CHAPTER X
Surgical Aspects of Diseases of the Chest
Brian Blades, M.D., B. Noland Carter, M.D., and Michael E.DeBakey, M.D.
BRONCHIECTASIS
Incidence
Army statistics testify to the importance of bronchiectasisamong diseases of the chest. Admissions during 1942-45 (table15) numbered 6,207, of which 5,164 were to hospitals inthe continental United States. During this same period, there were 12 deaths inthe U.S. Army in which bronchiectasis was the underlying cause, and, moreimportant from the standpoint of Army manpower, there were 4,487 disabilityseparations for this cause.
TABLE 15. -Admissions forbronchiectasis in the U.S. Army, by area and year, 1942-45
[Preliminary data based on sample tabulations of individual medical records]
[Rate expressed as number of admissions per annum per 1,000 average strength]
Area | 1942-45 | 1942 | 1943 | 1944 | 1945 | |||||
Number | Rate | Number | Rate | Number | Rate | Number | Rate | Number | Rate | |
Continental United States | 5,164 | 0.35 | 980 | 0.37 | 2,185 | 0.42 | 1,214 | 0.31 | 785 | 0.27 |
Overseas: | ||||||||||
Europe | 381 | 0.09 | 17 | 0.20 | 49 | 0.18 | 160 | 0.10 | 155 | 0.07 |
Mediterranean1 | 174 | .12 | 4 | .17 | 75 | .16 | 70 | .11 | 25 | .07 |
Middle East | 18 | .12 | 1 | .17 | 8 | .15 | 9 | .19 | --- | --- |
China-Burma-India | 48 | .11 | 4 | .46 | 6 | .15 | 23 | .14 | 15 | .07 |
Southwest Pacific | 176 | .10 | 15 | .21 | 24 | .13 | 62 | .11 | 75 | .07 |
Central and South Pacific | 159 | .13 | 18 | .12 | 55 | .19 | 56 | .13 | 30 | .08 |
North America2 | 42 | .09 | 17 | .17 | 17 | .09 | 8 | .06 | --- | --- |
Latin America | 40 | .10 | 15 | .15 | 21 | .17 | 4 | .05 | --- | --- |
| 1,043 | 0.10 | 93 | 0.16 | 255 | 0.15 | 395 | 0.10 | 300 | 0.06 |
| 6,207 | 0.24 | 1,073 | 0.33 | 2,440 | 0.36 | 1,609 | 0.21 | 1,085 | 0.14 |
1Includes North Africa.
2Includes Alaska and Iceland.
3Includes admissions on transports.
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Even granting the assumption that not every admission for bronchiectasisrepresented an actual instance of this disease, the numbers are sufficientlylarge to indicate the extent of the problem. The figures also suggest the possibleincidence of this disease in the general population: These 6,207 patients werein a selected age group of men, who had passed the physicalexamination and roentgenologic examination for induction into the Army. Thenumber of draftees who were rejected for service because bronchiectasis wasdetected is undoubtedly several times greater.
The manifestations of bronchiectasis were essentially the same in military asin civilian practice and call for no special discussion. They were chieflydependent upon the degree of sepsis, which in turn was chiefly dependent uponthe adequacy of bronchial drainage. When the disease was advanced, thedestructive changes were always permanent and irreversible and could be managedonly by extirpation of the involved tissue.
The following material, which can be assumed to be typical, is based on ananalysis of 390 consecutive patients with bronchiectasis treated at Percy JonesGeneral Hospital, Battle Creek, Mich., and the chest center at Kennedy GeneralHospital, Memphis, Tenn., during World War II by Maj. Earle B. Kay, MC; Maj.(later Lt. Col.) Richard H. Meade, Jr., MC; and Maj. Felix A. Hughes, Jr., MC (1).
Diagnosis
Diagnosis was based on:
1. Roentgenologic examination, repeated as necessary.
2. Bronchography, with outlining of all five pulmonary lobes.This measure had to be employed with caution, for it sometimes disclosed minordegrees of dilatation on which a diagnosis of bronchiectasis was based, in theabsence of clinical symptoms. For this, there was no warrant.
3. Bronchoscopic examination, to determine the source of theexudate. If the bronchial mucosa seemed unduly inflamed, the possibility ofbronchial occlusion secondary to a retained foreign body or a neoplasm had to beconsidered and eliminated.
4. Bronchospirometric studies, which were important ifthe disease was bilateral, to determine which was the worse side (p. 421).It was also important to determine the pulmonary reserveof the uninvolved lung if dyspnea was a symptom and to establish the extent offunctional tissue in borderline cases.
Differential diagnosis chiefly concerned the reversiblebronchial dilatations that sometimes followed an acute attack of respiratoryinfection, particularly atypical pneumonia. In October 1943, Maj. (later Col.) Brian Blades, MC, wrote to Lt. Col.(later Col.) B. Noland Carter, MC, that Major Meade had reported thiscomplication at the Kennedy General Hospital chest center and that it was alsobeing observed at the chest center at Walter Reed General Hospital, Washington,D.C. The temporary nature of the bronchial dilatation
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in these cases could be demonstrated by repeating thebronchogram a few weeks later; the bronchial configuration then usually showed acomplete return to normal. Bronchoscopic examination was also useful.Differential points were the marked edema and generalized inflammatory reactionin the postpneumonia patients, lesser friability and vascularity, and absence ofthe characteristic odor of the purulent sputum of bronchiectasis.
Conservative Management
The high hopes originally entertained for the use of penicillin inbronchiectasis were not fulfilled. It was never likely that they would be. Thisis a disease characterized by bronchial and bronchiolar destruction, permanentbronchial dilatation, chronic infection, and marked sepsis. In advanced stages,the normal bronchial architecture is replaced by less specialized tissue, apathologic change that explains the recurrent periods of exacerbation and thechronic state of sepsis that characterize it. Penicillin was of considerablevalue in the treatment of recurrent pneumonic episodes as well as in decreasingthe sepsis and toxicity of the interval stages. Occasionally, it changed thecharacter of the sputum. It frequently decreased the cough and sputum andincreased the sense of well-being. These improvements lasted, however,only as long as penicillin was administered. When administration wasdiscontinued, they were promptly lost.
At the Kennedy General Hospital chest center, 45 patients with advanced bronchiectasis were treated with intramuscular injections of 25,000 unitsof penicillin every 3 hours for 1 or 2 months and, in 4 cases,for 3 months. The improvements just listed occurred in about two-thirds of thepatients, usually during the first few weeks of treatment. Regression occurredwhen penicillin was discontinued, and no patient with advanced bronchiectasishad any permanent benefit from the treatment.
Intratracheal penicillin was used in another 45 patients with bronchiectasis, with somewhat betterresults. The seven patients with minimal disease had almost complete relief, anddefinite improvement occurred in two-thirds of the remaining patients.
