J.Jpn. Surg. Soc.. 56(8): 1008-1033, 1955

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CLINICAL AND EXPERIMENTAL STUDIES ON ENDOTHORACIC MANIPULATIONS AND REFLEX DISTURBANCES

Acute respiratory and circulatory disturbances during endothoracic manipulations were studied clinically and experimentally with special reference to reflex disturbances.
1. As so-called vago-vagal reflex, bradycardia was observed clinically and experimentally but usually infrequently. Bradycardia was caused by the foIIowing manipulations: rubbing of the bronchus, esophagus and aortic arch, tying and crushing of the bronchus and pulmonary vessels, and pulling of the hilum. Bradycardia appeared sometimes markedly during asphyxia or Total Spinal Block experimentally and when digitalis-overdosis, myocardial damage, cyanosis or abnormal anesthetic course existed clinically. The appearance of arrhythmias, such as auricular fibrillations or premature beats, may be sometimes due to this reflex.
2. As blood pressure reflex, hypotention was noted experimentally by the following manipulations but usually independently of bradycardia: rubbing of the bronchus and esophagus, tying the bronchus and pulmonary vesseIs and pulling of the hilum. Hypotention, which was observed cIinically, was usually slight, transient and infrequent. In one patient of cancer of the esophagus, 74 years of age, slight stimulation of the vagus nerve resulted in very marked blood pressure fall repeatedly. Blood pressure was sometimes elevated and this was noted frequently under light anesthesia. Hypotensive reflex was relatively mild under ether anesthesia.
3. Premature beats and transient tachycardias, which occurred during other manipulations than those of pericardium and vessels near the heart, did not disappear after bilateral vagotomy and administration of atropine, became fewer after administration of hexamethonium, and disappeared after Total Spinal Block. These arrhythmias were prevented by deepening anesthesia but did not always disappear under anesthetic overdosis. In clinical cases, these arrhythmias were not frequently observed under usual depth of anesthesia.
4. Supraventricular premature beats, which were frequently observed during proximal manipulations of pulmonary vessels, did not disappear after bilateral vagotomy, administration of atropine and Total Spinal Block. These arrhythmias may be in part due to Iocal reactions, such as axon reflexes or direct efferent accelerative stimulations.
5. Premature beats, which were caused by pericardial manipulations had the same correlations as these, and may be chiefly due to mechanical stimulations of the heart.
6. As respiratory reflexes, apnoea, respiratory sIowing and irregularity were observed mainly during manipulations involved pulmonary nerve plexus clinically and experimentally. Respiratory accelerations were frequently observed under light anethesia and did not disappear after bilateral vagotomy.
7. As pathological conditions, decreased blood volume, increased blood potassium, ethyl chlorid anesthesia, Total Spinal Block, asphyxia and combinations of these conditions were produced experimentally. Endothoracic manipulations under these conditions failed to cause permanent cardiac standstill. Aortic arch manipulation under Total Spinal Block caused transient but marked ventricular standstill in one case. After bilateral vagotomy or administration of relatively large dosis of hexamethonium, pericardial manipulations under asphyxia caused ventricular fibrillations.
8. The causes of acute circulatory disturbances during endothoracic manipulations were not only reflexes but also mechanical circulatory disturbances and the secondary effect of respiratory arrest.
9. These results indicate that the following preventive measures would be advisable : First, protection against other factors than reflexes which cause acute circulatory disturbances ; second, in usual cases, administrations ofatropine, anesthetic depth of the second plane in the third stage, local anesthesia of manipulative areas or blockade of the intrathoracic vagus nerve, and preventions of anoxia and adequate blood transfusions ; third, when sever reactions appear, proper measures with respect to manipulations and types of reactions, and finally, protections against factors which could increase such reactions in individual patients, and these factors were discussed.
(author's abstract)

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