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SURGICAL TREATMENT OFHYDATID DISEASE OF THE LUNG

By WALTER PHILLIPS, F.R.C.S., M.R.C.P.Cape Town

Hydatid disease has long been recognized incountries such as Australia, Iceland and SouthAmerica, but it is not generally known that thisdisease is also relatively common in South Africawhere sheep-raising is carried out on a large scale.The opinions of authorities in these differentcountries vary so greatly that the choice of a lineof treatment to be adopted becomes a difficultproblem.

Diagnosis of the simple hydatid cyst of the lungmay be extremely difficult, particularly when itoccurs in a patient living in a country where thedisease is uncommon. Problems in diagnosis areincreased because of the clinical and radiologicalsimilarity of hydatid cysts to several of the com.moner lung tumours and cysts. The cyst may besymptomless for a considerable time, and may onlybe discovered when a radiograph of the chest istaken. There is no doubt that many people havehydatid cysts of the lung without symptoms untilsome complication occurs. The true nature ofmany of these cases is only revealed at operation,particularly in the case of the simple or uncom-plicated cyst. Many patients have been known tocough up their cysts, and subsequent radio-graphic examination has shown a normal lung.The number of spontaneous cures, however, isalways exaggerated.The increasing number of mass radiographic

surveys will inevitably reveal many cases of pul-monary tumours and cysts, which will prove to beof echinococcal origin. Surgical treatment willtherefore be of increasing importance.Types of CystHydatid cysts may reach the lung by two

routes:-(i) Primary infection. The ingested larva enters

the circulation through the intestinal vessels, andafter passing through the hepatic capillaries,reaches the right side of the heart. The parasitethen passes through the pulmonary or thebronchial vessels to the lung, where it is filteredout.

(ii) Secondary infection. As all the intestinalblood first passes through the liver, it is mostprobable that the hydatid parasite is caught upthere. About one-fifth of the parasites manage topass through the liver, to be trapped later in the

lung. Four times as many cysts are found in theliver, and it is there that they finally develop. In-fection and suppuration are not infrequent andeventually the infected cyst may rupture throughthe liver into the pleural cavity. If the lung hasbecome fixed by adhesions, the cyst ruptures intothe lung and is responsible for secondary pul-monary contamination. This contamination,whether of the lung or of the pleural cavity, isdue either to scolices or to germinal epithelium,which in due course leads to the formation ofdaughter cysts.

Solitary or univesicular hydatid cysts of thelung are more common than multiple cysts. It isstated that they occur on the right side morefrequently than on the left, and this is attributed tothe fact that the course of the right pulmonaryartery to the right lung is direct, whereas the leftpulmonary artery has to run back towards the leftlung. Such a cyst may be recognizable when it hasreached a diameter of half an inch, and may in-crease in size until it is large,enough to occupy anentire lobe of the lung.

Multiple cysts are seen less frequently and inmany instances are due to the formation ofdaughter cysts from an original solitary parent.The cysts may affect both lungs, or only one lungmay be involved. Occasionally more than one cystoccurs in a lobe.

Position of CystsThe position of cysts is classified according to

the radiographic appearances. The cyst may appearto be in the substance of the lung whereas, inreality, it is situated in the region of the interlobarfissure, lying immediately under a layer of visceralpleura.

Peripheral cysts. These are described as being inrelation to the visceral pleura and may occur on thecostal surface of the lung where they appearattached to the ribs, or on the mediastinal aspectwhere they appear to arise from the mediastinalstructures (Fig. ia, ib). Special radiographicmeasures, such as tomography and bronchography,may be required to determine whether a cyst is inthe substance of the lung or adjacent to an inter-lobar fissure (Fig. 2).

Hilar cysts. Hilar cysts are not often seen.They are believed to arise from embryos which

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POST GRADUATE MEDICAL JOURNAL

have reached the lung through the bronchialarteries. The embryo is held up near the mainbronchus close to the hilar structures. Thesecysts are there developed in a confined space,bounded by the main bronchus and major divisionsof the pulmonary arteries and veins. On themediastinal side lie the pericardium and heart.These hilar cysts enlarge and m.ay rupture intoany of the important surrounding structures withfatal outcome.

