Program

All meetings will be held at the Atlanta Biltmore Hotel

9:00 a. m. Business Meeting.

9:30 a. m. Scientific Session.

1. Treatment of Acute Empyema Thoracis by Open Intercostal Drainage: A Report of Fifty-three Consecutive Cases with No Mortality.

Joseph Weinberg, Omaha, Nebraska.

Abst.— Despite the accepted surgical methods of “open” and “closed” drainage of acute empyema, operative results still indicate the possibility for improvement. The method herein described consists of the complete excision of the intercostal and overlying muscles between two ribs for a length of five to eight centimeters. The drainage opening so established is blocked by a tampon formed by rubber tissue packed with gauze, which permits free escape of pleural exudate while blocking ingress of air. The tampon is removed within forty-eight hours and the cavity is then irrigated with Dakin solution, usually without the use of tubes or other drainage material. The method is simple in its application and requires no special apparatus.

Fifty-three cases have been treated in this way, of greatly variant age, type of infection, and physical condition. There has been no mortality, and the postoperative morbidity of consequence is limited to two cases which became chronic, but which eventually recovered, with closure at subsequent operation.

2. Beck’s Operation: Report of two cases in which it was used.

A. L. Lockwood, Toronto, Canada.

3. Wounds of the Heart.

I. A. Bigger, Richmond, Virginia.

Abst.— Sixteen patients with heart wounds have been operated upon in the Medical College of Virginia Hospitals during the last eight years. There were ten recoveries and six deaths. These cases are reported, and an attempt has been made to obtain a late study on the survivors. The follow-up study includes teleoroentgenograms, electrocardiograms, and fluoroscopic examinations as well as physical examinations. The results of these examinations will be reported.

A questionnaire has been sent to the members of the Southern Surgical Association, the American Association for Thoracic Surgery, and the American Surgical Association, in an attempt to arrive at a more accurate estimate of the mortality rate following the surgical treatment of heart wounds. The results of the study of the answers to this questionnaire are included in the report.

4. Carcinoma of the Thoracic Esophagus: Experimental investigation and report of a successful resection with anastomosis of the stomach with the esophagus.

W. E. Adams and (by invitation) D. Phemister,

Chicago, Illinois.

Abst.— An unsuccessful attempt at gastroesophageal resection with reanastomosis in a case of carcinoma involving these organs in March, 1937, was the stimulus for the following experiments: The experiments performed used 35 dogs. In the first group of 24 dogs an anastomosis of the esophagus with the stomach was performed after resection of four to seven cm. of the lower esophagus. In 13 of these fundus of the stomach was brought up through a new opening in the diaphragm for the anastomosis and with the exception of four dogs in which a cutting needle was used, no leak occurred following the anastomosis. Two dogs died of pneumonia. The remainder functioned well and were sacrificed at intervals of 11 days to 6 months. In the remaining 11, the anastomosis was carried out through an enlarged normal hiatus with the open end of the stomach, where the resection was made, being used for the anastomosis. In two of these a continuous suture was used and in both some stenosis followed, one case requiring a lateral anastomosis about the stenosis. These dogs were sacrificed at the end of 11 and 15 week periods. Only one of the other nine was successful, the remaining dying of leak of the anastomosis, pneumonia or pneumothorax.

In the second group of 11 dogs the entire esophagus was mobilized and brought out through a cervical incision. All died in from 2 to 8 days. A second case of carcinoma of the esophagus has been recently operated upon. This patient was a fifty-three year old female complaining of difficulty in swallowing for four months and loss of ten pounds in weight. At operation the approach was through the left thorax after the resection of most of the left seventh rib. The tumor involved the lower two inches of the esophagus. The lower three inches of the esophagus with one inch of the cardiac end of the stomach were resected and with it one involved lymph node at the lesser curvature of the stomach. The opening into the stomach was closed and the esophagus was anastomosed with the fundus of the stomach. The diaphragm was sutured about the stomach remaining in the thorax. The chest was closed with one pezzar catheter.

