Monday Morning, May 31, 1948

9:00 A.M. Business Meeting.

9:30 A.M. Scientific Session.

1. Streptomycin as an Adjunct in Surgical Treatment of Pulmonary Tuberculosis.

Daniel A. Mulvihill, Laurence Miscall, and (by invitation)

Robert Klopstock, Joseph Bitsack, Jamaica, N. Y.

In our experience on the surgical service of Triboro Hospital as illustrated by the series of 85 cases presented herewith, streptomycin has been a most valuable adjunct in the surgical treatment of pulmonary tuberculosis, and has proven efficacious for the following indications:

1. Preoperatively and postoperatively for all pulmonary resections and intrapleural surgery on Tbc patients.

2. Preoperatively and postoperatively for all thoracoplasties considered substandard risks, or with complications such as contra-lateral pneumothorax, diabetes, etc.

3. For acute exudative postoperative spread, where streptomycin has not been used prophylactically.

4. Intrapleurally for pure tuberculous empyema without broncho-pleural fistula.

5. In combination with open Schede thoracoplasty for Tbc-mixed empyema with bronchopleural fistula.

6. In the infected chest wounds and sinuses.

2. The Role of Streptomycin in the Surgical Treatment of Pulmonary Tuberculosis.

P. T. Chapman (by invitation), E. J. O'Brien and

Paul V. O'Rourke, Detroit, Mich.

The paper concerns the marked change in the surgical treatment of pulmonary tuberculosis since the advent of streptomycin. There is a very noticeable decrease in the number of pneumothorax treatments, phrenic nerve operations, etc., in the early stages of the disease, and a striking increase in more drastic procedures such as thoracoplasty and pulmonary resection in those patients with more advanced disease. Many patients with extensive soft disease that need these procedures, but were formerly denied them because the disease was "too hot" can now be "cooled off" with streptomycin and prepared for these extensive procedures early with comparative safety.

The paper deals also with the prevention of spreads and the clearing of them, if they occur, by the use of streptomycin. Many patients with endobronchial disease, blocked cavities, etc., are sufficiently unproved to warrant major surgical procedures. An increasing number of cavities is closed. The mere fact that bronchial ulceration cannot be seen through the bronchoscope does not exclude the possibility of endobronchial disease beyond the field of vision, and excellent results are sometimes obtained in these patients.

The paper also discusses extrapulmonary lesions such as enteritis, genito-urinary disease, lymphatic glands, etc., which often were a contraindication to major surgery. The results of the use of streptomycin in these conditions are evaluated.

3. Experimental and Clinical Studies of the Role of Streptomycin in the Pleural Cavity.

Edward J. Beattie, Jr. (by invitation), Brian Blades

and Charles Horton (by invitation), Washington, D. G.

Observations have been made both in experimental animals and humans on the rate of absorption of streptomycin from the pleura. These studies indicate an extremely rapid absorption rate which might cause toxic effects from too high blood levels when both parental and intrapleural streptomycin are employed. The rate of absorption from scarred and unscarred pleuras seems to vary and has some clinical significance.

4. Results in Pulmonary Resection for Tuberculosis (100 Cases Without Streptomycin Contrasted With 100 Cases Operated With Streptomycin Therapy).

Charles P. Bailey, and (by invitation) Thomas O'Neill

and Robert P. Glover, Philadelphia, Pa.

During the past seven years resections for pulmonary tuberculosis have been increasingly utilized at our clinics. While anesthetic methods and surgical technics have improved steadily during this period, the most important single element in the postoperative mortality and morbidity has been the use of streptomycin. The surgical indications for selection were liberalized during the same period so that progressively more complicated and desperate cases were chosen. Thus the effects of improved anesthesia and surgery were largely neutralized by selection of poorer risk cases. It is believed therefore that the sudden improvement in results appearing with the advent of streptomycin were largely due to its systemic and local inhibition of the tuberculous process.

In the nonstreptomycin treated cases there was an operative mortality of 25 per cent, contralateral spreads 15 per cent, homolateral spreads 3 per cent, bronchopleural fistulae 8 per cent, empyemas 11 per cent, sputum conversions were 62 per cent.

