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Ambulant chemotherapy: A practical advance in the treatment of pulmonary tuberculosis
Brit. 07. Dis. Chest (x959) 53, I93-
AMBULANT CHEMOTHERAPY: A PRACTICAL ADVANCE IN THE TREATMENT OF PULMONARY TUBERCULOSIS BY S. E. gLADE* From the Department of Public Health, Perth Chest Clinic, Government of Western Australia TH~ advent of effective drugs in the treatment of pulmonary tuberculosis has altered the natural history of the disease in individuals and probably also the epidemiology (Joint Tuberculosis Council, I955). I n the past, conservative treatment was the only hope of those whose symptoms brought them to diagnosis, but mass radiography has led large numbers to the tuberculosis service before they are aware of ill-health and before they are able to infect others. As a result the chest clinic is attended by many who h a v e radiographic lesions of doubtful activity. The absence of constitutional symptoms and signs has persuaded many physicians to adopt a hopeful attitude and await the excretion of acid fast bacilli, deterioration in the X-ray appearances, or complaints of ill-health, before instituting treatment. From the patient's point of view there are adequate reasons for remaining at work, the most important being that during the patient's stay in hospital jobs are lost, often irrevocably, promotion is compromised and the stigma of " T.B." may be affixed, effectively closing many firms to these patients when they are discharged. The financial stress to a man earning an average wage of £ i o or a woman £ 5 a week (Ministry of Labour Gazette i955) when deprived of their livelihood by illness is insufficiently relieved by National Insurance and National Assistance. In addition a tuberculous in-patient becomes a national fiability of approximately £ I 2 a week (Hospital Costing Returns 1954), setting aside the cost to the nation of health visitors, almoners, home helps and rehabilitation organisations. An attempt has been made to diminish these difficulties by prescribing ambulant chemotherapy in suitable cases. T h a t is to say, the administration of an effective combination of anti-tuberculosis drugs while disturbing the patient's life as little as possible. In this way the patient loses neither money nor position and the community is saved the loss of his skill and productivity. Suitability for this type of treatment is suggested when radiographic evidence of disease is associated with the absence of tubercle bacilli in the sputum of an intelligent patient without signs of toxaemia, i.e. no constitutional disturbance and a normal sedimentation rate. Twelve of this series fall into this category; in addition twenty-eight had tubercle bacilli demonstrated by laryngeal swab or sputum examination but refused institutional treatment although it was indicated and advised. The economic advantages of ambulant chemotherapy defeat accurate evaluation, but an estimate of this aspect suggests that this type of treatment *Formerly Registrar at the Windsor Chest Clinic. (Receivedfor publication October 28, 1958.)
194
SLAD~
T A B L E SUMMARIZING THE EFFECT OF AMBULANT CHEMOTHERAPY IN THE TREATMENT OF F O R T y CONSECUTIVE CASES OF PULMONARY TUBERCULOSIS OBSERVED DURING A PERIOD OF Two
YEARS
Case
No.
i 2 3 4
5 6 7
8 9
IO II
I2 I3 I4 I5 I6 I7
18 X9 GO
21 22* 23 24 25 26 27 28 29 3o
31 32 33 34 35
36 37
38 39 4°
Occupation
bex
Instrument maker .. Greengrocer . . . . C o m m e r c i a l traveller Tool maker .. .. Instrument mechanic Railway porter .. T a n k liner . . . . R e t i r e d clerk . . . . Housewife .. .. Traffic i n s p e c t o r .. Engineer . . . . Master baker .. Clerk . . . . . . Foundry worker .. Publican . . . . Secretary . . . . Instrument maker T r u c k driver . . . C o m m e r c i a l traveller Typist . . . . . . Housewife .. .. Cabinet maker .. Clerk . . . . . . Draughtsman .. F o r e m a n fitter Caf6 p r o p r i e t o r Scullion .. Housewife .. .. Waiter Farm labourer Sccretary .. Painter .. .° Gardener Battery assembler Gas worker .. Housewife .. .. Colour matcher .. Research student A i r c r a f t fitter . . . . Handyman . . . .
T o t a l s : 8 w o m e n , 32 m e n
Neg.
F
he.
~+ Jr
+ + + + + + + +
+
3 4 6
47
7 7 6 6
14
+
I2 12 13
15
+ +
+
+ +
2 9
+
IO
+ + + + +
+ + + + +
12 12 i8 9 +
+ +
+ + + + + + +
+ + + +
7
43 29 6 6
7 4 4 4
io 6
4 7~
33 31 6
6 6 6
6 it?
