Saturday Morning Session,

June 8, 1940

AUDITORIUM

MEDICAL LIBRARY ASSOCIATION

9:00 a. m. Scientific Session.

11. Individual Ligation Technique for Lower Lobe Lobectomy.

Brian Blades, St. Louis, Missouri.

Abst. A technique involving separate ligation of each anatomical structure in the hilum of the lobe is recommended for lower lobe lobectomy.

The method is based on investigations of the surgical anatomy of the lower lobes and experiences with ten successful cases in which the procedure was employed. Important anatomical anomalies which influence the surgical technique are discussed.

A lower incidence of bronchial insufficiency and associated putrid empyemata are considered the principal advantage of the operation.

The question of the immediate hazard of the method as compared to mass ligation of the lobar hilum cannot be answered without further experience.

Discussion to be opened by John B. Flick,

Philadelphia, Pa.

12. Aseptic Pleural Adhesions Experimentally Produced.

J. J. Singer, John C. Jones and L. J. Tragerman (by invitation),

Los Angeles, California.

Abst. Thirty-nine rabbits were injected into the pleura with the following sterile materials:

(1) Poudragewith (a) iodized talc.

(b) thymol iodide powder

(c) bismuth formic iodide powder

(2) Iodized talc (magnesium silicate) in normal saline

(3) Talc only in normal saline.

(4) Thymol iodide in (a) normal saline

(b) cottonseed oil

(5) Gomenol in cottonseed oil

(6) Bismuth formic iodide powder in normal saline

(7) Sodium morrhuate

(8) Theridol

(9) Graphite in normal saline

(10)Normal saline only

(11)Peptone broth only

Successful production of aseptic adhesions occurred in a majority of instances, particularly with iodized talc in saline. No adhesions were found when beef broth or normal saline solution were injected. The adhesions produced were particularly effective in the fixation of the mediastinum which represents the most vulnerable area of infection following lobectomy. The adhesions responsible for mediainal fixation were usually band-like or diffuse, as were those occurring between the dial phragmatic pleura and the base of the lung. Adhesions occurring laterally between the visceral and parietal pleura were generally fine and string-like. Gross thickening of the pleura was rarely seen.

Many operations on the rabbit have been performed. These include lobectomy, ligation of hilum of lobe of lung, freeing the lung from adhesions, ligation of the pulmonary artery and exploratory thoracotomy. It was found that animals that had been injected and the pleura thickened withstood large thoracotomy wounds better than untreated ones. Most of the animals have had pneumothorax done and several thoracoscopies.

A new method of depositing particulate matter has been developed. This consists of making a suspension of the desired powder in normal saline. Under local anesthesia a pneumothorax is produced under manometric control. 5-10 cc. of the suspension is introduced into the pleural cavity and the animal is rotated in all directions. This permits the distribution of the powder over the entire chest cavity, inasmuch as the saline is rapidly absorbed it leaves the powder spread evenly.

Conclusion:

1. An effective method of producing sterile adhesions has been obtained.

2. Histological studies have been made on the pathway of particulate matter when injected into the pleural cavity and with regard to the mechanism of protection by the procedures employed.

3. The risk of thoracic surgery is reduced by the preliminary treatment of the pleura.

Discussion to be opened by Frank B. Berry,

New York, N. Y.

13. Experiences with Lobectomy and Pneumonectomy in Pulmonary Tuberculosis.

Frank S. Dolley and John Jones,

Los Angeles, California.

Abst. Seven cases are to be reviewed: their course and present condition discussed. Indications that, in the authors' opinion, warrant lung removal; complications that have occurred that might have been materially lessened or obviated; and the technique the authors have found most successful will be described.

Discussion to be opened by John Alexander,

Ann Arbor, Michigan.

14. An Experimental Study of the Fate of the Remaining Lung Following Total Pneumonectomy.

J. J. Longacre, Cincinnati, Ohio, (by invitation),

Ralph Johansman, Cincinnati, Ohio.

