Tuesday Afternoon, April 18, 1950

2:00 P.M. Scientific Session

26. Pulmonary Function Before and After Extrapleural Pneumothorax.

Edward A. Gaensler, M.D. (by invitation), Boston, Mass,

and John W. Strieder, M.D., Brookline, Mass.

The loss of pulmonary function after most types of collapse procedures has been intensively studied during the past twenty years. Extrapleural pneumothorax has been neglected from this standpoint beyond the finding that patients with small pulmonary reserve usually tolerate this procedure very well.

Sixteen patients with extrapleural pneumothorax and one with extrapleural lucite sphere plombage were studied immediately prior to operation, 14 days after operation and two months to one year after surgery. Studies included maximum breathing capacity, vital capacity and subdivisions, residual air and lung volume, walking ventilation, simple spirometry and differential bronchospirometry.

An average maximum breathing capacity of 76.4 liters before operation was increased to 77.3 liters per minute two weeks after surgery, an increase of one percent. There was no further increase or decrease two to 12 months later.

The average vital capacity of 2,227 cc. before operation was reduced to 1,960 cc. after operation, a loss of 12 percent. There was a small improvement during the following two to 12 months. The mean lung volume was decreased by about 25 percent. Extrapleural pneumothorax thus appeared to be created chiefly at the expense of residual air.

Accidental opening of the pleura in two cases with admission of air into the intrapleural space resulted, 14 days after operation in a 50 percent loss of maximum breathing capacity and a 60 percent loss of vital capacity in spite of assiduous aspiration of air and fluid post-operatively. This compares most unfavorably with a loss of 12 percent of vital capacity and no loss of maximum breathing capacity in 15 patients where the pleura was not opened, or, if opened, was found to be adherent to the visceral pleura in that region.

Differential bronchospirometry showed a one percent loss of oxygen uptake, an eight percent loss of ventilation and a six percent loss of maximum breathing capacity of the collapsed lung. The ventilatory equivalent for these lungs was thus reduced and ventilation became more efficient.

Compared to other collapse procedures the loss of pulmonary function after extrapleural pneumothorax was very small indeed. The loss was very much smaller than that following an unselected group of patients after pneumonectomy, lobectomy, thoracoplasty and intrapleural pneumothorax. It was somewhat smaller than the functional loss after phrenemphraxis and smaller in most cases than the loss occurring after pneumoperitoneum.

In the patients presented there was a contralateral pneumothorax or unexpandable pneumothorax lung present in eight cases, a contra-lateral four-rib and ten-rib thoracoplasty respectively in two cases, a surgically decorticated lung in one case and a previous pneumonectomy had been performed in one case. The loss of function here could, therefore, not be truly compared to pulmonary disability caused by a variety of other collapse measures. Extrapleural pneumothorax was carried out in most cases on lungs which performed the major portion and in three cases all of the total respiratory function. The mean oxygen uptake was 56.8 percent of the total as determined by differential bronchospirometry. The mean oxygen uptake of 48 patients prior to thoracoplasty was 22 percent of the total on the side to be operated upon while the mean oxygen uptake of 21 lungs to be resected was 12 percent of the total prior to operation.

The extrapleural pneumonolysis, in the cases presented, was invariably carried down to the hilus of the lung and the resulting air spaces were usually very large, particularly 14 days after operation.

The astonishing lack of loss of function not only some months after operation, but even two weeks after surgery, was felt to be due to the fact that all of the usual causes for loss of function, other than collapse of diseased tissue, were absent after this operation. These factors, not present after extrapleural pneumothorax are felt to be: (1) paradoxical motion of the chest wall, the diaphragm and the mediastinum, (2) permanent partial destruction of the thoracic cage, (3) paralysis of the hemidiaphragm, (4) postoperative pain and (5) interference with the intrapleural pressure mechanism.

Data obtained in the physiology laboratory were supported by postoperative clinical findings. No patient was dyspneic at any time after operation except where the pleura was opened. Dyspnea could not even be detected when extrapleural pneumothorax was carried out in the absence of a contralateral lung or in the face of a contralateral 10-rib thoracoplasty.

Without entering the controversy concerning the indications for the extrapleural pneumothorax operation, the data presented suggest that this operation can be carried out with the certain knowledge that the resulting loss of pulmonary function will be very small or nonexistent. The operation can, therefore, be offered to a number of patients whose pulmonary reserve would not permit any other type of collapse therapy.

27. Summary of Pulmonary Tuberculomas, Pathogenesis, Diagnosis and Management.

Gordon J. Culver, M.D. (by invitation),

Joseph P. Concannon, M.D. (by invitation) and

Joseph E. Macmanus, M.D., Buffalo, N. Y.