The post-operative course was practically afebrile. The patient was fed through a gastrostomy tube for the first two weeks. The thoracic wound healed by primary intention. She was allowed up on the 17th day and was taking all food by mouth three weeks following operation. Discharged on the 24th day following operation.

5. Upper Esophagostomy: Its Indications and Uses.

Carl Eggers, New York.

12:30 p. m. Luncheon.

Monday Afternoon, April 4, 1938

2 :00 p. m.

6. Observations on Mediastinal Tumors: A Study of Fifty-two Cases Excluding Aneurysms and Substernal Thyroids.

Evarts A. Graham and (by invitation) Brian Blades,

St. Louis, Mo.

Abst.— An analysis of the type of tumors is made. In twenty-three cases an operation was performed; in practically all other cases the tumor was hopelessly inoperable because of malignant invasion of the thoracic organs. The general management of and the surgical approach to the tumor will be especially discussed.

7. Aspiration Biopsy of the Lung.

J. Samuel Binkley, New York (By invitation).

Abst.— This work in brief, is a review of the subject of aspiration biopsy (needle) of the lung, including a description of technique and indications, as used in the Memorial Hospital. An analysis of 90 cases aspirated for suspected primary carcinoma of the lung during the ten-year period 1927 and 1937 will be presented, with special reference to diagnostic results, complications and relative merits as compared to bronchoscopy. Tables and charts will illustrate the rising curve of successful aspirations for carcinoma; the number of successful aspirations following bronchoscopic failures; and the general percentages of successful aspirations, significant negatives, and proven technical failures.

3:15 p.m. Buses will leave Hotel Biltmore for inspection of Cyclorama of Atlanta, and Barbecue, Druid Hills Club.

(Members and Guests Invited).

Tuesday Morning, April 5, 1938

9:00 a. m.

8. Results of Thoracoplasty Using Extensive Costal Resection Over a Period of Seven Years: Study of Operative and End-Results in 500 Cases.

Edward J. O’Brien and J. C. Day, Detroit, Michigan,

(By Invitation)

Abst.— The study comprises a thorough appraisal of the operative and end-results in over 500 individual cases who have submitted to thoracoplasty in the past seven years. Approximately 300 of these cases have been followed for a length of time varying from two to five years following the completion of their thoracoplasty. The incidence of recurrence of disease on the thoracoplasty side has been thoroughly studied in this out-patient group. A large number of these patients are now working and it has been the purpose of this study to determine how well such cases stand up over a period of years after they have been released from the hospital.

9. Tension (Giant) Tuberculous Cavities: Pathogenesis, Mehanics and Surgical Management.

Pol N. Coryllos and G. G. Ornstein, New York.

Abst.— Older authors have designated as “vomicas” tuberculous cavities which grow larger and more spherical in shape than ordinary cavities and present peculiar changes in their size in the course of the disease. They increase and decrease in size within a relatively short time without any marked changes of their walls and the surrounding parenchyma. Their development does not seem to depend upon the progressive aloughing out of the parenchyma of the lung.

These cavities have recently been called “blocked cavities” and “check valve cavities.” It is believed that the principal character of these cavities is that they contain air under positive pressure and that this air is richer in oxygen and poorer in carbon dioxide than the alveolar air.

The investigation of these cavities was carried on with the following methods:

1. Direct study of these cavities by an optical instrument introduced into the cavity, especially designed for that purpose and called a “cavernoscope.”

2. By serial gas analysis of the air contained in them.

3. By injection of contrast media into the cavities through the chest wall and radiographic follow-up.

4. By careful study of the pathologic specimen.

5. By surgical attempts to close such cavities by direct action upon the intra-cavity orifices of their draining bronchi; either by injection of sclerosing chemical substances around these orifices before collapse treatment or by applying upon them a muscular flap (procedure analagous to that used in ordinary bronchial fistulae) when pneumothorax, extensive thoracoplasties and reoperations have failed to close these cavities and convert the sputum.