In the streptomycin treated cases the mortality was 14 per cent, contralateral spreads 1 per cent, homolateral spreads 0 per cent, bronchopleural fistulae 1 per cent, empyemas 2 per cent and sputum conversions in 94 per cent of living cases.

5. An Evaluation of Streptomycin as a Protective Agent in Pulmonary Resections for Tuberculosis.

J. A. Moore, Asheville, N. C., J. D. Murphy, Oteen, N. G.,

and (by invitation) P. D. Elrod, Oteen, N. C.

This is a review of 70 cases of pulmonary tuberculosis treated by resection in which streptomycin was used pre- and postoperatively. The mortality rate in the series was 7 percent, with 84 per cent negative sputum. There was an incidence of tuberculous spread of 3 per cent, of bronchopleural fistulae 3 per cent, of empyemata 2 percent with no tuberculous wound infections. The 10 per cent of patients with positive sputum all have bronchial ulcerations and are undergoing treatment for these lesions. It is expected that most of these will become negative when the ulcerations clear. These results are compared with a 50 per cent sputum conversion in most other series before the use of streptomycin. Our indications for pulmonary resection, pre- and postoperative care, and the operative technic employed in this series are given.

We have reviewed the results of pulmonary.resections for tuberculosis now in the literature and compared results before and after the use of streptomycin A brief history of pulmonary resection is given including an analysis of the advances responsible for the marked reduction in tuberculous spreads, fistulae and empyemata.

6. An Anatomic Approach to Segmental Resection.

J. Gordon Scannell, Boston, Mass, (by invitation)

to be introduced by Edward D. Churchill, Boston, Mass.

In recent years the bronchopulmonary segment has assumed the role of the surgical unit of the lung predicted for it by Churchill in 1939. Lingulectomy and separate removal of the dorsal and basal segments of the lower lobes have become standard procedures. Specific segments of the upper and lower lobes have been removed.

Segmental resection as applied to the anterior segment of the upper lobe, and the medial basal segment of the right lower lobe is presented with illustrative > cases. The anatomic features of the bronchopulmonary segment are reviewed and the aforementioned cases, plus the general problem of segmental resection, discussed in the light of recent anatomic investigations in this field.

Monday Afternoon, May 31, 1948

2:00 P.M. Scientific Session.

7. Endobronchial Occlusion During Pulmonary Resection. Preliminary Report. Movie: An Endobronchial Balloon for Pulmonary Resection.

James D. Moody, Durham, N. C.

The control of bronchial secretions during resection for suppurative pulmonary diseases still remains a problem in thoracic surgery. The many attempts at solution, including the subject of the present discussion, have been described in two previous reports (J. Thor. Surg. 16:258, 1947, and J. Thor. Surg. (in press).

Inasmuch as our own instrumental approach to the problem appears to hold some hope of solution, a movie on the mechanics of the instrument will be presented followed by a short discussion of the results of its clinical application.

8. Medullary Pegging of Ribs in Thoracotomy Incisions.

Karl P. Klassen, Columbus Ohio

In posterolateral thoracotomies the pleural space is entered through an incision carried through the periosteal bed of a resected rib or through the intercostal muscles with transection of the adjacent ribs. In both types of thoracotomies postoperative pain is common, the result of operative trauma, overlapping and nonunion of the cut rib ends and excessive callus formation. Depression deformities, thoracic instability and bulging of the anterior segments of the sectioned ribs have followed these types of incisions.

The prerequisite of a good thoracotomy, a pain-free and stable thorax permitting early ambulation, has been met in our experience by the use of an intercostal incision with autogenous medullary pegging of the transected ribs.

The posterolateral incision is carried through the skin and the extrathoracic muscle layers in the usual manner. The sacrospinalis muscle group adjacent to the planned intercostal incision is retracted medially down to the transverse processes. A 1 cm. area of the periosteum is stripped from the adjacent ribs 2 cm. distal to the transverse processes and the two ribs transected, without the removal of a segment. The intercostal nerves are exposed and crushed or injected with novocaine. The intercostal vessels are ligated with a transfixion suture and cut. Transection of two ribs usually gives excellent exposure, although more can be cut should wider exposure be desirable.

