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Chapter X

Contents

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 bronchiectasis among diseases of the chest. Admissions during 1942-45 (table 15) numbered 6,207, of which 5,164 were to hospitals in the continental United States. During this same period, there were 12 deaths in the U.S. Army in which bronchiectasis was the underlying cause, and, more important from the standpoint of Army manpower, there were 4,487 disability separations for this cause.

TABLE 15. -Admissions for bronchiectasis 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

---

---

Total overseas3

1,043

0.10

93

0.16

255

0.15

395

0.10

300

0.06

Total Army

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.


416

Even granting the assumption that not every admission for bronchiectasis represented an actual instance of this disease, the numbers are sufficiently large to indicate the extent of the problem. The figures also suggest the possible incidence of this disease in the general population: These 6,207 patients were in a selected age group of men, who had passed the physical examination and roentgenologic examination for induction into the Army. The number of draftees who were rejected for service because bronchiectasis was detected is undoubtedly several times greater.

The manifestations of bronchiectasis were essentially the same in military as in civilian practice and call for no special discussion. They were chiefly dependent upon the degree of sepsis, which in turn was chiefly dependent upon the adequacy of bronchial drainage. When the disease was advanced, the destructive changes were always permanent and irreversible and could be managed only by extirpation of the involved tissue.

The following material, which can be assumed to be typical, is based on an analysis of 390 consecutive patients with bronchiectasis treated at Percy Jones General Hospital, Battle Creek, Mich., and the chest center at Kennedy General Hospital, 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 minor degrees of dilatation on which a diagnosis of bronchiectasis was based, in the absence of clinical symptoms. For this, there was no warrant.

3. Bronchoscopic examination, to determine the source of the exudate. If the bronchial mucosa seemed unduly inflamed, the possibility of bronchial occlusion secondary to a retained foreign body or a neoplasm had to be considered and eliminated.

4. Bronchospirometric studies, which were important if the disease was bilateral, to determine which was the worse side (p. 421). It was also important to determine the pulmonary reserve of the uninvolved lung if dyspnea was a symptom and to establish the extent of functional tissue in borderline cases.

Differential diagnosis chiefly concerned the reversible bronchial dilatations that sometimes followed an acute attack of respiratory infection, 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 this complication at the Kennedy General Hospital chest center and that it was also being observed at the chest center at Walter Reed General Hospital, Washington, D.C. The temporary nature of the bronchial dilatation


417

in these cases could be demonstrated by repeating the bronchogram a few weeks later; the bronchial configuration then usually showed a complete return to normal. Bronchoscopic examination was also useful. Differential points were the marked edema and generalized inflammatory reaction in the postpneumonia patients, lesser friability and vascularity, and absence of the characteristic odor of the purulent sputum of bronchiectasis.

Conservative Management

The high hopes originally entertained for the use of penicillin in bronchiectasis were not fulfilled. It was never likely that they would be. This is a disease characterized by bronchial and bronchiolar destruction, permanent bronchial dilatation, chronic infection, and marked sepsis. In advanced stages, the normal bronchial architecture is replaced by less specialized tissue, a pathologic change that explains the recurrent periods of exacerbation and the chronic state of sepsis that characterize it. Penicillin was of considerable value in the treatment of recurrent pneumonic episodes as well as in decreasing the sepsis and toxicity of the interval stages. Occasionally, it changed the character of the sputum. It frequently decreased the cough and sputum and increased the sense of well-being. These improvements lasted, however, only as long as penicillin was administered. When administration was discontinued, they were promptly lost.

At the Kennedy General Hospital chest center, 45 patients with advanced bronchiectasis were treated with intramuscular injections of 25,000 units of 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 the patients, usually during the first few weeks of treatment. Regression occurred when penicillin was discontinued, and no patient with advanced bronchiectasis had any permanent benefit from the treatment.

Intratracheal penicillin was used in another 45 patients with bronchiectasis, with somewhat better results. The seven patients with minimal disease had almost complete relief, and definite improvement occurred in two-thirds of the remaining patients.

Indications for Lobectomy

Neither penicillin nor any other form of conservative therapy was the solution of the problem of advanced bronchiectasis. Only surgery provided the answer. The decision to resort to it depended upon the extent of destructive changes, the physical evidences of chronic toxicity, and the amount of disability and invalidism. Of particular importance was the evaluation of the patient as a whole, including not only his present symptoms but his past history, with special reference to the increasing frequency or severity of acute episodes.

Operation was never indicated in patients with minimal disease, who could be treated conservatively with good results. It was not indicated in patients who had no clinical evidence of the disease, even though roentgeno-


418 

grams showed varying degrees of apparently permanent bronchial dilatation. Nor was it indicated in patients with disease of all five lobes; they were beyond surgical help.

Bilateral bronchiectasis, which was present in about 30 percent of the patients observed in World War II, was not considered a contraindication to surgery. Past experience had shown that those with advanced disease on one side and minimal disease on the other were usually greatly improved by operation on the more severely involved side. If the disease was extensive 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 free from disease and the cardiorespiratory reserve was adequate.

These indications were followed in the 184 lobectomies in this series, in 36 of which the disease was bilateral and in 6 of which bilateral lobectomy was performed. In another case, the right middle and lower lobes had been removed earlier, and the left lower lobe and the lingula of the left upper lobe were removed later (p. 420).

Preoperative Preparation

Operation was not scheduled until 4 to 6 weeks had elapsed after bronchography, to allow time for the elimination of the injected iodized oil. In the absence of this precaution, a postoperative pneumonitis was a possibility.

