Friday Morning, May 31, 1946

9:00 A.M. Scientific Session.

22. Decortication for Tuberculous Empyema.

Fraser B. Gurd, Montreal.

As a result of the performance of a relatively large number of decortications for chronic infected open pneumothorax (chronic empyema) among Canadian soldiers following the first stage of the War, the author has had considerable experience in the performance of this operation in longstanding chronic cases. Although not invariably, it has been found that, even after compression of the lung for several years, removal of the confining membrane has resulted in immediate expansion.

Since the orthodox treatment by extensive thoracoplasty of empyema complicating pneumothorax in cases of pulmonary tuberculosis has been, on the one hand, relatively unsatisfactory and, on the other hand, has inevitably resulted in marked interference with pulmonary function, the author has during the past two years carried out decoortication in three cases of this sort. It has been found possible to remove the membrane from the surface of the lung without undue difficulty and in each of the three cases, although the lung had been compressed for periods of from fifteen months to four years, immediate expansion took place with ultimate healing of the empyema cavity.

Certain technical aspects of the problem require special consideration. The chronic chest cannot be easily spread therefore it is necessary to perform thoracotomy, in stages, so that sufficient room for intrathoracic operation may be obtained. Furthermore, in the chronic chest not only must the fibrous membrane be removed from the surface of the lung but the dissection must be carried towards the hilar region if the maximum expansion of the lung is to be obtained.

23. Lobectomy and Pneumonectomy in the Treatment of Pulmonary Tuberculosis.

Richard H. Sweet, Boston, Mass.

In 1943 Drs. Churchill and Klopstock reported an experience with lobectomy as an elective operation applied in the treatment of six patients with pulmonary tuberculosis at the Massachusetts General Hospital. At that time, although the operative technique had been developed to the point where the operation could be performed with reasonable safety, the indications for its use were not clear and no long time observations of end results were available. It was decided, therefore, to apply the principle of extirpation in a series of suitable cases so as to have available a record of experience upon which to formulate judgment in the future. *

In order to simplify the evaluation of the procedure, reducing the number of variable factors as much as possible, routine post-bbectomy or post-pneumonectomy thoracoplasties have not been performed.

Fifty-seven cases of lobectomy or pneumonectomy have been added to Dr. Churchill's original six cases, making a total of 63 cases. The results to date are presented as an experience with the method in the management of certain types of cases of pulmonary tuberculosis. The tabulation of these results demonstrates in general what types of cases may be expected to do well or badly. Detailed discussion will be confined to the completed paper.

24. Further Experiences in Pulmonary Resection in the Treatment of Pulmonary Tuberculosis.

Richard H. Overholt, and (by invitation)

Norman J. Wilson, and Lazaro Langer, Boston, Mass.

This report shall deal with the experience in approximately two hundred cases of pulmonary tuberculosis treated by resection. These operations were performed between 1934 and the present time. One section of the paper shall deal briefly with late follow-up results in the first ninety-three cases which were operated upon prior to April, 1944. In this earlier group, the patients received general anesthesia and were placed in the classical side position during operation. The major section of the paper shall deal with technical problems and present-day methods. This section of the paper is concerned with a report on the immediate results in the treatment of approximately one hundred patients treated since April, 1944. All of these patients were operated upon under local anesthesia and all except ten of them were placed in a reverse, or face-down position on the operating table. The benefits of both local anesthesia and the face-down position shall be emphasized, and the statistics of this group shall be compared with the earlier group.

25. Cavernostomy.

E. J. O'Brien and (by invitation) P. V. O'Rourke,

F. C. Test, and E. F. Skinner, Detroit, Mich.

Open surgical drainage of tuberculous pulmonary cavities has been reported in the past by several surgeons, but in general the results have not been encouraging.

The authors present an analysis of about 70 cases of cavernostomy for tuberculosis, operated upon in the four years preceding September, 1945.

Three main types of lesion were selected for cavernostomy:

1. Solitary large cavity without acute or progressive exudative disease, in patients with too limited a cardio-respiratory reserve to allow collapse therapy.

2. Large solitary cavity with minimal surrounding infiltration, located in the lower lobe, without active disease of the upper lobe.

