Thursday Afternoon, March 31, 1949

2:00 P.M. Scientific Session.

27. Plastic Reconstruction of Tuberculous Bronchostenosis With Dermal Grafts.

Paul W. Gebauer, M.D., Honolulu, Hawaii

28. Pulmonary Resection of Metastatic Malignancy.

Hawley H. Seiler, Oteen, N. G. (by invitation)

29. Bronchiogenic Carcinoma-A Study of Full-sized Mounts in the Correlation of Pathological Characteristics and Clinical Manifestations in Resected and Non-Resected Tumors.

F. J. Phillips, M.D., George M. Bogardus, M.D.

(by invitation), Glair E. Basinger, M.D. (by invitation)

and W. E. Adams, M.D., Chicago, Ill.

The controversy among clinicians and pathologists regarding the pathogenesis of primary carcinoma of the lung stimulated us to make and study full sized mounts of representative cross-sections of all tumors of the lung removed. An attempt was made to correlate the type of tumor, the site of the tumor and the size of the tumor with the clinical manifestations as demonstrated by history, physical and radiologic and bronchoscopic examination and findings at exploration. The cell type has been studied in its relationship to the site and size of the tumor, the rate of growth, the extension into contiguous tissues and metastases to other organs. Of the forty cases thus studied, 27 were found to be of squamos cell type with or without pearl formation and 13 exhibited both epidermoid and adenocarcinoma.

A similar study was made of 36 nonresectable tumors and 36 unexplored cases in which tumors were found at autopsy. Of the nonresectable group, approximately half were of an undifferentiated cell type. The other half were of a nonkeratinizing squamous cell variety. Of the tumors studied from autopsy specimen, 15 were adenocarcinoma, 14 were undifferentiated cell, 6 were epidermoid and 1 a mixture of adeno and squamous cell carcinoma. Illustrations of the above factors are presented and their significance discussed.

30. The Management of Chylothorax.

Richard H. Meade, Jr., M.D., Jerome R. Head, M.D., and

Chester W. Moen, M.D. (by invitation), Grand Rapids, Mich.

Although chylothorax is often associated with an incurable disease, or with severe injury, it may occur as a result of mild trauma. In most instances, untreated chylothorax results in death. Experimental work and clinical experience have proven that the thoracic duct can be safely ligated. Anatomical studies show that there is a wide variation in its gross structure, and that there may be only one duct, or there may be a number of minute ones. Chylothorax can be cured by ligation of the thoracic duct, but it may also be controlled at times by repeated aspirations, or by suction drainage. A general discussion of the anatomy of the duct, and of the physiological effects of its ligation will be given. Three cases will be reported illustrating different etiological factors, and different, successful methods of treatment. Chylothorax should rarely be fatal if recognized in time and properly treated.

31. The Surgical Treatment of Round Tuberculous Lesions (Tuberculomata).

Hugh W. Mahon, Colonel, M.C. (by invitation), and

James H. Forsee, Colonel, M.C., Fitzsimons General Hospital,

Denver, Colo.

This paper deals with a group of 35 patients treated by pulmonary resection, either lobectomy or wedge shaped excision, for so-called tuberculomata at Fitzsimons General Hospital. The clinical manifestations were generally characterized by minimal symptomatology and the solid-like found shaped lesion was often detected by routine X-ray examination of the chest. The similarity to other lesions, in particular coccidioidomycosis and neoplasms is discussed. In approximately 80 percent exploratory thoracostomy was necessary as an aid in diagnosis but a positive diagnosis was not established until histopathologic and bacteriologic examinations were completed. The pathology of this lesion is discussed in detail including a correlation of the radiological appearance with the gross and microscopic pathology. The hazards of considering this lesion as benign or arrested tuberculosis is emphasized. Our policy of management after operation has been largely determined by bacteriologic and histopathologic findings. Those patients in whom tubercle bacilli were demonstrated were advised to follow a period of hospital management of six to twelve months or longer. In those patients in whom tubercle bacilli were not demonstrated in the tuberculoma and in whom daughter tubercles were absent and who had no other lung pathology were returned to military duty or to their normal activities in approximately three months after operation. A follow-up study of these patients is presented.

32. Transthoracic Thyroidectomy.

Herbert D. Adams, M.D., Boston, Mass.

Intrathoracic goiter may be defined as goiter in which the goitrous mass lies in the mediastinum entirely below the level of the superior thoracic strait. At the Lahey Clinic nearly 28,000 patients with goiter have been operated on and hundreds of these goiters have been classified as being truly intrathoracic by these criteria. Practically all of these, many of tremendous size, have been removed satisfactorily by the cervical route. This has been technically possible chiefly by a maneuver described by Doctor Lahey of evacuation of the necrotic and colloid central portions of these masses, thereby permitting the capsular portions to be delivered from the mediastinum. This has been technically feasible and satisfactory in by far the majority of cases. However, there have been three cases in which the intrathoracic goiter has been removed by the transthoracic route. Two patients were operated on transpleurally because of inability to differentiate by roentgenologic and other studies the mediastinal shadow from other types of mediastinal tumors, and because of their extremely low position in the mediastinum. This differential diagnosis is discussed fully. The third case was done transpleurally because an attempt had been made elsewhere to remove the goiter through the neck, with failure due to the extreme vascularity and size of this goiter. The surgical management and technical aspects of transthoracic thyroidectomy are presented.