Preoperative preparation was extremely careful and painstaking. It consisted of the following measures:

1. Patients who had been ill over a long period of time had a detailed medical study, to eliminate possible cardiac, hepatic, and renal complications. 

2. An otolaryngologic examination was made, and any infection found received the proper treatment. Sinusitis was treated by nebulized penicillin. 

3. The diet was high in vitamins and calories, and supplementary vitamin therapy was used as necessary. The vitamin C content of the blood was brought to normal.

4. The plasma protein components of the blood were also brought to normal by supplementary protein components in the diet or by blood transfusions if they were indicated. A blood transfusion was always begun when operation was started and was usually continued throughout its course, in the amount of 1,000 to 1,500 cubic centimeters.

5. A physiotherapist explained and demonstrated the breathing exercises to be used during the entire postoperative period.

6. If postural drainage proved useful, it was employed three or four times a day.

7. If sputum was copious and bronchitis severe, a course of intratracheal penicillin, given for 7 to 14 days, was frequently helpful in reducing the amount of sputum.


419

8. Intramuscular injections of penicillin were begun the day before operation. When penicillin became available in preparations of beeswax and peanut oil, single injections of 300,000 units were given daily before operation, usually for 3 to 7 days, and were continued after operation until the temperature was normal.

Technique

The individual ligation technique was used in 182 of the 184 lobectomies in this series; only the first 2 were performed by the mass ligation technique. If purulent secretions were excessive, the bronchus was closed as soon as possible, but seldom before the arteries were divided. The inferior pulmonary vein was always the last vessel ligated. It was thought that the danger of embolism from involved lobes was less important than the technical disadvantage of permitting the lobe to become engorged.

Pleuritic adhesions between the upper lobe and the chest wall were cut. If they were allowed to persist, they might prevent the upper lobe from readily readjusting to the larger space now available to it.

In all partial pulmonary resections, the pleura was drained by an airtight catheter connected to water-seal suction. Drainage was usually maintained for 48 hours. Bronchoscopic aspiration was performed routinely at the end of the operation.

At the end of the operation, roentgenograms were taken and immediate corrective measures were instituted if they showed atelectasis or if reexpansion of the remaining lung tissue was not satisfactory.

Postoperative Routine

The usual routine of postoperative care was followed after lobectomy, with special 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 during the early postoperative period, temporary phrenic nerve paralysis was performed. This was a particularly important precaution if an emphysematous lobe had been removed, to prevent overdistention of the remaining lobe (lobes), as well as in high lingulectomies or middle lobe lobectomies performed in combination with lower lobe lobectomies.

3. The patient was usually ambulatory by the fifth day and was permitted out of bed earlier if he had difficulty in voiding.

4. Daily roentgenograms were taken at the bedside, to keep constant check on the remaining lobe or lobes.

5. When the hemithorax was satisfactorily filled with the remaining lung tissue and the patient's general condition was good, he was given a convalescent furlough. His disposition was determined on his return to the hospital.


420

Mortality and Complications

The single surgical death in this series occurred in the fourth of the 184 lobectomies. The patient had had bronchiectasis of the right lower lobe for many months, with repeated hemoptyses. Anesthesia was trying. It was hard to maintain a clear airway. The operation was technically difficult and time consuming. It is doubtful that this fatality, which was attributed to cerebral and pulmonary edema, would have occurred if the patient 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 five cases. Its infrequency was the result of the vigorous endeavors to keep the bronchi free of secretions by early movement, frequent voluntary coughing, and aspiration of retained secretions as necessary. In one case, however, atelectasis was alarming. This patient had had the right middle and lower lobes removed at one operation, and the left lower lobe and lingula at another sitting 6 months later. On the third day after the last operation, atelectasis of the remaining portion of the left upper lobe developed and persisted to some degree for the next 3 days. During this time, the patient was maintained only on the right upper lobe, with repeated intratracheal aspiration and the intermittent use of intranasal oxygen. Recovery thereafter was uncomplicated.

Hemothorax developed in two cases, probably because of injury of the intercostal vessels when the thoracotomy tubes were inserted.

Bronchopleural fistula with resulting empyema occurred in 20 cases, all early in the series. There were only 5 such complications in the last 100 lobectomies. Postlobectomy empyema was not a serious problem at any of the thoracic surgery centers. It was thought that careful surgical technique and prompt reexpansion of the remaining lung had more to do with this than did the use of penicillin.

Jaundice developed in six cases, whether secondary to blood transfusion or as the result of concomitant hepatitis is not clear; a number of other patients developed hepatitis at about this time.

One patient had a cerebrovascular accident, probably from a septic embolus. He was treated with penicillin and streptomycin. Six weeks later, a trephine operation was performed, and a small, sterile cystic cavity was evacuated. Recovery followed. Penicillin was given by vein during operation in subsequent cases, to reduce the likelihood of this complication.

There was no complication from the contralateral lung in any patient with bilateral bronchiectasis, probably because in these cases, the postoperative regimen was particularly rigid.


421

Bronchospirometry

Ten patients in this series upon whom bronchospirometric studies were performed before operation had an average oxygen consumption on the affected side of only 37 percent of the total and an average ventilation of 44 percent of the total. These figures show the effects of bronchiectatic destruction of tissue on the pulmonary function. They also show that the efficiency of oxygen absorption into the alveolar capillaries or through the alveolar membrane is even more impaired in this disease than is the ability to ventilate the lung.

In one instance, bronchospirometric studies on a patient with bilateral disease showed that oxygen consumption was 61.1 percent on the more severely impaired side and only 38.9 percent on the other side, on which there was thought to be only minimal disease in the right upper lobe. Evidently, destructive changes not apparent by roentgenogram or bronchogram were present in the supposedly good lung. Two patients, not included in this series, were found to have such copious amounts of sputum and such a degree of bronchial obstruction that there was no oxygen absorption at all on the affected side.

