Wednesday Morning, June 2, 1948

9:00 A.M. Scientific Session.

24. Chronic Atelectasis and Pneumonitis of the Middle Lobe.

Donald L. Paulson and Robert R. Shaw, Dallas, Tex.

Thirty-one patients having chronic atelectasis and pneumonitis of the right middle lobe for periods varying from five months to twenty years have been studied. Twenty-seven patients were subjected to right middle lobectomy. In all instances the middle lobe was either partially or completely atelectatic. A review of the symptomatology and the findings by roentgenogram, bronchoscopy and bronchography reveals a characteristic diagnostic pattern on the basis of which the diagnosis can be made preoperatively with a high degree of accuracy. The characteristic pattern of this type of middle lobe disease justifies its separation as a clinical entity and stimulated our making this report.

The bronchial obstruction producing the atelectasis was due to extrinsic pressure by enlarged lymph nodes in eleven patients and by calcified lymph nodes in seven patients. In two instances the obstruction was due to foreign body reaction in the bronchial wall. In seven patients the bronchial obstruction was apparently due to bronchial changes secondary to pneumonia. The pathogenesis of chronic atelectasis and pneumonitis of the middle lobe will be discussed.

25. Surgical Management of Pulmonary Coccidioidomycosis in Focalized Lesions.

Sam J. Greer (by invitation), James H. Forsee and

Hugh W. Mahon (by invitation)

Fitzsimmons General Hospital, Denver, Colo.

Focalized lesions of pulmonary Coccidioidomycosis are circumscribed and may be solid or cavitary. They closely simulate tuberculosis and can be positively differentiated only by recognition or hyphae or spherules of c. immitis in tissue sections or by the isolation of c. immitis in cultures from lesions. The pathological discussion includes the pathology of the solid round lesions, the cavitary lesions, and the conglomerate nodose lesions simulating a round lesion in roentgenograms. The presence of hyphae in three of the cavitary lesions stimulates speculation as to possibility of person to person infection. In a group of 15 patients these lesions have been subjected to surgery. Nine were treated by lobectomy and six by wedge-shaped excision of the lesion. In cavitary lesions the absence of tubercle bacilli in the sputum and the history of residence in an area endemic for Coccidioidomycosis were the most important diagnostic aids. The frequent presence of daughter granulomata has made lobectomy a preferable procedure especially in the presence of cavitation. The indications for operation have included recurrent moderate hemoptysis, failure of closure of the cavity after many months' observation, spontaneous pneumothorax with failure of the lung to re-expand, and the exclusion of neoplastic disease. The operative technic and postoperative care have not differed from that employed in lobectomy for bronchiectasis. There has been no evidence of dissemination of the disease following the operation. In one instance re-expansion of the remaining lobes failed to fill the hemithorax entirely. No other operative complications were encountered. Recent follow-up data on the patients is presented.

26. Changes in Blood Volume and Available Fluid Volume During Thoracic Operations.

Bernard J. Miller (by invitation), John H. Gibbon, Jr., and

Frank F. Allbritten, Jr., Philadelphia, Pa.

It is desirable to replace accurately, quantity for quantity, the blood which is lost during major operations. If this quantitative replacement can be achieved, there should be no disturbance in the circulatory balance of the patient and at the conclusion of the operation his blood volume should be the same as immediately before the operation. It has been our experience that it is fallacious to depend upon an increase in the pulse rate or a decrease in the blood pressure to indicate the need for transfusing additional blood. Counting the number of blood-stained sponges is also an extremely unreliable method of estimating the blood lost.

This report is based upon a series of 57 patients subjected to major thoracic operations. In all these patients, the plasma volume was determined both preoperatively and postoperatively by the dye method (T-1824). The blood volume was calculated from the hematocrit and the plasma volume. In 27 of the 57 cases, the blood lost during the operation was calculated from the increase in weight of dry gauze sponges used during the operation. In 31 of the 57 cases the available fluid volume was determined both preoperatively and postoperatively by the sodium thiocyanate method. The group of 57 operations comprised the following categories: 17 pneumo-nectomies, 12 lobectomies, 11 exploratory thoracotomies, 10 first stage thoracoplasties, and seven esophagectomies. The maximum, minimum and average blood loss in each of these categories will be reported. The correlation between the dye method and the sponge weight method will be presented. The changes in the available fluid volume, before and after operation, will be correlated with the duration of the operative procedure and the extensiveness of exposure of tissue in the operative field.

It is concluded that the method of weighing sponges during major thoracic operations is sufficiently accurate for clinical purposes and that it offers the only reliable method at present for the accurate quantitative replacement of blood lost during major thoracic operations.

27. Monaldi Suction in the Treatment of Bullous Emphysema and Large Pulmonary Cysts.

Jerome R. Head and (by invitation)

Edward E. Avery, Chicago, Ill.