The parenchymal cyst. Most cysts developwithin the lung substance, where they mayeventually occupy the entire lobe, or they maybecome displaced peripherally until they becometrue peripheral cysts. The ordinary parenchymalcyst has a layer of lung tissue overlying it varyingin thickness from about an inch to just the thick-ness of the adventitial lining.

Pleural cysts. These cysts are not common andare usually extrusions from the lung. They maydrop down to become situated on the diaphragm-atic surface (Fig. 3). Occasionally a peripherallysituated cyst ruptures into the pleural cavitywhich then becomes littered with daughter cysts.

Thoracic wall cysts. Thoracic wall cysts mayresult from contamination from a lung cyst whichhas ruptured, or may be due to the primary depositof an embryo in the structures of the thoracic wall.Thus the ribs and muscles of the thoracic cage maybe the sites of hydatid disease (Fig. 4).Condition of the Cyst

The simple cyst. This is also referred to as anon-infected or intact cyst. As a rule it is a truecyst, being a collection of fluid in a sac formed bythe laminated membrane, and enclosed in a thinelastic adventitia derived from the surroundinglung tissue. The parasitic cyst is thus formed bythe laminated membrane which encloses thehydatid fluid. Though such a cyst has a welldefined capsule, it may be distorted because itscovering is not rigid. The radiographic appear-ances of a simple cyst resemble those of severalother conditions, such as a solitary congenital cystof the lung containing fluid, or a benign tumour ofthe thorax such as a neurofibroma (Figs. 5, 6, 7).In many cases it is only exploratory thoracotomythat reveals the true pathology. .The fluid in thecyst is under tension so that rupture takes placeeasily.

The complicated cyst. When changes have oc-curred in the simple cyst or in the adventitialcapsule, the cyst is said to be complicated. Acommunication may develop between the ad-ventitial capsule and an adjacent bronchus. Airescapes into the sac so that the hydatid cyst maycome to lie in an air-containing adventitial sac.The radiographic appearances of such a com-

plication are characteristic, and show the cyst witha crescent of air above it (Figs. i Ia, i ib). Fre-quently the laminated membrane also ruptures sothat some of the cyst contents escape into thebronchus. Patients have reported the salty tasteof hydatid fluid. In such circumstances air notonly passes into the adventitial capsule, but alsointo the cyst, again leading to a characteristicradiographic appearance. The entire cyst mayrupture through the opening in the adventitia,escape into the bronchus and be coughed up(Fig. 8). Sometimes the description of coughingup ' grapeskins ' is elicited as this describes theappearance of the laminated membrane. Whenthe parasite dies, calcification ensues and a cal-cified mass may be seen in the lung causing verylittle disability and discovered only on routineexamination.When a communication develops between a

bronchus and the adventitial sac or the hydatidcyst, infection usually supervenes. The hydatidcyst may be converted into a lung abscess. Thedevelopment of complications causes changes inthe radiographic appearances which are almostpathognomonic of hydatid disease. Where multiplecysts are present, one may be simple, anothercomplicated (Figs. 9a, 9b). A complicated cystloses its elasticity and becomes a firm, hardened,inelastic structure, which becomes more markedwith the extension of the inflammatory changes.

The adventitial lining is not part of the parasitebut is produced by the host as a response to theparasite. In the simple hydatid cyst, the adventitialsac is produced by fibrous tissue reaction andconsequently is thin and elastic. Removal of thehydatid cyst would leave behind a thin walled sacwhich could be obliterated quite easily by ex-pansion of the lung. The laminated membrane isthe firm, brittle covering of the actual parasite.Thickening of the adventitia occurs when a com-munication develops between the adventitial sacand a neighbouring bronchus. The sac may be-come toughened and leather-like and its oblitera-tion after the removal of the parasite is mostunlikely. This may take place if rupture of thesac or of the cyst has eventuated. The adventitialsac is therefore thickened and tough in a com-plicated hydatid cyst, and in old-standing cases theadventitia is quite rigid.The Surrounding Lung TissueAs the simple hydatid cyst enlarges it brings

about some compression and displacement oflung tissue. When the cyst has increased in sizeto occupy an entire lobe, the lung tissue is stretchedand thinned out and may not be visible at all.

