Tuesday Morning, April 26,1955

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

32. Pulmonary Resection in Active Cavitary (Open-Positive) Tuberculosis.

Robert H. Holland (by invitation), John W. Bell (by invitation) and

Edward S. Welles, Sunmount, N. Y.

Current attempts to control cavitary tuberculosis with prolonged chemotherapy result in a predictable incidence of medical failures. When a resistant strain of tubercle bacilli develops, definitive surgical treatment is followed by a high incidence of major complications.

This study deals with over eighty resections in patients who had positive sputa or gastric washings, and cavities visible on planigrams immediately prior to surgery. Studies of bacterial sensitivity to Streptomycin, Para-Amino-Salicylic Acid and Isoniazid are available on admission, preoperatively and postoperatively. Accordingly, we have divided these cases into Original Chemotherapy (Susceptible and Resistant) and Retreatment Chemotherapy (Susceptible and Resistant). A number of patients in the Retreatment-Resistant group were given short term pre and postoperative courses of viomycin and terramycin in combination. These four groups have been studied from admission, through surgery, and on follow-up examinations.

It is felt that medical failure can be anticipated in the early months of chemotherapy when certain indications exist. These indications are presented, together with recommendations for earlier surgical treatment.

33. Simultaneous Bilateral Resection for Pulmonary Tuberculosis in Mental Patients.

F. John Lewis, M. Taufic (by invitation), B. Zimmerman (by invitation),

Morley Cohen (by invitation) and J. F. Perry (by invitation),

Minneapolis, Minn.

In 14 patients with bilateral pulmonary tuberculosis we have resected parts of both lungs at one operation. The operation has been done through an anterior incision with transverse division of the sternum and entry into both pleural cavities through the third interspaces. Diseased segments in both lungs were then removed sequentually by one operating team, or at the same time with two. The former method is preferred. A lobectomy on one side plus a segmental resection on the opposite side was necessary in one patient while the others all had bilateral segmental resections. There were no deaths. The patients were all inmates of a State Mental Hospital and they were in relatively good health except for their tuberculosis.

For these particular patients, and perhaps for others as well, this method has several advantages over the staged bilateral resection. The total time of treatment can be shortened by 9 to 12 months and we have been able to attend more expeditiously to the long list of mental patients with tuberculosis who are awaiting surgery. For most of the patients the operation has been no harder to bear than the second operation of a staged bilateral resection. Perhaps this is because a simultaneous bilateral operation forces a more uniform distribution of the respiratory load postoperatively. Then, too, with a bilateral anterior incision there is less muscle trauma and disability than with either side of a staged procedure. We plan to continue using the simultaneous operation for good risk patients with limited bilateral disease.

34. Blood Volume Studies in Pulmonary Tuberculosis.

John H. Kehne (by invitation) and Felix A. Hughes, Memphis, Tenn.

Previously published reports indicate the importance of blood volume deficiencies in the chronically ill patient but limited work has been done specifically in the field of tuberculosis. Significant replaceable deficiencies in blood volume, plasma volume and hemoglobin mass have been found in 62% of an unselected survey series of 100 cases of pulmonary tuberculosis presented as candidates for thoracic surgery. Average deficiencies found were 12% in blood volume, 19% in hemoglobin mass and 9% in plasma volume. The deficiency in the hemoglobin mass was found to exceed 500 cc. of whole blood in 62% of the total series, 1000 cc. of blood in 46% of the series, and 1.500 cc. of blood in 23% of the entire group.

Blood volume determinations represent the only method to evaluate these deficiencies and should be employed more frequently in chronic pulmonary tuberculosis in order to provide better supportive therapy in both the medical and surgical phases of treatment. Considering the fact that these patients had been under treatment in different hospitals for prolonged periods and assumed to be normal, the problem of blood deficiencies should be presented and re-evaluated.

35. Surgical Treatment in Tuberculosis Complicated with Pulmonary Emphysema.

Robert W. Newman, Perry M. Huggin, Charles L. Butler and

Medford C. Bowman (all by invitation), Knoxville, Tenn.

The authors have been impressed that surgical treatment in patients with tuberculosis complicated by pulmonary emphysema is much more hazardous both as to the operative and to the postoperative course. Since the majority of surgery in tuberculosis is now excisional in nature, a study of results comparing emphysematous tuberculous patients with non-emphysematous patients would be helpful.

The presentation is an analysis of 30 surgical patients with pulmonary tuberculosis complicated by moderate to severe generalized emphysema. A concept of the pathology involved and the rationale of surgical approach is presented. The complications, morbidity and mortality in these 30 patients are compared to a group of 259 surgical patients treated during the same period who had pulmonary tuberculosis without complicating emphysema. A discussion of the postoperative problem of the "emphysema syndrome" is presented and recommendations as to the prevention of its development are made.

Physiological data is presented relative to the preoperative diagnosis and evaluation of this group of patients with complicated tuberculosis. A discussion of the decisions as to the best surgical approach to treatment in the light of our experiences with the problem is presented.

36. Surgery for Cavitary Tuberculosis in Patients with a Single Lung.

Francis M. Woods and Norman J. Wilson, Boston, Mass.

Control of cavitary tuberculosis in the single remaining lung has been nearly insuperable when rest and anti-microbial agents fail. Pneumothorax, both intra and extrapleural, modified thoracoplasty, pneumoperitoneum, cavity drainage have all been tried. Resection remains the surest method when applicable. We have removed segments or single lobes in the lung remaining after pneumonectomy in seven instances since 1951. Only one operative mortality occurred. The problems of case selection, anesthesia, technical difficulties at operation, the postoperative management and the favorable end results will be reported. Some physiologically similar situations will also be discussed where the active disease is in the lung opposite a totally destroyed lung.

37. Surgical Treatment of Pulmonary Histoplasmosis with MRD-112 as an Adjunct.

John W. Polk (by invitation), Chas. A. Brasher (by invitation),

Joao De Castro (by invitation) and W. W. Buckingham, Kansas City, Mo.

A brief history of histoplasmosis is described. Detailed pathological findings in resected and autopsy specimens are considered. The methods of treating pulmonary histoplasmosis are discussed with emphasis on surgical resection and the use of MRD-112. Experiences with surgical resection in four patients having chronic, progressive, pulmonary histoplasmosis are discussed. The organism, Histoplasma Capsulatum, was cultured in each case. One case resected without drug therapy is reviewed in detail; a second case treated with MRD-112 prior to thoracotomy is also outlined. In contrast, cases of four patients treated medically with MRD-112 are outlined.

All cases have been followed thoroughly to determine the benefits of each form of therapy. The role of complement fixation determination, in both surgical and medical treatment, is discussed fully. These experiences with chronic, progressive, pulmonary histoplasmosis led us to believe that it is a generalized disease, similar in many ways to tuberculosis. It is believed that for localized, chronic disease, surgical resection offers the best prognosis. Treatment with MRD-112 has been utilized in cases with extensive pulmonary disease. Follow-up studies will be needed before the final evaluation of this drug can be ascertained. Surgical resection may be used for destroyed areas of lung following MRD-112 treatment. We propose that careful complement fixation data offers the best method of following post-treatment cases.