Thursday Morning, June 6, 1940

HOTEL STATLER

Joint Session

American Association for Thoracic Surgery

and

National Tuberculosis Association

Dr. J. Burns Amberson, Presiding,

President, American Trudeau Society.

9:30 a. m. Scientific Session.

1. Forms of Pulmonary Insufficiency Associated with Collapse Therapy.

Andre Cournand, D. W. Richards, Jr., and

Herbert C. Maier, New York.

Abst. In patients with physical disability due to disease of the lungs or restriction of breathing apparatus, three general forms of insufficiency can be recognized: (1) Failure of pulmonary ventilation leading primarily to dyspnea (ventilatory insufficiency). (2) Failure of respiratory gas exchange leading to anoxemia and cyanosis (respiratory insufficiency). (3) Combined failure of ventilo-respiratory and of cardio-circulatory mechanisms, with variable symptomatology. By direct and relatively simple measurements, it is often possible to recognize and differentiate these forms of insufficiency. Two cases are presented, which illustrate different aspects of ventilatory, respiratory, and circulatory insufficiency associated with collapse therapy.

The first case demonstrates the following: (1) the extreme degree of emphysema that may develop in young subjects with chronic pulmonary tuberculosis. (2) The small margin of safety that exists in these cases when treated with pneumothorax. (3) The development of profound arterial anoxemia without accompanying increase in dyspnea. (4) The insidious and variable symptomatology associated with anoxemia. (5) The effect of anoxerm'a in precipitating cardiac failure. In the second case the points of chief interest are: (1) Marked kyphoscoliosis developing in a young subject following extensive thoracoplasty. (2) Physical dysfunction caused by disturbance in mechanics of breathing. (3) Minimal evidence of ventilatory and respiratory insufficiency when the patient was examined under resting conditions. (4) Extreme degree of both ventilatory and respiratory insufficiency during even light exertion, due primarily to failure of the ventilatory mechanism of the chest. (5) Insignificant evidence of cardio-circulatory failure in this case. Detailed measurements of pulmonary and circulatory functions in each case are presented and discussed.

2. Empyema and Unexpanded Lung Problems in Pneumothorax.

E. P. Eglee, R. H. Wylie (by invitation), and

Adrian V. S. Lambert, New York City.

Abst. Discussion of the series of empyemas in the course of pneumothorax met with at Bellevue Hospital and in the Bellevue Clinic during the past five or ten years. An attempt has been made to find out what percentage of pneumothorax cases develop empyema, tuberculous and mixed, and also what percentage are left with an un-expanded lung, and then for which of the above purposes thoracoplasty has been done. There will then be given a brief description of this group of patients, their mortality, the risks, and the complicated surgical problems. The total series will be quite large for the entire group, numbering about 500.

Discussion to be opened by B. Noland Carter,

Cincinnati, Ohio.

3. Hospital Mortality and Life Expectancy of Two Groups of Patients Treated With and Without Collapse Therapy.

B. P. Potter, Jersey City, N. J.

Abst. The author proposes to show the effect of sanatorium treatment supplemented by collapse therapy upon the total hospital death rate and the death rate per new admission, by comparing 1,458 patients treated during the period between 1926 and 1932 when 6.2 received collapse therapy, with 1,619 patients treated in the interval between 1932 and 1938 when 61.2 of the admissions were subjected to one or a combination of the procedures of pneumothorax, phrenic interruption and thoracoplasty. The cases in both groups are divided into three classes: (1) infiltrative and small cavity group; (2) collapse group; (3) group representing such extensive disease as to prohibit any active therapy. The criteria for therapy are as follows: The infiltrative form of pulmonary tuberculosis with negative sputum is treated by the usual rest regimen, unless cavitation or progression takes place during treatment. When, however, a patient presents infiltration, a positive sputum and disputed evidence of cavitation, he is placed in the small cavity group (2 cms. or less) in which, with few exceptions, collapse therapy is favored only after a liberal period of bedrest. Where the cavity is larger, collapse in one of its forms is immediately resorted to unless there are contraindications. The patients in both groups are comparable as to age and extent of disease. The fate of 992 patients subjected to collapse therapy in the period between 1932 and 1938 is demonstrated by comparing conditions of the patients, particularly with respect to the number of deaths, in those, in whom an effective collapse was obtained as against the patients in whom this was not possible. These figures are used as a basis for evaluating the status of the patient in the group treated between 1926 and 1932.

The comparison of the total annual deaths and death rate per new admission in the two periods indicate a definite reduction in the total and per new admission death rate in the later years. It is furthermore argued, that to show a favorable effect of collapse therapy on mortality rate, hospital reports are more accurate and deaths of new admissions and not total deaths per new admission should be the yardstick.

4. Standards and Criteria in Artificial Pneumothorax Therapy.

R. G. Block, W. B. Tucker (by invitation), and

W. E. Adams, Chicago, Illinois.

Abst. In this paper an attempt is made to isolate various standards and criteria to be applied before and during artificial pneumothorax treatment, but especially in judging the final results achieved by it in phthisic-therapy.

