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ARTIFICIAL PNEUMOTHORAX.
179
history has brought out so clearly, it is regretted that the zeal of temperance reformers in this country should be wasted in the advocacy of an attenuated type of prohibition, which would not only be futile in itself, but would tend to weaken and pervert the operation of the really effectual policy of control. This latter policy, of course, is still in a stage of imperfect development, and its elaboration and extension will provide ample scope for reforming activity in the future. It may well be, for instance, that its more thorough application will require the transfer of the liquor trade to public ownership. It should help to make clear the true path of progress if we recognise at the outset that local option and other manifestations of the principle of prohibition can have no place in any such programme of reform. Local option is in theory and in effect the negation of the rational and successful system of physiological control. which recent much to be
AN
ARTIFICIAL PNEUMOTHORAX. interesting stage in the development
"
of any after its
method of treatment is that in which, has been established, the indications and contra-indications for its employment, and the limitanew
value
tions of its usefulness, are being investigated. Artificial pneumothorax was first employed in the treatment of pulmonary tuberculosis in this country in 1910, over 20 years after its introduction in Italy by FORLANINI. It is now recognised by nearly all workers in tuberculosis here as a valuable addition to treatment, not infrequently helping cases in which the ordinary methods of treatment fail, and restoring to working capacity many patients who otherwise would be condemned at best to chronic invalidism and sooner or later to complete breakdown. The value of artificial pneumothorax is not, however, as widely recognised by the profession at large in this country as its importance deserves; the method is too often regarded as a desperate resort in
advanced
cases.
We publish this week two interesting papers; the first is by Dr. L. S. T. BURRELL, giving the results of his first 250 cases up to date, and extending and amplifying the information given in the valuable report1 presented to the Medical Research Council in 1922 by Dr. A. S. MACNALTY and himself; the second paper is by Dr. R. C. WINGFIELD and Dr. G. SELBY WILSON, which forms an admirable complement. This paper deals with the conduct of the cases in which artificial pneumothorax has been employed, correlating certain of the clinical features with the ultimate results obtained. Dr. BuRRELL’s results show, what might naturally be expected, that the best results are obtained in patients with moderate resistance to the disease, in whom the condition is unilateral. He finds that in bilateral cases although the immediate results of artificial pneumothorax on the more affected side may be good, relapse usually occurs and the late results are unsatisfactory, though life may be considerably prolonged. In the report to the Medical Research Council, Dr. BURRELL gave categorically his views as to the merits and demerits of this form of treatment. In the present paper he emphasises his opinion that early diagnosis in a great majority of cases enables arrest to be achieved by ordinary methods, and that artificial pneumothorax should be considered not as a routine treatment, but as a safe method of resting the 1 THE
LANCET, 1922, ii., 286.
diseased part of the lung where ordinary methods so that while it should not be used for early cases, its consideration should not be too long deferred in cases which do not respond to other methods. He discusses the dangers and the complications and shows that they are not serious enough to weigh against the undoubted benefits that it is capable of conferring upon cases properly selected. The paper by Dr. WINGFIELD and Dr. WILSON deals with 75 cases treated at Frimley Sanatorium, in 60 of which the induction of the pneumothorax was carried out at the Brompton Hospital. They deal specially with the criteria for estimating the effect of this form of treatment, and do not discuss its value or even the details of its application, such as the spacing of the refills or their amounts. Many observations of great interest emerge from the analysis of their cases. Thus the length of time between the induction and the commencement of exercise has varied from 6 days to 285, with an average of 106. These figures should warn us against expecting dramatic results from the treatment. After defining relapse as any condition, whether accompanied by pyrexia or not, necessitating stopping exercise and being put on rest" for four days or more, the authors find that the longer such a