5 3
4
4
2o 27
4 5
+
+
24
6 5
+
+
25
12 16 37
4 5 6
+ + + + + +
IO
4 4 5 6 4
7 12
+ + + + + + +
7 5 6
II
+ +
+
7 6
-1-
+ +
5 4
i2
q+
15
* Case 22 died d u r i n g t r e a t m e n t . Legend: N e g : Con. : Pos. : Imp. : Unc.: Tim. : Age:
io
~+
I2
Age
a
+
M M M M F
Tim.[
q-
+
F
M M
Pos. _ Imp.
+ + + +
M M M M M M F M M M M M M F M M M F F M M M M M M
Con.
S p u t u m negative a t the s t a r t o f t r e a t m e n t . S p u t u m conversion during treatment. C o n t i n u i n g positive a n d still receiving t r e a t m e n t . X-ray appearance improved during treatment. X-ray appearance unchanged. D u r a t i o n o f c h e m o t h e r a p y in m o n t h s . P a t i e n t ' s age in decades.
598 m o n t h s
2~BuI,ANT GHEMOTH]~RAPY
195
when effective is cheaper by several hundred pounds per patient per year. Individual benefit in terms of happiness and independence is incalculable. The effort of carrying out this treatment from the Windsor Chest Clinic has involvcd no increase in staff or expenditure. The forty cases presented in the table are a personal series whose treatment commenced during 1953 and 1954 . M a n y more are being treated in this way (Thompson, 1955). The technique is a logical advance from the methods of post-hospital care in common use (Dressier et al., 1954; Clarke, 1953) and may be in use at other centres. The only reports found in the literature of a similar method used prior to 1956 are from Scandinavia and South America (Kristenson, 1955; Sarno and Malet, 1955). The results assessed five years after commencing the series arc gratifying and in some cases startling. Twenty-five patients who were excreting tubercle bacilli when treatment began no longer do so. The X-ray appearances have improved in twenty-four and cavity closure has been observed in case 17 . Cases 27 and I are still undergoing treatment. The former is still active and the latter moved out of the district and broke continuity in treatment. He was found to have a positive sputum in J a n u a r y 1957 and is once more taking ambulant chemotherapy. His disease is at present inactive. Case 2 was admitted under pressure because his mental capability was unequal to the task of continuing ambulant chemotherapy. Case 7 has chronic bilateral excavating disease and resolutely refuses institutional treatment. Unfortunately the organism responsible for his illness is a chromogen not pathogenic to guinea pigs and insensitive to both streptomycin and I N A H which have been discontinued. Case 22 deteriorated and died after sixteen months' treatment. Thus of forty cases of active pulmonary tuberculosis, thirty-six were successfully controlled by ambulant chemotherapy alone without any restriction of their normal activities and with no time lost from work and living other than that needed to attend the clinic. The twelve cases regarded as suitable for this type of treatment have all remained inactive for more than three years. At the outset it was plain that the burden on the district nurses who would be giving injections after five o'clock would be heavy. Therefore as m a n y patients as can tolerate it are treated with PAS and I N A H made up into one cachet containing I. 5 g. of sodium aminosalicylate with 33 rag. of isonicotinic acid hydrazide. Twelve of these cachets are given daily in four divided doses. I have found that it is important before undertaking ambulant chemotherapy to choose those patients judged intelligent enough to co-operate and to take them fully into one's confidence, explaining the objects to be achieved and the method to be employed. In this way the patient and his physician are able to tackle the disease together, always a desirable arrangement, but an essential condition of success with this method.
Summary The nature and advantages of ambulant chemotherapy are described. Forty consecutive personal cases are analysed, twelve were sputum negative
I96
SL.~
a n d t w e n t y - e i g h t were excreting tubercle bacilli w h e n t r e a t m e n t began. T w e n t y - f i v e were converted to the s p u t u m - n e g a t i v e state. O n e p a t i e n t died d u r i n g treatment. O n e patient was u n c o n t r o l l e d a n d h a d atypical organisms. I t is submitted t h a t a m b u l a n t c h e m o t h e r a p y in suitable cases has domestic, social a n d financial advantages over conservative methods. I wish to record my thanks to Dr. Brian C. Thompson for encouraging me to publish these observations made in the Windsor Chest Clinic and for his helpful criticism. REFERENCES CLARKE, O. (I952) : Brit. meal.07., 2, 644. DRESSLER,S. H., ANT~IONY,E. M., RUSSELL,W. F., GRow, J. B., DENSr,J., COHN, M. L., and MIDDLF.BROOK,G. (I954) " Amer. Rev. Tuberc., 7o, I93o. JOINT TUBERCULOSISCOUNCIL; " The Changing Character of Tuberculosis." I955, Newton Abbot, Devon. KRISTENSON,A. (I955) " Acta. tuberc, scan&, 3o, I95. MINISTRYOF HEALTH:" Hospital Costing Returns." I954, x, 8I. Ministry of Labour Ga~zette, I955, 9, 3o6. SARNO,A., and MALET,S. C. (I955) : Hoja Tisiol, I5, 177. THOMPSON,B. C. (1955) : Brit. med. J., 2, 62o.