Emphysematous blebs (bullous emphysema) may become so large as seriously to interfere with the respiratory function. The mechanism causing these blebs is similar to that producing tension pneumothorax. The air leaks into them more easily than it can find an exit and they tend to become gradually larger. They collapse the lung and in extreme cases can fill the larger portion of one or both pleural cavities.

Until recently, there has been no treatment for this condition. Many of the patients have been respiratory invalids and others have been bothered by severe dyspnea.

The present paper is a report of fifteen cases of large emphyse-matous blebs and two cases of bronchiogenic cysts which have been treated by interacavitary suction (Monaldi). The majority of these people have been greatly benefited. The indications, the technic and the results are discussed in detail.

28. A Review of Seven Years' Experience With Intracavitary (Monaldi) Drainage of Tuberculous Cavities.

Warriner Woodruff, Saranac Lake, N. Y.

Winfield O. Kelley, Norwich, Conn.

Allan Stranahan (by invitation), Albany, N. Y.

This review is based on 100 cavities in 90 patients who were accepted for Monaldi therapy between late fall, 1940, and December 31, 1947. Indications have fallen into two general groups: (1) As a palliative procedure for extensive bilateral cavernous disease. (2) As a preliminary to thoracoplasty in so-called tension cavities. In the vast majority of cases in which the catheter was successfully introduced, there has been marked symptomatic improvement, with closure of cavity in a large number, a rather early conversion of drainage and a decrease in the amount of sputum. Thirty-eight per cent of the cases in which the catheter had been introduced had had some further form of definitive therapy, such as thoracoplasty, before the time limit set in this paper. Several others have since had such interference.

Technic is discussed and statistics are presented regarding indications, methods of obliterating the pleural space, conversion of drainage and sputum, complications, length of time cavities have remained closed after removal of catheter, subsequent procedures and mortality.

Wednesday Afternoon, June 2, 1948

2:00 P.M. Scientific Session.

29. Coarctation of the Aorta.

H. Brodie Stephens and Orville F. Grimes (by invitation)

San Francisco, Calif.

Four patients, aged one, four and one-half, sixteen and thirty-four years, respectively, have undergone operation for coarctation of the aorta. One patient has survived and has been greatly benefited by the operation.

The two patients in the older age group expired from hemorrhage eleven and twenty-eight days following operation. End to end union was performed in one of these patients and end to side, subclavian to aorta in the other.

The child of one year of age succumbed immediately following the completion of the entire operation.

Necropsy examination was performed in the three fatal cases. The causes of death in these three patients are discussed and deductions outlined to establish better indications and contraindications for operation.

30. The Correction of Aortic Insufficiency in Dogs With an Artificial Aortic Valve-A Preliminary Report.

J. Moore Campbell (by invitation), Oklahoma City, Okla.

A survey of the literature fails to reveal any successful attempt to relieve insufficiency of a cardiac valve by means of an artificial valve or any other prosthesis.

At present, several valve patterns are under study and improvement. The valve, studies of which form the basis of this report, is fabricated from methyl methacrylate. Within a polished tube of the plastic material, a moving valve is located that opens and closes with systole and distole. The tube is approximately the same diameter as the aorta, is placed in the aorta distal to the aortic leaflets.

Under Nembutal anesthesia, the aortic valve leaflets are lacerated and aortic regurgitation is produced as demonstrated by murmur and a kymographic recording of pulse pressure increase greater than 150 per .cent. Next, the artificial aortic valve is placed in the aorta distal to the destroyed leaflets with a kymagraphic recording of the corrective changes in the pulse pressure. In addition, stethocardio-graphic tracings of the regurgitant murmur and the sounds of the valve prosthesis are demonstrated.

When carefully polished methyl methacrylate is introduced into the aorta, clotting of blood about the moving valve has not occurred during the length of time the dogs have been observed.

There is some narrowing of the functioning lumen of the aorta due to the presence of the valve, but the obstruction has been minimal and serves partially to raise the mean pressure in the coronary arteries, which are proximal to the artificial valve and therefore do not benefit by correction of the regurgitation.

Valvular designs and physiologic effects from valvular insertions are to be discussed. Successful implantation of functioning aortic valves has been so recently achieved that to date only acute experiments have been done and ultimate survival time has not been established, but is under study.

31. Experiences With the Anastomosis of the Left Subclavian Artery to Left Pulmonary Artery for Pulmonary Stenosis.

Emile Holman, San Francisco, Calif.

Blalock has repeatedly expressed a preference for a right subclavian to right pulmonary artery anastomosis, but recognizes the superiority of the left subclavian artery when operating for pulmonary stenosis in young adults.