The use of the term tuberculoma is defined, and limitations are established in the use of this term. The pathogenesis of tuberculomas is described as arising from (1) the encapsulation of a giant primary focus, (2) the encapsulation of a restricted reinfection focus, and (3) by means of the occlusion of a stem bronchus to a cavity. A case is presented demonstrating the evolution of a cystic lesion to an almost solid tumor by means of bronchial occlusion.

The roentgenographic history oftuberculomas is discussed. The differential diagnosis of round circumscribed lesions is described at some length, particularly the differentiation between peripheral bronchiogenic carcinoma and tuberculoma.

Tuberculomas are classified into two major types with sub-types. This is of importance because the treatment will be predicated on the type of tuberculoma. The question is brought up whether all tuberculomas in the lung fields should be removed. It is felt that conservative, well managed observation may be the treatment of choice in well calcified tuberculomas without breakdown. Tuberculomas without calcification, or with areas of breakdown, certainly should be removed.

Ten cases are presented to illustrate various types of pulmonary tuberculomas and their management. Two cases of mediastinal tuberculomas are included to complete the study of tuberculomas within the thorax.

28. One Stage Thoracoplasty for Pulmonary Tuberculosis.

R. C. Laird, M.D. and C. E. Lindenfield, M.D. (by invitation)

Toronto, Canada

It has been felt for some time that with modern knowledge and control of shock, it might be possible to do many thoracoplasties in one stage, rather than in two or three stages. It is felt that this would give a much better collapse, it would shorten the period of postoperative hospitalization and would partly eliminate the distress of second and third operations.

Accordingly, we are now reporting seventy-five one stage thoracoplasties, and comparing them with seventy-five two or three stage thoracoplasties done under the same conditions and for approximately the same type of disease. We have noted the postoperative date of conversion of the sputum, the hospital morbidity, the mortality, if any, and the present occupation of the patients. Our conclusions have been that the collapse achieved is more adequate, the time in hospital is considerably decreased and the patient's comfort considerably increased.

29. Further Experiences with Segmental Resection in Pulmonary Tuberculosis.

J. Maxwell Chamberlain, M.D. and Robert Klopstock, M.D.

(by invitation), New York, N. Y.

Seventy-five consecutive cases of segmental resection in the treatment of cavitary tuberculosis are reviewed. Though the procedure is still a therapeutic uncertainty, it has greater merit than was originally anticipated.

Its natural evolution was based upon the desire to remove the diseased components with maximum preservation of lung function. Though the function in the residual segments may not be great, it is reasoned that as a "space-filler", over-distention and anatomical distortion of residual parenchyma can be minimized.

Developmental hurdles to overcome were (1) the philosophy of removing only the "main offending lesion" and (2) the possible transgression of tuberculous disease during the operation. The clinical picture and serial X-rays were helpful in estimating the degree of stability in the various segments, but the actual location and full appreciation of the problem was realized only by the use of tomography, and especially lateral tomography.

The indications, as we know them, improvements in technic, pathological observations, complications and deaths (three) are statistically analyzed. The longest follow-up is only two and one-half years, but early results are encouraging. Until sufficient time has passed, no conclusions are drawn.

30. Resection in the Treatment of Pulmonary Tuberculosis.

William M. Tuttle, M.D., E. J. O'Brien, M.D. and

J. Claude Day, M.D., Detroit, Mich., and (by invitation)

Foster Hampton, Jr., M.D., Chattanooga, Tenn., and

Truxton L. Jackson, M.D., Detroit, Mich.

Increasing enthusiasm for resection of tuberculous pulmonary lesions has paralleled improved surgical technic, refinements of anesthesia, better preoperative and postoperative care and streptomycin protection. Although marked improvement in fatality and complication rates has occurred in recent years, the results still fall considerably short of desirable goals. It is likely that an irreducible minimum as regards mortality and morbidity is being approached, beyond which further improvement is not attainable. In view of well known factors inherent in the disease, the uniformly good results to be anticipated in resection for non-tuberculous disease may never be equalled.

Our experience with resection in pulmonary tuberculosis, which consists of approximately 170 operations, is presented to supplement the large experience already recorded. It is our purpose to attempt an evaluation of the role of resection in the management of pulmonary tubrculosis and to further define its limitations.

The indications and contraindications are discussed, the complications are analyzed and the causes of death are listed. The role of streptomycin is discussed in relation to its known protective function as well as in relation to the potential hazards inherent in its ill-advised use.

31. Pulmonary Resection in Pulmonary Tuberculosis.

A. Himmelstein, M.D., Frank B. Berry, M.D. and

(by invitation) C. T. Read, M.D., New York, N. Y.

In the period from 1939 to December 1948 seventy resections for tuberculosis were done-forty lobectomies and thirty pneumonectomies. An attempt was made to follow for at least one year all cases of this study. This report deals with the results at the present time in these seventy patients.