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Aspiration bronchopneumonia of the secondarily affected lung in adult phthisis
ASPIIIATION
BRONCHOPNEUMONIA AFFECTED LUNG By
OF IN ADULT
J. F. LANDRETH,
THE SECONDAI{ILY PHTHISIS.
M.B., 51.I{.C.P.
L~tte Resident Jtled.ic~d (J~'cr, AND
H. V. MOnLO('~;, M.])., M.R.C.P. l)]~ysici(~l~ to) o~lt-l't~t~ents, City of Lo~,doTt Hospitcd for Disease,s of tlze He~rt clnd Lungs, Victoria Park.
THlg predilection of the primary lesion of adult phthisis for the apical region of one lung has been recognised almost as long as the disease itself. Laennec, who, by the introduction of the stethoscope and the correlation of clinical and post-mortem findings, laid the foundations of modern phthisiology, asserted that tubercles are almost always developed primarily in the summits of the superior lobes. In addition he drew attention to the development of secondary eruptions spreading towards the base. L a t e r writers have confirmed this description and, although a type of pulmonary tuberculosis commencing at the base has been found to occur, it is generally regarded as a rarity, and the spread of lesions in the primarily affected lung is held to be from apex to base. The distribution of secondary foci in the opposite lung has been less carefully s t u d i e d - - p r o b a b l y because bilateral pulmonary tuberculosis is generally regarded as a hopeless condition and less w o r t h y of investigation than the early case. Fowler's study of " The Localisation of the Lesions of P h t h i s i s " is still the best account of the spread of the tuberculous process. H e concludes, as ~ result of analysis of post-mortem records, that this spread follows a definite line of march. His description of the spread from apex to base in the primarily affected lung is substantially the same as that of previous writers. I n discussing extension to the opposite lung, however, he describes three sites of secondary infection. The first two are the same as the common situations of the primary lesions, i.e., (i) 189 in. below the summit of the lung and rather near to the posterior and external borders, and (ii) at a point corresponding on the chest wall with the first and second interspaces below the outer third of the clavicle. The third site is close to the interlobar septum about midway between its upper and lower extremities and corresponds on the chest wall to the upper part of the axilla. The essentially apical character of adult phthisis is so much stressed by most teachers that clinical examination of the tuberculous patient is usually directed mainly to the apices and in consequence physical signs of disease in other situations are hkely to be overlooked. Fowler's third type of spread has thus often not been recognised. The increasing importance of artificial pneumothorax in the therapy of puhnonary tuberculosis has necessitated the closer examination of the socalled sound lung. While considering cases from this point of view, we have been impressed with the frequency of radiological evidence of infection 7
102
T~BERCLL
[December, 1928
of the midzone of the sound lung and have been led to analyse a series of 292 consecutive cases of pulmonary tuberculosis admitted to Victoria Park. As a result of X-ray examination we classified 106 as unilateral and 186 as bilateral. Of these latter 82 were cases of far advanced disease and we were unable to determine the mode of spread, 58 were cases where there was apical involvement only of the second lung, 46 showed infection of the midzone only of the second lung. The term " m i d z o n e " has been used because radiologically the pneumonic spread has taken place in the middle field of the skiagram, where it is difficult to decide if it is the lower part of the upper lobe or the upper part of the lower lobe which is affected. I n this series of the two cases which came to autopsy, one had the spread in the upper lobe, while the other was in the lower lobe. The radiological appearances in these 46 cases were strikingly uniform. The