AMBULANT CHEMOTHERAPY: A PRACTICAL ADVANCE IN THE TREATMENT OF PULMONARY TUBERCULOSIS BY S. E. gLADE* From the Department of Public Health, Perth Chest Clinic, Government of Western Australia TH~ advent of effective drugs in the treatment of pulmonary tuberculosis has altered the natural history of the disease in individuals and probably also the epidemiology (Joint Tuberculosis Council, I955). I n the past, conservative treatment was the only hope of those whose symptoms brought them to diagnosis, but mass radiography has led large numbers to the tuberculosis service before they are aware of ill-health and before they are able to infect others. As a result the chest clinic is attended by many who h a v e radiographic lesions of doubtful activity. The absence of constitutional symptoms and signs has persuaded many physicians to adopt a hopeful attitude and await the excretion of acid fast bacilli, deterioration in the X-ray appearances, or complaints of ill-health, before instituting treatment. From the patient's point of view there are adequate reasons for remaining at work, the most important being that during the patient's stay in hospital jobs are lost, often irrevocably, promotion is compromised and the stigma of " T.B." may be affixed, effectively closing many firms to these patients when they are discharged. The financial stress to a man earning an average wage of £ i o or a woman £ 5 a week (Ministry of Labour Gazette i955) when deprived of their livelihood by illness is insufficiently relieved by National Insurance and National Assistance. In addition a tuberculous in-patient becomes a national fiability of approximately £ I 2 a week (Hospital Costing Returns 1954), setting aside the cost to the nation of health visitors, almoners, home helps and rehabilitation organisations. An attempt has been made to diminish these difficulties by prescribing ambulant chemotherapy in suitable cases. T h a t is to say, the administration of an effective combination of anti-tuberculosis drugs while disturbing the patient's life as little as possible. In this way the patient loses neither money nor position and the community is saved the loss of his skill and productivity. Suitability for this type of treatment is suggested when radiographic evidence of disease is associated with the absence of tubercle bacilli in the sputum of an intelligent patient without signs of toxaemia, i.e. no constitutional disturbance and a normal sedimentation rate. Twelve of this series fall into this category; in addition twenty-eight had tubercle bacilli demonstrated by laryngeal swab or sputum examination but refused institutional treatment although it was indicated and advised. The economic advantages of ambulant chemotherapy defeat accurate evaluation, but an estimate of this aspect suggests that this type of treatment *Formerly Registrar at the Windsor Chest Clinic. (Receivedfor publication October 28, 1958.)
194
SLAD~
T A B L E SUMMARIZING THE EFFECT OF AMBULANT CHEMOTHERAPY IN THE TREATMENT OF F O R T y CONSECUTIVE CASES OF PULMONARY TUBERCULOSIS OBSERVED DURING A PERIOD OF Two
YEARS
Case
No.
i 2 3 4
5 6 7
8 9
IO II
I2 I3 I4 I5 I6 I7
18 X9 GO
21 22* 23 24 25 26 27 28 29 3o
31 32 33 34 35
36 37
38 39 4°
Occupation
bex
Instrument maker .. Greengrocer . . . . C o m m e r c i a l traveller Tool maker .. .. Instrument mechanic Railway porter .. T a n k liner . . . . R e t i r e d clerk . . . . Housewife .. .. Traffic i n s p e c t o r .. Engineer . . . . Master baker .. Clerk . . . . . . Foundry worker .. Publican . . . . Secretary . . . . Instrument maker T r u c k driver . . . C o m m e r c i a l traveller Typist . . . . . . Housewife .. .. Cabinet maker .. Clerk . . . . . . Draughtsman .. F o r e m a n fitter Caf6 p r o p r i e t o r Scullion .. Housewife .. .. Waiter Farm labourer Sccretary .. Painter .. .° Gardener Battery assembler Gas worker .. Housewife .. .. Colour matcher .. Research student A i r c r a f t fitter . . . . Handyman . . . .
T o t a l s : 8 w o m e n , 32 m e n
Neg.
F
he.
~+ Jr
+ + + + + + + +
+
3 4 6
47
7 7 6 6
14
+
I2 12 13
15
+ +
+
+ +
2 9
+
IO
+ + + + +
+ + + + +
12 12 i8 9 +
+ +
+ + + + + + +
+ + + +
7
43 29 6 6
7 4 4 4
io 6
4 7~
33 31 6
6 6 6
6 it?
5 3
4
4
2o 27
4 5
+
+
24
6 5
+
+
25
12 16 37
4 5 6
+ + + + + +
IO
4 4 5 6 4
7 12
+ + + + + + +
7 5 6
II
+ +
+
7 6
-1-
+ +
5 4
i2
q+
15
* Case 22 died d u r i n g t r e a t m e n t . Legend: N e g : Con. : Pos. : Imp. : Unc.: Tim. : Age:
io
~+
I2
Age
a
+
M M M M F
Tim.[
q-
+
F
M M
Pos. _ Imp.