These studies indicate (1) that, in many instances, the bronchiectatic lobe contributes very little to the oxygenation and gaseous exchange of the blood circulating in the pulmonary tissues; (2) that the blood returns to the heart unoxygenated and with a high carbon dioxide content; and (3) that these phenomena are responsible in large measure for the cyanosis and dyspnea observed in bronchiectasis. Only by removal of the bronchiectatic tissue can blood be circulated through the alveoli, with proper oxygenation and diffusion of gases.

Postoperative bronchospirometric studies in 26 cases in this series showed that the pulmonary function of the remaining lung tissue on the affected side was largely dependent on the presence or absence of postoperative pleural complications (figs. 190, 191, 192 and 193). In none of these cases was the pulmonary function significantly impaired when recovery was uneventful; in numerous instances, it was within normal limits 2 or 3 months after operation. That good results persist is suggested by the fact that function was normal in two other patients examined, respectively, 1 year and 3 years after lobectomy.

Results

The good results in this series were unquestionably influenced by the fact that practically all of the patients were excellent risks as compared with candidates for surgery in civilian practice. Their disease was such that it could be cured only by pulmonary resection, and the risks they underwent were so small compared to the risks of persisting disease that operation was recommended without hesitation in every case in which it was indicated.


422

FIGURE 190.-Bronchospirometric tracing 1 month after left lower lobe lobectomy for bronchiectasis. Left side now contributes 53 percent of total oxygen consumption and 52 percent of total ventilation. Convalescence was entirely uneventful.

FIGURE 191.-Bronchospirometric tracing 7 weeks after left lower lobe lobectomy for bronchiectasis in patient with residual dysfunction of right lung secondary to pneumonia and empyema. The decreased pulmonary function secondary to pleural thickening on this side is evident from the fact that the left side contributes 76.4 percent of the total ventilation.


423

FIGURE 192.-Bronchospirometric tracing 8 weeks after right middle and lower lobe lobectomy for bronchiectasis. The phrenic nerve was crushed 8 days after operation to prevent overdistention and emphysema of upper lobe. The right side now contributes 47 percent of total oxygen consumption and 43 percent of total ventilation.

FIGURE 193.-Bronchospirometric tracing 7 weeks after resection of left lower lobe and lingula of the upper lobe for bronchiectasis. The phrenic nerve was crushed 3 days after operation to prevent overdistention of remaining segment of upper lobe. Remaining segment of upper left lobe now contributes 33.3 percent of total oxygen consumption and 26.3 percent of total ventilation.


424

Administrative Considerations

When bronchiectasis was clearly not "line of duty," as manifested by a history of previous symptoms pointing to it, disposition could be accomplished at any hospital at which authorized disposition boards were held.

All patients with bronchiectasis considered to be line of duty were transferred to a thoracic surgery center, where treatment was carried out and disposition was effected by consultation between the medical and the surgical services. The policy was to discharge men who did not wish to be operated on or in whom operation was contraindicated. Those with extensive bilateral disease were given medical discharges. Those with advanced disease not suitable for surgery were usually transferred to a Veterans' Administration hospital.

Although many men were returned to full duty after lobectomy, there was some hesitancy all through the war about returning to duty, or accepting for duty, any man who had any type of thoracic disease. This problem first came up in October 1943, after more than 50 lobectomies had been performed at the Walter Reed thoracic surgery center, 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 have been expected, for both roentgenologic and screening techniques were crude by modern standards. In World War II, the efficient screening and case-finding methods that had been developed between the wars were put to good use, and tuberculosis in the Armed Forces was never a major concern. 

The finding of active disease in a soldier, at least in the first years of the war, was considered almost synonymous with his permanent release from active duty. As the war progressed, however, this concept began to be altered, and surgery was employed in occasional, carefully selected cases, with remarkably good results.

A listing of the procedures accomplished at the chest center at Fitzsimons General Hospital, Denver, Colo., in 1944 and 1945 shows interesting changes in the procedure employed, as well as an increasing interest in surgery for tuberculosis (table 16).

All patients selected for surgery were first carefully considered by the medical board of the hospital, and the responsibility of the chest center for them varied according to the operation. Patients who underwent only phrenic emphraxis were brought to the operating room from the medical ward and returned to the medical ward immediately after the operation. Patients who underwent pneumonolysis were transferred to the surgery section the afternoon


425

TABLE 16.-Operations for pulmonary tuberculosis, Fitzsimons General Hospital thoracic surgery center, 1944-45

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

Total 

860

402

458


before operation. A roentgenogram was taken at once to determine the degree of pneumothorax present.

The patients were held on the surgical ward after operation only until the intrapleural pressure was well stabilized, which was usually within 72 hours. Candidates for other operations were transferred to the surgery section before operation and held on it until their immediate convalescence was complete.

Pulmonary resection for tuberculosis was introduced at this center in 1944. There was 1 death in the 12 operations, from massive postoperative spread of the process. The patient was a poor surgical risk, with bilateral cavitary disease, and left upper lobectomy was performed in the desperate hope of controlling it. A mixed empyematous process developed 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 patients recovered smoothly. These results were considered so encouraging that the policy was continued and extended in 1945. There were no deaths in the 28 lobectomies performed in that year, and postoperative spread of the disease occurred in only one case. The center closed before long-term results of lobectomy could be observed, but the immediate results were considered most encouraging.

It was not always easy to select patients for lobectomy. In general, the procedure was limited to chronic disease with localized involvement which had not responded to standard collapse therapy.