On completion of the intrathoracic operation a 4 cm. long, 4 mm. wide, diamond shaped section of the inferior border of the lateral portion of the rib above the intercostal incision is resected superiosteally. The periosteum of this area is closed with interrupted fine silk. The removed section of rib is cut diagonally into two 3 cm. long pointed cortical bone pegs which are inserted for a depth of 1.5 cm. into the medullary cavity of the proximal rib stumps. On approximating the anterior rib segment to the proximal stump, the sharp protruding peg will enter the medullary cavity, locking the rib in place. For additional stability the sacrospinalis muscles are sutured to the sectioned ribs. The intercostal muscles can now be sutured without tension and the extrathoracic muscles and skin are closed in the usual manner.

In a series of fifty posterolateral thoracotomies performed in the last six months using medullary pegging of the ribs, the patients postoperative pain has been minimal and X-ray studies have shown excellent position of the transected ribs.

9. Sputum in Cancer of the Lung: A Study of the Incidence and Causative Factors.

J. R. McDonald (by invitation), Stuart W. Harrington

and O. Theron Clagett, Rochester, Minn.

Several recent studies have shown that it is possible to recognize cancer cells in the sputum of approximately 80 per cent of patients who have cancer of the lung. The present study was stimulated by these investigations.

It was considered desirable to determine how many patients who have a primary cancer of the lung have sputum, and how early in the course of a cancer of the lung sputum develops. Furthermore, the mechanism by which sputum is produced in patients with cancer of the lung has been studied. The basis for this study is an analysis of data concerning 185 patients who underwent surgical resection of the lung for pulmonary neoplasms.

10. Cytology of Bronchial Secretions-An Aid to Early Diagnosis of Lung Cancer.

William L. Watson and (by invitation) Henry Cromwell,

Lloyd Graver and George N. Papanicolaou, New York, N. Y.

An improved method of staining and studying microscopically speciments of bronchial secretion in order to arrive at a positive diagnosis in pulmonary neoplastic disease was first proposed and carried out in June 1945 by Dr. George N. Papanicolaou. Since then an experience covering a series of more than nine hundred cases has accumulated. The proposed paper deals with the clinical and statistical evaluation of this material.

The relative value of sputum specimens as compared with material obtained by bronchial washing and aspiration is discussed. The Papanicolaou classification into five groups and his technics of staining are briefly described. Several pitfalls and early mistakes in diagnosis are pointed out.

Pneumonectomy has been correctly carried out in five instances where the only positive preoperative information was a Class V bronchial cytology report.

A plea is made for the general adoption of the Papanicolaou method, as it sometimes proves to be the only means of making an early and positive diagnosis of lung cancer.

11. Malignant Nature of Bronchial Adenoma.

Alfred Goldman, Los Angeles, Calif.

In several previous reports series of patients with bronchial adenoma with no metastases nor great invasion- of surrounding tissue were observed. During the last two years, six additional cases have been operated upon and one observed at post mortem. Of these six, three exhibited mediastinal metastases, one exhibited unusual invasive qualities, and another had a complete "transformation" of its histology from that of adenoma to squamous cell anaplastic carcinoma with multiple numerous pleural, mediastinal and pulmonary metas-* tasis. Of this group of six hitherto unreported, surgically resected adenomas, all but one exhibited more than the usual invasive and metastastic manifestations. These experiences lead the author to conclude that pathologically, as well as clinically, bronchial adenoma should be considered as malignant. This malignancy is low grade and compatable with long life (20 years). These cases will be described in detail and the histology of the metastases demonstrated.

12. Adenoma of the Bronchus.

Harold Neuhof and (by invitation)

Coleman B. Rabin, New York, N. Y.

