Saturday Morning, May 4, 1957

8:30 A.M. Business Meeting-Grand Ballroom

9:00 A.M. Presentation of Presidential Badge and Chain of Office by the Society of Thoracic Surgeons of Great Britain and Ireland.

Scientific Session: REGULAR PROGRAM

1. A Roentgen Study of the Evolution of Carcinoma of the Lung.

Leo G. Rigler, Minneapolis, Minn.

A retrospective study of fortuitously made roentgenograms of the chest of patients eventually proved to have carcinoma of the lung, will produce much valuable information as to the evolution of this tumor from its early beginnings. Such observations support the following conclusions:

1. A considerable percentage of such tumors arise in small bronchi and extend centrally if not interrupted in their course.

2. There are marked differences in the rapidity of growth at various times.

3. Obstructive emphysema of a whole lobe or even of a whole lung may occur concomitantly with segmental atelectasis.

4. Cavitation may occur very early in the course of peripheral lesions.

5. Inflammatory manifestations may appear and disappear during the life of the

tumor.

6. There are differences in the symptomatology of peripheral as compared to central lesions; likewise changes in symptoms occur in those lesions which originate in the periphery and extend centrally.

A reconstruction of the anatomical situation and of the development of carcinoma of the lung, based upon serial roentgenograms of the chest in untreated cases, will be presented especially to illustrate the behavior of the various types of this tumor.

2. Intraepithelial Carcinoma in the Tracheobronchial Tree of Lung Cancer Cases.

Oscar Auerbach, J. Brewster Gere (by invitation), Joseph M. Pawlowski

(by invitation) and Arthur Purdy Stout (by mvttation), East Orange, New Jersey.

The increase in the incidence of carcinoma arising in the lung during the past 30 years has given rise to much effort directed at early detection and surgical extirpation of these lesions. To date the results of such efforts have been characterized by discouragingly low five year survival rates.

It is the purpose of this paper to attempt to shed some light on this dismal picture, based on anatomic studies of the tracheobronchial tree.

During our investigation of the changes in the bronchial mucosa by the step section technique several pertinent observations have been recorded. Among these was the large number of foci of carcinoma in-situ present in the mucosa of the tracheobronchial tree in patients who died of carcinoma of the lung.

Over 40 cases of white men who have died and were autopsied at the VA Hospital, East Orange, N. J., were used in this study. The tracheobronchial trees were dissected from the lungs and cut into 208 comparable 4.0 mm. sections, except for the portions destroyed by the disease process. Approximately 6000 slides were prepared, examined and the findings of basal cell hyperplasia, squamous metaplasia, and carcinoma-in-situ recorded.

The percentage of slides showing carcinoma-in-situ was calculated. The distribution of these slides from a representative case was plotted on a schematic diagram.

The incidence and distribution of intramucosal carcinoma is discussed in relation to the pathogenesis of bronchogenic carcinoma. The data obtained by this multiple section technique is then examined in relation to the clinical experience of early detection and surgical resection of primary lung cancer.

3. Bilateral Therapy for Unilateral Spontaneous Pneumothorax.

Ivan D. Baronofsky, Horace G. Warden (by invitation"), James L. Kaufman

(by invitation), Joseph Whatley (by invitation) and Joseph M. Hanner

(by invitation), San Diego, Calif.

The relative frequency of spontaneous pneumothorax in apparently healthy young individuals has been attestea to by numerous publications. This problem is all the more acute in military establishments because of the age of the population. The most commonly suggested therapy has been needle aspiration and/or catheter drainage with water trap decompression with a first episode, and more radical procedures such as induction or artificial pleuritis, open thoracotomy with the introduction of irritating substances or pleurectomy, following recurrences. During the convalescence of one of our patients following open thoracotomy for recurrent spontaneous pneumothorax on one side, a spontaneous pneumothorax developed on the opposite side. This occurrence coupled with the fact that bilateral pneumothorax occurs in about 10 to 15% of patients with spontaneous pneumothorax and recurrences are quite common with unilateral spontaneous pneumothorax has led us to adopt an investigative policy of bilateral thoracotomy for all patients admitted with a diagnosis of spontaneous pneumothorax. To date 25 consecutive patients have undergone this type of therapy. The great majority were performed as a one stage procedure and have included simultaneous segmental resection on occasion. There has been no mortality. The technique of bilateral anterior thoracotomy utilizing a muscle splitting incision will be presented, as well as pre and postoperative function studies, plamgraphy findings, a comparison of various methods of producing pleural symphysis and complications. The findings at surgery will be presented and show that the etiological factors which can cause spontaneous pneumothorax are present bilaterally and suggest therefore that therapy should be bilateral.