The results of pneumonectomy were not encouraging, which was not unexpected, for all operations were done for advanced disease involving the entire lung. All the patients were extremely poor surgical risks, and operation was a last resort. There were two deaths in the three operations performed in 1944. 

Tuberculomas.-The seven segmental pulmonary resections performed at the Fitzsimons General Hospital chest center in 1945 were all for tuberculomas. These neoplasms were formerly considered extremely uncommon. Routine


426

roentgenologic examinations of men in service at induction, at separation, and sometimes more often, showed that they were by no means as uncommon as they had originally seemed.

Most tuberculomas were asymptomatic, but careful inquiry into the previous history often revealed positive or suspicious stories of active disease. The majority of the masses were solitary, but in a number of instances, satellite fibrocaseous nodules were associated with the larger growths, particularly in the upper lobes.

When a tuberculoma was diagnosed, its presence was regarded as an indication for surgery. These lesions have dangerous potentialities for breaking down and spreading. At operation, they are usually found to be more extensive than roentgenologic examination has suggested. Finally, neither roentgenologic examination nor any other measure is sufficiently accurate to differentiate them from bronchogenic carcinoma.

If bacteriologic examination revealed acidfast bacilli, medical treatment was employed before operation. The possibility of endobronchial disease always required investigation before operation; it was unusual, but preoperative treatment was necessary if it was found.

Excision was usually possible by wedge resection, with conservation of as much lung tissue as possible. Lobectomy was necessary if the lesions were large or if there were satellite nodules.

Recovery was usually smooth, and most operations could be considered successful. The postwar experience has shown that many patients treated 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 in which recovery was complicated by activation of latent tuberculosis (p. 165). The following similar case was observed at Halloran General Hospital, Staten Island, N.Y., by Maj. Richmond L. Moore, MC:

Case 1.-A private in the infantry was struck in the left lower chest on 2 May 1944, in England, by a fragment from an accidentally exploded 60-mm. mortar shell. When he was seen in a general hospital 2 hours later, he was in moderate shock and was complaining of severe upper abdominal pain. The upper abdomen was rigid and tender, and there was beginning dullness in both flanks. The thoracic wound, which was about 15 cm. long, was in the left midaxillary line, at the level of the tenth intercostal space. A portion of the spleen had herniated through it. Roentgenograms of the chest and abdomen showed neither pneumothorax nor foreign bodies.

Exploration of the abdomen through a T-shaped incision revealed a ruptured spleen, a 7-cm. rent in the left leaf of the diaphragm, perforations on the greater and lesser curvatures of the stomach, and a puncture wound on the inferior surface of the left lobe of the liver. The peritoneal cavity was full of blood mixed with gastric contents. The operation consisted of splenectomy and repair of the perforations in the stomach and the diaphragm. The puncture wound of the liver was not explored. The wound of the chest wall was debrided before closure, which was complete.


427

Roentgenograms on 12 May showed a left hemopneumothorax, but the chart bore no record of treatment by aspiration. On 15 May, 100 cc. of purulent exudate was evacuated from the upper half of the abdominal wound.

Both wounds then healed well, and convalescence was uneventful until the latter part of June, when the patient began to run an intermittent septic fever, for which no cause was discovered. He was received at a general hospital in the Zone of Interior on 8 August. On 22 August, aspiration of the chest yielded 300 cc. of thick pus. The following day, 4 cm. of the ninth rib was resected, and drainage was established.

When the patient was received at Halloran General Hospital, on 19 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 6 centimeters. A metallic foreign body 7 by 15 mm. was in the upper abdomen, in the region of the liver.

Drainage was obviously inadequate, and a second thoracotomy was done on 25 September, with resection of the eighth and ninth ribs and the intervening intercostal muscle bundles and pleura. Microscopic examination of the excised sinus tract showed numerous tubercles with central necrosis and borders of granulomatous tissue. The diagnosis of tuberculosis was confirmed by examination of a second specimen on 27 October. 

Another persistent sinus developed after the second thoracotomy and showed no tendency toward healing in spite of vigorous local treatment. On 3 January 1945, roentgenograms of the chest 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 that the sinus extended deep into the substance of the lung. The tissue excised at this operation included the surrounding zone of scar tissue, all of the regenerated bone surrounding the external opening of the sinus tract, and additional segments from the stumps of the eighth and ninth ribs. Sections of tissues stained by the Ziehl-Neelsen technique showed acidfast organisms.

The lung apparently healed rapidly, but another persistent sinus appeared. At exploration on 22 June, it was found to extend through the lung to the diaphragm. It was thoroughly excised by the radical technique used at the operation on 2 May. The resulting extensive defect in the chest wall was closed by undermining and approximating the muscles and subcutaneous tissue. A small 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 was removed on 25 July, and 4 days later, the sinus was completely closed, as it was when 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 September 1944 and was in excellent general condition (fig. 194), he was considered unfit for further military duty and was separated from service. 

The tissues removed at this operation again showed classical tubercles with central necrosis, rimmed by epithelioid cells and lymphocytes and the typical Langhans type of giant cell.

Comment.-This man received excellent surgery within 3 hours of his injury, and his recovery must be attributed to it. It was wise not to attempt to remove the shell fragment in the liver or to explore the chest, for his 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 days after wounding been treated by aspiration, it is highly probable that the empyema which developed would have been prevented.