+ + + +
M M M M M M F M M M M M M F M M M F F M M M M M M
Con.
S p u t u m negative a t the s t a r t o f t r e a t m e n t . S p u t u m conversion during treatment. C o n t i n u i n g positive a n d still receiving t r e a t m e n t . X-ray appearance improved during treatment. X-ray appearance unchanged. D u r a t i o n o f c h e m o t h e r a p y in m o n t h s . P a t i e n t ' s age in decades.
598 m o n t h s
2~BuI,ANT GHEMOTH]~RAPY
195
when effective is cheaper by several hundred pounds per patient per year. Individual benefit in terms of happiness and independence is incalculable. The effort of carrying out this treatment from the Windsor Chest Clinic has involvcd no increase in staff or expenditure. The forty cases presented in the table are a personal series whose treatment commenced during 1953 and 1954 . M a n y more are being treated in this way (Thompson, 1955). The technique is a logical advance from the methods of post-hospital care in common use (Dressier et al., 1954; Clarke, 1953) and may be in use at other centres. The only reports found in the literature of a similar method used prior to 1956 are from Scandinavia and South America (Kristenson, 1955; Sarno and Malet, 1955). The results assessed five years after commencing the series arc gratifying and in some cases startling. Twenty-five patients who were excreting tubercle bacilli when treatment began no longer do so. The X-ray appearances have improved in twenty-four and cavity closure has been observed in case 17 . Cases 27 and I are still undergoing treatment. The former is still active and the latter moved out of the district and broke continuity in treatment. He was found to have a positive sputum in J a n u a r y 1957 and is once more taking ambulant chemotherapy. His disease is at present inactive. Case 2 was admitted under pressure because his mental capability was unequal to the task of continuing ambulant chemotherapy. Case 7 has chronic bilateral excavating disease and resolutely refuses institutional treatment. Unfortunately the organism responsible for his illness is a chromogen not pathogenic to guinea pigs and insensitive to both streptomycin and I N A H which have been discontinued. Case 22 deteriorated and died after sixteen months' treatment. Thus of forty cases of active pulmonary tuberculosis, thirty-six were successfully controlled by ambulant chemotherapy alone without any restriction of their normal activities and with no time lost from work and living other than that needed to attend the clinic. The twelve cases regarded as suitable for this type of treatment have all remained inactive for more than three years. At the outset it was plain that the burden on the district nurses who would be giving injections after five o'clock would be heavy. Therefore as m a n y patients as can tolerate it are treated with PAS and I N A H made up into one cachet containing I. 5 g. of sodium aminosalicylate with 33 rag. of isonicotinic acid hydrazide. Twelve of these cachets are given daily in four divided doses. I have found that it is important before undertaking ambulant chemotherapy to choose those patients judged intelligent enough to co-operate and to take them fully into one's confidence, explaining the objects to be achieved and the method to be employed. In this way the patient and his physician are able to tackle the disease together, always a desirable arrangement, but an essential condition of success with this method.
Summary The nature and advantages of ambulant chemotherapy are described. Forty consecutive personal cases are analysed, twelve were sputum negative
I96
SL.~
a n d t w e n t y - e i g h t were excreting tubercle bacilli w h e n t r e a t m e n t began. T w e n t y - f i v e were converted to the s p u t u m - n e g a t i v e state. O n e p a t i e n t died d u r i n g treatment. O n e patient was u n c o n t r o l l e d a n d h a d atypical organisms. I t is submitted t h a t a m b u l a n t c h e m o t h e r a p y in suitable cases has domestic, social a n d financial advantages over conservative methods. I wish to record my thanks to Dr. Brian C. Thompson for encouraging me to publish these observations made in the Windsor Chest Clinic and for his helpful criticism. REFERENCES CLARKE, O. (I952) : Brit. meal.07., 2, 644. DRESSLER,S. H., ANT~IONY,E. M., RUSSELL,W. F., GRow, J. B., DENSr,J., COHN, M. L., and MIDDLF.BROOK,G. (I954) " Amer. Rev. Tuberc., 7o, I93o. JOINT TUBERCULOSISCOUNCIL; " The Changing Character of Tuberculosis." I955, Newton Abbot, Devon. KRISTENSON,A. (I955) " Acta. tuberc, scan&, 3o, I95. MINISTRYOF HEALTH:" Hospital Costing Returns." I954, x, 8I. Ministry of Labour Ga~zette, I955, 9, 3o6. SARNO,A., and MALET,S. C. (I955) : Hoja Tisiol, I5, 177. THOMPSON,B. C. (1955) : Brit. med. J., 2, 62o.