Saturday Afternoon, April 15, 1950

2:00 P.M. Scientific Session.

6. Conservative Management of Empyema Following Total Pneumonectomy.

Edward M. Kent, M.D., Pittsburgh, Pa.

During the past five years there have been eleven patients who have developed an open bronchus following total pneumonectomy, an incidence of about four percent. In addition, there have been five patients who have developed thoracic empyema following total pneumonectomy without bronchial fistula. In the first group mixed infection was encountered in each instance while in the second group the pure infection was present in all cases. In both groups surgical drainage of the empyema was established.

In those patients in whom bronchial fistula had occurred healing of the fistula took place in every instance after surgical drainage. Following this a program of instillation of antibiotics into the pleural space was pursued. Subsequently, the drainage tubes were removed and the antibiotics were continued by local instillation for an arbitrary period of time. In eight patients, the empyema was cured by this technique without radical surgery. In one of these patients a recurrence was encountered three and one-half months later which was treated in the same fashion, following which recovery became complete and has remained so for sixteen and one-half months. In the three remaining patients, recurrence was encountered in two and in both instances the patients have refused a second trial of therapy and radical surgery, and are wearing their thoracotomy tubes up until the present. In the third instance, the response to antibiotic therapy was inadequate and the program was abandoned after which a thoraco-plasty was performed with a cure.

In the second group in which no bronchial fistula occurred, a similar program of antibiotic therapy was employed immediately after the institution of surgical drainage. As before, the drainage tubes were removed when certain criteria were met and the antibiotic therapy' continued by injection through the chest wall into the pleural space. In four patients, the primary recovery of the empyema was obtained.

In the fifth patient a recurrence was encountered four months after therapy and the same program was observed again with satisfactory initial results, however, a second recurrence was encountered three months later at which time a thoracoplasty was performed with cure of the empyema.

It is interesting to note that the onset of the empyema in some instances was late, in one patient, nineteen months after pneumonectomy; in another patient, ten months after pneumonectomy; and in several instances, a few months after operation.

7. The Utilization of Streptokinase-Streptodornase in: (1) A Patient with Hemopneumothorax and (2) A Patient With Postpneumonectomy Sanguineous Coagulum.

C. Thomas Read, M.D. (by invitation) and

Frank B. Berry, M.D., New York, N. Y.

The rapid lysis of blood clot and related coagula takes place, as has been shown by Tillett and Sherry, when concentrated and partially purified preparations derived from broth cultures of hemolytic streptococci are instilled into them. These products, Streptokinase and Desoxyribosnuclease (Streptodornase), acting as enzymes lyse fibrin and neucleoprotein respectively.

This report relates our experience with the enzymes (essentially Streptokinase) in the successful management of a case of hemopneumothorax and one of sanguineous coagulum following pneumonectomy wherein it was desirable to evacuate the thorax before thoracoplasty.

From the striking results obtained in these cases, the further application of the enzymes to thoracic surgical problems appears indicated.

8. Pulmonary Paraffinoma (Lipoid Pneumonia), A Critical Study.

Thomas H. Burford, M.D. and Ralph Berg, M.D.

(by invitation) St. Louis, Mo.

The authors desire to establish more precisely the clinical and radi-ographic picture of pulmonary paramnoma. The study is based on an extensive review of the literature and personal experience with cases in which the lesion was resected. The importance of associated habits, pathologic processes and anatomical and functional changes is stressed. The relation of the lesion to the clinical presence of chronic sinusitis, esophageal and hpyopharyngeal diverticula, cardiospasm, paralysis agitans and habitual use of mineral oil is reiterated. Radiographic features and methods of establishing a clinicopathologic diagnosis are pointed out. Emphasis is placed on differentiation of the lesion from carcinoma, either primary or metastatic, both clinically and at the operating table. A discussion of the relation of paraffinoma to carcinoma and its possible role as an etiologic agent in certain pulmonary carcinoma is made.

9. Surgery in Pulmonary Coccidioidomycosis-Preliminary Report of 25 Cases.

Bert H. Cotton, M.D. and J. W. Birsner, M.D.

(by invitation) Beverly Hills, Calif.

1. A series of 25 cases of pulmonary coccidioidomycosis treated by surgical methods is presented.

2. Surgical treatment in pulmonary coccidioidomycosis can be used to prevent death and is effective in arresting the disease process.

3. Surgical treatment in pulmonary coccidioidomycosis does not cause dissemination of the disease to the skeletal or nervous system, but may even prevent dissemination.

4. Surgical treatment is definitely indicated in pulmonary coccidioidomycosis in the following conditions: 1. Specific types of cavities (a) giant cavity; (b) secondarily infected cavity; (c) blocked cavity. 2. Rupture of cavity (a) spontaneous pneumothorax; (b) empyema. 3. Non-expansile lung. 4. Hemoptysis (a) continued; (b) severe. 5. Coccidioma expanding lesion. 6. Failure of medical treatment (collapse therapy, etc.).

5. Coccidioma, which is usually single but may be multiple, must be differentiated from a tuberculoma, hamartoma, and both primary and metastatic carcinomatous lesions.

6. Lung complications resulting from the pulmonary coccidioidomycosis should be evaluated surgically from the standpoint of pathologic lesions without regard to the fungus origin or activity of the disease.

7. Surgical treatment in selected cases of pulmonary coccidioidomycosis results in rapid rehabilitation of the patient as contrasted to long term and frequently ineffective medical care.

8. The combination of pulmonary cavities due to tuberculosis and coccidioidomycosis does not constitute a contraindication to surgical management.

10. Pectus Excavatum-Management of a Case With Severe Cardiopulmonary Disability With Pre- and Postoperative Angiocardiographic Studies.

Ralph A. Dorner, M.D., Philip G. Keil, M.D. (by invitation)

and Donald J. Schissel, M.D. (by invitation)

Des Moines, Iowa

The literature regarding surgical correction of funnel breast is briefly reviewed. A case with marked deformity in a twenty-eight year old male is presented. Severe cardiac dysrhythmia and bilateral lower lobe bronchiectasis coexisted. This case is of particular interest since detailed preoperative and postoperative studies of the circulation, including repeated angiocardiograms, have been made. Relief of distressing cardiopulmonary symptoms has been dramatic. The changes in the angiocardiograms and other studies over a six months' postoperative period have been correlated with this improvement.

7:00 P.M. Cocktail Party-Hotel Cosmopolitan.

8:00 P.M. Banquet-Hotel Cosmopolitan. Dancing