Monday Afternoon, May 3, 1954

2:00 P.M. Scientific Session: REGULAR PROGRAM.

7. Opportunities for Research in Thoracic Surgery with the Use of Tissue Culture Methods.

C. M. Pomerat (by invitation), Galveston, Texas

Recent advances in the management of cells in culture, particularly with the use of recordings made by phase contrast, time-lapse cinematography, find new important applications in research on chest pathology. Cultures of pulmonary tissue from human fetuses have demonstrated differentiation in vitro and differential viability of epithelial versus connective tissue cells as a function of the incubator temperature. On the basis of studies performed with exfoliative cells from breast tissue and prostatic secretions an important challenge is offered to study the desquamated epithelium from the pulmonary tree with in vitro techniques. Pleural fluid can be easily managed in tissue culture for the analysis of pathological processes. The modulations observed in the behavior of many species of cells invites much further study. In borderline malignancies the use of tissue cultures may assist in establishing a clear diagnosis. Pleural effusions are useful for the demonstration of the deposition of acellular fibrillar material, silver staining revealing feltworks of reticular fibers produced within one or two weeks of the cultivation of pleural fluid of certain types. A series of studies performed on the adult human nasal mucosa serve as illustrations of what may be learned from an analysis of the behavior of pulmonary epithelium in vitro. The most notable finding to date has been the demonstration of nuclear rotation in cells of epithelial origin as revealed by time-lapse moving picture technique. The nature of this process will be discussed following cinematographic demonstrations.

8. The Results of Treatment in Carcinoma of the Lung.

David P. Boyd, Howard B. Kirtland (by invitation), Magnus I. Smedal

(by invitation) and John G. Trump (by invitation), Boston, Mass.

This report is an analysis of 403 proven cases of carcinoma of the lung seen at the Lahey Clinic up to January 1, 1952. We were especially concerned with assessing our results in terms of five-year survivals: Prior to January 1, 1948, there were 159 cases; from January, 1948, to December, 1951, there were 244 cases.

Of great interest today is the question of etiology in carcinoma of the lung. Despite the enthusiastic endorsement of thoracic specialists, it would appear from our figures that a longer period of time will be required to settle the true role of smoking.

The question of diagnosis is reviewed and therapy is considered.

The Survival Figures: The tragically low salvage rate in carcinoma of the lung is well shown by our statistics. The average duration of life of all patients after discharge from the clinic or hospital was 10.7 months. Patients treated medically lived an average of four months. Those treated with X-ray alone lived 7.9 months. All patients who had resections lived an average of 27.9 months after discharge from the clinic or hospital.

Every patient who had a resection was followed. It was found that 15 patients lived five years more. This is 9.4 per cent of our total cases. One patient who had X-ray therapy alone is alive five years after treatment. Thus, it is seen that 9.5 per cent of all patients and 37.8 per cent of those given a curative resection (who survived), lived five years or longer. There was a total hospital mortality for all the years of 7.6 per cent.

The role of super voltage therapy and the results up to this point are reviewed. Certain misconceptions regarding the use of this very powerful agent have appeared in the recent literature. Our experience with more than 40 cases at the Lahey Clinic and at the Massachusetts Institute of Technology is presented.

9. A Clinical Survey of Adenomas of the Trachea and Bronchus in a General Hospital.

Lamar Soutter, Boston, Mass.

In the past 44 years the diagnosis of adenoma of the trachea or bronchus has been established by pathologic means in 59 patients at the Massachusetts General Hospital. Twenty-nine were diagnosed microscopically 10 or more years ago and 45, five or more years ago. Three were found at autopsy, 10 were biopsied but not resected and the remaining 46 were removed by pneumonectomy, lobectomy, seg-mental or local resection.

In an attempt to obtain a clearer picture as to the behavior of these tumors, the clinical courses of the patients subsequent to the tissue identification of these growths have been carefully studied. Although the malignant implications of the ademona are well known, the longevity of many of these patients provides evidence that the actual course of the disease is usually benign.

The causes of death among the untreated patients and those who left the hospital alive following surgical extirpation of their growths have been analyzed. Some of the patients have lived untreated for many years without evidence of spread of their tumors. One death due to a recurrent cylindroma has been recorded but none have been found due to the recurrence of a so-called carcinoid adenoma.

Although this series of cases has been small, the evidence presented is somewhat enhanced by the consistency of the results and the fact that the follow-up in all cases is complete.

