Wednesday Morning, May 29, 1946

9:00 A.M. Business Meeting.

9:30 A.M. Scientific Session.

1. The Management of Thoraco-Abdominal War Injuries.

Reeve H. Betts, Boston, Mass.

One of the most outstanding achievements of the Army Medical Corps .during World War II was the reduction in mortality rate for thoraco-abdominal injuries from 50 to 60 per cent, as it was in the First World War, to a level comparable to straight abdominal injuries. This achievement was the result of the application of the principles and practices of civilian thoracic surgery to states produced by missiles instead of diseases. These principles and practices include: adequate anesthesia; the application of the trans-diaphragmatic approach for repair of upper abdominal lesions; amelioration of disturbed cardio-respiratory physiology, pre-operatively; provision for adequate blood-replacement therapy before, during and after surgical repair of the injury; and the realization of the importance of maintaining a clear tracheobronchial airway at all times.

During a thirty-month period in the Mediterranean Theater of Operations, fifty-one patients with thoraco-abdominal wounds were treated by the author. Of this group, forty-eight were operated upon and form the basis of this report. The mortality rate, including both early and late phases, in so far as follow-up studies were possible, was 22.9 per cent.

The author, also, was one of a group of four thoracic surgeons who reviewed the 903 thoraco-abdominal injuries treated by the Second Auxiliary Surgical Group. Some of the impressions gained thereby are incorporated in this report.

2. Crushing Injuries of the Chest.

Ross Robertson, Vancouver, B. C.

The types of crushing injuries of the chest as seen in the Royal Canadian Air Force during the war will be discussed. Death from such injuries were due to hemorrhage, cardiac tamponade or respiratory failure from mechanical asphyxia. Of these, cardiac tamponade was found to be the commonest preventable cause of death.

A clear understanding of the underlying pathological process was essential for proper treatment. Any of the following conditions could be present in an individual case: -hemothorax, tension pneumothorax, massive atelectasis, mediastinal hematoma, mediastinal emphysema, hemopericardium, diaphragmatic hernia and air embolism.

Hemothorax was aspirated only if cardiac tamponade was present and then only in amounts sufficient to relieve pressure symptoms.

Cardiac tamponade from a tension pneumothorax was relieved by water seal intercostal drainage. If due to massive atelectasis pneumothorax was induced to relieve the great negative pressure and later the bronchial obstruction cleared.

Cardiac tamponade from hemopericardium was relieved by aspiration,-from mediastinal emphysema by incision in the neck, -and from herniation of viscera through diaphragmatic defects by thoractomy repair.

Two cases illustrating most of the above conditions will be presented.

3. The Pathology of Chronic Hemothorax.

Hiram T. Langston, Chicago, HI.

and William M. Tutttle, Detroit, Mich.

Experience has shown that all too frequently a traumatic hemothorax is not reducible by thoracentesis. This is so, because of clotting of the pleural content. The important element responsible for this solidification of the pleural content is fibrin, from whatever source it may come. The pathogenesis of this condition is not clear, but accumulated evidence suggests that the best explanation lies in the response made by the pleura to the inciting trauma and irritating blood. This seems to be the adequate source of fibrin. The clot precipitating substances may be supplied by the wounded tissues.

Once dotting has occurred, organization follows exactly as in the case of intravascular thrombi. It is believed that minimal degrees of this process are seen, manifested chiefly by slow pulmonary expansion hi cases where traumatic pneumothorax is the predominating clinical entity. This may be referred to as "deforming adhesive pleuritis." Neglected, gross, organizing hemo-thorax will become a fibrothorax, or will eventually suppurate. This delay in suppuration is occasioned by the time required for organization of blood vessels to proceed into the fibrin mass sufficiently far to allow the leucocytes migrating from, this point to accumulate in sufficient numbers to be recognizable as pus. Obviously, neglect of this situation, or procrastination in treatment until suppuration has occurred, allows for such advanced organization along the visceral pleural surface that the lung or the involved portion thereof is encased in a cuirass of fibrous tissue so dense that expansion is not likely to ever occur, and a persistent infected intrathoracic space is the result.

4. The Treatment of Organizing Hemothorax by Pulmonary Decortication.

W. M. Tutttle, H. T. Langston and (by invitation)

R. T. Crowxey.

The study to be presented relates experiences in the use of pulmonary decortication in the treatment of chronic organizing hemothorax of the sterile and infected types.

Decortication is an old operative procedure which because of the poor results obtained was discarded after a relatively short-period of use. Its revival during the past war and its application to the treatment of organizing hemothorax has given uniformly good results.

Decortication was carried out in approximately one hundred and fifty instances. There were no operative deaths.

In this series approximately 25%of the patients treated had a grossly infected hemathorax. The lungs reexpanded in all instances and there were no chronic empyemas.

Its use in the uninfected hemathoraces resulted in the reestablishment of a more normal pulmonary function.

Results of the operative procedure are discussed and its usefulness appraised.

5. Total Pulmonary Decortication: Its Evolution and the Present Concepts of Indications and Operative Technique.

Paul C. Samson, Oakland, Calif, and (by invitation)

Thomas H. Burford, Mokane, Mo.

