Friday Morning, March 27, 1953

9:00 A.M. Business Meeting.

9:30 A.M. Scientific Session.

1. Unilobar Obstructive Emphysema in Infancy Treated by Lobectomy.

Herbert Sloan, Ann Arbor, Mich.

Obstructive emphysema, limited to a single lobe, has been observed by the speaker in four infants. Although there was a history of respiratory infection in two of the infants, this was not present at the time they were admitted. Localized emphysema is commonplace in the presence of pulmonary infection or an intrabronchial foreign body but has rarely been described in otherwise apparently normal infants.

In each of the four infants the greatly overdistended lobe produced serious respiratory distress. Uniformly the condition was confused at some time with cystic disease of the involved lobe, pneumonia or atelectasis of the adjacent lobes.

Lobectomy was carried out successfully in each of the infants, the youngest having been six days old and the oldest eight months old. Resection of such localized areas of obstructive emphysema has not been reported frequently. Examination of the removed lobes showed marked generalized emphysema, due presumedly to a check valve mechanism in the lobar bronchus. The exact etiology of the obstruction has not been determined but congenital abnormalities in the bronchi are probably responsible.

2. Mucocele, Congenital Bronchiectasis and Bronchogenic Cyst.

B. H. Ramsay and Francis X. Byron, Los Angeles, Calif.

Mucocele, congenital bronchiectasis and bronchogenic cyst are variants of the same pathologic process. The gross picture of recent surgical cases clearly shows the relationship. One case presented a smooth, thin, translucent septum which completely occluded the left lower lobe superior segmental orifice; as a result, the tributary bronchial tree was distended with clear mucus. The pathology of a second patient involved the middle lobe medial segment; one subsegment showed severe cylindrical bronchiectasis with just a trace of ruptured septum at its orifice; the other subsegment revealed an infected multilocular cystic dilatation beyond a thin septum which obstructed the orifice, a pin-point sized opening being present in the septum.

It appears clear that during bronchial development, temporary interruption of tubular growth results in formation of an atresic area beyond which normal bronchial structure exists. Progressive accumulation of secreted mucus produces cylindrical distension of the blocked bronchial branches-a mucocele. If the atresic area breaks down at an early phase of distension, true congenital bronchiectasis results. If extreme distension occurs before septal rupture, there is cystic dilatation, unilocular or multilocular, and the walls of such have small blind outpouchings which are the dilated terminations of the smaller bronchi.

Other findings of interest include: a. normal inflation-deflation of the alveoli belonging to the obstructed segments; b. the presence of an air-fluid level in one area of bronchial dilatation; c. failure of repeated x-rays to demonstrate the branching mucocele.

3. Hydatid Disease as it Affects the Thoracic Surgeon.

M. P. Susman (by invitation), Sydney, Australia

Based on a personal series of 70 cases the life history of the parasite will be presented together with general comments on incidence, sites of infection, radiologic appearances and general difficulties in diagnosis. Cysts of the lung, of the diaphragm, of the heart and of the liver will be considered. The most common are cysts of the lung and here will be discussed indications for operations together with types of operation, the incidence and severity of complications and their treatment.

Cysts of the diaphragm and of the heart are considerably more rare and the differential diagnosis is not always easy. The treatment of these cysts will be considered. Cysts of the liver are described because of their frequent simulation of intrathoracic disease. In addition, intrathoracic complications may develop from cysts of the liver because of erosion into the pleural cavity, the lung, or pericardium. The treatment of these complications will be considered.

4. Surgical Considerations in Focalized Pulmonary Histoplasmosis.

James H. Forsee and Thomas F. Puckett (by invitation),

Denver, Colo.

The frequently encountered so-called round lesion noted on the chest roentgenogram in patients with few or no symptoms and from which tubercle bacilli or coccidioides immitis cannot be isolated is often a manifestation of focalized histoplasmosis. During the past two years 28 patients have had lesions of this nature surgically removed. There is nothing distinctive in the symptomatology, physical examination, or roentgenographic findings. Approximately 40 percent of the patients had resided in Panama, the remainder having lived in endemic areas including eight different states. The serological findings and skin tests were helpful but inconclusive. Emphasis is placed on the histopathologic interpretations using the Periodic-Acid-Schiff stain which has revealed the specific organism in each instance. The organisms have been cultured from the surgical specimens in only two patients. The observations made at the time of operation, follow-up data, and relationship to other similar round pulmonary lesions is detailed. All lesions were removed by segmental resection or wedge excision except one lobectomy. There were no deaths.

5. Extensive Bronchiectasis: A Clinical and Physiologic Evaluation of the Results of Surgical Treatment.

Edgar P. Mannix, Jr. (by invitation), Francis S. Gerbasi

(by invitation), Charles E. Obrien (by invitation), and

Richard H. Adler (by invitation), Forest Hills, N.Y.

We believe that a challenging problem still exists in successfully treating patients with extensive bronchiectasis. Therefore in 1949 at the University of Michigan Hospital a clinical and physiologic study of a group of patients with total unilateral or bilateral bronchiectasis was begun. The physiologic investigations have included the following determinations:

1. Fractionation of lung volumina

2. Maximum breathing capacity

3. Carbon dioxide and oxygen values of arterial blood and exhaled gases at rest and following a standard one minute exercise test.

This report encompasses approximately 14 patients who have already had either a pneumonectomy or bilateral pulmonary resections of from seven to thirteen bronchopulmonary segments. A number of these patients have been studied preoperatively and at various intervals post-operatively. Illustrations of the sequellae of extensive pulmonary resections as well as such additional influences as the presence of incompletely removed bronchial lesions, phrenemphraxis, allergic asthma, and pleural complications will be presented.

6. Decisions in Thoracic Surgery as Influenced by Knowledge of Pulmonary Physiology.

Warriner Woodruff, Carl G. Merkel and George W. Wright,

Saranac Lake, N.Y.

The need for cognizance of the importance of pulmonary function as one of the basic determinants of surgical therapy in diseases of the respiratory apparatus will be demonstrated by suitable cases. Unfortunate instances will be shown in which surgical therapy was undertaken without an adequate appreciation of the preexisting derangements of pulmonary physiology and knowledge of the effect of surgery. Fundamentals of normal and deranged respiratory physiology specifically related to surgical therapy will be emphasized. Various surgical procedures will be discussed from the point of view of their effect upon pulmonary physiology. By means of illustrative case reports it will be shown how evaluation of pulmonary reserves and attention to physiologic principles can be of aid in (1) avoiding unnecessary damage to the individual; (2) accepting for surgical therapy cases that might otherwise be refused as unwarranted surgical risks; (3) choosing the type of therapy for a given individual which promises to be most effective and vet the most conservative as regards respiratory function.