The particular point of interest in this case is the diagnosis of tuberculosis in the tissues at the site of injury. Careful inquiry showed nothing in the previous history to suggest acidfast infection of any kind. The tuberculous infection supplied an adequate explanation for the chronicity of the process and the repeated failures to obtain satisfactory


428

FIGURE 194 (case 1).-Patient after final closure of tuberculous sinus complicating thoracoabdominal wound 16 months earlier. Note complete healing of wound and excellent cosmetic result.

healing despite the establishment of adequate drainage. A satisfactory result was obtained only when all of the diseased tissues had been excised and the resulting defect closed by the approximation of well 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 of chronic indolent abscess. During the entire war, only three acute lung abscesses required drainage at the Walter Reed General Hospital chest center. There were several explanations for this situation:

1. One of the chief etiologic factors in lung abscess, dental sepsis, was almost entirely eliminated in World War II by the excellent dental care provided for all soldiers in the Army.

2. The almost universal use of the sulfonamides, and later of penicillin, in pneumonia and other severe respiratory infections probably accounted for the absence of the fulminating infections formerly seen and also explained the presence of more chronic, less severe types.

3. Because of the effectiveness of penicillin, many patients with small abscesses, which were treated promptly, were probably cured in smaller hospitals and did not have to be referred to chest centers.

Chronic lung abscesses, nonetheless, furnished numerous problems. As early as October 1943, Major Blades reported to Colonel Carter that the thoracic surgeons at all centers complained that these patients were not being trans-


429

ferred to the centers early enough; most of them had been ill for 4 to 6 months when they were first seen.

In War Department Technical Bulletin (TB MED) 69 (2), 22 July 1944, directions were given to transfer all patients with lung abscesses to thoracic surgery centers if conservative treatment failed to produce prompt symptomatic improvement, accompanied by roentgenologic evidence of clearing of the surrounding pneumonia and progressive decrease in the size of the cavity. In view of the difficulties of management of chronic lung abscess, transfer was to be effected within 30 days of the patient's admission to the hospital unless the rate of healing clearly indicated that surgical treatment would not be required.

Management

As in other suppurative diseases, the response to penicillin of 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 any severity was likely to be symptomatic improvement and that regression would occur as soon as therapy was discontinued. It could scarcely be expected that a pathologic process characterized by tissue destruction, necrosis, and gangrene would be improved by any antibiotic, even if the organisms present were sensitive to it and were of low virulence.

Even before the war, drainage of lung abscesses had fallen into disfavor because of the poor results. This operation decreased the sputum and reduced the fever, but it wrought no real improvement in a patient in whom an entire lobe had been destroyed and whose infection involved the interlobar fissures and had spread to adjacent lobes. It was only in very early cases, when the abscesses were well circumscribed and drainage was instituted promptly, that the results of conservative surgery were satisfactory.

Excisional surgery had begun to be popular before the war, as technical refinements and developments in anesthesia greatly reduced the surgical risks. It was the preferred method of treatment for chronic lung abscesses in the thoracic surgery centers in the Zone of Interior. The risk of lobectomy was somewhat greater than in bronchiectasis, but it was generally regarded as worth taking in view of the prospect of chronic invalidism which otherwise faced the patient, and, on the whole, the results were excellent.

EMPYEMA

When the sulfonamide drugs first became available, shortly before World War II, accumulated data promptly showed that the almost universal use of these agents in the treatment of pneumonia was resulting in a marked decrease in the postpneumonic variety of suppurative pleurisy. The local and systemic use of the various sulfonamide derivatives also showed, however, that once a purulent exudate had formed in the pleura, cure by chemotherapy was not possi-


430 

ble: Toxic reactions prevented the use of sufficiently large doses by the systemic route to effect a cure, while local injections into the pleural cavity were equally ineffective, since the admixture with purulent fluid inhibited their antibacterial action.

Management

When penicillin became available, it seemed, at least theoretically, that it would be ideal for the management of postpneumonic empyema caused by micro-organisms susceptible to it. It has a strong antibacterial action when used systemically, and retains its potency in the presence of pus and blood. Its low toxicity permits the use of very large doses both locally and systemically with little risk of toxic or other side effects.

In spite of these favorable circumstances, the original high hopes were not fulfilled. When acute empyema was treated in the early stages by aspiration and injection of penicillin, there were numerous good results. This was not always true, however, even in acute cases, and it was seldom true in chronic cases, in which its prolonged use was an invitation to chronicity. There was no reason, for instance, for the 11 thoracenteses and 300 intramuscular injections of penicillin employed in one of the early cases over a 6-month period of hospitalization. There was never any justification, in fact, for the continuation of conservative treatment unless there was a progressive decrease in 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 employed when the pus in the empyema cavity was thick, since its presence predisposed to thickening and fixation of the pleura and the consequent development of chronic empyema. It was further directed that all patients with chronic empyema be transferred to a thoracic surgery center for treatment and disposition. An empyema was considered to be chronic when, at the end of 6 weeks after the original operation, the cavity measured 30 cc. or more.

The following policies of management finally become routine:

1. An injection of penicillin was given intrapleurally as soon as infected fluid was demonstrated in the cavity. Additional local therapy was then withheld until the organisms present were identified and it was determined that they were penicillin susceptible. Delay in local treatment was particularly emphasized when penicillin first became available and quantities were so limited that it could not be wasted.

2. If systemic penicillin had not been employed during the pneumonic stage of the disease, it was begun at once. The chief advantage of this route was that it put into the blood a bacteria-inhibiting substance which might prevent or control a spreading cellulitis or invasive infection. This was particularly important when the responsible organism was streptococcus or staphylococcus.

3. Three intrapleural injections of 50,000 units each, on alternate days, were usually sufficient. Before the injection, as much fluid as possible was removed by thoracenteses.