The conclusions we have arrived at can be summarized as follows:

1. Tension cavities are formed when the draining bronchi of ordinary tuberculous cavities become narrowed so that air can enter them during inspiration but cannot be completely eliminated during expiration; thus a valve mechanism is formed and “obstructive emphysema” is developed in the cavity.

2. That these cavities although they may appear intermittently “blocked” are really open cavities, as is proved by gas analysis.

3. The “valve mechanism” formed by the narrowed and irregular draining bronchi is enhanced and maintained by the positive pressure built up into these cavities and it is totally or partially released when the pressure becomes atmospheric or negative.

4. That the only way to obliterate these cavities and bring about their “cure” is the complete and permanent obliteration of their draining bronchi (atelectatic shrinkage).

5. That there is no danger of the development of septic phenomenan following closure of their bronchial outlets and subsequent accumulation of secretion because the contents of these cavities show no pyogenic microbes.

6. Pathological material of cavities treated by plugging with pedunculated muscular flaps present special interest and throw a new light upon the pathogenesis, biology and treatment of “tension cavities.”

10. Extrapleural Thoracoplasty: Further Experiences with the Multiple Stage Muscle-Splitting Operation.

Jerome R. Head, Chicago, Illinois.

Abst.— An operation is described in which the full length of the ribs are removed through multiple small muscle-splitting incisions. The operation was devised for and first used on the veterans of the Edward Hines Hospital in May-wood, Illinois.

Its chief advantages are:

1. The marked lessening of post-operative reaction.

2. The very gradual production of the collapse.

3. The preservation of the muscles of the shoulder girdle.

11. Thoracoplasty for Tuberculosis and Chronic Empyema Through Short Incisions: Experiences with a New Method of Rib Removal.

Owen W. Wangensteen, Minneapolis, Minn.

Abst.— The writer has found that complete or subtotal costectomy may be performed through short anterior and posterior incisions. The basis of this operative procedure is the direction of insertion of the external intercostal muscle bundles to the rib. Through an anterior transverse incision five cms. in length the intercostal bundle may be separated from the lower border of the rib as far posteriorly as its angle with employment of an appropriate periosteal stripper. Three or four ribs may be divided and dealt with in this fashion—short anterior segments of rib (two or three cms.) and the corresponding costal cartilages (if desired) being removed. Five to seven days later, these same ribs are divided posteriorly through a vertical incision about ten cms. in length and the attachment of the intercostal muscle bundles along the superior border of the rib is detached in the same manner. By plying the stripper alternately along each surface of the rib and by gentle pushes of a sponge on a long hemostat, the accessory muscle attachments, such as of the serratus anterior or pectoralis minor, are loosened and the entire rib can be removed. If the scalenus anticus attachment to the first rib is removed at the time of the anterior operation, the first rib may be removed also in this manner. A great advantage of this method of rib removal in large chronic empyemas is that the cavity may be obliterated without excision of the thickened parietal pleura. Total empyema cavities have been dealt with successfully in this manner in three stages: the second, through the tenth ribs being divided and separated from their periosteal beds on their lower surface through three short anterior incisions in one stage; the tenth, through the first ribs are divided and removed through two subsequent posterior procedures. The indications, technique and the results obtained with this method of rib removal will be related.

12. Results and Complications of the Apicolysis Thoracoplasty.

Joseph Gale and W. H. Oatway, Jr.

Madison, Wisconsin.

(By Invitation)

Abst— Much discussion has been aroused by the work of Semb on extrafascial apicolysis. The results obtained by different surgeons have varied a great deal and the opinions of its value and advantages over thoracoplasty are still unsettled. In this paper the authors will give their experience with this procedure covering a period of two years and one hundred cases. The indications, type of lesion and advantages will be discussed. The pre- and post-operative care, extent of the operation, alteration in technique, complications and dangers are worthy of consideration. The results have been determined by the percentage of cavity closures, sputum conversions (gastric aspiration), and mortality. The value of post-operative compression is well-established and is particularly applicable to these cases.

13. Myoplastic Thoracoplasty.

Ethan F. Butler, Ithaca, New York.