3. Residual cavity beneath an optimal thoracoplasty collapse, in the absence of acute progressive exudative disease.

As was to be expected in a group mostly composed of "salvage" cases, post-operative morbidity and mortality were high. Results, however, in groups 2 and 3 especially, were sufficiently encouraging to warrant further evaluation of cavernostomy as a procedure applicable to certain tuberculosis patients unsuited for any other surgical measures.

Friday Afternoon, May 31, 1946

2:00 P.M. Scientific Session.

26. Surgical Removal of Foreign Bodies from the Heart.

(Moving Picture Demonstration)

Dwight E. Harken, Boston, Mass.

27. Cardiac Resuscitation.

Mercier Fauteux (by invitation), Boston, Mass.

The usual methods, (massage, adrenalin, electrical shocks), utilized to resuscitate the heart following cardiac arrest or primary ventricular fibrillation secondary to various causes have been studied in a considerable number of dogs. Even when applied during the brief period of safety which follows complete stoppage of the circulation, they are not always successful in reviving the cardiac functions definitely.

Some of the essential causes of failure are: (1) hyperirritability of the heart, (2) absence of cardiac tone, (3) increase of the myocardial temperature, (4) peripheral circulatory failure.

The value of novocain, barium chloride, cold solutions, and intracardiac perfusions of dextrose, Ringer, and blood to control these causes of failure has been investigated.

The results obtained indicate clearly that these measures, when properly employed and in conjunction with two, usual methods for revival diminish considerably the incidence of failure.

28. Traumatic Diaphragmatic Hernia.

Felix Hughes, Earle B. Kay (by invitation)

and R. H. Meade, Jr. and (by invitation)

T. R. Hudson and Julian Johnson

An analysis is made of twenty-three traumatic herniae, of which four were on the right side. Acute symptoms of obstruction developed in two cases while under observation. Resection of the colon was necessary in one case admitted with evidence of obstruction.

All herniae were repaired by a transpleural approach. This gave excellent exposure of both the abdominal and thoracic organs. The phrenic nerve was crushed in most instances. The chest wall was closed without drainage, except in the case that required resection of the bowel, and no complications occurred.

The possibility of a diaphragmatic hernia occurring in all patients having combined thoracic-abdominal wounds or injuries to the diaphragm should be considered. Since many diaphragmatic injuries occurred during the war, there is the probability that this condition will be seen more frequently in the future.

29. Thoraco-Gastric Fistula Caused by Surgical Mistreatment of Herniated Stomach.

(Report of Two Cases)

G. E. Lindskoo, and E. A. Lawrence (by invitation)

New Haven, Conn.

The authors have had the opportunity of treating two cases in which a herniated intrathoracic stomach had been inadvertently drained surgically (by other surgeons) under the misapprehension that a left pyothorax was present. The first case developed a chronic peptic ulcer at the site of previous catheter drainage, with erosion of an overlying rib and repeated hemorrhage from the intercostal artery. Successful treatment consisted of partial gastric resection, reduction of herniated viscera, and repair of the diaphragm.

The second case presented with a massive pyopneumothorax and gastric fistula following a similar contretemps, was treated by thoracotomy for drainage, jejunostomy for feeding and subsequent reduction and repair of the herniated stomach.

Both cases had a definite history of previous chest trauma, which was the clue to proper diagnosis and treatment. In view of the large number of war wounds of the chest returning to civilian life, it is well to call attention to the possibilities of misdiagnosis in this connection, and the method of handling complications following ill-advised surgical intervention.

30. Congenital Eventration of the Diaphragm: Surgical Management. Case Report.

Dewey Bisgard, Omaha, Neb.

Congenital eventration is a rare condition; at least, it is rarely recognized and probably mistaken in some instances for other lesions which cause dyspnea and cyanosis in infants.

The paper will include a discussion of the literature dealing with this subject and a report of a six weeks old infant with eventration of the right diaphragm which was cured by plication of the diaphragm through an introthoracic approach. Dyspnea and cyanosis present at birth increased so that survival was possible only in an oxygen chamber prior to operation. The infant has remained well and free of symptoms and has developed normally to the present, eighteen months following operation.