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4. If exudate continued to form and became thicker, surgical drainage was established without further delay. Thick pus could not be evacuated satisfactorily by needle, and even sterile fluid was often so thick that thoracotomy was necessary for adequate drainage. Valuable as penicillin was as an adjunct to surgery, it did not permit the violation of fundamental surgical principles.

ACTINOMYCOSIS

Official statistics for actinomycosis show 207 admissions for this cause in the 1942-45 period, with 4 deaths and 24 separations for disability. 

Particular interest was aroused in this disease at the Kennedy General Hospital chest center when the ray fungus was isolated in two patients under treatment for pulmonary suppuration. Thereafter, this organism was searched for routinely in all suppurative chest disease and was found with surprising 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 patients under treatment for chronic bronchopulmonary infections. In no instance was it the only organism found. In a number of patients it appeared to predominate, but usually such other organisms as streptococci, staphylococci, spirochetes, fusiform bacilli, and other less common microorganisms were also identified. Actinomyces was found in the sputum in all 109 cases by direct examination and by culture, in specimens secured by bronchoscopy in 65 cases, in exudate aspirated from lung abscesses in 6 cases, and in drainage from sinus tracts in 2 patients with empyema secondary to pulmonary suppuration. The 65 patients from whom the organisms were cultured from bronchoscopic specimens included 37 with bronchiectasis and pneumonitis of varying degrees of severity, 8 with lung abscess, 5 with pulmonary suppuration, 5 with aspiration pneumonia, 2 with suppuration distal to obstructing carcinoma, and 8 with chronic bronchitis.

These findings at first caused considerable concern among medical officers whose previous experience with this condition had been limited to isolated cases. There was debate as to whether these cases should be considered as instances of bronchopulmonary actinomycosis or as instances of bronchopulmonary suppuration in which the ray fungus was present among other infecting organisms. As experience accumulated, it was evident that the clinical significance of Actinomyces was far less than had originally been feared. The clinical course and the response to surgery and chemotherapeutic measures did not seem to be influenced by its presence or absence; chronic pulmonary suppuration is a very chronic condition per se.

The precautions originally taken when Actinomyces was identified included increased dosages of the sulfonamides and penicillin before drainage operations and, in a number of instances, postponement of the indicated surgery, for fear of development of a chronic draining sinus and empyema after lobectomy. In no instance did this happen. The fungus was isolated in the


432

pleural fluid of one patient after pneumonectomy, but it promptly disappeared when intrapleural injections of penicillin and sulfadiazine were used. In other words, as time passed, it became evident that this fungus was of less significance in the clinical course, chronicity, and prognosis of pulmonary and pleural infections than the mechanical factors of bronchial occlusion or drainage, tissue destruction, fibrosis, and avascularity. Patients who presented these findings were just as resistant to conservative therapy as were patients who harbored Actinomyces.

Management

The response to treatment depended upon the chronicity and the severity of the infection. Penicillin and sulfadiazine, used in combination and in large doses, gave the best results, but it was important that they be continued well beyond clinical improvement and roentgenologic clearance; otherwise, recurrence was certain. The routine of treatment required the injection of 50,000 units of penicillin intramuscularly every 3 hours for 8 to 12 weeks or longer, and the maintenance of a sulfadiazine blood level of 10 mg. percent. It was thought that streptomycin might prove even more effective, but the evidence was inconclusive when the survey ended.

If cavitation was present, the routine just described was considerably less effective; the patients were improved symptomatically, and there was clearing of pneumonitis about the cavity, but the basic disease was not affected. Lobectomy was required in two cases in this series in which medical treatment failed and drainage was also unsatisfactory, and pneumonectomy was necessary in two similar cases. It was thought that one or the other of these procedures would also be necessary in other cases.

SPONTANEOUS PNEUMOTHORAX OF NONTUBERCULOUS ORIGIN

Spontaneous pneumothorax of nontuberculous origin was observed at all chest centers. Colonel Meade and Colonel Blades (4) analyzed the 18 cases jointly observed at the chest centers at Kennedy General Hospital and Walter Reed General Hospital. Eight of the pneumothoraces were recurrent, eleven were chronic, and all were cured by surgery. In 3 of the 18 cases, no etiologic factor could be determined. In the remaining cases, rupture of peripheral emphysematous blebs and bronchogenic cysts was the most frequent cause.

The policy was to perform open thoracotomy on any patient who did not respond promptly to simple aspiration of air or induction of a chemical pleuritis. The procedures employed included excision of blebs and cysts; closure of fistulas; division of isolated adhesions; lobectomy; and pulmonary decortication, which was necessary in five cases before satisfactory reexpansion of the lung was accomplished. Open operation was employed in all cases, so that the underlying cause could be dealt with and decortication performed if reexpansion was not satisfactory.


433

MALIGNANT NEOPLASMS

Incidence

Figures collected by the Medical Statistics Division, Office of The Surgeon General, for 1944 and 1945 (table 17) show a total of 205 primary admissions for malignant neoplasms of the thorax, of which 140 were in the lung and the bronchus. Another 45 admissions were recorded for secondary malignancy of the thoracic structures. No instances of malignant neoplasm of the trachea were recorded during this period. Though the total number of cases is small, a wide variety of histologic patterns is represented (table 18).

There were 141 deaths in the 205 primary malignant neoplasms, 83 of which occurred in the Zone of Interior (table 19). Men whose disease was discovered overseas were evacuated to the United States at once.

While the figures represent only the 1944-45 period, it is possible that both the 141 deaths and the 53 disability separations recorded for the 2 years include some patients admitted before 1944. As to the remaining 11 patients not included in the deaths and disability separations, it is highly probable that some died after separation from service.