primarily affected lung in all eases showed evidence of chronic fibroid tuberculosis with cavitation. I n the opposite lung the appearances were those of patches of bronchopneumonia in the midzone. These patches occupied a wedge-shaped zone, varying in extent, with the base at the periphery and the apex towards the hilum. A s u m m a r y of the chief clinical features of these cases appears in the table on p. 103. M.any of the cases have been observed for a few months only and none has been watched longer t h a n eighteen months. Results of t r e a t m e n t have therefore been expressed as : (1) Good progress where the resting temperature and pulse have become normal and the patient has gained w e i g h t ; (2) fair progress where there has been general improvement but some untoward symptom has remained, e.g., temperature occasionally irregular, gain in weight u n s a t i s f a c t o r y ; (3) worse, and (4) died. It is worth noting that sputum was present in all these cases and in all was sputum positive on some occasion. A few cases became sputum negative under t r e a t m e n t , but the period of observation was too short to allow of frequent re-examination, and so tabulation of these cases has not been attempted. The table on p. 103 does not bring out any striking causative factor for the pneumonic spread in the sound lung, other t h a n the presence of cavitation in the previously affected lung and sputum containing tubercle bacilli~ and these two factors would seem to be the main ones in the mtiology. This would, therefore, suggest that the pathology of the spread is an ~spiration bronchopneumonia. The following facts support this view : ~ (1) The presence of a cavity containing tubercle bacilli. (2) The radiological appearance. (3) I n 15 of our cases the condition followed an hsemoptysis. (4) If Renke's theory of primary, secondary and tertiary stage is accepted, the process in the sound lung has already reached the tertiary stage, so t h a t a fresh spread in the midzone of the " sound " lung is most likely to be an aspiration spread. (5) T h a t in four of our cases the spread followed the starting of an artificial pneumothorax in the cavity-containing lung (artificial pneumothorax often at first leading to an increase in the sputum). (6) Post-mortem examination in two cases showed this process to be present.
TUBERCLE.
DECEi~IBER, 1928.
PLATE
Case No. 14.
Cavity, right upper lobe.
I.
Bronehopneumonie spread in left " m i d z o n e . "
To illustrate article, " A s p i r a t i o n Bronchopneumonia of the Secondarily Affected Lung in Adult P h t h i s i s , " by T. F. LANDRETH and H. u hIORLOCK.
Face p. ]02.
TUBERCLE.
DECEMBER, 1928.
PLATE II.
Case No. 14.
After treatment by sanocrysin, showing absorption and fibrosis of bronchopneumonic spread in left " m i d z o n e . "
December, 1928]
ASPIRATIONJ3RONCItOPNEUMONI&
103
It, therefore, seems logical to conclude with Matson, Matson and Bisaillon, that " cavity cases with abundant expectoration should be subjected to early pneumothorax treatment in order that aspiration spread to the opposite lung should be prevented." The clinical picture has no~ been as uniform as the radiological appearances of these cases. The majority of the patients have come into
No.
S~'x Ptg~,
Physical s i g n s ot
N~te of i m i m l l e s i o n
~econdsly
H~emoptyms or p l e m ~,~
T1 e a t n l e l l t
I{~sult
leslolls i
M hi F F M F F 8 9 10 11 12 13 14 15 16
F hi F 25I F M M M F
I7 18 19
F F hi
20 21 22 23
hi M hi
24 25 26 27 "28 "29 30 31 32 33 3~ 35 36 37
F F hi hi F F 5][ F F F M F F
38 39 40 41 42 43 44
F M hi: M
45 4:6
F F
F
36 25 33 16 3~
i
i~ u p p e r lobe c a v i t y 1r ,, ., ,, :
+ + ~+ +
tL IL
,. . . . . ,, ,,
,,
R.
,,
,,
,,
g . 4 weeks ago H. 3 ,, H . 18 ,,
General A.P... Sanoe rysin
H . 9, m o n t h s a g o
+ A b: Good A.P. Died Sanoerysin .. Good Sound lung affected following A.P.
K. 2 m o n t h s a g o
General"
..
A.P.
..
General'" A.P. General" " Sanoerysin
.. .. .. ..
it. 3 weeks ago H. 7 Sound lung affeetod"following" ' A.P. A.P .
