Monday Morning, March 30, 1953

9:00 A.M. Scientific Session.

22. The Problem of the Hiatus Hernia of the Diaphragm.

Conrad R. Lam and Leo J. Kennedy (by invitation),

Detroit, Mich.

At the present time, patients with hiatus hernia of the diaphragm receive conflicting advice, even from thoracic surgeons. Many with small but symptomatic hernias are told that a change of diet and habits is all that is indicated. For others, crushing of the phrenic nerve is suggested. Surgical conversion of small hernias into large ones has been advocated by several surgeons. Among those who use the more conventional surgical methods, there are proponents of both the trans-abdominal and transthoracic approaches. Surgeons who prefer the latter route differ with regard to the technical details of obliteration of the sac, phrenic nerve interruption, and more importantly, with the manner of reducing the size of the esophageal hiatus.

In an early series of eighteen transthoracic repairs by the senior author, follow-up x-rays revealed some degree of recurrence in one-third of the cases. The technic of closure of the hiatus has been changed to give a more anatomically sound repair. An antero-posterior row of sutures is placed and the esophagus is moved to an anterior position. This modification is in agreement with the technic proposed by Merendino, Varco and Wangensteen, and by Allison of Leeds. No recurrences of hernias have been noted in this group of patients. Some anatomic and physiologic features of the esophageal hiatus as noted at operation and in autopsy material will be considered.

23. Muscle Wall Tumors of the Esophagus.

Richard H. Sweet and Lamar Soutter, Boston, Mass.

Over a twenty-year period 22 cases of tumors of the muscular wall of the esophagus have been observed. Of these, 21 were smooth-muscle tumors which are properly classified as leiomyomata, one of which was a leiomyosarcoma. In one patient the tumor was a rhabdomyosar-coma.

Of these 22 examples, 9 were incidental findings, 5 at autopsy and 4 in surgical specimens removed at operation for resection of carcinoma of the esophagus. In one instance no operation other than an esophago-scopic biopsy was performed. In 12 patients a curative procedure was carried out. This consisted of local excision of the tumor in 9 and resection in 3. In the latter group the indication for resection was the enormous size of the turner in two instances and the fact that the tumor was malignant in the third.

A detailed presentation of the clinical aspects, indications for operation, and technical problems encountered in the 12 patients who were treated by surgical extirpation of the tumor is given.

In view of the fact that tumors of this sort are infrequently encountered, it seemed worthwhile to report the series.

24. Reinforcement of Aortic Aneurysms by Wrapping - A Research Report.

J. Karl Poppe, Portland, Ore.

Polyethylene film was suggested by the author in 1946 as the most satisfactory material for reinforcing the walls of aortic aneurysms. Confusion arose from the comparison of the plastic film with cellophane and failure to recognize the presence of a contaminant, dicetyl phosphate, as the irritating substance. Inconsistent results have followed the use of pure polyethylene which either never contained dicetyl phosphate or lost it during sterilization.

It is the purpose of this paper to report the results of further research in selection and preparation of the most effective material for reinforcing aneurysms. Experimental work reported previously indicated that dicetyl phosphate produced a more extensive fibrosis than did any type of cellophane.

Since recognizing dicetyl phosphate as the active ingredient and polyethylene as only its supporting framework all of the polyethylene film used by the author is being especially prepared. The pure film is heavily impregnated on both sides with dicetyl phosphate by rubbing the powder into the polyethylene while it is softened by heating.

Attempts were made to substitute a temporary vehicle, such as gelfoam, to avoid the presence of a permanent foreign body, but the other material disintegrated too rapidly to hold the irritant in place. Other irritating substances, such as asbestos and talc, were tested and found to be less effective than dicetyl phosphate, although the asbestos was more irritating than the talc.

All forms of sterilization were slow to reduce the concentration of dicetyl phosphate on the polyethylene film but the least damage was noted in the film soaked in 1:1000 aqueous zephrin at room temperature for 25 minutes.

