Wednesday Morning, June 11, 1941

ROYAL YORK HOTEL

9:00 a. m. Scientific Session.

22. A Method of Treatment of Large Pulmonary Air Cysts (Balloon Cysts) by an Endocutaneous Flap.

A. Lincoln Brown, and (by invitation),

William Brock, San Francisco, California.

Abst. The vast majority of pulmonary cysts either pass unrecognized, or if diagnosed require no therapy. A certain number of cases demand intervention because they become infected, or because through a valve-like bronchial mechanism they become so distended they seriously decrease the patient's vital capacity. The methods of handling such conditions in the past have not been entirely satisfactory. Complete removal of the cyst in one manner or another is often not surgically feasible. The use of sclerosing solutions, tube drainage, etc., is far from ideal. The relatively simple and safe method of treatment of large pulmonary air cysts by the production of an endocutaneous flap was devised and successfully employed.

A review of the rationale of this procedure considering the problem in hand, the pathology involved, the available methods of treatments and the dangers involved is discussed.

23. Cancer of the Thoracic Esophagus and the Upper End of the Stomach: A Review of Nineteen Cases That Have Undergone Surgical Exploration.

H. Brodie Stephens, San Francisco, California.

Abst. Since a report by Dr. Brunn and myself in 1937 upon the successful removal of a carcinoma of the mid-esophagus, twelve additional cases have been explored. In addition there have been six cases of carcinoma of the cardiac end of the stomach surgically explored by the trans-thoracic route.

In the group of 13 cases where the cancer involved the thoracic esophagus only 2 patients are alive today and one of them has probable metastasis. In the group of 6 cases where the cancer involved the cardiac end of the stomach only 2 patients are alive.

One of them had a resection of the tumor with a re-anastomosis of the esophagus to the stomach at a level just below the arch of the aorta (December, 1939). This patient is still alive but has definite recurrence of the tumor. The other member of this group is still alive but has an inoperable tumor.

Of the entire 19 patients there is only one where life expectancy is good. (This patient had a Torek resection in July, 1940. The lymph glands removed with the esophageal tumor were free of metastasis.) For the most part the duration of symptoms is rather short in both groups. Occasionally the duration of symptoms is well over a year and one is left with the impression the tumor might well have been operable save for the long delay before reaching the surgeon.

24. Experiences with Eight Cases of Resection for Carcinoma of the Esophagus.

Dallas B. Phemister (by invitation), Chicago, Illinois.

25. Carcinoma of the Esophagus-Demonstration of Cases.

Harold W. Wookey (by invitation),

Toronto, Ontario, Canada.

26. An Experimental Study of Tubes Made from the Greater Curvature of the Stomach.

B. Noland Carter, M.D., and (by invitation)

Osler A. Abbott, M.D., and C. Rollins Hanlon, M.D.

Abst. There is need for a method of re-establishing the continuity of the gastro-intestinal tract after the resection of a portion of the thoracic esophagus. With this in mind, studies have been carried out on dogs in which long tubes have been fashioned from the greater curvature of the stomach. These tubes have been formed at the first operation through a trans-abdominal approach and left attached at each end as is done in a skin tube for pedicle grafting. In one series of dogs the diaphragm was opened widely at a second stage operation, the tube divided at its pyloric end and led through the thorax to the second interspace where its end was brought out through the thoracic wall. In another series of dogs the tube was divided at its cardiac end and brought up beneath the skin of the thoracic wall. By utilizing a separate stage for the formation of the tube one can be assured of sound healing and good function when the tube is finally placed either within the thorax or beneath the skin.

Wednesday Afternoon, June 11, 1941

ROYAL YORK HOTEL

2 :00 p. m. Scientific Session.

27. Atelectasis and Bronchiectasis.

Joseph Tannenberg (by invitation) and

Max Pinner, New York City.

28. The Use of Sulfanilamide in Resection of the Lung.

Frank Allbritten (by invitation),John B. Flick and

John H. Gibbon, Jr., Philadelphia, Pennsylvania

Abst. Both prophylactic general use of Sulfanilamide in operative procedures and local use of the drug in operative wounds that are potentially infected, have been productive of good results in several fields of surgery. For the past two years we have routinely given sul-fanflamide by mouth, to patients 24 hours prior to lobectomy for bronchiectasis, and to pneumonectomy, with and without suppuration in the lung. In addition, in about one-half of our cases, we have placed from IV to VII Gm. of Sulfanilamide in and about the bronchial stump and the pleural cavity at the conclusion of operation.

This paper is a report of blood, and in many cases, pleural fluid Sulfanilamide concentrations, in a series of four pneumonectomies and twelve lobectomies. In no instance was there a severe toxic reaction to Sulfanilamide, although occasionally minor reactions did occur. In the infected cases, the onset of infection was late and general manifestations were not severe. From this group of patients we have concluded:

1. That operative methods remain the primary factor in the control of infection.

2. When Sulfanilamide is not used locally, the pleural fluid concentration quickly reaches and remains at the concentration in the blood. When Sulfanilamide is used locally, a high concentration results in the pleural fluid in the first 24 hours. In the drained cases, however, it quickly falls to the concentration in the blood.

3. Sulfanilamide delays the onset and decreases the severity of the infection following lobectomy or pneumonectomy, in present treatment of pulmonary infection.

