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it cannot be repeated too often that, in an acute empyema, the tube should never be
removed finally until the lung has completely expanded and entirely obliterated the
cavity.
Abscess of the lung always carries a high mortality, and of our 9 cases 5 died.
In two of the fatal cases there was widespread gangrene of the lung at the time of
operation ; one patient (with a chronic cavity) was successfully treated by lobectomy;
two others, treated by more conventional methods, are well on the way to recovery,
and another left the hospital very much improved. It is a moot point whether
these lung abscess cases would not have a better chance if they could be transferred
to the centre by ambulance as soon as they are diagnosed. How long one should
continue conservative measures such as postural drainage and bronchoscopy, etc.,
is always a difficult question, but on the other hand it must be remembered that
the more chronic a pulmonary cavity is, the poorer the chances are of complete
success by drainage.
Three cases of bronchiectasis were treated by lobectomy. One case in which
the disease was localised to the lower lobe has been completely cured, another in
which the upper lobe was also affected has been improved, while a third unfortunately
died. We feel that more advance has been made in the treatment of this
disease than in that of any other thoracic condition. In unilobar cases, lobectomy
is the procedure of choice. This operation now has a standardised technique and a
mortality in the region of only 10 per cent. In bilateral cases, or cases where surgery
is out of the question continuous postural drainage based on the anatomical distribution
of the disease has produced remarkable amelioration of symptoms (vide Nelson
H. P., B.M.J., Aug. 11th, 1934, vol. II, p. 25). Several cases at St. Andrew's hospital
have been treated by this method in the past year with very gratifying results.
All our 8 cases of intrathoracic neoplasm died, for all were malignant. There
are, indeed, few cases reported in the literature where operation has effected a cure.
One of our patients, in whom complete removal was accomplished by an upper
lobectomy, lived for four months after the operation, and at the post-mortem examination,
though metastases were found to be present in the chest wall, there was none
in the mediastinum. We are anxious to see all cases of intrathoracic neoplasm at
the clinic. Cases in which no tumour can be seen through a bronchoscope and yet
there is an X-ray opacity with a rounded convex margin should be subjected to exploratory
thoracotomy. It is in this type of bronchial carcinoma that removal is
sometimes possible. Innocent intrathoracic neoplasms too, always produce more or
less spherical opacities on the X-ray film, and all of them require surgical
treatment.
(2) ST. JAMES' HOSPITAL.
By W. L. Maccormac, M.B., Ch.B., F.R.C.S. (Edin.), Medical Superintendent,
St. James' Hospital.
The thoracic unit, under the direction of Mr. Tudor Edwards, is a new departure,
hence the number of cases treated during the year ended 31st December, 1934, is
small; yet, small as it is, the diversified nature of the cases gives a fair representation
of those diseases of the chest to which surgery can be wisely applied because reasonably
safe and offering a good prospect of cure.
The four main diseases with which this type of surgery deals are all represented—
abscess, tuberculosis, bronchiectasis, neoplasm-tuberculosis predominating. The
smooth convalescence of the two one-stage lobectomies carried out for that pestilential
malady bronchiectasis, as also the large margin of safety and sureness displayed in
the removal of a fibroma of the mediastinum, was a revelation of the astounding
advance that has been made in thoracic surgery since the War, aided materially as
it has been by the greater accuracy in diagnosis afforded by the use of lipiodol and
modern radiology. Also one must not omit the developments in anaesthesia that
have enabled the surgeon to advance so rapidly and profitably.