Bronchiectasis may develop in the bronchi inclose relation to the cyst. The bronchiectasis in

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PHILLIPS : Surgical Treatment of Hydatid Disease of the Lung

such cases is due to the partial obstruction ofbronchi with associated atelectasis of lung tissuedistal to the obstruction. Usually the associatedbronchiectasis has been present for a long timeand is irreversible. Particularly is this so if thecyst is complicated, as by rupture or infection. Insuch cases, the retention of cyst contents in someof the surrounding bronchi may be the cause of theatelectasis and bronchiectasis. Not infrequentlybronchiectasis develops in anothei lobe but fromthe same cause. Hydatid disease can thereforebring about complications in lung tissue distantfrom the actual site of the cyst.

Adhesions may be present even if infection hasnot supervened, as the cyst may stimulate forma-tion of adhesions between the lung and the chestwall. Generally these adhesions are thin andfilmy. They separate readily with a little pressurebut are best and most safely divided with scissors.When infection has supervened or a cyst has rup-tured, the surtounding adhesions are usually muchfirmer and denser.

Pneumonitis. There is often a spread of infec-tion from the infected cyst to the surrounding lungtissue. This is most commonly seen when aruptured hydatid cyst becomes a lung abscess.The original architecture of the hydatid cyst be-comes replaced by inflammatory tissue thoughhydatid remnants may remain recognizable.Destruction of the entire lung due to spreadinginflammation may result from such infection.

Pleural effusion may develop as a response topleural irritation. The fluid may contain largenumbers of eosinophils or may be quite clear.When a cyst ruptures into the pleura, gross generalsymptoms including anaphylaxis and urticariamay be seen. The pleural exudate is considerablein amount and hooklets and scolices may be seenon microscopic examination.Empyema is likely to develop when an infected

liver hydatid ruptures through the diaphragm intothe pleural cavity.

Fatal hamorrhage may result either from therupture of the cyst into the heart or into one of thegreat vessels, or by erosion of the great vessels bythe inflammatory process of an infected hydatidcyst. A cyst which has become a chronic lungabscess shows the same pathological changes.Pre-Operative Investigations

Careful attention must be paid to the generalcondition of the patient. A complete blood pictureshould be obtained, and any deficiency should berectified. Blood-grouping should be done as inall cases of major thoracic surgery a blood trans-fusion should be set up and running before theoperation actually commences. As the patientwill have to undergo a major operative procedure,

it is important to have information about the stateof the cardiovascular system and an electro-cardiogram should be taken. Rarely, a hydatidcyst in the myocardium may cause bundle branchdefects. Chronic sepsis may lead to myocardialdegeneration.A vital capacity estimation is a routine measure

before any thoracic operation. A low vitalcapacity in a patient who has suffered from pro-longed ill health may preclude a procedure whichinvolves removal of part of a lung. A vitalcapacity of less than 1,500 cc. is a contraindicationto removal of lung tissue as respiratory in-adequacy and cardiac failure may eventuate.

Complete radiographic investigation is of par-ticular significance in hydatid disease. Cases aredivided into two main groups according to theradiographic examination:

(i) The Suspected Cyst. When a rounded shadowin the lung fields is seen the question of hydatiddisease must be considered (Fig. io). Thesecases are often discovered during routine radio-graphic examination, or the patient may have com-plained of some vague thoracic symptom. Manyof these cases are diagnosed by the so-calledspecific tests but most are proved to be of hydatidorigin only at operation. Our experience has beenthat the Casoni skin test and the complementfixation test are both unreliable. In several provencases of hydatid disease the Casoni test has beennegative, whilst in a series of examinations in award 50 per cent. of the patients showed positiveresults without any clinical or radiological evidenceof hydatid disease. Radiographs of other con-ditions are presented to show how difficult thediagnosis of hydatid disease may be.

(2) The Complicated Cyst. A much more certaindiagnosis can be made from the radiographicappearances when complications have developed.The three signs of hydatid disease are (i)Escudero-Nemenow, (2) the 'water lily ' sign and(3) the ' translucent crescent' sign.

If hydatid cyst of the lung is suspected, furtherradiographic investigations are essential in order tolocalize the cyst. On a postero-anterior film a cystmay appear to be in the lower lobe, while a lateralview may show it in the lingular portion of theupper lobe. When the cyst appears to be in thecentre of the lung it may be impossible to decidein which lobe it is situated. The relationship tovital structures must be clearly demonstrated.Careful observation of the patient in differentpositions may demonstrate a cyst which ordinarilywould be obscured by the heart shadow.