1. A review of the pathological forms, distribution of pulmonary lesions, and the symptomatic pictures is offered, in connection with the question of indication. Special reference is made to the problem of simultaneous bilateral pneumothorax.

2. During the treatment the reactions of the pleural membranes are the dominating factor. The significance, for the outcome of treatment, of adhesions, lability of the mediastinal structures, pleural effusion and empyema is discussed. The skilful application of air-collapse alone yields no satisfactory results. The demand for the combination of artificial pneumothorax with carefully supervised rest treatment has to be upheld as of paramount importance.

3. The manner in which the overwhelming number of reports on results of artificial pneumothorax treatment have been made in the literature is largely responsible for an overenthusiasm as to its possibilities in curing tuberculosis. Few reports are based on the cognizance of the fact that a successful treatment means:

a. Restoration of the lung to its physiologic function, i.e., complete re-expansion;

b. Adequate roentgenologic evidence of healing of the tuberculous involvement, especially of the disappearance of cavities;

c. Return of the patient to normal life; with

d. Persistent absence of tubercle bacilli in the sputum;

e. Persistent absence of all symptoms of activity; and

f. Complete disappearance of all extrapulmonary complications.

Only after at least two years of satisfactory application of these criteria should a patient be considered as cured by the treatment.

A distinct line is to be drawn between such final results and initial symptomatic improvement, which is frequent and striking but also often misleading as to the ultimate outcome. The application of stricter standards in judging final results tends to reduce the percentage of "cures" considerably, and has made us more modest in our expectations of the treatment.

We offer a report of our own results to which the above standards and criteria have been applied.

Discussion to be opened by Jerome R. Head,

Chicago, Illinois.

Thursday Afternoon, June 6, 1940

HOTEL STATLER

Joint Session Concluded.

Dr. Adrian V. S. Lambert, Presiding,

President, American Association for Thoracic Surgery.

2:00 p. m. Scientific Session.

5. The Pathology of Cavity Healing.

Oscar Auerbach and Henry Green, Staten Island.

Abst. The true incidence of healed tuberculous cavities is difficult to establish on anatomic grounds at a tuberculosis institution. The vast majority of cases which do come to necropsy at Sea View Hospital are those in which there is a progressive pulmonary tuberculosis with a total duration of less than two years. Therefore the present study, based as it is essentially on postmortem material, is qualitative and directed at the methods of cavity healing, rather than qantitative in the sense of establishing a frequency of healing.

Criteria and Material: There are two sources from which our material could come: (1) those cases in which the cavities undergo healing and death occurs as a result of the complications of chronic pulmonary tuberculosis as amyloid uremia, mixed infection empyema or some cause other than tuberculosis, and (2) those cases in which the tuberculous cavity has undergone healing in one lobe and a progressive tuberculous process is present in the remaining lung parenchyma with resultant death. The latter cases were not included in this report. The only cases included in this study were those where: (1) the sputum examination had initially shown acid-fast bacilli until sputum conversion occurred, after which the sputum examination was persistently negative, and (2) where complete serial X-ray study of the cavity or cavities was available.

We found that healing of the tuberculous cavity occurred in one of two ways: (1) the lumen of the cavity is obliterated-"closed" healing, and (2) the lumen of the cavity remains patent-"open" healing.

Healing by Obliteration of the Cavity Lumen: This type of cavity healing results either in the replacement of the cavity by a scar or in the retention and inspissation of caseated material within the cavity thus filling and obliterating its lumen.

Healing with an Open Cavity Lumen-"Open Healing": The healing of such cavities may occur in the presence of draining bronchi which opens widely into the lumen of the cavity. There are two components to this form of healing: one is the complete shedding of the inner zone of caseation. This manifests itself clinically by the disappearance of tubercle bacilli from the sputum. The other component, which probably goes on simultaneously with the first, is the transformation of the tuberculous granulation tissue of the cavity wall into a non-specific fibrous tissue.

Microscopically there is a gradual transformation of the wall into fibrous tissue at the expense of the specific tuberculous elements. In the case observed there was extensive but not complete epithelialization of the inner wall of the cavities. The epithelium varied from columnar to squamous in character and arose from the draining bronchi.

6a. Intracavitation Studies in Tuberculosis.

Harold Brunn, Sidney Shipman and Alfred Goldman (by invitation),

San Francisco, California.

Abst. Pressure studies, examinations with the cavernoscope and also bacteriological studies of cavities as well as bronchoscopies to determine the character of the bronchi have been made. The conclusions from these studies cannot be fully drawn, but it is felt the method of study is worthwhile presenting. This work follows somewhat the method of Monaldi in Italy, but more careful studies of the process have been made and some few conclusions drawn.

6b. Further Experiences with Blocked Cavities, in Pulmonary Tuberculosis.

Leo eloesser, San Francisco, California.

Abst. Attempts at making a clinical diagnosis of the cause of cavitation in various kinds of tuberculous cavities will be discussed. These include manometric measurements made by needling the cavity, the effect of pneumothorax on cavities, the effect of inspiration and expiration and various postures on the shape and size of the cavity as seen in the X-ray. Experiences with attempts at a cure by needling, aspiration and applying permanent suction drainage will be discussed. A few autopsy experiments will be presented.

