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THORACIC SURGERY UNITS.—(1) ST. ANDREW'S HOSPITAL.
Report for the year ending 31st December, 1934.
By J. W. Linnell, M.C., M.D., M.R.C.P., Consulting Physician,
and
H. P. Nelson, M.A., M.D., F.R.C.S.(Eng.), Consulting Thoracic Surgeon,
St. Andrew's Hospital.
The work at this centre has steadily increased ever since it began in September,
1932. During 1934, no less than 70 cases were operated upon, some of them on more
than one occasion, and many bronchoscopies were performed, either for diagnosis or
by way of treatment. The average number of cases in hospital at one time varied
from 18 to 25.
Many of the cases seen at the clinic presented the rarer and more difficult chest
conditions, some of which had been complicated by previous operations. In some
the outlook appeared almost hopeless. Even the few successes experienced among
this latter group are encouraging.
The majority of cases were those of chronic pulmonary tuberculosis, where
artificial pneumothorax had failed altogether, had only resulted in a partial collapse
leaving the cavities on the lung unclosed, or the complication of pyopneumothorax
had supervened. Thus, on looking through the list of cases of chronic pulmonary
tuberculosis sent for one reason or another, it is found that 9 underwent
thoracoplasty, either partial or complete, 13 phrenic evulsion, 7 thoracoscopy and
division of adhesions, 4 prolonged pleural drainage and irrigation preparatory to
thoracoplasty, and 1 apicolysis.
In this connection we would say advisedly that, judging by our own experience
here and elsewhere, there must be many patients in the Council's hospitals the
victims of unilateral pulmonary tuberculosis uncontrollable by artificial pneumothorax,
who could be restored by thoracoplasty to such a degree of health as would
allow them to earn their own living. It is far from being the deforming operation
it is generally believed to be ; when dressed indeed, a patient appears normal, and,
moreover, is capable of doing light work.
The principal use of a phrenic evulsion as a solitary procedure is in the treatment
of early soft tuberculous lesions or thin walled tuberculous cavities where artificial
pneumothorax has not been successful. In cases treated by artificial pneumothorax,
where the apex of the lung is adherent, healing is greatly facilitated by the
paralysis of the diaphragm, and we believe that in almost all cases of artificial
pneumothorax the diaphragm should be paralysed before the lung is allowed to
expand.
The division of pleural adhesion by cautery is often of the greatest value in
cases which are being treated by artificial pneumothorax, for thereby an unsatisfactory
collapse can frequently be converted into a satisfactory one.
In pure tuberculous empyemata or secondary infected tuberculous empyemata
the only method of treatment likely to give any chance of success is, in our opinion,
one whereby the lung is encouraged to expand and obliterate the pleural cavity to
such an extent that a satisfactory thoracoplasty is possible. In those cases that are
not secondarily infected the cavity is best treated by pleural irrigations by the two
needle method, but once a secondary infection has occurred intercostal drainage is
usually essential.
Air replacement has no place in the treatment of a pyothorax.
Apicolysis has a limited use in the treatment of apical cavities when other
methods have failed and thoracoplasty is contra-indicated on account of bilateral
disease.
We have treated 8 cases of chronic non-tuberculous empyema during the year,
and on the whole with considerable success. These cases are, as is well known, some
of the most troublesome in surgery, requiring long continued drainage and Dakins
irrigations, followed by a modified thoracoplasty operation. Their commonest
cause by far is the premature removal of the drainage tube in the first instance, and
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