10. Palliation of Esophageal Obstruction Due to Carcinoma with a Permanent Intra-Luminal Tube.

S. Mackler and Roland Mayer (by invitation), Chicago, Ill.

Resection of the esophagus is feasible only in approximately one-third of the cases of carcinoma. The rate of unresectability rises in accord with the anatomic height of the lesion because of involvement of contiguous vital structures; primarily the bronchus and the aortic arch. Extirpation of the diseased segment, thus, is not possible frequently even for the sole purpose of palliation of obstruction without the expectation of cure. The esophagus, particularly in the upper region, does not lend itself to short-circuiting procedures to circumnavigate the obstructed site, as does the lower alimentary tract. A gastrostomy, or a jejunostomy, is the sole alternative to death by starvation. Either procedure leaves much to be desired from the standpoint of mechanical function as well as esthetic appeal. Moreover, gastrostomy or jejunostomy does not affect the distressing symptom of salivary overflow, resulting from obstruction. A disinclination to perform either procedure is furthered by its attendant mortality risk, which is not inconsiderable, and which must be added to that of the primary thoracotomy.

To eliminate the need for a gastrostomy or jejunostomy, a procedure was devised whereby food could negotiate the site of carcinomatous obstruction, and is performed at the time of the primary thoracotomy. In essence, the method consists of locally intubating the esophagus at the site of neoplastic constriction with an especially designed tube. The latter is passed into the lumen through an incision in the normal esophageal wall immediately above the lesion, and after having been threaded through the pathologic segment, is left in place as a permanent prosthesis. An artificial lumen is therefore constantly maintained in spite of the continued growth of the tumor.

A motion picture film is presented to demonstrate the surgical technique.

11. Studies on Cardiac Arrest: The Relationship of Hypercapnia to Ventricular Fibrillation.

Will C. Sealy, W. Glenn Young (by invitation) and

Jerome S. Harris (by invitation), Durham, N. C.

The factors responsible for sudden cessation of cardiac action during surgery are still poorly understood. In an investigation of this problem the role of hypercapnia in the production of this accident was studied. In dogs hypercapnia is well tolerated for hours even though the arterial blood pH is reduced to 6.7 - 6.9. On the other hand, striking changes in the EKG and even ventricular fibrillation frequently occur in the immediate post-hypercapneic period in dogs allowed to breathe carbon dioxide for three or more hours. The EKG changes were similar to those caused by hyperkaliemia. Studies of the blood potassium during hypercapnia showed a rise to levels below that expected to cause EKG changes. In the post-hypercapneic period, however, the potassium continued to rise even though the arterial blood pH approached normal. This rise was of sufficient magnitude to explain the EKG changes and the ventricular fibrillation that frequently developed.

In other experiments dogs were given potassium intravenously in quantities below that necessary to give EKG alteration. If 30% carbon dioxide and 70% oxygen mixtures were then administered, severe changes in the electrocardiogram developed; and the blood potassium level increased to levels consistent with the EKG changes.

In other experiments it was found that intravenous hypertonic solutions of glucose, sodium bicarbonate, and sodium chloride would reverse the changes in the EKG that indicated impending ventricular fibrillation. Once the latter state occurred, these methods were unsuccessful.

The case records of 34 patients who died from cardiac arrest were reviewed. These studies and other clinical findings are correlated with the laboratory observations on dogs.

12. The Physiology of Hypothermia and Its Application to Cardiac Surgery.

W. G. Bigelow (by invitation), Toronto, Ont.

General hypothermia is being investigated as a means of reducing the oxygen requirements of the body sufficiently to allow exclusion of the heart from the circulation, thereby permitting intracardiac surgery under direct vision. Ordinary adult laboratory animals cannot be cooled safely to a body temperature much below 20° C. In dogs, the oxygen consumption, blood pressure, venous pressure, heart rate and cardiac output have been studied during cooling to 20° C. and during rewarming.

In monkeys, electrocardiogram and electro-encephalogram changes have been studied during cooling and rewarming and behaviour tests have been performed.

The resuscitation from low body temperatures has resulted in the development of an electrical artificial pacemaker for standstill of the heart and a radio frequency re-warming device. Applying this principle surgically in monkeys with body temperatures of 16 to 19° C., has been found possible to exclude the heart from the circulation and open it from 14 to 24 minutes with survival in 12 of the 13 experiments.

As another approach to the problem, a study of hibernation was initiated. The groundhog will not only hiberate at low body temperatures as low as 3°C., but he can be artificially cooled at this level. His unusual cold tolerance is attributed to a hibernating gland which appears to have an endocrine function and the activity of this gland is related to the animal's ability to tolerate very low body temperatures. This gland is at present under study.

Application to hypothermia to intracardiac surgery and techniques will be discussed.

6:30 P.M. -8:00 P.M. Cocktails

Informal, Sheraton-Mt. Royal Hotel. Guests limited to Members of the Association and their wives. This party is tendered by the Local Committee: Dr. C. A. McIntosh, Chairman.