Abst. Hyperplastic regeneration of the remaining lung following total ablation of one lung in young mammals has often been recognized and in a few instances these changes have been contrasted with the dilatation of the definite lobules occurring in adult animals. Physiologic studies have shown that immediately following pneumonectomy, the cardio-respiratory reserve is cut in half as the result of the removal of practically fifty percent of the functional diffusing lung surface area. This is still sufficient for resting conditions and moderate exercise. But as the amount of strain is increased the impairment of the cardio-respiratory reserve becomes increasingly more apparent. On succeeding runs two months later there is a tendency for the animals to show less and less embarrassment, due to compensatory changes. Within nine months to one year when subjected to severe and absolute strain animals (pneumo-nectomized as adults) are found to come back only seventy to eighty percent of the way. Animals pneumo-nectomized as puppies show no impairment whatsoever at the end of this period when compared with their normal control mates. These results indicate that the capacity of the organism for further growth accounts not only for the difference in the anatomic changes, but also for the difference in function.

A second group of dogs (some pneumonectomized as puppies, others pneumonectomized as adult animals) have been followed, studied and then sacrificed at various intervals up to six years (actually more than half their normal life expectancy). Observations were made of the changes in intra-pleural pressure as an index of the integrity of the elastic tissue in the remaining lung. Physiologic studies showing the response of the animal to severe and absolute strain were performed. The animals were then sacrificed at various intervals. The lungs were fixed under constant pressure in Bouins fluid and large microscopic serial sections were then made, so as to include a large portion of the cross-sectional area of the remaining lungs. Small sections were also made and stained with differential stains. The findings noted in these sections were then correlated with the changes noted in the physiologic studies.

Discussion to be opened by Charles W. Lester,

New York, N.Y.

15. The Role of Bronchoscopy in the Treatment of Pulmonary Abscess.

Chevalier L. Jackson and A. R. Judd (by invitation),

Philadelphia, Pa.

Abst. The present study of pulmonary abscess constitutes a review of 137 cases seen in the Chevalier Jackson Bronchoscopic Clinic over a period of ten years. Their collection has been based upon the patients' history, the roentgen and laboratory findings. The data has been analyzed with special reference to etiology, duration of symptoms, bacteriological findings, complications, treatment and results. Special attention was given to the bronchoscopic phase of the treatment with a view to correlating this procedure with the problem as a whole. The authors believe that bronchoscopy affords a definite aid not only in the diagnosis and the combined treatment of pulmonary abscess, but also as the principal method in certain cases. It is emphasized, however, that bronchoscopic and so-called non-surgical treatment should not be carried beyond the optimum time for the employment of some other procedure. This optimum point varies in the different patients, and must therefore be quite individualized, but generally it can be determined by concerted consideration of the various aspects of the case when a patient fails to improve within a reasonable time.

Discussion to be opened by Paul C. Samson,

Oakland, California.

1:15 p. m. Luncheon-University Hospital

(Harvey House Dining Room)

Saturday Afternoon Session,

June 8, 1940

AUDITORIUM

MEDICAL LIBRARY ASSOCIATION

2 :00 p. m. Scientific Session.

16. The Differentiation of Bronchiogenic Carcinomas.

Paul W. Gebauer, Cleveland, Ohio.

Abst. 1. Pathologically and clinically small cell carcinoma, adenocarcinoma and squamous cell carcinoma are three fundamental types of bronchiogenicb cancer.

2. The differences of these types early in the course of the disease sometimes permit their distinction by combined clinical, radiologic and bronchoscopic investigations. Late in the disease this is true in approximately 60 percent of cases.

3. Bronchoscopy will be negative in 40 to 50 percent of cases if performed at the onset of symptoms. When negative, it should be supplemented by other biologic, endoscopic, and radiographic diagnostic methods until the cause for symptoms is known.

4. The impression that clinical symptoms tend to occur early, when the tumor is in an operable state, has been gained from this study. Therefore, it is felt, that if diagnosis is made early and there is the proper selection of operative material, surgical treatment will gain a respectable position in therapeusis.

Discussion to be opened by W. E. Burnett,

Philadelphia, Pa.

17. Controversial Points in Anesthesia for Thoracic Surgery.

Henry K. Beecher (by invitation), Boston, Mass.

(Introduced by Edward D. Churchill, Boston, Mass.)