Indications for Lobectomy
Neither penicillin nor any other form of conservative therapywas the solution of the problem of advanced bronchiectasis. Only surgeryprovided the answer. The decision to resort to it depended upon the extent ofdestructive changes, the physical evidences of chronic toxicity, and the amountof disability and invalidism. Of particular importance was the evaluation of thepatient as a whole, including not only his present symptoms but his pasthistory, with special reference to the increasing frequency or severity of acuteepisodes.
Operation was never indicated in patients with minimal disease, who could betreated conservatively with good results. It was not indicated in patients whohad no clinical evidence of the disease, even though roentgeno-
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grams showed varying degrees of apparently permanentbronchial dilatation. Nor was it indicated in patients with disease of all fivelobes; they were beyond surgical help.
Bilateral bronchiectasis, which was present in about 30percent of the patients observed in World War II, was not considered acontraindication to surgery. Past experience had shown that those with advanceddisease on one side and minimal disease on the other were usually greatlyimproved by operation on the more severely involved side. If the disease wasextensive on both sides, operation was still considered indicated as long as (1)the right upper lobe and (2) the upper aspect of the left upper lobe were freefrom disease and the cardiorespiratory reserve was adequate.
These indications were followed in the 184 lobectomies in this series, in 36of which the disease was bilateral and in 6 of which bilateral lobectomy wasperformed. In another case, the right middle and lower lobes had been removedearlier, and the left lower lobe and the lingula of the left upper lobe wereremoved later (p. 420).
Preoperative Preparation
Operation was not scheduled until 4 to 6 weeks had elapsedafter bronchography, to allow time for the elimination of the injected iodizedoil. In the absence of this precaution, a postoperative pneumonitis was apossibility.
Preoperative preparation was extremely careful and painstaking. It consistedof the following measures:
1. Patients who had been ill over a long period of time had a detailedmedical study, to eliminate possible cardiac, hepatic, and renal complications.
2. An otolaryngologic examination was made, and any infection found received theproper treatment. Sinusitis was treated by nebulized penicillin.
3. The diet washigh in vitamins and calories, and supplementary vitamin therapy was used asnecessary. The vitamin C content of the blood was brought to normal.
4. The plasma protein components of the blood were also brought to normal bysupplementary protein components in the diet or by blood transfusions if theywere indicated. A blood transfusion was always begun when operation was startedand was usually continued throughout its course, in the amount of 1,000 to 1,500cubic centimeters.
5. A physiotherapist explained and demonstrated the breathing exercises to beused during the entire postoperative period.
6. If postural drainage proved useful, it was employed three or four times aday.
7. If sputum was copious and bronchitis severe, a course ofintratracheal penicillin, given for 7 to 14 days, was frequently helpful inreducing the amount of sputum.
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8. Intramuscular injections of penicillin were begun the day beforeoperation. When penicillin became available in preparations of beeswax andpeanut oil, single injections of 300,000 units were given daily beforeoperation, usually for 3 to 7 days, and were continued after operation until thetemperature was normal.
Technique
The individual ligation technique was used in 182 of the 184lobectomies in this series; only the first 2 were performed by the mass ligationtechnique. If purulent secretions were excessive, the bronchus was closed assoon as possible, but seldom before the arteries were divided. The inferiorpulmonary vein was always the last vessel ligated. It was thought that thedanger of embolism from involved lobes was less important than the technicaldisadvantage of permitting the lobe to become engorged.
Pleuritic adhesions between the upper lobe and the chest wallwere cut. If they were allowed to persist, they might prevent the upper lobefrom readily readjusting to the larger space now available to it.
In all partial pulmonary resections, the pleura was drainedby an airtight catheter connected to water-seal suction. Drainage was usuallymaintained for 48 hours. Bronchoscopic aspiration was performed routinely at theend of the operation.
At the end of the operation, roentgenograms were taken andimmediate corrective measures were instituted if they showed atelectasis or ifreexpansion of the remaining lung tissue was not satisfactory.
Postoperative Routine
The usual routine of postoperative care was followed after lobectomy, withspecial emphasis upon the following measures:
1. Oxygen was administered for the first 12 to 24 hours.
2. If the patient complained of tightness in the chest duringthe early postoperative period, temporary phrenic nerve paralysis was performed.This was a particularly important precaution if an emphysematous lobe had beenremoved, to prevent overdistention of the remaining lobe (lobes), as well as inhigh lingulectomies or middle lobe lobectomies performed in combination withlower lobe lobectomies.
3. The patient was usually ambulatory by the fifth day and was permitted outof bed earlier if he had difficulty in voiding.
4. Daily roentgenograms were taken at the bedside, to keep constant check onthe remaining lobe or lobes.
5. When the hemithorax was satisfactorily filled with theremaining lung tissue and the patient's general condition was good, he was givena convalescent furlough. His disposition was determined on his return to thehospital.
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Mortality and Complications
The single surgical death in thisseries occurred in the fourth of the 184 lobectomies. The patient had hadbronchiectasis of the right lower lobe for many months, with repeated hemoptyses.Anesthesia was trying. It was hard to maintain a clear airway. The operation wastechnically difficult and time consuming. It is doubtful that this fatality,which was attributed to cerebral and pulmonary edema, would have occurred if thepatient had been operated on later in the series.
The complications in these 184 lobectomies were as follows:
Significant shock from blood loss occurred in only one case.
Postoperative atelectasis occurred in fivecases. Its infrequency was the result of the vigorous endeavors to keep thebronchi free of secretions by early movement, frequent voluntary coughing, andaspiration of retained secretions as necessary. In one case, however,atelectasis was alarming. This patient had had the right middle and lower lobesremoved at one operation, and the left lower lobe and lingula at another sitting6 months later. On the third day after the last operation, atelectasis of theremaining portion of the left upper lobe developed and persisted to some degreefor the next 3 days. During this time, the patient was maintained only on theright upper lobe, with repeated intratracheal aspiration and the intermittentuse of intranasal oxygen. Recovery thereafter was uncomplicated.
Hemothorax developed in two cases, probably because of injuryof the intercostal vessels when the thoracotomy tubes were inserted.
Bronchopleural fistula with resulting empyemaoccurred in 20 cases, all early in the series. There were only 5 suchcomplications in the last 100 lobectomies. Postlobectomy empyema was not aserious problem at any of the thoracic surgery centers. It was thought thatcareful surgical technique and prompt reexpansion of the remaining lung had moreto do with this than did the use of penicillin.
Jaundice developed in six cases, whethersecondary to blood transfusion or as the result of concomitant hepatitis is notclear; a number of other patients developed hepatitis at about this time.
One patient had a cerebrovascular accident, probably from aseptic embolus. He was treated with penicillin and streptomycin. Six weekslater, a trephine operation was performed, and a small, sterile cystic cavitywas evacuated. Recovery followed. Penicillin was given by vein during operationin subsequent cases, to reduce the likelihood of this complication.