Neoplasms of the lymphatic and hematopoietic tissue are not included in these tables, but some figures (based on 20 percent samples) are available. During the 1944-45 period, there were:

35 primary and 5 secondary admissions for neoplasms of the mediastinum, with 3 deaths and 10 disability separations.

5 primary admissions for neoplasms of the larynx, with 1 death and 1 disability separation.

Two deaths and three disability separations for this category of pulmonary neoplasms were also recorded during 1944-45.

Carcinoma of the Lung and the Esophagus

No special discussion of carcinoma of the lung during the war is called for. The manifestations were the same as in civilian life, most of the tumors being inoperable by the time the diagnosis was made. A number of highly malignant peripheral bronchogenic cancers gave no warning of their presence until metastases contraindicated even palliative surgery. Results were only slightly better in a smaller group of older patients whose tumors were centrally located and of the squamous cell type.

How discouraging the results of treatment were in carcinoma of the lung is evident in the 1945 report from Fitzsimons General Hospital: Of 10 bronchogenic carcinomas observed that year, 7 were inoperable when the diagnosis was made, and irradiation was completely ineffective; all 7 patients died promptly. Of the three who underwent pneumonectomy, one died of extensive metastases and one of pneumonia in the remaining lung 3 months after operation. The third patient in this group was still in the hospital undergoing irradiation when the report was made.


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TABLE 17.-Incidence of malignant neoplasms1of the respiratory system (by anatomic site) and of the esophagus, by area of admission, U.S. Army, 1944-45

[Preliminary data based on 20 percent sample tabulations of individual 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

---

---

Total overseas

40

10

5

15

15

---

Total Army

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

---

---

---

---

---

Total overseas

20

5

5

---

5

---

Total Army

30

5

5

---

5

---


1Neoplastic conditions of lymphoid and hematopoietic tissues are excluded.
2Ten secondary cases of malignant neoplasm of lung were reported among battle admissions-5 each in the European and the Central and South Pacific theaters; all other secondary cases were reported among disease admissions.
3Includes North Africa.

The outlook in malignant lesions of the esophagus was equally poor. In seven carcinomas observed at the Kennedy General Hospital chest center, three were found to be inoperable in exploration. Three were treated by resection with anastomosis, and the remaining patient underwent, respectively, total gastrectomy; transverse colectomy; and esophagojejunostomy, a procedure which almost implies a fatal outcome.


435

TABLE 18.-Morbidity and mortality from malignant neoplasms1 of the respiratory system (by anatomic site) and of the esophagus, by histologic type and type of case, U.S. Army, 1944-45 

[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

---

Total

115

30

86

19

Bronchus:

Carcinoma

20

5

26

4

Malignant tumor, unspecified

5

---

1

---

Total

25

5

27

4

Pleura:

Carcinoma

5

---

1

1

Endothelioma

---

---

---

1

Mesothelioma

---

5

---

---

Total

5

5

1

2

Mediastinum:

Carcinoma

5

---

5

1

Sarcoma, unspecified

5

---

2

---

Malignant tumor, unspecified

5

---

9

6

Total

15

---

16

7

Larynx:

Carcinoma

30

5

3

15

Angiosarcoma

---

---

1

---

Sarcoma, unspecified

---

---

---

1

Chordoma

5

---

---

1

Malignant tumor, unspecified

5

---

---

---

Total

40

5

4

17

Esophagus:

Carcinoma

5

---

7

4

Total

5

---

7

4

Grand total

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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TABLE 19.-Deaths due to malignant neoplasms1 of the respiratory system (by anatomic site) and of the esophagus, by area of admission, U.S. Army, 1944-452

[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

---

---

Total overseas

531

13

1

9

1

3

Total Army

86

27

1

16

4

7


1Neoplastic conditions of lymphoid and hematopoietic tissues are excluded.
2These are all deaths due to the conditions indicated which occurred 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 with mediastinal tumors were operated on at the five thoracic centers in the Zone of Interior. The figures collected by Colonel Blades (5) include only the cases in which the chest was explored because of symptoms or because of the discovery of a mediastinal mass on routine roentgenologic examination, which was the primary means of diagnosis in 94 of the 109 cases.

Five of the masses proved to be aneurysms, not neoplasms. Of the 104 true tumors, 15 were malignant and 89 were benign.

The malignant group included six teratomas, two thymomas, two lymphoblastomas, and one neurosarcoma. It also included four instances of Hodgkin's disease, in three of which the diagnosis was not realized until histologic examination of the specimen. In one case, the tumor had invaded the upper lobe of the lung, and lobectomy was necessary for its removal. Surgical intervention would not have been undertaken deliberately in any of these cases if the true nature of the tumor had been established before operation. Short-term observation, however, showed that the patients had not been harmed by removal


437

of the visible tumors, and there was some evidence that they might have been benefited.

Exclusive of the 4 instances of Hodgkin's disease and the 5 aneurysms just mentioned, the essential data in the remaining 100 cases were as follows:

Bronchogenic cysts.-There were 23 bronchogenic cysts in this series, 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 the remainder, the mass was found on roentgenologic examination. Even with detailed studies, the true nature of the masses was difficult to establish. On the frontal projection, they suggested either teratoid tumors or primary nerve tumors. On the lateral view, the shadow was not so distinct as in teratoid tumors, and the extreme posterior position characteristic of most primary nerve tumors was not evident. Since most bronchogenic cysts are attached to the trachea (most often near the tracheal bifurcation in the superior mediastinum), the mass moved during swallowing, as could be demonstrated by fluoroscopic examination, which was of some diagnostic assistance. A patent lumen communicating with the trachea or a bronchus was not demonstrable in any case. 

