John A. Meyer

Survival following nonpenetrating traumatic rupture of cardiac chambers.

We report the cases of 3 patients who survived cardiac chamber rupture resulting from blunt external trauma. All were drivers in motor vehicle collisions. All were seen with signs of pericardial tamponade and were treated by pericardiocentesis followed by emergency thoracotomy performed in the operating room. Ruptures of the right atrium and right and left ventricles were repaired by manual suture techniques without cardiopulmonary bypass. The cases of 37 previously reported patients who survived this injury are reviewed. We believe that patients with cardiac rupture who reach the hospital alive can often be saved by prompt diagnosis and immediate surgical treatment.

The Prospect of Disease Control by Surgery Combined with Chemotherapy in Stage I and Stage II Small Cell Carcinoma of the Lung

Ten patients with localized small cell carcinoma of the lung (clinical stages I and II) were treated by surgical resection more than 2 years ago; operation was followed by a course of intensive combination chemotherapy. Relapse of the disease has occurred in the central nervous system in 1 patient. One patient died of a surgical complication, and another died more than 4 years later of an unrelated malignancy. All others remain well, and 3 patients have survived longer than 5 years following resection.

Splenectomy, suppressor cell activity, and survival in tumor bearing rats

Young female rats of the Fischer strain were subjected to splenectomy at 10 weeks of age. Three weeks later, these animals and a comparable group of intact animals were inoculated subcutaneously with 3 × 106 cells of the syngeneic Ward colon carcinoma. Tumor growth was recorded by serial measurement. Lymph node cells from control, intact tumor-bearing, and asplenic tumor-bearing animals were tested for reactivity in mixed lymphocyte culture (MLC) and for ability to suppress the allogeneic mixed lymphocyte reaction. At 3 weeks after tumor inoculation, lymphocyte reactivity in MLC was somewhat depressed in asplenic tumor-bearing hosts but severely depressed in intact hosts (P < 0.001); suppressor activity was demonstrable in intact hosts but not in asplenic hosts (P < 0.001). At 5 weeks, lymphocyte reactivity in MLC was severely depressed in both groups; suppressor cell activity was present in both groups and differences were no longer significant. Median survival of intact tumor-bearing animals was 97 days after inoculation (P < 0.0001 by the log-rank test), and 120 days in asplenic animals (P < 0.001). We conclude that both depression of lymphocyte reactivity and onset of suppressor activity are delayed in asplenic tumor-bearing animals. Host survival was significantly prolonged.

Refractory paroxysmal supraventricular tachycardia: Treatment with patient controlled permanent radio frequency atrial pacemaker☆

Abstract A patient with incapacitating recurrent supraventricular tachycardia, refractory to medical management, was evaluated for possible surgical intervention. Several types of competitive artificial pacemakers were considered, as was surgical section of the His bundle plus conventional pacing. The patient was treated with a competitive, radio-frequency-coupled atrial pacemaker, which she herself operates to break her supraventricular tachycardias. The device has operated successfully on numerous occasions for over 15 months. Several other aspects of this patients arrhythmias were discussed.

Misleading density of mediastinal cysts on computerized tomography.

Five patients seen with roentgenographic evidence of smooth, rounded mediastinal masses were evaluated by computerized tomographic (CT) scanning. Density readings from the lesion were interpreted in all patients as being equivalent to solid tissue. With these findings, thoracotomy seemed necessary for definitive diagnosis. All 5 lesions were found to be thin-walled cystic structures containing thick viscid fluid. Contrary to views expressed in the radiology literature, we conclude that computerized tomography does not differentiate reliably between solid and cystic mediastinal masses.