Since the first report in 1932 of the features of a group of cases of bronchial adenoma (Wessler and Rabin) varying views concerning pathology and treatment have been entertained. In particular, divergent views concerning treatment have been based upon differences of opinion as to the pathology. In the original description occasional involvement of the tissues beyond the bronchial wall was described and evidence of "malignant transformation" was presented. Subsequently these features have been stressed by others to such an extent that the prevailing opinion amongst surgeons is (1) that the lesion is not completely removable bronchoscopically and (2) that surgical eradication by lobectomy or pneumonectomy should comprise the sole treatment. Some believe the lesion to be actually or potentially malignant, others that nothing but radical operative treatment is permissible because of a high incidence of malignant transformation.

The series studied by the group at the Mount Sanai Hospital now numbers more than 64 certified cases and the follow-up as well as further studies which have been made permit conclusions drawn from long observation and experience. If one of the conclusions takes issue with the uniform application of radical surgery to the problem of bronchial adenoma, a counterargument may be that it is only of academic interest since no mortality and but little morbidity is to be anticipated following lobectomy or pneumonectomy for adenoma with the present-day development of thoracic surgery. In a sense, the argument against taking any chances with malignancy or potential malignancy is particularly strong because most of the subjects for the operation are young and otherwise healthy. However, it is just because the preponderance of patients with bronchial adenoma have many years of life before them that they should not be deprived unnecessarily of large areas of pulmonary tissue and therefore that certain conclusions to be drawn may be of practical import.

Analysis of the pathology of bronchial adenoma in our series (with the exclusion of cylindroma, a separate entity) establishes an incidence of malignant transformation which is less than 10 per cent. It is significant that certain features of malignant bronchial adenomata are unique: (1) the microscopic appearance of adenoma is almost invariably unchanged not only in the tumor but also in its metastases; (2) the latter usually are confined to contiguous lymph nodes; (3) metastases are known to persist essentially unchanged for many years. The term "malignant transformation" applied to adenoma is one of convenience rather than accuracy in view of these three points.

The essentially benign nature of bronchial adenoma is established. Acknowledging that the term "adenoma" is objectionable insofar as true gland formation usually is lacking, the lesion is a distinctive pathological entity. Its features are restated (slide). Formerly confused at times with carcinoma, there should now be no difficulty in its microscopic recognition with adequate material for examination. Features of mixed tumors are not found. Calcification and ossification, as noted in adenomas elsewhere, are seen rarely in bronchial adenoma. Cylindromas, which may be placed amongst mixed tumors, comprise a separate pathological and clinical entity not to be confused with adenoma.

The clinical course of uncomplicated bronchial adenoma is benign, in keeping with slight growth over many years. It remains essentially unaltered in the presence of malignant transformation (slide of case histories with particular reference to long life history of many). The clinical and other features of complicated adenoma such as infection, empyema, etc., will be discussed. Adenoma as a more or less accidental finding will be cited. Reference will be made to the clinical manifestations of adenoma with special reference to "clean" hemoptysis.

The following will be discussed: (1) Incidence of adenoma in main bronchi and in branch bronchi. (2) Incidence of adenoma which does not extend into and that which extends beyond the walls of bronchi. (3) Superficial adenoma which is more common in main bronchi. (4) Methods of recognition of superficial and invasive adenoma.

Noninvasive adenoma of main bronchi is a proven suitable field for bronchoscopic treatment. Repeated biopsy of the base of the tumor after endoscopic removal is essential to prove complete eradication. Report is made of follow-up of 15 cases which establishes the correctness of this statement and report of past errors in selection of cases for bronchoscopic treatment. Report will be made of past errors in performing pneumonectomy for an endoscopically removable tumor (slide).

The discussion will also include variations in appearance of adenoma in branch bronchi; limits of endobronchial visibility; extra-bronchial growth; growth into cavities; operation (lobectomy) the sole treatment for branch bronchus tumors; pneumonectomy indicated for invasive main bronchus tumors, for malignant transformation with metastatic nodes, or for irreversible infection of the lung; question of pneumonectomy under certain circumstances even with known persistence of tumor after opened pathway for drainage of infection; question of lobectomy or pneumonectomy in the aged or poor risk patient when symptoms are neither severe nor progressive (illustration by an operative and a nonoperative case).