There were two sound reasons for advising the surgical removal of bronchogenic cysts 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 mediastinum with grave malignant potentialities resemble bronchogenic cysts on roentgenologic examination. Moreover, since bronchogenic lesions are considered as cell rests, there is no assurance that malignant changes will not occur in them. 

2. Bronchogenic cysts may become infected. If they do, operative interference is necessary, and technical difficulties at this time may be considerable. Also, cysts which are presently asymptomatic may increase in size and produce later pressure and other symptoms.

Teratoid tumors-Twenty of the tumors in this series were teratoid, to use the inclusive nomenclature suggested by Harrington (7). Fourteen were benign and were removed without difficulty. Advanced changes were evident in the six malignant growths. Only surgical extirpation can be considered for these tumors, because of the risk of malignant degeneration.

Up to 1945, close to 250 teratoid tumors had been reported in the medical literature (6), and they are the most common lesions of the anterior mediastinum. In the collected cases, only three were in other locations. The number observed in the chest centers during World War II would undoubtedly have been larger except that these tumors produce sharp shadows and are so easily detected by roentgenogram that most men who harbored them were probably identified at the preinduction examination and were rejected for service.

Neurogenic tumors-The 29 benign primary nerve tumors of the mediastinum observed in this series included chiefly neurofibromas, ganglioneuromas, and sympathicoblastomas. Up to 1944, 105 of these tumors had been collected


438

by Kent and his associates (8), all but 2 of which were located posteriorly. In their series, 37 percent of the tumors had undergone malignant change, which makes clear why surgical excision is the correct treatment as soon as the tumor becomes evident.

One patient with a neurogenic sarcoma was explored, but invasion of the surrounding structures precluded its removal. All the other tumors were excised.

Pericardial cysts-The 10 pericardial cysts in the series were all discovered on routine roentgenologic examination. Except for their characteristically anterior location, there is nothing to differentiate these cysts from other mediastinal tumors, and surgical excision is the only way to establish their character.

Thymomas-Four of the six patients with thymomas, two of which were malignant, had no symptoms referable to the mass. In one case, in which the patient had advanced myasthenia gravis, it was impossible to remove the malignant mass completely.

Lipomas-Only 4 lipomas were encountered, which is not surprising, since less than 40 mediastinal tumors of this type could be collected by Watson and Urban (9) in 1944.

Other tumors-Other mediastinal tumors in this series included one fibroma, which was probably a neurofibroma; one thyroid adenoma; one cyst arising from the esophagus; one osteochondroma; one Boeck's sarcoid, diagnosed by biopsy of tissue at the hilus; and two tuberculomas.

Comment-There was not complete agreement among the surgeons at the chest centers as to the best exposure for mediastinal tumors. Some routinely employed a posterolateral exposure; others preferred an anterior approach if the location of the tumor made it logical. The technique employed usually reflected the early training which the surgeon had received. On one point there was general agreement, that if difficulties were anticipated, a lateral or posterolateral incision should be used.

Before World War II, tumors of the mediastinum were frequently treated by irradiation, surgery being resorted to only if satisfactory results were not accomplished. This was never a safe or a desirable plan. As has been pointed out several times in this brief analysis of the 109 mediastinal masses treated at the chest centers in the Zone of Interior during World War II, it is not possible, in most instances, to determine the true character of a mediastinal tumor without direct inspection at operation. If operation is delayed until symptoms and signs become apparent, the chance for successful extirpation will frequently have been lost.

The reasoning behind the use of irradiation in preference to exploration was the risk originally attendant upon exploratory thoracotomy. This risk ceased to exist when refinements in surgical and anesthetic techniques made exploration of the chest safe. Risks were negligible in the chest centers during


439

World War II. Errors in diagnosis occasionally occurred, and a few tumors were operated on which might have responded to irradiation, but the danger to the patients was slight compared to the harmful potentialities of prolonged and ineffective irradiation. Irradiation will not reduce the size, or halt the malignant degeneration, of these tumors unless they are of lymphatic origin, and surgery is more dangerous and more difficult after prolonged use of X-rays.

The results in this series justify the management of mediastinal tumors by prompt exploration of the chest. There were no deaths that could be attributed to the operation and no postoperative complications in the cases in which only exploration and biopsy were performed. Suppurative pleuritis developed in three cases in which a tumor was removed, but adequate drainage was followed by prompt healing. In one of these cases, it had been necessary to remove 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 esophagus treated at Kennedy General Hospital, Major Kay's (10) survey of esophageal lesions 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 tuberculous nodes (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 beverages consumed 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 civilian practice. 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 July 1944. Notes on Certain Diseases of the Chest.

3. Kay, E. B.: Bronchopulmonary Actinomycosis. Ann. Int. Med. 26: 581-593, April 1947.


440

4. Meade, R. H., Jr., and Blades, B. B.: The Surgical Treatment of Recurrent and Chronic Spontaneous Pneumothorax of Nontuberculous Origin. Am. Rev. Tuberc. 60: 683-698, December 1949.

5. Blades, B.: Mediastinal Tumors. Report of Cases Treated at Army Thoracic Surgery Centers in the United States. Ann. Surg. 123: 749-765, May 1946.

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 of Mediastinal and Intrathoracic Teratomas. J. Thoracic Surg. 3: 50-72, October 1933.

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: A Case Report. J. Thoracic Surg. 13: 16-29, February 1944.

10. Kay, E. B.: Surgical Lesions of the Esophagus Seen in an Army Thoracic Surgery Center. J. Thoracic Surg. 16: 207-214, June 1947.

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