Emergency hypophysectomy in pregnancy after induction of ovulation.

"The treatment of spontaneous pneumothorax is a rather unhappy story. Many methods have been and are still being tried, but none is entirely satisfactory" (British Medical Yournal, 1965). There is general agreement that a tension pneumothorax must be treated as an emergency by inserting a wide-bore needle or intercostal catheter (Davies, 1969), which can be connected subsequently to an underwater seal or to a valve (Knight, 1967). There is, however, considerable controversy about the treatment of cases not under tension. Some believe that, in the absence of respiratory distress or underlying lung disease, the patient can be followed up as an outpatient while continuing at work in most cases (Stradling and Poole, 1966; Davies, 1969). Stradling and Poole (1966) successfully managed 80% of their patients in this way. Some believe that an intercostal catheter should be inserted in those with a large pneumothorax (Home, 1966; British Medical 7ournal, 1968; Lennox, 1970), and others that catheter drainage or some otfier surgical procedure should be carried out in almost all cases (Ruckley and McCormack, 1966; Thompson and Bailey, 1966). The principal reason put forward for inserting an intercostal catheter in those with a large pneumothorax is to shorten the course of treatment (Lennox, 1970). The average length of hospital stay in several large series treated by intercostal catheter varied from 5 to 30 days, with a mean of 13 days (Klassen and Meckstroth, 1962; Smith and Rothwell, 1962; Killen and Jackson, 1963; Ransdell and McPherson, 1963; Withers et al., 1964; Lynn, 1965; Timmis et al., 1965; Thompson and Bailey, 1966). There was an average failure rate of 19%. In one series of 88 patients nine died (Ransdell and McPherson, 1963). In the present series oxygen therapy resulted in a fourfold increase in the mean rate of absorption. Further study would be necessary to check whether a similar increase in absorption could be achieved with a lower flow rate of oxygen. The observation that the effect of oxygen was less pronounced in patients with a small pneumothorax may be due to the fact that in these patients the two layers OC the pleura tended to come into contact in parts of the pleural space, so that the surface area available for absorption was reduced. The calculated time for full re-expansion with daily oxygen therapy ranged from three to eight days, with a mean of five days. The patient can presumably be discharged from hospital either at this stage or else before full re-expansion has been obtained. This method of treatment, therefore, compares favourably with the use of an intercostal catheter as a method of shortening hospital stay. There were no failures in the present study, and no serious complications. Though high concentration oxygen at atmospheric pressure can have a toxic effect on the lungs, this seems to be limited to patients receiving it continuously for 24 hours daily, and the effects of intermittent exposure are not cumulative (Pratt, 1965). Administration was intermittent in the present study, and none of the patients developed radiological changes suggestive of oxygen toxicity. The inspired oxygen concentration was not measured, but it is very unlikely to have been as high as 100%, though it was probably higher than the 50 to 60% obtained with the Polymask using a lower flow rate of eight litres per minute (Leigh, 1970). It is clearly important that treatment with high concentration oxygen should be avoided in patients with respiratory failure and in those with a tension pneumothorax. This method of treatment should probably be limited to the common primary type of spontaneous pneu-rothorax occurring in the absence of any generalized lung disease.