This paper will trace the origin and development of the operation known as decortication. Contributions of the surgeons responsible for its evolution will be cited. Based primarily on extensive experience with organizing hemothorax and its infections, complications following war wounds of the thorax, the authors will present the present indications for and the technique of total pulmonary mobilization by decortication.

Consideration will be given the uses of this operation in civilian surgery and its application to the treatment of total empyemas other than those complicating a hemothorax.

Wednesday Afternoon, May 29, 1946

2:00 P.M.

6. Thoracic Neoplasms in Navy Personnel.

William Law Watson, New York, N. Y.

This report is based on clinical material studied and treated on the Tumor Service of the United States Naval Hospital, Brooklyn, New York during the years 1943, 1944, and 1945. 746 cases of cancer and other allied diseases were admitted during this period and of that number there were thirty-four in which the primary growth was located in the thorax.

Eight patients with mediastinal Hodgkin's Disease and two with malignant thymoma were treated by radiation measures. A group of twenty-five patients with benign or malignant thoracic growths was treated surgically. Of this latter group fourteen patients had silent tumors discovered by chance roentgenography. This group is studied in detail.

Each case will be demonstrated by means of lantern slides showing the preoperative and postoperative chest radiographs together with slides in color showing the gross specimen removed at operation and a photomicrograph depicting the histopathology of each lesion.

7. Pulmonary Cysts.

Herman J. Moersch, Rochester, Minnesota.

Forty-four consecutive cases of surgically proven pulmonary cysts have been reviewed. In each instance tissue was removed for microscopic examination. For purposes of study the cases of pulmonary cyst were divided into three groups. The first group consisted of twenty-five cases, and in this group the cysts were lined with an epithelial lining and the walls contained cartilage, muscle, glands and other bronchial elements in varying degree. These were classified as broncbiogenic cysts. The second group, consisting of eleven cases, had all the characteristics of the first group but the epithelial lining had been destroyed or altered by secondary infection. The third group, comprising eight cases, had marked localized dilatation of .the bronchi and were designated as cystic bronchiectasis.

The group consisted of twenty-four males and twenty females. The youngest patient was seven years of age-and the oldest, fifty-eight.

A review of the case histories would seem to indicate that pulmonary cysts are not always congenital in origin and that pulmonary infection is often an important factor in their development. One case of cystic bronchiectasis is presented which clearly demonstrates the rapidity with which cystic changes hi the lung may develop.

Cough, expectoration, hemotysis and pain were the most common symptoms associated with the cases included in the present study. In seven of the forty-four cases the pulmonary cyst was found accidentally. Although the clinical history should cause one to suspect the presence of an infected pulmonary cyst, the difficulty in diagnosis is well illustrated by the fact that in twelve of the cases the condition had been previously misinterpreted.

The majority of the cysts were found to be single. The right lung was more frequently involved than the left lung. Roentgen examination was found to be the most valuable adjunct in the diagnosis of pulmonary cyst, although errors in interpretation were not uncommon. Bronchoscopy and bronchographic studies were generally found of very little value in differential diagnosis except in the cases of cystic bronchiectasis.

Infected pulmonary cysts, which are invariably associated with clinical symptoms, should be promptly removed, not only for local reasons but also because they may exercise deleterious effects upon other organs.

In addition, in two of the cases carcinoma was found to be present in the wall of the cyst. The question presented itself as to whether or not the cystic changes were secondary to the carcinoma. The clinical history would seem to indicate that the carcinoma occurred secondarily in the cyst. Although surgery is the procedure of choice in the treatment of pulmonary cyst, the fact that carcinoma may develop in such a lesion makes it more imperative that surgery be undertaken as soon as feasible. The results following surgical removal of pulmonary cysts are found highly satisfactory.

8. Report of the Chest Tumor Registry.

J. E. Ash, Col. M. C. Curator, Army Medical Museum.

9. A Report of 194 Lobectomies Performed at Kennedy General Hospital, Chest Surgical Center-1943-1946, with One Death.

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

E. B. Kay and Felix Hughes, Memphis, Term.

Although the majority of patients admitted to Kennedy General Hospital, Chest Center, were battle casualties their treatment presented few problems, due to the excellent care given them overseas. The bulk of the operative work was done for bronchiectasis and other non-military indications. From November 1943 to March 1946, 194 lobectomies were performed by the staff, with one death. Three surgeons performed most of the operations but a number were done by three others. Empyema developed in 8% of the cases. Discussion will be given of the indications for operation and of the management of the patient before, during, and after operation.

10. Pulmonary Function After Adolescence Following Pneumonectomy in Childhood.

Andre Cournand (by invitation), and

Charles W. Lester, New York, N. Y.

Five years ago we reported on the pulmonary function in a group of three children each of whom had undergone pneumonectomy two to four years previously. We have continued to observe these children and have added a fourth who falls in the same category. They have been studied with regard to lung volumes, maximum breathing capacity and ventilation, breathing reserve and respiratory gas exchange as was done in the first report. In addition observations have been made on cardiac output and pressure in the right ventricle using the technique of right heart catheterization. These studies indicate that there has been no development of pulmonary emphysema nor cor pulmonale and that the cardio-respiratory function has continued good during the growth of the child through the years of adolescence.

5:00-6:00 P.M. Cocktail Party-Hotel Statler.

(Members and invited guests)