Abst.— One of the present trends in thoracoplasty is toward an extensive separation of the pleural cupola from its cervical attachments. Advantages gained in cavity closure may be offset by disadvantages of the resulting “dead-space.” An operation is here described whereby the dead-space is minimized, and is filled at time of operation, by viable transplanted tissue. Through a lateral incision the two pectoral muscles are separated from their respective insertions into numerous and coracoid, without interfering with their blood and nerve supply. The second and third ribs are completed resected. The apex is freed and dropped, with the decostalized chest wall, to any desired level. The pectorals are then inserted across the top of the pleura, into the posterior chest wall. Such subsequent stages as may be necessary conform to conventional patterns. Experiences in ten or more cases are reported.

12 :30 p. m. Luncheon.

Tuesday Afternoon, April 5, 1938

2:00 p. m. Executive Session.

2:30 p. m. Presidential Address.

Stuart W. harrington, Rochester, Minnesota.

Hiatus Hernia of the Diaphragm.

14. Extrapleural Pneumothrax.

Ronald Belsey, F.R.C.S., London, England.

(By Invitation)

Introduced by J. E. H. Roberts, London, England, and

Edward D. Churchill, Boston, Massachusetts.

15. Lobectomy and Pneumonectomy in Pulmonary Tuberculosis.

John C. Jones, Los Angeles, California.

Abst.— Indications for partial or total resection of a lung for tuberculosis will be discussed and experiences with and results of operated cases presented, along with the surgical specimens.

16. Tuberculosis of the Bronchi Complicating Pulmonary Tuberculosis: Its Effect Upon Closure of Pulmonary Cavity.

H. McLeod Riggins, New York.

7:30 p. m. Annual Dinner, Atlanta Biltmore Hotel.

(Members and Guests Invited).

Wednesday Morning, April 6, 1938

9:00 a.m.

17. Bronchopleural Fistulae Complicating Pulmonary Tuberculosis: A Clinical Pathological Study.

Oscar Auerbach and Samuel Lipstein, New York.

(By Invitation)

Abst.— In 950 consecutive autopsies of chronic ulcerative tuberculosis performed at the Sea View Hospital, New York, bronchopleural fistulae occurred in 75 cases (7.9%). These cases of fistulae were divided for study into those developing in previously uncollapsed lungs and those developing in artificially collapsed lungs. In the latter group 6 cases followed closed intrapleural pneumonolysis. A careful study of the various types of fistulae and of their pathogenesis is presented.

18. The Operative Correction of Pectus Excavatum: Report of a Case and Review of the Literature.

Alton Ochsner, New Orleans, La.

Abst.— A brief history of pectus excavatum is first given. This is followed by a discussion of the etiology, general manifestations, complications, with comments upon the operative indications as based upon all the collected cases recorded in the world literature.

The various types of operative procedures advocated are reviewed in detail accompanied by illustrations with general comments on their comparative value. The postoperative complications and the operative mortality are also’ discussed and illustrated graphically.

A case of rather severe pectus excavatum in a white female, twenty-one years of age, is presented. The patient was first seen in May, 1937, and complained of chest pain, dyspnea on exertion, and other manifestations characteristic of this condition. On May 23, 1937, the operation, consisting of excision of a small section, approximately 1 cm. to 1 ½ cm. in length, of the second to the ninth costal cartilages, inclusive, on both sides at a point about 1 cm. from the chondrosternal attachment was performed, thus permitting the sternum to be mobilized anteriorly. The sternum was held in this position by means of traction applied to a Parham-Martin band placed around the body of the sternum. Postoperative course uneventful.

Patient last seen in November, 1937, and was found free from all previous complaints with disappearance of chest deformity.

19. Late Results of Lobectomy for Bronchiectasis in Children.

John V. Bohrer and (by invitation) Chas. W. Lester,

New York.

Abst.— Pediatricians and surgeons are quite well agreed on the management of the minimal and far advanced cases of bronchiectasis but this agreement does not hold for the cases in the intermediate group. The pediatrician particularly wants to know about the condition of the remaining lung tissue after lobectomy, the general development of the child, the effects on the vascular system, the question of postural deformities as well as the late morbidity and mortality.