There was no complication from thecontralateral lung in any patient with bilateral bronchiectasis, probablybecause in these cases, the postoperative regimen was particularly rigid.
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Bronchospirometry
Ten patients in this series upon whom bronchospirometricstudies were performed before operation had an average oxygen consumption on theaffected side of only 37 percent of the total and an average ventilation of 44percent of the total. These figures show the effects of bronchiectaticdestruction of tissue on the pulmonary function. They also show that theefficiency of oxygen absorption into the alveolar capillaries or through thealveolar membrane is even more impaired in this disease than is the ability toventilate the lung.
In one instance, bronchospirometric studies on a patient withbilateral disease showed that oxygen consumption was 61.1 percent on the moreseverely impaired side and only 38.9 percent on the other side, on which therewas thought to be only minimal disease in the right upper lobe. Evidently,destructive changes not apparent by roentgenogram or bronchogram were presentin the supposedly good lung. Two patients, not included in this series, werefound to have such copious amounts of sputum and such a degree of bronchialobstruction that there was no oxygen absorption at all on the affected side.
These studies indicate (1) that, in many instances, thebronchiectatic lobe contributes very little to the oxygenation and gaseousexchange of the blood circulating in the pulmonary tissues; (2) that the bloodreturns to the heart unoxygenated and with a high carbon dioxide content; and(3) that these phenomena are responsible in large measure for the cyanosis anddyspnea observed in bronchiectasis. Only by removal of the bronchiectatic tissuecan blood be circulated through the alveoli, with proper oxygenation anddiffusion of gases.
Postoperative bronchospirometric studies in 26cases in this series showed that the pulmonary function of the remaining lungtissue on the affected side was largely dependent on the presence or absence ofpostoperative pleural complications (figs. 190, 191, 192 and 193). In none ofthese cases was the pulmonary function significantly impaired when recovery wasuneventful; in numerous instances, it was within normal limits 2 or 3 monthsafter operation. That good results persist is suggested by the fact thatfunction was normal in two other patients examined, respectively, 1 year and 3years after lobectomy.
Results
The good results in this series wereunquestionably influenced by the fact that practically all of the patients wereexcellent risks as compared with candidates for surgery in civilian practice.Their disease was such that it could be cured only by pulmonary resection, andthe risks they underwent were so small compared to the risks of persistingdisease that operation was recommended without hesitation in every case in whichit was indicated.
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Administrative Considerations
When bronchiectasis was clearly not "line of duty,"as manifested by a history of previous symptoms pointing to it, dispositioncould be accomplished at any hospital at which authorized disposition boardswere held.
All patients with bronchiectasis considered to be line ofduty were transferred to a thoracic surgery center, where treatment was carriedout and disposition was effected by consultation between the medical and thesurgical services. The policy was to discharge men who did not wish tobe operated on or in whom operation was contraindicated. Those with extensivebilateral disease were given medical discharges. Those with advanced disease notsuitable for surgery were usually transferred to a Veterans' Administrationhospital.
Although many men were returned to full duty after lobectomy,there was some hesitancy all through the war about returning to duty, oraccepting for duty, any man who had any type of thoracic disease. This problemfirst came up in October 1943, aftermore than 50 lobectomies had been performed at the Walter Reed thoracic surgerycenter, and Major Blades wrote to Colonel Carter about it.
PULMONARY TUBERCULOSIS
Surgical Procedures
In World War I, pulmonary tuberculosis was a major problem, as might havebeen expected, for both roentgenologic and screening techniques were crude bymodern standards. In World War II, the efficient screening and case-findingmethods that had been developed between the wars were put to good use, andtuberculosis in the Armed Forces was never a major concern.
The finding ofactive disease in a soldier, at least in the first years of the war, wasconsidered almost synonymous with his permanent release from active duty. As thewar progressed, however, this concept began to be altered, and surgery wasemployed in occasional, carefully selected cases, with remarkably good results.
A listing of the procedures accomplished at the chest centerat Fitzsimons General Hospital, Denver, Colo., in 1944 and 1945 shows interesting changesinthe procedure employed, as well as an increasing interest in surgery fortuberculosis (table 16).
All patients selected for surgery were first carefullyconsidered by the medical board of the hospital, and the responsibility of thechest center for them varied according to the operation. Patients who underwentonly phrenic emphraxis were brought to the operating room from the medical wardand returned to the medical ward immediately after the operation. Patients whounderwent pneumonolysis were transferred to the surgery section the afternoon
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Procedure | 1944-45 | 1944 | 1945 |
Thoracoplasty | 213 | 139 | 74 |
Phrenic emphraxis | 490 | 226 | 264 |
Intrapleural pneumonolysis | 25 | 23 | 2 |
Open pneumonolysis | 72 | --- | 72 |
Lobectomy | 40 | 12 | 28 |
Segmental resection | 7 | --- | 7 |
Pneumonectomy | 5 | 2 | 3 |
Partial pneumonectomy | 3 | --- | 3 |
Decortication | 5 | --- | 5 |
| 860 | 402 | 458 |
before operation. A roentgenogram was taken at once to determine the degreeof pneumothorax present.
The patients were held on the surgical ward after operationonly until the intrapleural pressure was well stabilized, which was usuallywithin 72 hours. Candidates for other operations were transferred to the surgerysection before operation and held on it until their immediate convalescence wascomplete.
Pulmonary resection for tuberculosis was introduced at this center in 1944. There was 1 death in the12 operations,from massive postoperative spread of the process. The patient was a poorsurgical risk, with bilateral cavitary disease, and left upper lobectomy wasperformed in the desperate hope of controlling it. A mixed empyematous processdeveloped in another case after operation, but the patient made a good recovery,and there was no spread of the disease in any other case. All other patientsrecovered smoothly. These results were considered so encouraging that the policywas continued and extended in 1945. Therewere no deaths in the 28 lobectomies performed in that year, and postoperativespread of the disease occurred in only one case. The center closed beforelong-term results of lobectomy could be observed, but the immediate results wereconsidered most encouraging.
It was not always easy to select patients for lobectomy. Ingeneral, the procedure was limited to chronic disease with localized involvementwhich had not responded to standard collapse therapy.
The results of pneumonectomy were not encouraging, which wasnot unexpected, for all operations were done for advanced disease involving theentire lung. All the patients were extremely poor surgical risks, and operationwas a last resort. There were two deaths in the three operationsperformed in 1944.
Tuberculomas.-The seven segmental pulmonary resections performed at theFitzsimons General Hospital chest center in 1945 wereall for tuberculomas. These neoplasms were formerly considered extremelyuncommon. Routine
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roentgenologic examinations of men in service at induction,at separation, and sometimes more often, showed that they were by no means asuncommon as they had originally seemed.