L. g. L. [4. 29 2O 35 29 27 25 32 2l 18 15 19 17 17 15
,, ,, ,, ,,
,, ,, ,, ,,
,, ,. ,, ,,
+ + + + § + +
Hi. 3 m o n t h s a g o , H . a n d P. 2 m o n t h s ago i P . 9, m o n t h s a g o i I t . 1 y e a r ago K. 2 m o n t h s ago H . a n d P. 4 w e e k s ago P. 2 m o n t h s ago H . 1 y e a r ago H. 4 m o n t h s a g o
tL
.,
,,
,,
+
I{, 5 w e e k s ago
.
.
,,
+ + + +
....
P. P. 3 m o n t h s a g o - -
- -
- -
- -
+
--
+
--
+
- -
- -
L~
L.
,~
,,
,,
,,
"Good ~Vorse Poor
Good Fair Died Fair
.
Good
Sanocrysin .. A.P.and sanocr. General .. Sanocrysin .~
Fair Good
A.P.. General Sanocrysin General
.. .. ..
A.e'.'abandonei] General
..
Poor Improved Worse Good Worse Imp'loved
].s.q.
H. 6monthsago
I~
I.S.Q. Improved
:: aui' ano 'r"
' A.P'.'
~,
,,
+ +
m
..
..
General A.P. Sanocrysin .. A.P. unsuccessful Sanocrysin .. A.P. a n d sanoer. Sanoerysin .. General .. ,~
19 35
.
It . . . . . . .
17 22 16 24 "25 16
..
..
Poor Good Improved Good. Worso p,
Fair Good ~P
..
Sanocrysin Sound lung s fected following A.P. General ..
D~ed
Worse
Good
104
TUBERCLe.
[December, 1928
hospital with the history and symptoms of an acute illness supervening on an old fibroid phthisis. I n some the history of such an acute exacerbation was lacking. The physical signs of this secondary spread were present in 55 per cent. of our cases. The signs most commonly found were impairment of percussion note and crepitations. Occasionally bronchial breathing was present. The usual position was in the axilla, around the nipple area and occasionally at the angle of the scapula. I n a proportion of the cases physical signs were only detected after a skiagram had called attention to this area. A history of pain suggesting pleurisy was obtained in seven cases, but in no case was a rub heard. There were no cases of pleural effusion. May calls attention to the occasional appearance of pleural effusions in these bronchopneumonic spreads. The course of the disease in these cases has been extremely variable and appears to depend on the treatment adopted. These cases have not been followed for a sufficient length of time to w a r r a n t our drawing any conclusions except as to immediate prognosis. Fifteen cases were treated on ordinary sanatorium lines and of these nine have progressed satisfactorily and six have become worse. T w e n t y cases have been associated with artificial pneumothorax treatment. I n four of these cases the spread followed t r e a t m e n t . Satisfactory collapse was not obtained in any of these cases, two are doing badly and two are dead. Including the above, 16 have been treated by artificial pneumothorax alone and of these three are dead, seven are worse and four are making satisfactory progress, two are in statue quo. F o u r have been treated by a combination of artificial pneumothorax and sanocrysin, and all have made good progress. Eleven have been treated by sanocrysin alone, and of these nine have improved and two became worse. The above figures, although small in numbers, support Riviere's assertion of the danger of pneumothorax in cases with axillary signs in the contralateral lung, and also his teaching t h a t the axilla area in the sound lung in pneumothorax cases must be carefully watched. Sanatorium treatment alone has produced several satisfactory results, and in some clearing of the original opacities in the X-ray film has occurred. I n these cases presumably resolution of the pneumonic process as described by Jacquerod has occurred. T r e a t m e n t by sanocrysin has been encouraging, and on theoretical grounds a pneumonic type of disease such as is here described would appear to be suitable for chemotherapeutic methods. Gravesen has reported several happy results from the combination of sanocrysin t r e a t m e n t of the pneumonic condition with later collapse of the primarily affected lung. This plan appears to the writers to be the logical scheme of treatment. CONCLUSmNS. (1) The spread of pulmonary tuberculosis to the axillary region of the second lung is more common than is generally realised. (2) Clinical examination of the tuberculous patient should be directed