Gotthard Bülau and Closed Water-Seal Drainage for Empyema, 1875–1891

Optimal treatment of pleural empyema remains controversial to the present day. In the preantibiotic era, surgical thinking favored early and aggressive drainage of closed-space infections, but the dynamics of the pleural space were poorly understood and open pneumothorax generally was considered the necessary price of surgical drainage. Against bitter opposition, revision of the dogma of early open drainage was achieved in 1918 by Evarts Graham and his associates on the US Armys Empyema Commission. Unacceptable mortality rates for early drainage were brought under control through a treatment program of repeated tapping, with surgical drainage only after loculation had occurred. Paradoxically, closed water-seal drainage for empyema had been used by a German internist, Gotthard Bülau, as early as 1875. His technique was published in 1891, 27 years before the report of the Empyema Commission. As a closed system, it would have been suited to empyema drainage in either the early diffuse or the loculated stages. Thoracotomy was not possible at the time, and Bülau probably could not foresee the future importance of his method to surgery.

Five-year survival in treated stage I and II small cell carcinoma of the lung

Ten consecutive patients were treated more than five years ago, for small cell carcinoma of the lung in clinical and surgical stages I or II. Patients underwent initial surgical resection, followed by intensive combination chemotherapy for at least a year, or to limit of tolerance. Four patients were classified as stage II, T2 N1; 4 had T2 N0; and 2 had T1 N0. One patient (T2 N1) died of tumor recurrence in the central nervous system 14 months after resection. Two died of other causes before five years, one (T2 N0) of a pulmonary embolus on the seventh postoperative day, and the other (T2 N1) of carcinoma of the prostate at 50 months. Seven patients (70%) remained well and disease-free at five years postoperation. Two of the 7 died of unrelated causes, one (T2 N0) at 72 months and one (T2 N1) at 108 months. Five remain well at 61 to 112 months after resection. Although this series is small, no reports have shown comparable survival in a defined group of small cell carcinoma patients treated nonoperatively or by surgical resection alone.

Werner Forssmann and catheterization of the heart, 1929.

Invasive study of cardiac anatomy and function traces its origin to the work of a 25-year-old surgical trainee in a provincial German town in the pre-Depression years of 1929 and 1930. Only 1 year out of medical school and undeterred by the medical professions fear of tampering with the heart, Dr Werner Forssmann explored methods for a more direct access to the cardiac chambers, finding it necessary to make the observations on himself. Later he was able to show that the right-sided cardiac chambers could be visualized radiographically after injection of iodinated contrast materials through a catheter into the right atrium, and again he tried the method on himself.

Indications for surgical treatment in small cell carcinoma of the lung.

Small cell carcinoma of the lung is notable for extreme malignancy in clinical behavior, with rapid growth, wide dissemination, and short survival after treatment. It is highly responsive to chemotherapy and radiation therapy, yet seldom cured. Prevalent therapeutic dogma rules out surgical resection as any part of treatment. We find, however, that patients with disease in stages I and II, treated with initial resection followed by the full course of chemotherapy, have a good prognosis for long disease-free survival.

Spinal Cord Ischemia Following Operation for Traumatic Aortic Transection

The danger of irreversible ischemic damage to the spinal cord following repair of traumatic aortic rupture has prompted many techniques designed to decrease this risk. Surgical repair was performed on 41 consecutive patients, using four different methods. These included: group 1 (15 patients), left-heart pump bypass with systemic administration of heparin; group 2 (7 patients), heparinized shunt from the ascending aorta to the descending aorta or to the femoral artery; group 3 (14 patients), heparinized shunt from the left ventricle to the aorta or femoral artery; group 4 (5 patients), aortic cross-clamp only. Spinal cord ischemia was not seen in groups 1 or 2, but paraparesis or paraplegia developed in 4 patients in group 3. Severe shock accompanied rupture in all patients in group 4, and no time was taken for a shunt or bypass. Four of the 7 deaths occurred in the operating room in patients who had arrived moribund and in severe shock. In our experience, shunts from the left ventricle to the aorta have failed to protect the spinal cord against ischemia. Left-heart bypass or aorta-to-aorta shunts are now our procedure of choice.