Most tuberculomas were asymptomatic, but careful inquiry into the previoushistory often revealed positive or suspicious stories of active disease. Themajority of the masses were solitary, but in a number of instances, satellitefibrocaseous nodules were associated with the larger growths, particularly inthe upper lobes.
When a tuberculoma was diagnosed, its presence was regardedas an indication for surgery. These lesions have dangerous potentialities forbreaking down and spreading. At operation, they are usually found to be moreextensive than roentgenologic examination has suggested. Finally, neitherroentgenologic examination nor any other measure is sufficiently accurate todifferentiate them from bronchogenic carcinoma.
If bacteriologic examination revealed acidfast bacilli, medical treatment wasemployed before operation. The possibility of endobronchial disease alwaysrequired investigation before operation; it was unusual, but preoperativetreatment was necessary if it was found.
Excision was usually possible by wedge resection, with conservation of asmuch lung tissue as possible. Lobectomy was necessary if the lesions were largeor if there were satellite nodules.
Recovery was usually smooth, and most operations could beconsidered successful. The postwar experience has shown that many patientstreated by excision of tuberculomas can be returned to full military duty.
Tuberculosis Complicating Combat-Incurred Wounds
Attention has been called to an unusual case in the Mediterranean theater inwhich recovery was complicated by activation of latent tuberculosis (p. 165).The following similar case was observed at Halloran General Hospital, StatenIsland, N.Y., by Maj. Richmond L. Moore, MC:
Case 1.-A private in the infantry was struck in the left lowerchest on 2 May 1944, in England, by a fragment from an accidentally exploded60-mm. mortar shell. When he was seen in a general hospital 2 hours later, hewas in moderate shock and was complaining of severe upper abdominal pain. Theupper abdomen was rigid and tender, and there was beginning dullness in bothflanks. The thoracic wound, which was about 15 cm. long, was in the leftmidaxillary line, at the level of the tenth intercostal space. A portion of thespleen had herniated through it. Roentgenograms of the chest and abdomen showedneither pneumothorax nor foreign bodies.
Exploration of the abdomen through a T-shapedincision revealed a ruptured spleen, a 7-cm. rent in the left leaf of thediaphragm, perforations on the greater and lesser curvatures of the stomach, anda puncture wound on the inferior surface of the left lobe of the liver. Theperitoneal cavity was full of blood mixed with gastric contents. The operationconsisted of splenectomy and repair of the perforations in the stomach and thediaphragm. The puncture wound of the liver was not explored. The wound of thechest wall was debrided before closure, which was complete.
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Roentgenograms on 12 May showed a left hemopneumothorax, butthe chart bore no record of treatment by aspiration. On 15 May, 100 cc. ofpurulent exudate was evacuated from the upper half of the abdominal wound.
Both wounds then healed well, and convalescence was uneventfuluntil the latter part of June, when the patient began to run an intermittentseptic fever, for which no cause was discovered. He was received at a generalhospital in the Zone of Interior on 8 August. On 22 August, aspiration of thechest yielded 300 cc. of thick pus. The following day, 4 cm. of the ninth ribwas resected, and drainage was established.
When the patient was received at Halloran General Hospital, on19 September, there was a discharging sinus at the site of the rib resection.Roentgenograms of the chest on the following day, after instillation of 20 cc.of Lipiodol, revealed a triangular cavity at the left base, measuring 3 by 6centimeters. A metallic foreign body 7 by 15 mm. was in the upper abdomen, inthe region of the liver.
Drainage was obviously inadequate, and a second thoracotomywas done on 25 September, with resection of the eighth and ninth ribs and theintervening intercostal muscle bundles and pleura. Microscopic examination ofthe excised sinus tract showed numerous tubercles with central necrosis andborders of granulomatous tissue. The diagnosis of tuberculosis was confirmed byexamination of a second specimen on 27 October.
Another persistent sinusdeveloped after the second thoracotomy and showed no tendency toward healing inspite of vigorous local treatment. On 3 January 1945, roentgenograms of thechest after instillation of Lipiodol showed an empyema cavity about 7 by 2 cm.and a bronchopleural fistula.
At a third operation on 2 May 1945, exploration showed thatthe sinus extended deep into the substance of the lung. The tissue excised atthis operation included the surrounding zone of scar tissue, all of theregenerated bone surrounding the external opening of the sinus tract, andadditional segments from the stumps of the eighth and ninth ribs. Sections oftissues stained by the Ziehl-Neelsen technique showed acidfast organisms.
The lung apparently healed rapidly, but another persistentsinus appeared. At exploration on 22 June, it was found to extend through thelung to the diaphragm. It was thoroughly excised by the radical technique usedat the operation on 2 May. The resulting extensive defect in the chest wall wasclosed by undermining and approximating the muscles and subcutaneous tissue. Asmall rubber tube was left in the center of the wound between the lung,diaphragm, and chest wall.
Healing was rapid and satisfactory. The drainage tube wasremoved on 25 July, and 4 days later, the sinus was completely closed, as it waswhen the patient returned on 5 September 1945 from a 30-day convalescent leave.Although he had gained 60 pounds since the second thoracotomy on 25 September1944 and was in excellent general condition (fig. 194), he was considered unfitfor further military duty and was separated from service.
The tissues removed atthis operation again showed classical tubercles with central necrosis, rimmed byepithelioid cells and lymphocytes and the typical Langhans type of giant cell.
Comment.-This man received excellent surgery within 3 hoursof his injury, and his recovery must be attributed to it. It was wise not toattempt to remove the shell fragment in the liver or to explore the chest, forhis condition was poor and his blood pressure fell to 0 on the operating table.Complete primary closure of the chest wound after debridement was, however,contrary to military teachings. Furthermore, had the hemothorax evident 6 daysafter wounding been treated by aspiration, it is highly probable that theempyema which developed would have been prevented.
The particular point of interest in this case is the diagnosisof tuberculosis in the tissues at the site of injury. Careful inquiry showednothing in the previous history to suggest acidfast infection of any kind. Thetuberculous infection supplied an adequate explanation for the chronicity of theprocess and the repeated failures to obtain satisfactory
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healing despite the establishment of adequatedrainage. A satisfactory result was obtained only when all of the diseasedtissues had been excised and the resulting defect closed by the approximation ofwell nourished, healthy tissues.
LUNG ABSCESS
The incidence of lung abscess was remarkably low in World War II (table 10)and the incidence of acute fulminating abscesses far lower than the incidence ofchronic indolent abscess. During the entire war, only three acute lung abscessesrequired drainage at the Walter Reed General Hospital chest center. There wereseveral explanations for this situation:
1. One of the chief etiologic factors in lung abscess, dental sepsis, wasalmost entirely eliminated in World War II by the excellent dental care providedfor all soldiers in the Army.
2. The almost universal use of the sulfonamides, and later ofpenicillin, in pneumonia and other severe respiratory infections probablyaccounted for the absence of the fulminating infections formerly seen and alsoexplained the presence of more chronic, less severe types.