This paper will report a follow-up of the cases that were reported to this Association in 1934, together with all other cases that have been operated on since that time, amounting to approximately ten in number, all children. It will also present data from a larger number in the middle group who have not been operated upon but have been under constant medical care, showing their present status, the mortality and the morbidity. Such follow-up data as may be found in the literature, and particularly the information that may be derived from an anatomical and histological study of autopsied cases, as well as any helpful experimental findings, will be included.

20. Mechanics of Pulmonary Abscess and Bronchiectasis with Suggested Method of Treatment.

Minas Joannides, Chicago, Illinois.

Abst.— 1. Pulmonary abscess and bronchiectasis are the end results of a specific infection of the lung (fusospirochetes).

2. The acute stages are clinically similar to the pneumonia produced by pneumococcus type and other pyogenic types or organisms.

3. Instead of a resolution and clearing up, process goes on to putrefaction and abscess formation.

4. Routine examinations of the sputum for fusospirochetes in all cases of pneumonia will aid in the recognition of this type of infection and proper steps may be taken to abort abscess formation.

5. Neoarsphenamine and sulpharsphenamine in doses of 0.3 gms. to 0.6 gms. every 2-3 days will be of material aid.

6. Promotion of drainage of the lung by inhalations of oil of eucalyptus or gomenol aids in a more rapid healing of lung by preventing atelectasis of the lung and promoting the closure of cavities.

7. Proper handling of these cases during the early stages causes complete disappearance of any changes visible in the x-ray, except for occasional increase in fibrous tissue of the lung.

8. Artificial pneumothorax in the treatment of this disease is definitely contraindicated because it promotes atelectasis of the lung and causes the extension of the infected exudates into uninvolved portions of the lung.

9. Surgical interference may be prevented in a large number of cases by discovering these cases during the early stages of the disease.

21. Cinefluoroscopic Studies of Peculiar Breathing and Chest Motion.

Otto C. Pickhardt, William H. Stewart,

Grant Thorburn, New York.

Wednesday Afternoon, April 6, 1938

Arrangements for Golf and Skeet Shooting

Papers to be Read by Title

1. Bronchial Obstruction as an Etiologic and Perpetuating Factor in Empyema.

C. L. Jackson, Philadelphia, Pa.

2. The Significance of Scoliosis in the Differential Diagnosis of Intrathoracic Conditions.

W. Dewitt Andrus and Cranston Holman,

New York.

3. End Results of Foreign Body Injuries of the Heart and Pericardium.

Ryerson Decker, Pittsburgh, Pa.

4. Gunshot and Stab Wounds of the Thorax.

Carl Steinke, Akron, Ohio.

5. Disease of Aberrant Intrathoracic Lung Tissue.

Samuel O. Freedlander, Cleveland, Ohio.

6. Nodular Lesions of Pulmonary Tuberculosis and Their Confusion with Tumors of the Lung.

Donald King, Boston Massachusetts.

7. Pulmonary Lesions Resulting from First Infection with the Bacillus of Tuberculosis.

W. S. Lemon, Rochester, Minnesota.

8. Extrapleural Thoracoplasty for Pulmonary Tuberculosis: A General Hospital Resume.

Herbert Willy Meyer, New York.

9. Extrapleural Thoracoplasty in Presence of Contralateral Pneumothorax: A Study of 100 Cases.

William M. Tuttle and (by invitation) J. P. O’Connor,

Detroit, Michigan.

10. Has Thoracoplasty a Place in the Treatment of Acute Progressive Pulmonary Tuberculosis?

Herbert Meltzer, Ninette, Manitoba, Canada.

11. A New Technique for Phrenic Crush.

Louis Wallace Frank, Louisville, Ky.

12. The Immediate Effects of Scaleniotomy Upon the Size of Apical Cavities.

John H. Gibbon, Jr., Philadelphia, Pa.