relapse, the worse the ultimate prognosis, and the earlier it occurs after exercise has been started, the less likelihood of an eventual good result. On the other hand, a relapse occurring for the first time when the patient has reached a high grade of exercise is of little importance. They find that better results are obtained in those with a complete collapse than in those in whom partial collapse only has been obtained, but in the absence of details as to the degree of disease before induction, they deprecate the use of their figures as an argument in favour of dividing adhesions. Their views on the value of pneumothorax treatment in bilateral disease are in substantial agreement with those of Dr. BURRELL. They find that an irregular or a periodic temperature in men is an unfavourable indication. One of the great benefits of this form of treatment is the cessation of cough and sputum, or, if sputum persists, the disappearance from it of tubercle bacilli. Dr. WINGFIELD and Dr. WILSON’s figures show that when the bacilli persist in the sputum in spite of the treatment the outlook is very unfavourable: As with other modes of treatment gain in weight is a valuable index of the beneficial effect of this treatment. Early loss of weight is of grave import and should lead to a reconsideration of the treatment as a whole. A complication discussed in both papers is that of pleural effusion occurring in the course of artificial pneumothorax. Dr. WINGFIELD and Dr. WILSON maintain that where the effusion is clear and non-purulent it has no influence on the ultimate result, an opinion in which Dr. BURRELL concurs, except that he finds that in cases occurring in association with bilateral disease the outlook is less good and that there is a tendency for the effusion to become purulent. It is allowed in both papers that a purulent effusion is a grave occurrence. Perhaps the most striking result is that in Dr. WINGFIELD and Dr. WILSON’s cases, which were an unselected, consecutive series, including a proportion of the late stage or " last resort " types of case, no less than 49 per cent. were restored to working capacity. It is noteworthy that these results were obtained in a sanatorium, and it serves to emphasise Dr. BURRELL’S opinion to the effect that artificial pneumothorax is not to
fail,
be regarded as a cure for pulmonary tuberculosis, but as a safe method of ensuring rest of the diseased part of the lung, to be used in conjunction with other methods of treatment. This seems to us to be the true perspective, and used with due discrimination the induction of artificial pneumothorax will give It must be 3ven better results than at present. emphasised, however, that the selection of cases should be most carefully made, and here X ray examination is, we hold, indispensable.
history has brought out so clearly, it is regretted that the zeal of temperance reformers in this country should be wasted in the advocacy of an attenuated type of prohibition, which would not only be futile in itself, but would tend to weaken and pervert the operation of the really effectual policy of control. This latter policy, of course, is still in a stage of imperfect development, and its elaboration and extension will provide ample scope for reforming activity in the future. It may well be, for instance, that its more thorough application will require the transfer of the liquor trade to public ownership. It should help to make clear the true path of progress if we recognise at the outset that local option and other manifestations of the principle of prohibition can have no place in any such programme of reform. Local option is in theory and in effect the negation of the rational and successful system of physiological control. which recent much to be
AN
ARTIFICIAL PNEUMOTHORAX. interesting stage in the development
"
of any after its
method of treatment is that in which, has been established, the indications and contra-indications for its employment, and the limitanew
value
tions of its usefulness, are being investigated. Artificial pneumothorax was first employed in the treatment of pulmonary tuberculosis in this country in 1910, over 20 years after its introduction in Italy by FORLANINI. It is now recognised by nearly all workers in tuberculosis here as a valuable addition to treatment, not infrequently helping cases in which the ordinary methods of treatment fail, and restoring to working capacity many patients who otherwise would be condemned at best to chronic invalidism and sooner or later to complete breakdown. The value of artificial pneumothorax is not, however, as widely recognised by the profession at large in this country as its importance deserves; the method is too often regarded as a desperate resort in
advanced
cases.