3. Because of the effectiveness of penicillin, many patientswith small abscesses, which were treated promptly, were probably cured insmaller hospitals and did not have to be referred to chest centers.
Chronic lung abscesses, nonetheless, furnished numerous problems. As early asOctober 1943, Major Blades reported to Colonel Carter that the thoracic surgeonsat all centers complained that these patients were not being trans-
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ferred to the centers early enough; most of them had been ill for 4 to 6months when they were first seen.
In War Department Technical Bulletin (TB MED) 69 (2), 22 July1944, directions were given to transfer all patients with lung abscesses tothoracic surgery centers if conservative treatment failed to produce promptsymptomatic improvement, accompanied by roentgenologic evidence of clearing ofthe surrounding pneumonia and progressive decrease in the size of the cavity. Inview of the difficulties of management of chronic lung abscess, transfer was tobe effected within 30 days of the patient's admission to the hospital unless therate of healing clearly indicated that surgical treatment would not be required.
Management
As in other suppurative diseases, the response to penicillinof a patient with a lung abscess depended upon the process. A number of small,carefully supervised series showed that the only effect in abscesses of anyseverity was likely to be symptomatic improvement and that regression wouldoccur as soon as therapy was discontinued. It could scarcely be expected that apathologic process characterized by tissue destruction, necrosis, and gangrenewould be improved by any antibiotic, even if the organisms present weresensitive to it and were of low virulence.
Even before the war, drainage of lung abscesses had falleninto disfavor because of the poor results. This operation decreased the sputumand reduced the fever, but it wrought no real improvement in a patient in whoman entire lobe had been destroyed and whose infection involved the interlobarfissures and had spread to adjacent lobes. It was only in very early cases, whenthe abscesses were well circumscribed and drainage was instituted promptly, thatthe results of conservative surgery were satisfactory.
Excisional surgery had begun to be popular before the war, astechnical refinements and developments in anesthesia greatly reduced thesurgical risks. It was the preferred method of treatment for chronic lungabscesses in the thoracic surgery centers in the Zone of Interior. The risk oflobectomy was somewhat greater than in bronchiectasis, but it was generallyregarded as worth taking in view of the prospect of chronic invalidism whichotherwise faced the patient, and, on the whole, the results were excellent.
EMPYEMA
When the sulfonamide drugs first became available, shortlybefore World War II, accumulated data promptly showed that the almostuniversal use of these agents in the treatment of pneumonia was resulting in amarked decrease in the postpneumonic variety of suppurative pleurisy. The localand systemic use of the various sulfonamide derivatives also showed, however,that once a purulent exudate had formed in the pleura, cure by chemotherapy wasnot possi-
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ble: Toxic reactions prevented the use of sufficiently largedoses by the systemic route to effect a cure, while local injections into thepleural cavity were equally ineffective, since the admixture with purulent fluidinhibited their antibacterial action.
Management
When penicillin became available, it seemed, at least theoretically, that itwould be ideal for the management of postpneumonic empyema caused bymicro-organisms susceptible to it. It has a strong antibacterial action whenused systemically, and retains its potency in the presence of pus and blood. Itslow toxicity permits the use of very large doses both locally and systemicallywith little risk of toxic or other side effects.
In spite of these favorable circumstances, the original high hopes were notfulfilled. When acute empyema was treated in the early stages by aspiration andinjection of penicillin, there were numerous good results. This was not alwaystrue, however, even in acute cases, and it was seldom true in chronic cases, inwhich its prolonged use was an invitation to chronicity. There was no reason,for instance, for the 11 thoracenteses and 300 intramuscular injections ofpenicillin employed in one of the early cases over a 6-month period ofhospitalization. There was never any justification, in fact, for thecontinuation of conservative treatment unless there was a progressive decreasein the size of the cavity accompanied by clearing of the purulent fluid.
In TB Med 69 (2), it was directed that surgical drainage must be employedwhen the pus in the empyema cavity was thick, since its presence predisposed tothickening and fixation of the pleura and the consequent development of chronicempyema. It was further directed that all patients with chronic empyema betransferred to a thoracic surgery center for treatment and disposition. Anempyema was considered to be chronic when, at the end of 6 weeks after theoriginal operation, the cavity measured 30 cc. or more.
The following policies of management finally become routine:
1. An injection of penicillin was given intrapleurally assoon as infected fluid was demonstrated in the cavity. Additional local therapywas then withheld until the organisms present were identified and it wasdetermined that they were penicillin susceptible. Delay in local treatment wasparticularly emphasized when penicillin first became available and quantitieswere so limited that it could not be wasted.
2. If systemic penicillin had not been employed during the pneumonic stage ofthe disease, it was begun at once. The chief advantage of this route was that itput into the blood a bacteria-inhibiting substance which might prevent orcontrol a spreading cellulitis or invasive infection. This was particularlyimportant when the responsible organism was streptococcus or staphylococcus.
3. Three intrapleural injections of 50,000 units each, onalternate days, were usually sufficient. Before the injection, as much fluid aspossible was removed by thoracenteses.
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4. If exudate continued to form and became thicker, surgical drainage wasestablished without further delay. Thick pus could not be evacuatedsatisfactorily by needle, and even sterile fluid was often so thick thatthoracotomy was necessary for adequate drainage. Valuable as penicillin was asan adjunct to surgery, it did not permit the violation of fundamental surgicalprinciples.
ACTINOMYCOSIS
Official statistics for actinomycosis show 207 admissionsfor this cause in the 1942-45 period,with 4 deaths and 24 separationsfor disability.
Particular interest was aroused in this disease at the KennedyGeneral Hospital chest center when the ray fungus was isolated in two patientsunder treatment for pulmonary suppuration. Thereafter, this organism wassearched for routinely in all suppurative chest disease and was found withsurprising frequency, as is evident in a report by Major Kay (3).
Between May and November 1945, Actinomyces bovis (israeli) was found in 109 of 240 patientsunder treatment for chronic bronchopulmonary infections. In no instance was itthe only organism found. In a number of patients it appeared to predominate, butusually such other organisms as streptococci, staphylococci, spirochetes,fusiform bacilli, and other less common microorganisms were also identified. Actinomyceswas found in the sputum in all 109 cases by direct examination and by culture, inspecimens secured by bronchoscopy in 65 cases,in exudate aspirated from lung abscesses in 6 cases,and in drainage from sinus tracts in 2 patientswith empyema secondary to pulmonary suppuration. The 65 patients from whom the organisms were cultured frombronchoscopic specimens included 37 with bronchiectasis and pneumonitis ofvarying degrees of severity, 8 with lung abscess, 5 withpulmonary suppuration, 5 withaspiration pneumonia, 2 withsuppuration distal to obstructing carcinoma, and 8 with chronic bronchitis.