Abst. Discussion of the pros and cons of several disputed points such as intratracheal tube versus gas mask differential pressure; noxious versus harmless effects of ether in pulmonary tuberculosis; bronchial occlusion by balloon tipped catheters during anesthesia; rationale of Crafoord's method of rhythmic positive and negative pressure ventilation; relative status of various inhalation anesthetic agents, etc.

Discussion to be opened by Harry R. Decker, Pittsburgh, Pa.,

and Gustaf E. Lindskog,

New Haven, Conn.

18. The Operative Treatment of Cardiospasm.

Howard K. Gray and I. C. Skinner (by invitation),

Rochester, Minnesota.

Abst. This paper deals with the relatively few cases of cardio-spasm in which operative treatment has been found to be necessary for relief of the condition. In over 1200 cases of cardiospasm seen at the Mayo Clinic operations for the relief of cardiospasm have been performed only seven times. These cases are reported. Mikulicz' operation of manual dilatation of the cardia was performed four times, esophagogastrostomy one time, thorococervi-cal sympathectomy one time, and abdominal sympathec-tomy combined with manual dilatation of the cardia one time. It is our opinion that in those few cases in which the esophagus is markedly dilated, lengthened and tortuous (sigmoid esophagus) with the development of a reservoir below the opening of the cardia, surgery will at times be found necessary. A brief historical resume of cardiospasm from the original interesting description by Thomas Willis in 1674 until the present time is given with quotations from this early article. The etiology, pathology, symptomatology, diagnosis and non-operative treatment of the disease has been considered in a very brief manner. A discussion of the various operative procedures designed for the relief of cardiospasm includes Mikulicz' procedure, transpleural and transperitoneal esophagogastrostomy, the resection of the sympathetic nerve supply to the cardia, Heller's operation of extramucosal cardioplasty and its modifications, esophagoplication, etc. The technique of abdominal esophagogastrostomy is given in detail with illustrations

Discussion to be opened by Edward D. Churchill,

Boston, Mass.

19. The Injection Treatment of Esophageal Varices.

H. J. Moersch, Rochester, Minnesota.

Abst. A review of the subject with the report of a case of esophageal varices successfully injected with sclerosing solution through an esophagoscope will be given.

Discussion to be opened by Edwin J. Grace,

Brooklyn, N. Y.

20. Surgical Aspects of Carcinoma of the Esophagus.

Alton Ochsner, and (by invitation), Michael

DeBakey and Samuel Murray, New Orleans, La.

Abst. Carcinoma of the esophagus has generally been considered a hopeless condition, and until relatively recently the treatment has been palliative. However, a revival of interest in the subject lately has indicated the feasibility of surgical intervention as a means of curative therapy.

In this presentation the authors have reviewed the world literature on the subject of the surgical approach to esophageal carcinoma. The cases in which a surgical procedure was performed in an attempt to remove the lesion are collected and analyzed. Various procedures that have been advocated are reviewed, diagrammatically illustrated, and discussed from the standpoint of advantages and disadvantages. The most desirable procedures in the authors' opinion, for lesions at various levels in the esophagus are considered and illustrated. Three cases of carcinoma of the esophagus operated upon by the authors are reported, One of these patients in whom the lesion was resected and normal function reestablished lived over one year with no evidence of recurrence.

Discussion to be opened by John H. Garlock,

New York City.

21. Esophago-gastrostomy-An Experimental Study.

B. noland carter, and (by invitation),

jean stevenson and osler A. abbott, Cincinnati, Ohio.

Abst. With the background of clinical experience derived from two successful esophago-gastrostomies performed upon patients suffering from cancer of the esophagus, the problems pertaining to the performance of an ideal esophago-gastrostomy were dealt with in the laboratory. Experiments were carried out on dogs to discover the defects and advantages of various types of anastomoses. Clinically, the chief danger of esophago-gastrostomy is leakage at the line of suture and this is most commonly due to tension. A method to obviate tension on the anastomosis has been devised. This consists in anchoring both the stomach and the esophagus to the periosteum of nearby ribs or vertebral bodies. From a clinical viewpoint an important late complication of the operation is stricture, and this point is emphasized in this experimental work.

Discussion to be opened by W. E. Adams,

Chicago, Illinois.