Monday Morning, May 3, 1954

8:30 A.M. Business Meeting.

9:00 A.M. Scientific Session: REGULAR PROGRAM.

1. Lipid Deposition in Pulmonary Tissue.

William R. Waddell (by invitation), Ronald C. Sniffen (by invitation)

and Lawrence L. Whytehead (Traveling Fellow of the Association),

(by invitation), Boston, Mass.

In 1949 Waddell, Sniffen and Sweet drew attention to a form of chronic interstitial pneumonitis in man characterized by unusual deposits of cholesterol within the lung (cholesterol or endogenous lipid pneumonia). The present report concerns observations on the experimental reproduction of the condition in animals and the pathogenesis of the lesions. The pulmonary inflammatory lesions produced by bacterial agents have been compared with inflammatory response in muscles made ischemic by ligation of the major blood supply.

In rabbits the intratracheal inoculation of either Pasteurella pseudotuberculosis or Klebsiella pneumoniae results in an interstitial pneumonitis in which large numbers of macrophages appear. In the presence of lipemia and hypercholesterolemia these cells become laden with cholesterol and fat, reproducing the pathologic picture seen in the human cases mentioned above. Even normocholesterolemic animals accumulate lipid in inflammatory sites but the amount is much less and the lesions develop over a longer period of time.

Muscle ischemia in the presence of lipemia results in the accumulation of lipid within macrophages activated in response to the degenerating muscle. This observation shows that specific infectious agents are probably not etiologically related to the pulmonary lesions and that local physicochemical conditions are responsible for the local deposition of fat and cholesterol. The known facts concerning the factors responsible for lipid deposition in tissue will be discussed.

2. Absence and Hypoplasia of a Pulmonary Artery Unassociated with Congenital Heart Disease.

Herbert C. Maier, New York, N. Y.

Increasing experience with atypical thoracic lesions and the greater use of angiocardiography in the study of patients with obscure pulmonary conditions has resulted in the more frequent recognition of congenital anomalies of the pulmonary vessels. Numerous reports of anomalous systemic arteries supplying portions of a lung which was often the site of inflammatory or cystic disease have appeared in recent years. But less well known are the clinical and radiologic findings in persons with complete absence of the pulmonary artery to one lung, or those with hypoplasia of one pulmonary artery associated with anomalous systemic arteries. Although such anomalies may be associated with congenital heart disease, in some cases the only cardiac lesion, if any, that is present is secondary to the abnormal pulmonary circulation. The recognition of such anomalies can be of clinical importance as illustrated by the fact that some of our patients were incorrectly treated because of error in diagnosis. When large anomalous systemic arteries cause a considerable high pressure blood flow to a lung, an interesting clinical syndrome may be present. The surgical treatment of such lesions will be discussed.

3. Surgical Reconstruction of the Superior Vena Cava.

J. Gordon Scannell and Robert S. Shaw (by invitation), Boston, Mass.

It is unusual to find superior vena caval obstruction that lends itself to surgical relief. There is, however, a small group of patients in whom a "superior vena caval" syndrome is the result of a benign process and in whom the symptoms are sufficiently disabling to warrant operation.

The authors present two operative cases in which a free vein graft was placed between the internal jugular vein and the right atrium to reconstruct, in effect, a superior vena cava. One patient showed marked clinical improvement and in this individual patency of the graft was demonstrated by venography six months post-operatively. In the other case autopsy proved the graft to be patent one week following operation.

4. 2-Hydroxy-Stilbamidine as an Adjunct to the Surgical Treatment of Pulmonary Blastomycosis.

Page W. Agree (by invitation), Paul T. DeCamp and Alton Ochsner,

New Orleans, La.

The history of blastomycosis is briefly described and the literature of this disease is reviewed. Pertinent facts concerning pathologic physiology of the lungs are considered. The various methods of treating blastomycosis are discussed with particular emphasis on the use of stilbamidine.

Experience with surgical resection in 6 patients with pulmonary blastomycosis is presented. Two of these cases are recorded in detail. One patient died two years postoperatively with widely disseminated blastomycosis. In contrast, the other patient with widely disseminated bilateral pulmonary as well as cutaneous disease was treated with stilbamidine. This resulted in subsidence of the disease but left a destroyed left lower lobe, which was excised. The patient is well six months postoperatively.

Our experience with blastomycosis has led us to believe that it is a generalized systemic disease which is in many ways similar to tuberculosis. It is believed that stilbamidine is a better drug than anti-tuberculosis preparations for controlling the disease so that surgical treatment can be instituted if it becomes necessary.

5. The Conservative and Surgical Management of Benign Strictures of the Esophagus.

Paul H. Holinger, Kenneth C. Johnston (by invitation),

Willis J. Potts and Fernando Dacunha (by invitation), Chicago, Ill.

Benign strictures of the esophagus present a variety of problems depending upon their etiology, severity, duration and previous therapy. Strictures may be congenital, inflammatory, chemical, traumatic, or surgical in origin. They vary from small, superficial webs to extensive fibrous stenosis or atresia, with a duration ranging from acute, recent obstruction to years, and to complete closure.

Management must be sufficiently flexible and varied to be adapted to changing situations. Simple endoscopic dilatation suffices for the majority of congenital strictures. Early mercury bougie dilatation has been most effective in prevention of strictures due to chemical burns. Gastrostomy allowing for prograde or retrograde dilatation is the most rapid means of dilating firm, multiple strictures of this character once they have formed, and normal swallowing function is effectively restored in the majority of cases. Pneumatic, or large mercury bougie dilatation, is effective in the great majority of cases of cardiospasm, and in view of its effectiveness deserves an adequate trial.

Surgical resection of benign strictures is indicated only when endoscopic dilatation has been demonstrated, after prolonged trial, to be relatively ineffective. Furthermore, the most rapidly increasing series of patients with benign strictures of the esophagus are those with recurrent strictures following esophageal surgery. Sixty plus patients, adults and children, with post-surgical strictures will be analyzed giving the etiology of the original obstruction, the type of surgery, the post-surgical interval at which obstructive symptoms recurred and subsequent management required.

Some of the operative procedures for correction of extensive strictures in children will be discussed.

6. A Method of Preventing Peptic Esophagitis Following Esophago-gastrostomy: Exprerimental and Clinical Study.

David H. Watkins (by invitation), Arthur Prevedel (by invitation)

and Fred R. Harper, Denver, Colorado

Reestablishment of continuity by esophagojejunostomy or esophagogastrostomy following total gastrectomy or subtotal proximal gastrectomy is not entirely satisfactory because of the development of chemical esophagitis with its attendant complications of stricture formation, hemorrhage, and even perforation. This same problem also appears in the management of patients with esophageal hiatal hernias associated with chemical esophabitis.

Previous investigators have shown that even in dogs subjected to 50 per cent proximal gastrectomy followed by esophagogastrostomy, 62 percent died of spontaenous esophageal complications in an average of 56 days.

In order to overcome the above complications, we have prepared a series of dogs in which a flutter valve mechanism was fashioned in the esophageal portion of the esophagogastric anastomosis.

The method has been used on dogs which have been carefully followed and studied and also on patients with gratifying results.

The presentation will cover the technical procedure used and also carefully prepared studies of the animal experiments and case histories of the patients operated upon.