These findings at first caused considerable concern amongmedical officers whose previous experience with this condition had been limitedto isolated cases. There was debate as to whether these cases should beconsidered as instances of bronchopulmonary actinomycosis or as instances ofbronchopulmonary suppuration in which the ray fungus was present among otherinfecting organisms. As experience accumulated, it was evident that the clinicalsignificance of Actinomyces wasfar less than had originally been feared. The clinical course and the responseto surgery and chemotherapeutic measures did not seem to be influenced by itspresence or absence; chronic pulmonary suppuration is a very chronic conditionper se.
The precautions originally taken when Actinomyces wasidentified included increased dosages of the sulfonamides and penicillin beforedrainage operations and, in a number of instances, postponement of the indicatedsurgery, for fear of development of a chronic draining sinus and empyema afterlobectomy. In no instance did this happen. The fungus was isolated in the
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pleural fluid of one patient after pneumonectomy, but it promptly disappearedwhen intrapleural injections of penicillin and sulfadiazine were used. In otherwords, as time passed, it became evident that this fungus was of lesssignificance in the clinical course, chronicity, and prognosis of pulmonary andpleural infections than the mechanical factors of bronchial occlusion ordrainage, tissue destruction, fibrosis, and avascularity. Patients whopresented these findings were just as resistant to conservative therapy as werepatients who harbored Actinomyces.
Management
The response to treatment depended upon the chronicity andthe severity of the infection. Penicillin and sulfadiazine, used in combinationand in large doses, gave the best results, but it was important that they becontinued well beyond clinical improvement and roentgenologic clearance; otherwise,recurrence was certain. The routine of treatment required the injection of50,000 units of penicillin intramuscularly every 3 hours for 8 to 12 weeks orlonger, and the maintenance of a sulfadiazine blood level of 10 mg. percent. Itwas thought that streptomycin might prove even more effective, but the evidencewas inconclusive when the survey ended.
If cavitation was present, the routine just described wasconsiderably less effective; the patients were improved symptomatically, andthere was clearing of pneumonitis about the cavity, but the basic disease wasnot affected. Lobectomy was required in two cases in this series in whichmedical treatment failed and drainage was also unsatisfactory, and pneumonectomywas necessary in two similar cases. It was thought that one or the other ofthese procedures would also be necessary in other cases.
SPONTANEOUS PNEUMOTHORAX OF NONTUBERCULOUS ORIGIN
Spontaneous pneumothorax of nontuberculous origin was observed at all chestcenters. Colonel Meade and Colonel Blades (4) analyzed the 18 cases jointlyobserved at the chest centers at Kennedy General Hospital and Walter ReedGeneral Hospital. Eight of the pneumothoraces were recurrent, eleven werechronic, and all were cured by surgery. In 3 of the 18 cases, no etiologicfactor could be determined. In the remaining cases, rupture of peripheralemphysematous blebs and bronchogenic cysts was the most frequent cause.
The policy was to perform open thoracotomy on any patient whodid not respond promptly to simple aspiration of air or induction of a chemicalpleuritis. The procedures employed included excision of blebs and cysts; closureof fistulas; division of isolated adhesions; lobectomy; and pulmonarydecortication, which was necessary in five cases before satisfactory reexpansionof the lung was accomplished. Open operation was employed in all cases, so thatthe underlying cause could be dealt with and decortication performed ifreexpansion was not satisfactory.
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MALIGNANT NEOPLASMS
Incidence
Figures collected by the Medical Statistics Division, Officeof The Surgeon General, for 1944 and 1945 (table 17) show a total of 205 primaryadmissions for malignant neoplasms of the thorax, of which 140 were in the lungand the bronchus. Another 45 admissions were recorded for secondary malignancyof the thoracic structures. No instances of malignant neoplasm of the tracheawere recorded during this period. Though the total number of cases is small, awide variety of histologic patterns is represented (table 18).
There were 141 deaths in the 205 primarymalignant neoplasms, 83 of which occurred in the Zone of Interior (table 19).Men whose disease was discovered overseas were evacuated to the United States atonce.
While the figures represent only the 1944-45 period, it ispossible that both the 141 deaths and the 53 disability separations recorded forthe 2 years include some patients admitted before 1944. As to the remaining 11patients not included in the deaths and disability separations, it is highlyprobable that some died after separation from service.
Neoplasms of the lymphatic and hematopoietictissue are not included in these tables, but some figures (based on 20 percentsamples) are available. During the 1944-45 period, there were:
35 primary and 5 secondary admissions for neoplasms of themediastinum, with 3 deaths and 10 disability separations.
5 primary admissions for neoplasms of the larynx, with 1 deathand 1 disability separation.
Two deaths and three disability separations for this categoryof pulmonary neoplasms were also recorded during 1944-45.
Carcinoma of the Lung and the Esophagus
No special discussion of carcinoma of thelung during the war is called for. The manifestations were the same as incivilian life, most of the tumors being inoperable by the time the diagnosis wasmade. A number of highly malignant peripheral bronchogenic cancers gave nowarning of their presence until metastases contraindicated even palliativesurgery. Results were only slightly better in a smaller group of older patientswhose tumors were centrally located and of the squamous cell type.
How discouraging the results of treatment werein carcinoma of the lung is evident in the 1945 report from Fitzsimons GeneralHospital: Of 10 bronchogenic carcinomas observed that year, 7 were inoperablewhen the diagnosis was made, and irradiation was completely ineffective; all 7patients died promptly. Of the three who underwent pneumonectomy, one died ofextensive metastases and one of pneumonia in the remaining lung 3 months afteroperation. The third patient in this group was still in the hospital undergoingirradiation when the report was made.
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[Preliminary data based on 20 percent sample tabulations ofindividual medical records]
Area | Site of malignant neoplasm | |||||
Lung | Bronchus | Pleura | Mediastinum | Larynx | Esophagus | |
NUMBER OF ADMISSIONS | ||||||
Continental United States | 75 | 15 | --- | --- | 25 | 5 |
Overseas: | ||||||
Europe | 25 | 10 | --- | 5 | 10 | --- |
Southwest Pacific | 10 | --- | --- | --- | --- | --- |
Central and South Pacific | 5 | --- | 5 | 5 | 5 | --- |
Latin America | --- | --- | --- | 5 | --- | --- |
| 40 | 10 | 5 | 15 | 15 | --- |
| 115 | 25 | 5 | 15 | 40 | 5 |
NUMBER OF SECONDARY CASES2 | ||||||
Continental United States | 10 | --- | --- | --- | --- | --- |
Overseas: | ||||||
Europe | 10 | --- | 5 | --- | 5 | --- |
Mediterranean3 | 5 | 5 | --- | --- | --- | --- |
Central and South Pacific | 5 | --- | --- | --- | --- | --- |
| 20 | 5 | 5 | --- | 5 | --- |
| 30 | 5 | 5 | --- | 5 | --- |
1Neoplastic conditions of lymphoid and hematopoietic tissuesare excluded.