Discussion to be opened by Louis R. Davidson,

New York City.

7. Suction Aspiration of Tuberculous Cavities (The Monaldi Procedure).

Edward Kupka and Edwin Bennett,

Olive View, California.

Abst. The idea of direct surgical approach to tuberculous cavities has interested medical men since the seventeenth century. Open surgical drainage has been repeatedly revived only to be abandoned again. Closed cavity drainage, a very recent development, was limited to needling in connection with cavity research until its elevation by Monaldi into an important therapeutic measure. Beginning his work in the spring of 1938, Monaldi introduced safeguards into the procedure of transthoracic cavity puncture, and was the first to employ continuous or intermittent suction over a prolonged period through a catheter draining the cavity.

Mechanical causes play a large role in the formation of tuberculous cavities. Suction exerted at the center of a cavity may correct the mechanical factor, if disease changes in the parenchyma about the cavity have not progressed too far. The suction acts in several ways:

1. Initially, drainage of cavity contents such as pus, blood, detritus and bacilli.

2. Re-expansion of surrounding atelectasis.

3. Reaeration of surrounding areas of exudative infiltration.

4. Compensatory expansion (emphysema) of normal pulmonary tissue within a contiguous area.

5. Finally, holding of cavity walls in close apposition until symphisis takes place.

An open or potentially open pneumothorax space is an absolute contraindication to cavity puncture because of the danger of empyema. To seal the pleural surfaces together, single or repeated injections of the patient's own blood into the pleural space, until repeated pneumo attempts over the area to be punctured with the trocar fail to elicit manometer fluctuations.

A special Y-shaped trocar-cannula, which permits a closed air system connected with a manometer during puncture, and subsequent introduction of the catheter, has been devised. More or less intermittent suction is obtained by a simple two-bottle water pump. An interposed trap catches the secretions. Treatment is continued until the cavity is closed and the catheter spontaneously extrudes, with an upper limit of four to six months.

Success of the procedure depends not only upon the character of the cavity wall but also upon the degree of occlusion of the draining bronchus. The less fibrosis and caseation in the cavity wall, and the greater the degree of bronchial occlusion, the better the chance of cavity closure.

Isolated balloon type cavities between three and eight centimeters in diameter lying in the subclavicular area, with little surrounding parenchymal involvement, offer the most favorable indication. The procedure can be carried out in the presence of contralateral disease or collapse, low vital capacity, and poor general condition. It may be considered as preparatory to thoracoplasty, since cavities may reduce in size, sputum becomes negative, and general condition improve to a point where the major procedure can be done.

Among complications, pyogenic skin infection is frequent but not serious. Hemoptysis at time of puncture is uncommon and slight. Cerebral air embolism is theoretically possible but has as yet not been recorded.

In addition to Monaldi's large series of over 200 cases at the Forlanini Institute at Rome, of which 100 have been reported, Weber of Wilhernina Hospital at Vienna has reported 57 cases. The best documented series is that of six cases of Grass of Berlin. To date these are the only ones to have been published in the world literature, although the procedure is being done in many countries. Because of an insufficient post-operative interval, the ultimate results cannot be evaluated as yet. The Olive View series of 25 cases was begun in September, 1939, and the majority of the cases are still under suction. The results to date are given.

8. Treatment of Fungus Infections of the Lung.

David T. Smith, Durham, North Carolina.

Abst. Many of the pathogenic fungi produce diseases in man which have a higher mortality than tuberculosis. The more common pathogenic species are Actinomyces bovis, Actinomyces asteroides, Actinomyces gypsoides, Actinomyces madurae, Aspergillus fumigatus, Cryptococcus hominis, Monilia albicans, Blastomyces derma-titidis, Coccidioides immitis, Histoplasma capsulatum, Sporotrichum Schencki, Hormodendrum Pedrosoi, Hor-modendrum compactum, Phialophora verrucosa and Monosporium apiospermum.

All of the fungi except the Actinomyces grow readily on dextrose agar or Sabouraud's media. Actinomyces bovis is anaerobic and should be planted on ascitic agar or blood agar and incubated under anaerobic conditions. Potassium iodide orally, sodium iodide by intravenous injections, or ethyl iodide by inhalation is commonly used for treatment. Gentian violet in doses of 5 mg. per kilogram is effective in some types of pulmonary infection with Monilia. Colloidal copper or antimony and potassium tartrate may be used for coccidioidal granu-loma. Sulfanilamide has proven of value in the treatment of actinomycosis.

Many patients with fungis infections become hypersensitive to the products of the infecting organism. The administration of potassium iodide to these hypersensitive patients often results in an exacerbation of the infection. Hypersensitive patients should be actively desensitized with vaccine or extracts before the administration of potassium iodide or other chemical agents.

Discussion to be opened by Owen Wangensteen,

Minneapolis, Minn.

5:00 p. m. A Moving Picture Film Employed for Presentation of Collapse Therapy.

Fraser B. Gurd, Arthur Vineberg and

F. Douglas Ackman (by invitation), Montreal, Canada.

6:00 p. m. Cocktail Party-Wade Park Manor.