4. The Surgical Treatment of Chronic Progressive Pulmonary Histoplasmosis.

John W. polk (by invitation), Jose Cubiles (by invitation), Mt. Vernon, Mo.

and W. W. Buckingham, Kansas City, Mo.

Nineteen cases of chronic progressive pulmonary histoplasmosis, all having some type of surgical procedure, form the basis of this report. Seven cases have previously been reported before this Association. Of these cases, one represented a histoplasmoma, the other six progressive cavitary lesions. It has now become increasingly clear that a wide variety of pathological lesions may occur with the organism, Histoplasma capsulatum, as its sole etiological agent. This additional series includes definite pathological entities. Slides showing cases of bronchiectasis, giant tension cysts, acute abscess, middle lobe syndrome, one destroyed lung with tuberculosis complicating the picture, and one empyema necessitatis in which the organism, Histoplasma capsulatum, was cultured both from the sputum and the empyema fluid. These cases will show that chronic progressive histoplasmosis mimics all types and forms of acute and chronic inflammatory pulmonary diseases with pathological variations.

Further observations concerning the serological studies in these cases will be given and emphasis will be placed on the diagnosis of this disease from the clinical, radiological and pathological viewpoint. A followup on the seven cases previously reported will also be included. A comment regarding the treatment of this disease with amebacide and amphotericin will be included.

5. A Study of the Role of Drug Resistance in the Surgical Treatment of Pulmonary Tuberculosis (Period January 1947- June 1956).

william R. sweetman (by invitation) and john M. salyer, Denver, Colo.

The importance of drug resistance in the treatment of pulmonary tuberculosis is well established. Its role in the surgical treatment is, however, not so well documented. In an effort to furnish further data and help clarify this problem, 1061 consecutive pulmonary resections done at Fitzsimmons Army Hospital during the period January, 1947 to June, 1956 have been reviewed. Of this group, 46 resections in 44 patients were performed in the face of known drug resistance and were positive prior to operation. This group has been analyzed and compared to the total in respect to complication and mortality rates. Our study shows a major complication rate of 7.6% following the 1061 resections. 44 patients who harbored resistant tubercle bacilli had 46 resections with a major complication incidence of 32.6%. Of this group 13 patients had pneumonectomies with a major complication rate of 46.2% and mortality of 15.4%. Morbidity and mortality rates will be given for those patients undergoing lobectomy, segmental and wedge resections. The total surgical mortality during the 9½ a year period was 1.4%. This has been reduced to .97% during the past 3½ years. Resistant cases resulted in a mortality of 13%.

6. The Value of Routine Pulmonary Function Studies in Thoracic Surgical Cases.

Hurst B. Hatch, Jr. (by invitation), Joseph K. Bradford (by invitation)

and Alton Ochsner, New Orleans, La.

There is little doubt that over the preceding years and prior to the advent of methods of objectively evaluating pulmonary function, the medical profession and particularly the thoracic surgeons were quite adept in assessing this very important aspect of a patient's ability to withstand a thoracic procedure.

This paper is a report of the analysis of the preoperative study of pulmonary function of two hundred patients with various intrathoracic lesions. The routine and accepted methods of measuring both ventilatory and respiratory aspects of pulmonary function were utilized. In addition, one observer through the utilization of history and physical findings attempted to predict the adequacy of a patient's ventilatory and respiratory reserve and whether or not the patient could withstand the thoracic procedure. No attempt was made to grade these as to severity, but only as to whether or not the patient's pulmonary function was adequate. Comparative studies utilizing the observer's prediction and objective findings on pulmonary function tests were then compared.

From such a comparative study it became quite apparent that in about 85% of the patients one can predict fairly well the adequacy or inadequacy of the patient's ability to withstand a procedure. However, the most important group is the remaining 15% in which there is no direct or linear relationship between a patient's pulmonary disability and his pulmonary insufficiency. It is therefore felt that this study indicated that routine pulmonary function studies should be done on all patients who are being considered for a thoracic operative procedure and that it should be an integral part of the workup of all patients of this category.