2Ten secondary cases of malignant neoplasm of lung werereported among battle admissions-5 each in the European and the Central andSouth Pacific theaters; all other secondary cases were reported among diseaseadmissions.
3Includes North Africa.
The outlook in malignant lesions of the esophagus was equallypoor. In seven carcinomas observed at the Kennedy General Hospital chest center,three were found to be inoperable in exploration. Three were treated byresection with anastomosis, and the remaining patient underwent, respectively,total gastrectomy; transverse colectomy; and esophagojejunostomy, aprocedure which almost implies a fatal outcome.
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[Preliminary data based on tabulations of individual medical records]2
Anatomic site and histologic type | Admissions | Secondary cases | Deaths3 | Disability separations4 |
Lung: | ||||
Carcinoma | 100 | 25 | 77 | 19 |
Liposarcoma | 5 | --- | 1 | --- |
Osteogenic sarcoma | --- | 5 | --- | --- |
Sarcoma, unspecified | --- | --- | 1 | --- |
Endothelioma | --- | --- | 1 | --- |
Malignant tumor, unspecified | 10 | --- | 6 | --- |
| 115 | 30 | 86 | 19 |
Bronchus: | ||||
Carcinoma | 20 | 5 | 26 | 4 |
Malignant tumor, unspecified | 5 | --- | 1 | --- |
| 25 | 5 | 27 | 4 |
Pleura: | ||||
Carcinoma | 5 | --- | 1 | 1 |
Endothelioma | --- | --- | --- | 1 |
Mesothelioma | --- | 5 | --- | --- |
| 5 | 5 | 1 | 2 |
Mediastinum: | ||||
Carcinoma | 5 | --- | 5 | 1 |
Sarcoma, unspecified | 5 | --- | 2 | --- |
Malignant tumor, unspecified | 5 | --- | 9 | 6 |
| 15 | --- | 16 | 7 |
Larynx: | ||||
Carcinoma | 30 | 5 | 3 | 15 |
Angiosarcoma | --- | --- | 1 | --- |
Sarcoma, unspecified | --- | --- | --- | 1 |
Chordoma | 5 | --- | --- | 1 |
Malignant tumor, unspecified | 5 | --- | --- | --- |
| 40 | 5 | 4 | 17 |
Esophagus: | ||||
Carcinoma | 5 | --- | 7 | 4 |
| 5 | --- | 7 | 4 |
| 205 | 45 | 141 | 53 |
1Neoplastic conditions of lymphoid and hematopoietic tissues are excluded.
2Admissions and secondary cases are based on 20-percent samples; deaths and disability separations are based on complete files of the records.
3These are all deaths due to the conditions indicated which occurred during 1944-45.
4These are all cases separated from the service during 1944-45 because of disability from the conditions indicated.
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[Preliminary data based on tabulations of individual medical records]
Area | Malignant neoplasms in- | |||||
Respiratory system, by anatomic site | Esophagus | |||||
Lung | Bronchus | Pleura | Mediastinum | Larynx | ||
Continental United States | 55 | 14 | --- | 7 | 3 | 4 |
Overseas: | ||||||
Europe | 12 | 6 | --- | 2 | 1 | 1 |
Mediterranean3 | 8 | 1 | --- | 1 | --- | 1 |
Middle East | --- | 1 | --- | --- | --- | --- |
China-Burma-India | 1 | 1 | --- | --- | --- | --- |
Southwest Pacific | 5 | --- | --- | 2 | --- | --- |
Central and South Pacific | 3 | 1 | 1 | 3 | --- | 1 |
North America4 | 1 | 1 | --- | --- | --- | --- |
Latin America | --- | 2 | --- | 1 | --- | --- |
| 531 | 13 | 1 | 9 | 1 | 3 |
| 86 | 27 | 1 | 16 | 4 | 7 |
1Neoplastic conditions of lymphoid and hematopoietic tissuesare excluded.
2These are all deaths due to the conditions indicated whichoccurred during 1944-45.
3Includes North Africa.
4Includes Alaska and Iceland.
5Includes one death among admissions on transports.
Tumors of the Mediastinum
During the 3-year period of their activity, 109 patients withmediastinal tumors were operated on at the five thoracic centers in the Zone ofInterior. The figures collected by Colonel Blades (5) include only the cases inwhich the chest was explored because of symptoms or because of the discovery ofa mediastinal mass on routine roentgenologic examination, which was the primarymeans of diagnosis in 94 of the 109 cases.
Five of the masses proved to be aneurysms, not neoplasms. Of the 104 truetumors, 15 were malignant and 89 were benign.
The malignant group included six teratomas, two thymomas, twolymphoblastomas, and one neurosarcoma. It also included four instances ofHodgkin's disease, in three of which the diagnosis was not realized untilhistologic examination of the specimen. In one case, the tumor had invaded theupper lobe of the lung, and lobectomy was necessary for its removal. Surgicalintervention would not have been undertaken deliberately in any of these casesif the true nature of the tumor had been established before operation.Short-term observation, however, showed that the patients had not been harmed byremoval
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of the visible tumors, and there was some evidence that theymight have been benefited.
Exclusive of the 4 instances of Hodgkin's disease and the 5aneurysms just mentioned, the essential data in the remaining 100 cases were asfollows:
Bronchogenic cysts.-There were 23 bronchogenic cysts in thisseries, a surprisingly large number considering the fact that up to 1945,according to Laipply (6), only 35 had been recorded.
Only 2 of the 23 patients had clinical manifestations. In theremainder, the mass was found on roentgenologic examination. Even with detailedstudies, the true nature of the masses was difficult to establish. On thefrontal projection, they suggested either teratoid tumors or primary nervetumors. On the lateral view, the shadow was not so distinct as in teratoidtumors, and the extreme posterior position characteristic of most primary nervetumors was not evident. Since most bronchogenic cysts are attached to thetrachea (most often near the tracheal bifurcation in the superior mediastinum),the mass moved during swallowing, as could be demonstrated by fluoroscopicexamination, which was of some diagnostic assistance. A patent lumencommunicating with the trachea or a bronchus was not demonstrable in any case.
There were two sound reasons for advising the surgical removal of bronchogeniccysts even if they were asymptomatic:
1. There was no reliable method, except surgical exploration,for determining the true nature of the tumor. Many neoplasms of the mediastinumwith grave malignant potentialities resemble bronchogenic cysts on roentgenologic examination. Moreover, since bronchogenic lesions are considered as cellrests, there is no assurance that malignant changes will not occur in them.
2.Bronchogenic cysts may become infected. If they do, operative interference isnecessary, and technical difficulties at this time may be considerable. Also,cysts which are presently asymptomatic may increase in size and produce laterpressure and other symptoms.