Multiple cysts are not uncommon.X-ray examination also shows the state of the

adjacent lung and it is essential in all cases ofhydatid disease of the lung to exclude, if possible,

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the presence of liver hydatid disease. In my ex-perience, complications taking place in a liverhydatid are graver than those in the lung and Iprefer to operate on a pulmonary hydatid cystwhen the liver disease has been adequately dealtwith.

Pre-operative bronchography is essential in allcases. It may be very helpful in the localization ofthe cyst and thus in the planning of the incision.It will show the presence and extent, or absence ofbronchiectasis but it is rarely possible to demon-strate the communication between a bronchus andthe cyst in a complicated case, although apparentabsence of such a fistulous communication doesnot exclude it.

The Principles of Surgical TreatmentSeveral objects must be kept in mind when the

course of treatment is considered. Hydatiddisease of the lung is a serious condition. A fewcases will be cured spontaneously but the majority,if left untreated, will either endanger life or leadto chronic suppurative changes in the lung. Cureis the ideal aim of treatment and usually neces-sitates removal of the offending part. Although itmay be possible to cure the patient of his hydatiddisease, it may be impossible to cure him of allthe symptoms brought about by the disease; hemay, for instance, be left with some residualbronchiectasis after removal of a cyst.

Great care must be taken that spread of thedisease should not result from surgical manipula-tions during treatment.

Treatment aims at restoring the patient to hisoccupation as speedily as possible and all effortsshould be made to see that his convalescence,after surgical intervention, is complete. It is notenough to cure the patient of his hydatid diseasebut leave him with defects due to lack of adequatepost-operative physiotherapy.

Pre-operatively penicillin should be given,starting on the day before operation, ioo,ooo unitstwice daily, this dosage being maintained post-operatively. Recently streptomycin has also beenused.

AnaesthesiaAll surgical treatment in this condition starts as

an exploration and therefore the chosen anaestheticmust permit the surgeon to carry out major pro-cedures if these become necessary. I am con-vinced, after using local and general anaesthesiafor major intrathoracic operations, that a generalinhalational anaesthetic is preferable from everypoint of view.Many surgeons contend that local anaesthesia

has advantages because the cough reflex is retainedand the patient is able to expel the blood or fluid

which has escaped into the bronchi. Usually thepatients have some pre-medication before thelocal anaesthetic, so that the retained cough reflexis diminished. It is important to remember thata patient who is coughing is in a plane of con-ciousness which will also allow him to react tomanipulative stimuli.

Chest surgery has been made easier since theintroduction of. intra-tracheal cyclopropane andoxygen administered through a closed circuit. Thiscontrolled anaesthesia with a high oxygen contentprovides quiet, slow respiration. Straining,heaving respiration is now a thing of the past, asanaesthetists have become skilled in the ad-ministration of anaesthetics for thoracic surgery.With cyclopropane and oxygen the lung can bevirtually motionless. At regular intervals the lungis ventilated while a steady deep anaesthesia withsatisfactory oxygenation and correct carbon-dioxide tension is maintained. Cyclopropane andoxygen form an explosive mixture so that the useof the electro-cautery is not possible.As the anaesthetic is administered through an

intra-tracheal tube, the anaesthetist is able to in-crease the pressure in the lung instantly. If thereis any risk of fluid or blood being aspirated intothe bronchial system, the immediate increase inpressure of the anaesthetic gases will avoid or pre-vent this. The anaesthetist must observe theoperative procedure closely and must co-operatewith the surgeon. He can demonstrate thepresence of a leak or a bronchial fistula by in-creasing the pressures of his anaesthetic gases. Afine hissing sound indicates a leakage which maymean that a suture line is not air-tight. The lungis re-expanded at the end of the operation byincreasing the anaesthetic pressure. It is im-portant to have a fully re-expanded lung so thatno residual pleural space will remain in whicheffusions of blood or serum can collect.

Briefly, the advantages of cyclopropane are thatit can be given with a high oxygen concentration,anaesthesia is rapidly induced, recovery is quickand after-effects absent.

