THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION ORIGINAL CONTRIBUTIONS PETIT MAL EPILEPSY 227 Sam uel Livingston, MD, Ilum inada Torres, MD, L. L. P a u li, MD, and R. V. Rider, S c D , B a ltim o re SURGICAL CURE OF MALIGNANT HYPERTENSION 233 W. L. S tric k le r, MD, Boston GONOCOCCAL ARTHRITIS IN CHILDREN 23/ C. W. Fink, MD. D alla s SPIROMETRY IN A MEDICAL CLINIC 239 S. W. R o sn e r, MD, Sidne y A b raham , and C. A. Caceres, MD, W ashington. DC TRANSIENT OCCLUSION OF MIDDLE CEREBRAL ARTERY 243 S. A. Holfin, MD, and Allen Silverstein, MD, New York INACTIVATED MYCOPLASMA PNEUMONIAE VACCINE 248 K. E. Jensen, PhD, L. B. Senterfit, ScD, Te rre H aute, Ind, R. M. Ch ano ck. MD, C. B. Sm ith, MD. and R. H. Purcell, MD, Sethesda, Md PRELIMINARY COMMUNICATION PLEURECTOMY Jo hn Helwig, Jr., MD, Rachel Ash, MD, Sidney Friedm an, MD, T. G, Daughtridge, MD, and Ju lia n Johnson, MD, Philadelphia 253 CLINICAL SCIENCE ANTIBODIES AND IMMUNOGLOBULINS 255 II. NORMAL DEVELOPMENT AND CHANGES IN DISEASE J. L. Fahey, MD. B ethesda, Md SPORTS CONTRIBUTIONS SPORT PARACHUTING AND SKY DIVING 259 A. J. Ryan, MD, M adison, Wis, and C. L. Thom as, MD, W ilbraham , Mass PARACHUTING FOR SPORT 264 Maj F. W. Kiel, MC, U SA , W ashington , DC MATHEMATICAL BIOLOGY MODELS AND MATHEMATICS 269 J. T. Apter, MD, PhD, Chicago CURRENT CONCEPTS IN CANCER-NO 8 CANCER OF CERVIX, STAGE IV AND RECURRENT 273 Philip Rubin, MD, Rochester, NY, Alexander B ru n sch w ig , MD, an d E. W. M unnell, MD, New York, W alter Murphy. MD, Buffalo, and J. C. Batem an, MD, W ashington, DC NEGATIVE RESULTS CANCER TREATMENT BY THE METHOD OF REVICI D avid L y a ll, MD, M. S. Sch w artz, MD, F. P. Herter, MD, P. 8. H ud so n, MD, J. C. W righ t, MD C. W. Findlay, MD, New York, J . M. G alb raith , MD, Glen Cove, NY, A. P. Stout, MD, and C. D. Haagensen, MD, New York 279 LEGAL MEDICINE A SURVEY OF THE LAW OF MEDICAL PRACTICE 281 IV. NEGLIGENCE IN THE PRACTICE OF MEDICINE Sidney Shindell, MD, LLB , Pittsburgh CONTENTS CONTINUED AND "COVER STO RY" Adv Page 5 . Z095S 3 nu hinana oaia siav C3W hie aw ABiMone aoa P666 0 9fe'ZlO&Z.h9Z000 9Z009SC Preiiminary Communication chial arteries to be enlarged also in cases of Iiy rlP S tensive pulmonary-vascular disease with w id e siS rh ' occlusion of pulmonary arteries. These systemic arteries gave rise to thin-walled branches which entered the lung parenchyma. The observations of Pleurectomy Liebow and Heath suggested that these systemic pulmonary anastomoses were distal to the pul monary arteriolar obstruction of these patients John Helwig, Jr., MD, Rachel Ash, MD, Sidney Friedman, MD, T. Giffin Daughtridge, MD, and Julian Johnson, MD with pulmonary hypertension and might be stimu lated to develop by pleurectomy, as has been shown to be effective in patients with pulmonary stenosis. Pleurectomy was used to stimulate systemic Therefore, the rationale of the currently pro pulmonary anastomoses as a palliative treat posed procedure is to bring collateral blood flow ment for patients with cyanotic congenital heartinto the pulmonary circulation at the level of the disease with pulmonary hypertension. To our precapillaries and hence to increase the amount of knowledge, the successful application of this prin unsaturated blood flow past the capillary-alveolar ciple, suggested to us by Bernice Wedum, MD, has interface. not heretofore been reported. Patients with pulmonary hypertension associ Report of a Case ated with a right-to-left shunt within the heart A girl, born on J a n 13, 1947, was ad m itted to the Chil have systemic hypoxia due to the combination of a decreased effective pulmonary blood flow secondary to the mechanical pulmonary-arteriolar block and the effects of the right-to-left shunt itself. As a d re n s H ospital of P hiladelphia in 1948 and a diagnosis of pseudotruncus arteriosus was made. T h e first P o tt's opera tion done at the C hildren's H ospital was perform ed, and the anastomosis was made 4 mm in diameter. Immediately postoperatively she was pink and did extrem ely well. T he result of pulmonary arteriolar obliterative changes, m arked im provem ent in clinical status was to portend the progressive developm ent of pulm onary hypertension, prob For editorial com m ent, see page 290. ably the result of too large a system ic-pulm onary anasto mosis. Because of increasing dyspnea and cyanosis, she was adm itted to the H ospital of the U niversity of P en n sy l the pulmonary resistance is equal to or greater vania in Septem ber 1964 at which tim e right and retro than the systemic resistance. In effect, multiple peripheral "pulmonary stenoses" exist. In 1949, Barrett and Daley1 described pleurec tomy as a method for increasing the pulmonary grade left cardiac catheterizations were performed. The diagnosis of pseudotruncus arteriosus was confirmed by hemodynamic and cineangiocardiographic studies. The pulm onary arte ry was intubated by way of the P o tt's anastomosis in a retrograde fashion, and both the aortic blood flow in patients