25. Clinical and Cytologic Changes in Patients Receiving Aerosol Trypsin and Desoxyribonuclease.

Seymour M. Farber (by invitation), David A. Wood (by invitation),

R. Daniel Gorman (by invitation) and Samuel Pharr

(by invitation), San Francisco, Calif.

Twenty-four patients with pulmonary tuberculosis who had excessive cough and who were raising moderate to large amounts of sputum were given trypsin alone or in combination with desoxyribonuclease by aerosol inhalation. Trypsin alone was of little effect, but in combination with the desoxyribonuclease it reduced cough and sputum viscosity in a majority of instances. Results were not marked, however, except for three patients in which the decrease in cough was substantial. Almost three-fourths of the patients in the series had significant toxic reactions; in nine patients these were so severe as to require discontinuance of treatment. Sensitivity reactions of chills and fever or asthmatic attacks were encountered. Cytologic studies revealed marked alterations of epithelial cells consisting of metaplasia and dyskeratosis. The significance of the rapid cytologic changes in the epithelial components of the sputum is not understood, and further evaluation of the action of pancreatic enzymes of the tracheobronchial epithelium is strongly indicated. In some patients who have not received this trypsin aerosol for at least six months, metaplasia is still being produced.

26. Torsion Ballistocardiography in Cardiovascular Surgical Patients.

C. Frederick Kittle (by invitation), Kurt R. Reissmann (by invitation),

E. Grey Dimond (by invitation) and Paul W. Shafer,

Kansas City, Kansas

Pre-and postoperative ballistocardiograms were analyzed in approximately 100 patients with surgically amenable cardiovascular diseases. The objectives were to investigate alterations in the ballistocardiogram in relation to known surgical intervention.

A torsion ballistocardiograph was used in contrast to the conventional head-foot ballistocardiograph because of the following advantages: (i) Both longitudinal and transverse vectors could be measured; (2) The site of origin of the reactive forces could be estimated; (3) Abnormal patterns could be accentuated by positioning the patient relative to the center of rotation.

Of particular note were ballistocardiograms in patients with patent ductus arteriosus, mitral valve deformities, chronic constrictive pericarditis and coarctation of the aorta. The abnormal wave found in patients with patent ductus arteriosus disappeared following surgical correction. The marked changes toward a normal ballistocardiogram in patients with mitral stenosis following valvulotomy correlated well with improvement in other parameters of their cardiodynamics. In coarctation of the aorta the I:J ratio provided a reliable index of the pathological preponderance of the cephalad flow of blood during systole. Diagnostic patterns found in patients with chronic constrictive pericarditis reverted to normal following pericardiectomy.

Representative tracings will be shown and some basic problems of ballistocardiography discussed.

27. An Experimental Study of the Effect of Parasympathetic Denervation of the Lung on Pulmonary Artery Pressure.

Victor H. Kaunitz (by invitation) and Murray N. Andersen

(by invitation), Buffalo, N.Y.

Because of the dearth of knowledge of the mechanisms regulating the lesser circulation, it was thought useful to study changes in the pulmonary vascular bed following complete parasympathetic denervation of one and both lungs in the experimental animal. The parasympathetic innervation was chosen because of the availability of a measurement of complete denervation of parasympathetic supply to a lung.

This test consists of determining the presence or absence of the Hering-Breuer reflex during bronchospirometry. Following vagus section in the neck, or division of all vagus branches to the lung, the homo-lateral Hering-Breuer reflex is always abolished.

Ten dogs were studied, by means of the above ventilatory test and by cardiac catheterization, preoperatively and after parasympathetic denervation of each lung. This consisted of division of all vagus branches to the lung, below the recurrent laryngeal nerve, ten to thirteen being found. The Hering-Breuer reflex was absent after this procedure in all animals, indicating complete loss of parasympathetic innervation of the pulmonary vascular bed. Changes in pulmonary artery pressure as measured by cardiac catheterization, were thereby determined after complete parasympathetic denervation of both lungs. The significance of these changes will be discussed in relation to cor pulmon-ale, idiopathic pulmonary hypertension and other conditions involving hypertension of the lesser circulation.