Pre-operative bronchoscopy should be carriedout as a routine before all intrathoracic operationsfor hydatid disease. This manoeuvre ensuressafer anaesthesia as muco-purulent material orremnants of ruptured hydatid cysts can be removedpre-operatively.Operative ProceduresThe diagnosis of hydatid cyst may only be

reached after an exploratory thoracotomy. Whena cystic tumour is exposed or suspected, it must beregarded as a possible hydatid cyst. The sub-sequent surgical treatment must be consideredunder two headings:

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March 1949 PHILLIPS: Surgical Treatment of Hydatid Disease of the Lung 1

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FIG. Ia.--This case was examined for dyspnoea and alarge pleural effusion was found on the left side.There was also a rounded shadow on the right side.The pleural effusion was aspirated and containedtubercle bacilli.

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FIG. ib.-The appearance of the cyst in the righthemithorax following removal of the pleural effusionon the left side. Two months later this cyst wasremoved intact and proved to be echinococcal inorigin. The blood picture showed an eosinophilia;the specific tests were negative. Subsequentlyprogress was uninterrupted and there was no furtherevidence of tuberculous activity.

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IIG. 2.-A hydatid cyst of the lower lobe of the leftlung. presenting in the interlobar fissure. The cystwas complicated by the presence of bronchiectasisand was treated by lobectomy. It had producedsymptoms of cough, sputum and haemoptyses.

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FIG. 3.-A case of hydatid cyst of the lower lobe of theleft lung. This was a complicated cyst and therewas also gross bronchiectasis. Left lower 1, bec-tomy performed; the cyst was found to be lyingbetween the lobe of the lung and the diaphragm.



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130 POST GRADUATE MEDICAL JOURNAL March 194g

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FIG. 4.-Multiple hydatid cysts of the upper zone of theright lung. The fifth rib showed decalcification andenlargement. Case recovered after removal ofcysts and subsequent resection of the rib whichcontained hydatids.

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FIG. 5.-A tumour of the lung suspected to be hydatidin origin as the patient had an eosinophilia, in spiteof negative Casoni and complement-fixation tests.The tumour was aspirated-a measure which theauthor strongly condemns-and the fluid removedcontained torula histolytica.

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FIG. 6.-A case of carcinoma of the lung. at firstdiagnosed as a hydatid cyst because of positiveCasoni and complement-fixation tests. No evidenceof hydatid disease was found in the chest or else-where.

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FIG. 7.-A tumour of the lung believed to be due tohydatid disease because of a positive Casoni re-action. It was impossible to remove the tumourwithout doing a lobectomy. The tumour proved tobe a tuberculoma.



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.1 i.lch 1949 PHILL,IPS : Surgical Treatment of Hydatid Disease of the Lun,tg

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FIG. 8.-This patient coughed up the hydatid cyst. Allthe tests had been positive. Subsequently, theadventitial sac filled with air and she reported fortreatment because of recurrent severe haemoptyses.A right lower lobectomy was carried out.

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FIG. 9a.-Multiple bilateral hydatid cysts. There wzsa marked eosinophilia, but the Casoni and com-plement fixation tests were negative. An ad-venturous house surgeon aspirated the cyst in theupper zone of the left side. Hooklets were found inthe fluid removed and the patient had a severeanaphylactic reaction.

FIG. 9b.-This film was taken after the aspiration of thecyst in the left upper zone. Subsequently, whenthe Casoni and complement fixation tests were re-peated, they were strongly positive.



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32 POST GRADUATE MEDICAL JOURNAL March r949

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FIG. Io.-Calcification in the wall of a cyst of thesuperior mediastinum. The cyst dislocated theoesophagus causing some difficulty in swallowing.All the specific tests were negative. After removal,the cyst proved to be a thyroid adenoma.

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FIG. i Ia.-This patient had a routine radiographicexamination of his chest because of pain in the rightside. The film appeared normal.

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FIG. lib.-This film was taken six months after theprevious film, showing the tully developed cyst. Ashort while later this ruptured into the bronchus.