Teratoid tumors-Twenty of the tumors in this series wereteratoid, to use the inclusive nomenclature suggestedby Harrington (7). Fourteen were benign and were removed without difficulty.Advanced changes were evident in the six malignant growths. Only surgicalextirpation can be considered for these tumors, because of the risk of malignantdegeneration.
Up to 1945, close to 250 teratoid tumors hadbeen reported in the medical literature (6), and they are the most commonlesions of the anterior mediastinum. In the collected cases, only three were inother locations. The number observed in the chest centers during World War IIwould undoubtedly have been larger except that these tumors produce sharpshadows and are so easily detected by roentgenogram that most men who harboredthem were probably identified at the preinduction examination and were rejectedfor service.
Neurogenic tumors-The29benign primary nerve tumors of the mediastinum observed in this series includedchiefly neurofibromas, ganglioneuromas, and sympathicoblastomas. Up to 1944, 105of these tumors had been collected
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by Kent and his associates (8), all but 2 of which werelocated posteriorly. In their series, 37 percent of the tumors had undergonemalignant change, which makes clear why surgical excision is the correcttreatment as soon as the tumor becomes evident.
One patient with a neurogenic sarcoma was explored, but invasion of thesurrounding structures precluded its removal. All the other tumors were excised.
Pericardial cysts-The 10 pericardial cysts in the series were alldiscovered on routine roentgenologic examination. Except for theircharacteristically anterior location, there is nothing to differentiate thesecysts from other mediastinal tumors, and surgical excision is the only way toestablish their character.
Thymomas-Four of the six patients with thymomas, two of which weremalignant, had no symptoms referable to the mass. In one case, in which thepatient had advanced myasthenia gravis, it was impossible to remove themalignant mass completely.
Lipomas-Only 4 lipomas were encountered, which is not surprising, sinceless than 40 mediastinal tumors of this type could be collected by Watson andUrban (9) in 1944.
Other tumors-Other mediastinal tumors in this series included onefibroma, which was probably a neurofibroma; one thyroid adenoma; one cystarising from the esophagus; one osteochondroma; one Boeck's sarcoid, diagnosedby biopsy of tissue at the hilus; and two tuberculomas.
Comment-There was not complete agreement among the surgeons at the chestcenters as to the best exposure for mediastinal tumors. Some routinely employeda posterolateral exposure; others preferred an anterior approach if the locationof the tumor made it logical. The technique employed usually reflected the earlytraining which the surgeon had received. On one point there was generalagreement, that if difficulties were anticipated, a lateral or posterolateralincision should be used.
Before World War II, tumors of the mediastinum werefrequently treated by irradiation, surgery being resorted to only ifsatisfactory results were not accomplished. This was never a safe or a desirableplan. As has been pointed out several times in this brief analysis of the 109mediastinal masses treated at the chest centers in the Zone of Interior duringWorld War II, it is not possible, in most instances, to determine the truecharacter of a mediastinal tumor without direct inspection at operation. Ifoperation is delayed until symptoms and signs become apparent, the chance forsuccessful extirpation will frequently have been lost.
The reasoning behind the use of irradiation in preference to exploration wasthe risk originally attendant upon exploratory thoracotomy. This risk ceased toexist when refinements in surgical and anesthetic techniques made exploration ofthe chest safe. Risks were negligible in the chest centers during
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World War II. Errors in diagnosis occasionally occurred, anda few tumors were operated on which might have responded to irradiation, but thedanger to the patients was slight compared to the harmful potentialities ofprolonged and ineffective irradiation. Irradiation will not reduce the size, orhalt the malignant degeneration, of these tumors unless they are of lymphaticorigin, and surgery is more dangerous and more difficult after prolonged use ofX-rays.
The results in this series justify the management ofmediastinal tumors by prompt exploration of the chest. There were no deaths thatcould be attributed to the operation and no postoperative complications in thecases in which only exploration and biopsy were performed. Suppurative pleuritisdeveloped in three cases in which a tumor was removed, but adequate drainage wasfollowed by prompt healing. In one of these cases, it had been necessary toremove an infected right middle lobe that had been eroded by a teratoma.
LESIONS OF THE ESOPHAGUS
In addition to the seven malignant tumors of the esophagustreated at Kennedy General Hospital, Major Kay's (10) survey of esophageallesions at that center included:
2 benign new growths (neurofibroma and leiomyoma).
5 cysts (2 dermoid, 1 bronchogenic).
9 diverticula (4 traction, 3 pulsion, 1 epiphrenic).
1 varix (too extensive for treatment).
9 hiatal hernias (5 treated surgically).
4 paraesophageal hernias (1 treated surgically).
20 cardiospasms (11 treated surgically).
11 obstructions due to extrinsic tumors, cysts, aneurysms and tuberculousnodes (all treated by measures directed to the extrinsic lesion).
8 congenitally short esophagi (3 associated with stricture and 4 with ulcer).
18 strictures (11 due to ingestion of "sabotaged alcoholic beveragesconsumed accidentally overseas," and 3 to attempts at suicide).
24 traumatic injuries and war wounds (fistulas, abscesses, strictures,retained foreign bodies).
Management of all of these lesions followed the policies general in civilianpractice. There was only 1 death in the 42 major operations performed.
References
1. Kay, E. B., Meade, R. H., Jr., and Hughes, F. A., Jr.:Surgical Treatment of Bronchiectasis. Ann. Int. Med. 26: 1-12, January 1947.
2. War Department Technical Bulletin (TB MED) 69, 22 July1944. Notes on Certain Diseases of the Chest.
3. Kay, E. B.: Bronchopulmonary Actinomycosis. Ann. Int. Med.26: 581-593, April 1947.
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4. Meade, R. H., Jr., and Blades, B. B.: TheSurgical Treatment of Recurrent and Chronic Spontaneous Pneumothorax ofNontuberculous Origin. Am. Rev. Tuberc. 60: 683-698, December 1949.
5. Blades, B.: Mediastinal Tumors. Report of Cases Treated atArmy Thoracic Surgery Centers in the United States. Ann. Surg. 123: 749-765, May1946.
6. Laipply, T. C.: Cysts and Cystic Tumors of the Mediastinum.Arch. Path. 39: 153-161, March 1945.
7. Harrington, S. W.: Surgical Treatment in Eleven Cases ofMediastinal and Intrathoracic Teratomas. J. Thoracic Surg. 3: 50-72, October1933.
8. Kent, E. M., Blades, B., Valle, A. R., and Graham, E. A.:Intrathoracic Neurogenic Tumors. J. Thoracic Surg. 13: 116-161, April 1944.
9. Watson, W. L., and Urban, J. A.: Mediastinal Lipoma: ACase Report. J. Thoracic Surg. 13: 16-29, February 1944.
10. Kay, E. B.: Surgical Lesions of the Esophagus Seen in anArmy Thoracic Surgery Center. J. Thoracic Surg. 16: 207-214, June 1947.
