ondary inflammatory changes. Total removal of the lung may be required if resection is attempted, and when a small intrabronchial tumor is responsible for the entire process pneu¬ monectomy seems unjustifiably destructive. I believe that moderate infection distal to the tumor is not justification for removing portions of the lung. After the removal of an obstruc¬ tion, such as a foreign body, the lung has extraordinary reparative power, and in many patients the infection may disappear completely. I would like to ask Dr. Moersch whether he has found any tiny adenomas in the depths of the bronchus that might prove confusing in the diagnosis and treatment of so-called bronchial erosion with bleeding.Dr. Alfred Goldman, Beverly Hills, Calif. : There is much in this paper in favor of, and I am in favor of, a more active surgical approach to the treatment of bronchial adenoma. Nine¬ teen patients have been operated on for bronchial adenoma, 9 since I left the University of California ; in these 19, lobec¬ tomy or pneumonectomy was performed with 1 death, the first patient to undergo operation, giving a mortality of 5.8 per cent. The remainder of these patients are living and well, and all of the last 9 are able to work. The importance of what Dr. Vinson mentioned cannot be overlooked, that this is a slowgrowing tumor, locally invasive, seldom metastasizing and sel¬ dom becoming widespread in its malignant nature. Occasionally it may be wise to perform local excision transpleurally through bronchotomy. Transpleural bronchotomy has been done in 3 instances. One girl aged 17 had a left stem bronchotomy and has recovered, with no evidence in the plain roentgenogram of any residual opacities. She has a good functioning left lung. The second patient, with a tumor in the left stem bronchus, had a left lower lobectomy with extension of the excision to include the tumor in the left stem bronchus, thus saving the upper lobe of the left lung. She has been well for three years and is now working as a telephone operator. In the third case in which this was attempted it was impossible to remove the tumor by local excision because the tumor had surrounded and obstructed the left upper lobe bronchus, so a pneumonectomy was performed.Dr. Herman J. Moersch, Rochester, Minn. : In answer to Dr. Vinson's question regarding difficulty in the diagnosis of some extremely small adenomas, we, too, have difficulty with such lesions. Often the correct diagnosis depends on the pathologist. Without his help I am sure the problem would be much more difficult. I believe that bronchotomy offers definite possibilities in dealing with small lesions. The word benign, as far as adenoma of the bronchus is concerned, is misleading and should be discarded. The lesion is not benign ; it is a malignant tumor. Frequently a patient with adenoma of the bronchus is allowed to go untreated for too long simply because the lesion has been called benign, and it is not realized that adenoma can and does metastasize with serious conse¬ quences. Dr. Goldman has emphasize...