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March 949 PHILLIPS: Surgical Treatment

i. Removal of the cyst.2. Removal of the lobe containing the cyst." ~

i. Removal of the CystRemoval of the cyst alone is indicated :-(a) for

peripheral and parenchymal simple cysts whichare surrounded by normal lung tissue; removalof the cyst will result in a cure. (b) For com-plicated cysts, where the general condition of thepatient will not allow anything more radicalthan simple removal of the cyst. These cases arerare as usually such patients are toxic, have a lowvital capacity and are not suitable for surgery. Inthese cases removal of the cyst may alleviate thecondition but will not cure it.The patient is placed in the face downwards

position with the affected side slightly raised. Thisposition has been found most useful in prolongedoperations as fewer respiratory difficulties areencountered. When the patient lies in the truelateral position the weight of the mediastinalcontents lies on the sound Itng. The positiondescribed allows access to all parts of the thoraciccavity and less hazards exist if effusion or fluidenter the bronchi. The main disadvantage is thatthe surgeon must be orientated to working frombehind.

The Incision. A long postero-lateral incision ex-tending well forwards should be made over eitherthe fourth rib or the seventh rib. The upper in-cision provides a good approach to the upper lobe,while the lower incision gives access to the lowerlobe. Entry into the pleural cavity should beobtained either after the removal of a length ofrib and incision through its bed, or after an inter-costal incision has been made following on divisionof the posterior ends of two adjacent ribs. Theanaesthetist should be told when the pleuralcavity is about to be opened, so that he may in-crease the pressure of the anaesthetic gas and soprevent a sudden collapse of the lung from thechest wall. If adhesions are present this suddencollapse might well lead to an opening being torninto the cyst.The pleural cavity should be carefully examined

and any adhesions present should be divided withscissors. The lobe containing the cyst is carefullyinspected and the entire pleural cavity can then bepacked off with moist swabs. A peripheral cystmay be situated on any of the lung surfaces, thatis on costal, mediastinal or diaphragmatic surfacesor beneath the surface of the pleura in the inter-lobar fissure. The surgeon may be tempted to tryand remove in its entirety a favourable-lookingperipheral cyst. This may occasionally be possiblebut is usually dangerous, as the cyst may ruptureand thus contaminate the pleural surface.

Decompression of the Cyst. A fine needle, about

of Hydatid Disease of the Lung 133

3 in. in length, is connected up to the suctionapparatus. This is arranged so that the suctionforce is not very great but can be carried on con-tinuously by the application of an adjustable screw-clip to the suction tube. The anaesthetist shouldmaintain very shallow respiration whilst anassistant holds the lobe with swabs with the mostprojecting part of the cyst towards the surgeon.The needle, with the suction apparatus working,

is inserted well into the cyst whilst the assistantmops up any fluid escaping around the needlepuncture with small swabs soaked in io per cent.formalin. When the cyst is nearly empty, suctionis closed off completely. The adventitia is thengrasped with forceps, is incised for about an inch inlength and the entire cyst, with the needle still inposition, is lifted out.The anaesthetist increases the pressure slightly,

and a gauze swab moistened with formalin isplaced in the adventitial capsule which was pre-viously occupied by the. cyst. The swab should bemerely moistened with formalin but should notbe sodden. This swab will help to seal off anysmall bleeding points and will probably kill anyscolices which may have escaped from the cyst.The gauze plugging is left in position for aboutten minutes. The anaesthetist then ventilatesthe lung making certain that a positive pressure ispresent all the while. This prevents any formalinescaping from the moistened swab into the lung ifa fistula be present. Spurting blood vessels mustbe dealt with. If the cyst has ruptured into theadventitial sac, the contents of the sac must berapidly removed, being replaced at once by theformalin swab.

Treatment of the Adventitial Sac. When theswab has been removed, the sac is carefully in-spected. The anaesthetist will be able to provewhether any communication exists with abronchus by increasing the pressure of theanaesthetic gases. If the sac is proved air tightpreparation is made for closure of the operationincision. Fistulous openings must be closed bythe insertion of deep sutures. Non-irritating, non-absorbable sutures should be used. Deknatel orooo nylon on an atraumatic needle is the sututeof choice.

Closure. The adventitial sac should be dustedwith powdered sulphanilamide and after theinsertion of ioo,ooo units of penicillin and 0.5 gm.of streptomycin into the pleural cavity, the in-cision is closed without drainage. This methodhas been used both after lobectomy and after re-moval of cysts without ill effect. The lung is fullyexpanded at the end of operation. The an-aesthetist distends the lung while the suctionapparatus removes air during the closure of theoperation incision. As stated, in these cases there



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is neither drainage of the adventitial sac nor of thepleural cayity. Any seepage of fluid or blood fromthe adventitial sac can escape freely into the pleuralcavity from which it can be aspirated during thepost-operative period.