with cyanotic congenital heart disease with a decreased pulmonary blood flow and low pulmonary-artery pressures. They demonstrated the development of large, effective and pulm onary-artery pressures were found to be 110/70 mm Hg. T h e hemoglobin level was 18.4 gm /100 cc and the hem atocrit reading, 60%. Both the patient and her mother were most anxious that something be done. Pleurectomy on th e right side was perform ed on S ep t 28, 1964, an d the bronchopulmonary anastomoses with considerable clinical improvement in these patients. Through the years, this method of palliation has been em ployed in patients in whom Blalock or Pott's shunts could not be performed for technical rea surface of the lung was sprinkled w ith pow dered asbestos. t T he patient had an uneventful postoperative course with / a progressive increase in exercise tolerance. In M arch 1965 she was readm itted to the University of Pennsylvania Hos pital for rvaluation. A t this time, the patient could sons and who were not amenable to open-heart corrective surgery. Liebow and his coworkers' have beautifully dem 1. Preoperative chest x-ray film, Sept 21, 1964. Post operative chest x-ray film, March 8, 1965, was un changed except for pleural thickening on right side. onstrated by injection studies the bronchopulmo nary anastomoses in health and disease. (We will use the term bronchial arteries to include all sys temic arteries that supply or become related to the lungs, as does Liebow.) These precapillary anasto moses are difficult to demonstrate in health but may become very large in obliterative disease of the lungs or in tetralogy of Fallot with low pul monary-artery pressures. HeatlT found the bron- From the Cardiovascular Clinical Research Center, Hospital of the University of Pennsylvania; the Children's Hospital of Philadelphia; and the departments of medicine, pediatrics, radi ology, and surgery, School of Medicine, University of Pennsyl vania. Philadelphia. Dr. Helwig is now with the Cardiovascular Section, Germantown Dispensary and Hospital, Philadelphia. Reprint requests to Germantown Hospital, Philadelphia 19144 (Dr. Helwig). JAMA, Oct 18, 1965 o Vo! 194, No 3 o 139 2. Selective right middle intercostal film-changer arteriography demonstrates rapid filling of pulmonary veins 1/2 second after injection (upper left), iy 2 seconds after injection (upper right), 7.yz seconds after injection (lower left), and 4 seconds after injection (lower right). climb one flight of stairs without dyspnea, whereas, prior to surgery, a climb of only four steps caused significant dyspnea. On physical examination, she was considerably less cyanotic and the hem oglobin level was 16.2 gm/100 cc and th e hem atocrit reading was 56%. T h e chest x-ray film (Fig 1) and electrocardiogram were essentially u n changed. H er arterial oxygen pressure (P o 2) was 42 mm Hg (78% saturation) com pared to a preoperative Po of 33 mm Hg (64% saturation). Selective retrograde intercostal film-changer arteriography dem onstrated significant col lateral blood flow from th e intercostal and bronchial a r teries to the lung with early opacification of the right pulmonary veins (Fig 2). Considering that the postopera tive study was done only 5l/2 m onths following pleurectomy, th e degree of collateral circulation was rem arkable. Comment The clinical course and the angiographic demon stration of significant induced collateral circulation to the right lung of the patient with cyanotic con genital heart disease and pulmonary hypertension, strongly suggest that pleurectomy was of real pal liative benefit. The angiograms demonstrate con clusively that blood now flows from the systemic circulation through the pulmonary parenchyma - into the pulmonary veins. Although preoperative intercostal arteriograms were not obtained, the fact that no significant adhesions between the parietal and visceral pleura were found at surgery excludes the possibility that all the collaterals were due to preexisting bronchial collaterals alone. The marked change in systemic oxygen saturation strongly suggests that this collateral blood flow undergoes oxygenation at the alveolar level. On the basis of the observations made on this patient, we believe a cautious further trial of this procedure is indicated. This study was supported in part by Public Health Service grant HE-06352 and by the John A. Hartford Foundation. References 1. Barrett, W.R., and Daley, R.: A Method of Increasing the Lung Blood Supply in Cyanotic Congenital Heart Disease, Brit M ed J 1:699-702 (April 23) 1949. 2. Liebow, A.A.; Hales, M.R.; and Bloomer, W.E.: "Relation of Bronchial to Pulmonary Vascular Tree," in Adams, W., and Veith, 1. (eds.): Pulmonary Circulation, New York: Grune & Stratton, Inc., 1959, pp 79-98. 3. Heath, D.: "Structural Alterations of Pulmonary Vessels in Response to Pulmonary Hypertension," in Adams, W., and Veith, I. (eds.): Pulmonary Circulation, New York: Grune & Stratton, Inc., 1959, pp 122-125. 140 JAMA, Oct 18, 1965 Vol 194, No 3