Because of its greater length, the left subclavian artery would seem to offer certain advantages in all cases. At the Stanford Clinic, the left subclavian artery has been deliberately chosen in preference to the right subclavian in 23 cases. In four cases, because of interference with blood flow though the anastomosis due to sharp angulation of the subclavian artery at its emergence from the aortic arch following the completion of the end-to-side anastomosis, the left pulmonary artery has been deliberately divided proximal to the anastomosis, permitting relaxation and upward displacement of the anastomosis so that a good flow of blood through it occurred. No detrimental effect of such division was noted-on the contrary, all four patients were markedly improved following the operation, as were the other 19 patients in whom the left subclavian artery was employed.

Certain other modifications of the typical Blalock procedure will be presented.

32. Development of Anastomosis Between Coronary Vessels and Transplanted Internal Mammary Artery.

Arthur M. Vineberg, Montreal, Canada

During the past twenty-five years many attempts have been made to increase impaired coronary circulation. In most of the previous attempts, fresh blood has been brought to the myocardium by means of suturing other tissues to the heart surface. Thus, new blood vessels reached the heart across a line of scar. Some workers have attempted to improve ventricular circulation by ligation of the vena magna cordis.

In man, arterial schlerosis of the coronary vessels usually involves the primary vessels on the surface and leaves the smaller vessels deep within the myocardium comparatively normal.

It is our opinion that a new blood supply brought to the myocardium should be arterial in type and should also be brought to the secondary vessels. We have attempted to do so by implanting the left internal mammary artery after it has been freed from the chest wall directly into the myocardium.

In our experimental work anastomosis occurred between the transplanted internal mammary artery and the vessels of the myocardium. This has been proven by (1) injection of radio-opaque substances, (2) serial section, (3) plastic casts of the arterial tree. It has been shown that the part of the internal mammary artery lying within the heart, develops branches which anastomose with the smaller coronary vessels. The frequency of anastomosis is dependent upon many factors, such as angulation of the vessel, thrombosis, etc. In one series of sixteen dogs anastomoses were proven in four and suspected in two of nine surviving animals. Over one hundred animals have been operated upon.

(Colored slides will be shown.)

33. Bilobectomy-Surgical and Anatomical Considerations in Resection of Right, Middle and Lower Lobes Through the Intermediate Bronchus.

G. E. Lindskog, and (by invitation) A. A. Liebow,

M. R. Hales, New Haven, Conn.

A technic for resection of the right middle and lower lobes as a surgical unit through the intermediate bronchus has been described.

Vascular variations based on 25 injection studies are presented.

Results in six clinical trials are briefly presented.

The arguments for and against this procedure as compared to individual lobectomies performed seriatim are discussed.

34. An Experimental Study in Bronchial Anastomosis.

Truxton L. Jackson, Philip Lefkin, Foster Hampton

(by invitation) and William Tuttle, Detroit, Mich.

The purpose of the experiment was two-fold: 1. To resect portions of the major bronchi and re-anastomose the ends. 2. To create strictures in the major bronchi, resect them, and re-anastomose the ends.

A total of thirty-two dogs of nonspecific breeds was used for the two parts of the experiment.

In twenty dogs, one-eighth to one-fourth inch cylinders were removed from one of the main bronchi, or one of their first divisions. The proximal end of the bronchus was then plugged with a rubber balloon and bronchial suture completed. Two methods of bronchial suturing were used: 1. Interrupted through and through sutures of 00000 silk. 2. Interrupted, horizontal everting mattress sutures which turned up a cuff.

Both methods presented acceptable end results, but the "cuff" method led to a smoother postoperative course and, in general, to a superior anatomical union. The dogs were followed for varying periods up to eight months and were sacrificed for study. It was found that the use of any type of clamp on the bronchus to prevent leaking during surgery resulted in high grade stenosis at the suture line, pulmonary suppuration and bronchiectasis. In six dogs, clamps were used on the bronchus at the time of surgery. Four of these subsequently developed a high-grade stenosis with suppuration of the lung and severe bronchiectasis. In two there was breakdown of the suture line with development of local empyema. In the remainder of the dogs, the anatomical result was acceptable. The suture line was observed at regular intervals by bronchoscopy.

For the second part of the experiment, strictures were created in either of the main bronchi of twelve dogs. The dogs were followed clinically; the strictures were later resected; and reanastomosis was accomplished. These dogs were followed for varying periods up to six months, sacrificed and studied. The results were anatomically acceptable.

35. Mesothelial Mediastinal Cysts.

Everett C. Drash, Charlottesville, Va.

This is a discussion of five of our own cases with an embryological study of the origin of these tumors. In 1940, Lambert in his presidential address before the American Thoracic Surgical Association reported on two patients who had been operated upon by other surgeons and called these cysts pericardial coelomic cysts. In a study of the embryo we have come to the conclusion that these cysts are only incidentally related to the pericardium and that their true origin is from the mesothelium.

This paper reports the five new cases with a discussion of the microscopic and gross pathology of these cysts and in addition, the paper presents what we think is the more logical study of the origin. There is also a brief review of the literature on these tumors.