Post-operative care. Post-operative broncho-scopy should be performed as a routine even if thepatient sounds' dry.' Occasionally a small plug ofmucus will be found. Clinically, the presence of asmall pleural effusion or a residual pneumothoraxis difficult to detect. On the day following opera-tion while the patient is still in bed a film is takenof the chest.

Other post-operative care is as after lobectomy.If the patient is well enough, he should be made tostand out of bed on the second or third post-operative day. Physiotherapy and movementsshould be started early.Three months after the operation a radio-

graphic review including bronchography shouldbe performed.2. Lobectomy

In the majority of cases it is necessary to re-move the lobe in which the cyst is situated. Thisis a relatively safe method of treatment as there islittle risk of contamination of the pleural cavity.Little is achieved by removing the cyst and leavingpermanently damaged lung tissue. Even if thecyst could be easily removed, it is unfair to exposethe patient to a subsequent lobectomy for theresidual bronchiectasis.

Indications :-

(a) Simple cyst associated with bronchiectasis.(b) Simple hilar cyst. It is impossible to re-

move such a cyst with safety.(c) Complicated cyst. In these cases permanent

lung damage is present. The patient who seeksmedical aid because of symptoms produced by ahydatid cyst usually has a complicated cyst andlobectomy is generally necessary.The pre-operative preparations are as above.It is unnecessary for the purposes of this article

to describe the operation of lobectomy which isperformed after the individual ligature of the hilarstructures displayed by dissection. If possible,normal lung tissue can be preserved by performinga segmental lobectomy. This applies particularlyto complicated cysts in the lingular portion of theupper lobe on the left side and to cysts in thedorsal segment of either lower lobe.The post-operative treatment is that of the

standard lobectomy case.Cases of bilateral hydatid disease may require

combined methods of treatment. If a simple cystexists on one side and a complicated cyst on theother, the complicated side should be dealt with

first as there is less risk of complications from thesimple cyst.

Controversial Views(a) Diagnostic pneumothorax may help to decide

whether the cyst arises from within or from outsidethe lung. It is inconclusive, as has been demon-strated by radiographs, and dangerous as it maycause the sudden rupture of a peripheral cyst withall its attendant sequelae. A pre-operativepneumothorax is both dangerous and unnecessary.

(b) Removal of cyst. It is a principle that lungtissue should be preserved if possible, yet there isno rationale in removing a cyst which is infectedand leaving behind lung tissue in which bron-chiectasis is present. A slight degree of residualbronchiectasis exposes the patient to complicationsin the immediate or remote future. In such casesit is better to remove the entire lobe or segment of alobe, thus ensuring rapid convalescence and com-plete cure.

(c) Removal of cyst after overdistension of thelung. South American writers have described atechnique of safe removal of cysts by distendingthe lung so that the cyst projects outside theoperation incision. This technique has apparentlyprovided good results in the cases described but isan unnecessary procedure.

(d) Drainage of adventitial sac. Several methodsof obliteration of the sac have been described.It is none the less unwise because if there isleakage of blood or air into it, the original sac maybe simulated. Free drainage into the pleuralcavity prevents accumulation of fluid or blood inthe residual sac. Aspiration from the pleuralcavity is a simple matter and, with adequate post-operative care, the lung soon re-expands.

(e) Drainage of pleural cavity. Drainage of thepleural cavity is usually unnecessary. Theanaesthetist can demonstrate that no air hasleaked from the lung in cases of removal of a

cyst or in removal of a lobe. Occasionally ifthere is much oozing of blood into the pleuralcavity at operation, drainage into an under-watersystem for 24-48 hours may be necessary. Afterthis the drainage tube is removed.

(f) Fixation of the lung to the chest wall. This isan attempt to keep the lung expanded at the endof operation. This method has hazards as a boutof coughing may tear the lung away from thechest wall and a tension pneumothorax mayensue.

(g) Deliberate formation of adhesions. Attemptshave been made to obliterate the pleural space bythe deliberate formation of adhesions. This hasalso been used as a pre-operative measure, thehydatid cyst being subsequently removed by adirect approach. It is difficult to produce firm

March 1949134copyright.

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March 1949 Miscellaneous Notes 135

generalized adhesions and not infrequently apleural effusion develops.ResultsThe author has treated 22 cases of this disease.