We publish this week two interesting papers; the first is by Dr. L. S. T. BURRELL, giving the results of his first 250 cases up to date, and extending and amplifying the information given in the valuable report1 presented to the Medical Research Council in 1922 by Dr. A. S. MACNALTY and himself; the second paper is by Dr. R. C. WINGFIELD and Dr. G. SELBY WILSON, which forms an admirable complement. This paper deals with the conduct of the cases in which artificial pneumothorax has been employed, correlating certain of the clinical features with the ultimate results obtained. Dr. BuRRELL’s results show, what might naturally be expected, that the best results are obtained in patients with moderate resistance to the disease, in whom the condition is unilateral. He finds that in bilateral cases although the immediate results of artificial pneumothorax on the more affected side may be good, relapse usually occurs and the late results are unsatisfactory, though life may be considerably prolonged. In the report to the Medical Research Council, Dr. BURRELL gave categorically his views as to the merits and demerits of this form of treatment. In the present paper he emphasises his opinion that early diagnosis in a great majority of cases enables arrest to be achieved by ordinary methods, and that artificial pneumothorax should be considered not as a routine treatment, but as a safe method of resting the 1 THE
LANCET, 1922, ii., 286.
diseased part of the lung where ordinary methods so that while it should not be used for early cases, its consideration should not be too long deferred in cases which do not respond to other methods. He discusses the dangers and the complications and shows that they are not serious enough to weigh against the undoubted benefits that it is capable of conferring upon cases properly selected. The paper by Dr. WINGFIELD and Dr. WILSON deals with 75 cases treated at Frimley Sanatorium, in 60 of which the induction of the pneumothorax was carried out at the Brompton Hospital. They deal specially with the criteria for estimating the effect of this form of treatment, and do not discuss its value or even the details of its application, such as the spacing of the refills or their amounts. Many observations of great interest emerge from the analysis of their cases. Thus the length of time between the induction and the commencement of exercise has varied from 6 days to 285, with an average of 106. These figures should warn us against expecting dramatic results from the treatment. After defining relapse as any condition, whether accompanied by pyrexia or not, necessitating stopping exercise and being put on rest" for four days or more, the authors find that the longer such a relapse, the worse the ultimate prognosis, and the earlier it occurs after exercise has been started, the less likelihood of an eventual good result. On the other hand, a relapse occurring for the first time when the patient has reached a high grade of exercise is of little importance. They find that better results are obtained in those with a complete collapse than in those in whom partial collapse only has been obtained, but in the absence of details as to the degree of disease before induction, they deprecate the use of their figures as an argument in favour of dividing adhesions. Their views on the value of pneumothorax treatment in bilateral disease are in substantial agreement with those of Dr. BURRELL. They find that an irregular or a periodic temperature in men is an unfavourable indication. One of the great benefits of this form of treatment is the cessation of cough and sputum, or, if sputum persists, the disappearance from it of tubercle bacilli. Dr. WINGFIELD and Dr. WILSON’s figures show that when the bacilli persist in the sputum in spite of the treatment the outlook is very unfavourable: As with other modes of treatment gain in weight is a valuable index of the beneficial effect of this treatment. Early loss of weight is of grave import and should lead to a reconsideration of the treatment as a whole. A complication discussed in both papers is that of pleural effusion occurring in the course of artificial pneumothorax. Dr. WINGFIELD and Dr. WILSON maintain that where the effusion is clear and non-purulent it has no influence on the ultimate result, an opinion in which Dr. BURRELL concurs, except that he finds that in cases occurring in association with bilateral disease the outlook is less good and that there is a tendency for the effusion to become purulent. It is allowed in both papers that a purulent effusion is a grave occurrence. Perhaps the most striking result is that in Dr. WINGFIELD and Dr. WILSON’s cases, which were an unselected, consecutive series, including a proportion of the late stage or " last resort " types of case, no less than 49 per cent. were restored to working capacity. It is noteworthy that these results were obtained in a sanatorium, and it serves to emphasise Dr. BURRELL’S opinion to the effect that artificial pneumothorax is not to
fail,
be regarded as a cure for pulmonary tuberculosis, but as a safe method of ensuring rest of the diseased part of the lung, to be used in conjunction with other methods of treatment. This seems to us to be the true perspective, and used with due discrimination the induction of artificial pneumothorax will give It must be 3ven better results than at present. emphasised, however, that the selection of cases should be most carefully made, and here X ray examination is, we hold, indispensable.