29. Experimental Study of the Effect on Cardio-Respiratory Function of Blood Transfusion Following Lobectomy.

John H. Gibbon, Jr., Philadelphia, Pennsylvania.

Abst. Recently two patients were observed who died ten hours after removal of the right lower and middle lobes for bronchiectasis in whom the left lower lobe had been removed more than a year previously. Both patients were given blood transfusions during and after the operation. At autopsy the remaining upper lobes in both patients were edematous. This paper presents experimental evidence that in animals in which a large part of the functioning pulmonary tissue has been removed, blood transfusion may not only be harmful but may lead to death. The following observations have been made:

1. In a series of acute experiments on cats a sudden marked decrease in functioning pulmonary tissue was produced by removing all the lower lobes and the right middle lobe. The saturation of arterial blood with oxygen was determined before lobectomy, immediately afterwards, and again several hours later. In these control observations the arterial blood was always adequately saturated with oxygen.

2. The above procedure was then repeated, except that the third blood sample was taken after a blood transfusion of either 10 or 15 cc. of blood per kilogram of body weight. In these experiments the third blood sample was markedly unsaturated, and following transfusions of 15 cc. per kilogram body weight, the animals always died. In normal animals receiving transfusions of 15 cc. per kilogram of body weight there was no diminution in the saturation of arterial blood with oxygen and the animals did not die.

3. Measurements of the pressure in the pulmonary artery were made during blood transfusion in normal cats and in cats in which lobectomies had been performed. In normal animals there was only a slight rise in pulmonary artery pressure, while in cats with lobectomies transfusion produced a marked rise in pulmonary artery pressure.

4. In a series of normal cats the lungs were removed and the lobes weighed separately. The weights of these lobes were expressed in percentage of total lung weight and percentage of body weight. The lungs of normal cats which had been transfused were similarly studied. No significant increase in the total lung weight, as expressed in percentage of body weight, was found. In animals with lobectomies but without transfusion there was a moderate increase in the weight of the remaining lobes. In animals with lobectomies followed by transfusion, the remaining lobes were extremely congested and edematous, and greatly increased in weight.

5. We have concluded that, after a marked decrease in functioning pulmonary tissue has been produced by removing lobes of the lung, a blood transfusion, of a size well tolerated by normal cats, is followed by a decrease in the saturation of arterial blood with oxygen and death. The anoxemia is attributed to the pulmonary vascular engorgement and to pulmonary edema. Failure of the right side of the heart does not occur until some time after the anoxemia is marked.

30. Major Changes in the Fundamental Relationships of the Respiratory Drive Mechanisms during Evipal and Pentothal Anesthesia, with Special Consideration of Possible Applications to Transpleural Surgery.

Carl A. Mover (by invitation), Boston, Massachusetts,

introduced by Edward D. Churchill,

Boston, Massachusetts.

31. Observations on the Effects of the Prolonged Administration of High Oxygen Concentration to Dogs.

John R. Paine, (by invitation), Minneapolis, Minnesota.

Four dogs with obstruction of the terminal ileum of 48 to 72 hours duration and four dogs with obstruction of the descending colon of 48 to 96 hours duration were confined in a chamber in which a concentration of oxygen over 95% was maintained. At intervals of 6 to 12 hours the chamber was opened and samples of intestinal gas taken for analysis of the oxygen and carbon dioxide content. After 48 hours all surviving animals were sacrificed.

The results in both groups of animals were similar. Initially the oxygen concentration in the intestinal gas increased to 18-20% and the carbon dioxide decreased to less than 2%. After approximately 36 hours, however, there was a tendency for the oxygen concentration to decrease and the carbon dioxide concentration to increase.

Autopsies were performed on all the experimental animals. These as well as roentgenograms taken before and after the experiment showed that the respiration of over 95% oxygen decreased the amount of gas in the obstructed bowel. On the other hand that in the stomach was frequently increased in quantity.

In two animals that died during the course of the experiment no adequate cause of death could be found at autopsy. The possibility that these animals experienced oxygen poisoning was considered and the following experiments were performed.

Fifteen dogs were subjected to oxygen concentration of 80 to 100% without interruption for 51 to 168 hours. Signs which were assumed to be those of oxygen poisoning occurred in all animals before the experiment was terminated. These were 1) lethargy, 2) failure to eat, 3) dyspnea, 4) slow respiratory rate, 5) retching. Some animals died while others with definite symptoms recovered from an equal exposure. The lower the oxygen concentration the longer was the time required to produce symptoms. All animals that died were autopsied. The gross pathological findings were 1) small and large intestine empty of gas, 2) stomach distended with gas, 3) spleen contracted, 4) coagulated fluid in the pleural cavities, 5) intense congestion of lungs. The microscopic pathological findings were 1) intense congestion of the lungs with an inflammatory type of edema, 2) passive congestion of the liver with central necrosis of liver lobules, 3) contraction of spleen.

The pathological findings varied in degree directly with the concentration of the oxygen and the length of the experiment. Other observations showed that a marked increase occurred in the hemoglobin content and red blood cell concentration of the blood. Dogs that developed severe symptoms of poisoning but recovered were sacrificed 4 to 6 weeks later. No gross or microscopic pathological findings could be detected. Three dogs confined in the chamber for 168 hours with an oxygen concentration of 20% did not develop any symptoms of poisoning. When sacrificed immediately afterwards, no gross or microscopic pathological changes could be detected.