One case was too ill to undergo any form ofsurgical treatment, and one case was untreatablebecause bilateral multiple cysts were present.Sixteen cases of complicated cysts were treated bymeans of lobectomy. Two cases of complicatedhydatid cyst were treated by removal of the cystswith subsequent lobectomies for the bronchiectaticremains. Two cases allowed of simple removal ofthe cysts without removal of lung tissue.These 20 cases were treated surgically without

any mortality.Summary

i. Hydatid cysts are frequently discoveredaccidentally on routine examination.

2. The symptoms in hydatid disease are usuallya result of complications occurring to the cyst.

3. The various types of cysts are described withparticular attention to their origin, number, size,position and condition.

4. Complications in the surrounding lungtissue are outlined.

5. Pre-operative investigations and pre-operativetherapy are described.

6. The best anaesthestic is cyclopropane andoxygen.

7. Lobectomy offers the patient the quickest re-covery with the smallest risk of post-operativecomplications.

8. Treatment by removal of the hydatid cystalone and some controversial surgical methods oftreatment are discussed.

9. Results of treatment of 22 cases of hydatiddisease of the lung are described.

MISCELLANEOUS NOTESThis Section deals with New Drugs, Preparations, Surgical Instru-ments, etc. The description of each article is supplied by the Producer

D.F.P.(DI-ISOPROPYL FLUOROPHOSPHONATE)

BOOTSThe alkyl fluorophosphonates were first described by

Lange and Krueger in 1932. Because of their possibleuse in gas warfare interest in them was renewed duringthe 1939-45 war. Improved methods of preparationwere elaborated by McCombie and Saunders (I946),with particular reference to di-isopropyl fluorophos-phonate, which is the most active member of the series.

PHYSICAL PROPERTIESD.F.P. is a clear, colourless liquid, soluble in organic

solvents but only slightly soluble in water. It can bepurified by redistillation, but aqueous solutions are un-stable and are hydrolysed to the extent of 50 per cent. ini6 hours.

PHARMACOLOGYThe physiological action of D.F.P. results from a

strong inhibition of the enzyme, cholinesterase (Adrian,et al., 1947). In s6me ways, therefore, the drug re-sembles physostigmine but the inhibition by D.F.P. isirreversible and occurs at a much lower concentration.Its action on cholinesterase in blood corpuscles, plasma,the brain and other tissues has been the subject of con-siderable research (Mazur and Bodansky, 1946 ; Mazur,1946). The work of Mendel and Hawkins (1947)suggests that D.F.P. inhibits pseudo-cholinesterasemore readily than true cholinesterase.The anti-cholinesterase effect of the drug is re-

sponsible for the high toxicity. Thus inhalation of aconcentration of I in Io,ooo of D.F.P. for ten minutesproduced Ioo per cent. mortality in rats and mice, andkilled two out of three rabbits within 25 minutes. In

lower concentrations, however, the drug has an effecton the eyes which is of great therapeutic importanceThe pupils become acutely constricted, there is spasmof the ciliary muscle, false myopia and a decrease inintraocular tension, but there is little or no irritation.

INDICATIONSThe therapeutic value of D.F.P. is based upon its

anti-cholinesterase activity. The three conditions inwhich the drug has been used are:-

I. Glaucoma.2. Paralytic ileus.3. Myasthenia gra is.

GLAUCOMAThe use of D.F.P. in glaucoma is described in detail

by Leopold and Comroe (I946). Owing to the in-stability of the aqueous solution these workers employedthe drug dissolved in arachis oil. Three concentrationswere used:-0.05, o.I and 0.2 per cent., according to theindividual response. When a 0.2 per cent. solution wasineffective little was gained by using higher concentra-tions. Patients were admitted to hospital at least 72hours before treatment so that intraocular tensions couldbe watched. The preparation was applied as eye dropssufficiently often to control the glaucoma. It was neverused more frequently than three times daily and in somecases a single application every two or more days wasadequate. Fifty-two patients, representing a total of78 glaucomatous eyes, were treated during a period ofsix months. The results were a considerable improve-ment on those obtained with pilocarpine and/orphysostigmine.McDonald (1946) described a further series of 82

patients (122 eyes) in whom previous miotic therapyhad been of no avail. With D.F.P. the condition



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