December, 1928]
ASPIRATIONBRONCHO:PNEUMONIA
105
to the axillee, particularly in cases with recent symptoms who have signs of old disease at one apex. (3) The type of spread is a bronchopneumonia resulting from the aspiration of infected sputum, and therefore early pneumothorax is necessary in cavity cases with m u c h sputum. (4) Prognosis in such cases, though grave, is not hopeless, and resolution of the pneumonic process may occur. (5) T r e a t m e n t of tbo pneumonic process by sanocrysin, followed by collapse of the excavated lung, appears to be the best form of treatment. W e wish to t h a n k the honorary staff of the Victoria P a r k Hospital for their kind permission to use the notes and skiagrams of their series, also Dr. Clive :Riviere and Dr. d. V. Sparks for helpful criticism. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]
]~EFERENCES. LA~N~EC,R.T. " Trait~ d'Auscultation M~di~te," 1819. WALS~F~,W . H . " Dmeases of the Lungs," Fourth Edition, 1871, p. 415. KLSGSTONFOWnaR, Sir J. " Localisation of the Lesions of Phthisis," 188S. WESSLEa, H., and JncH~s, L. " Clinical Roentgenology of Diseases of the Chest," 1923. RANCI~E,K . E . Miinch. ~ned. Wochenschr., 1908, 1173. MATsoN, R. W., MATSON, R. C., and BESAILLON, M. Amer. Rev. T~tb., 1924-9~5, t0, 562. ANDREWS, PETER. Amer. Rev. Tub., 1924-25, t0, 583. R[VIERE, CLIVE. "Treatment of Pulr.lonary Tuberculosis by Artificial Pneumothorax," 1927. JACQUE~OD, ~i. " Natural Processes of Healing in Tuberculosis," 199.6. SEOHE~, K. " S~nocrysin Treatment," 1926. GRAVESE~,J. Proc. Roy. Soc. Med., 1927-28, 2t, Elec~.-Therap. Section, 11P, MAy, W. Zettschr. f. 7'uberk., 199.8, 50, 131. THE
C A U S E S OF B R E A K D O W N I N H E A L T H PULS[0NA]~Y TUBERCULOSIS.
IN
By F. R. \u M.D., M.R.C.P. Late 3fedical Director, Crooksb~try SaTzr~tori~t~. I SUPPOSE t h a t we are all agreed that pulmonary tuberculosis is a local manifestation of a general disease caused by infection with the tubercle bacillus. About 1 per cent. of our present population are affected with some form of tuberculosis, chiefly pulmonary. Our object is to discuss the reasons w h y 99 per cent. escape and 1 per cent. breaks down with tubercle. Dzfection alone D~adequate. Were we dealing with one of the infective fevers we should account for the small n u m b e r who fall ill by assuming that they alone have been infected; but in tuberculosis this explanation is inadequate, for the following reasons : - (1) M:~ny are infected who do not fall ill. Post-mortem e x a m i n a t i o n s and the results of the tuberculin test prove that the large majority of our present population become infected with tubercle. Probably quite 90 per cent. of our aclul~ population have been infected in this w a y - - a vastly l a r g e r number t h a n of those who develop the disease.
BRONCHOPNEUMONIA AFFECTED LUNG By
OF IN ADULT
J. F. LANDRETH,
THE SECONDAI{ILY PHTHISIS.
M.B., 51.I{.C.P.
L~tte Resident Jtled.ic~d (J~'cr, AND
H. V. MOnLO('~;, M.])., M.R.C.P. l)]~ysici(~l~ to) o~lt-l't~t~ents, City of Lo~,doTt Hospitcd for Disease,s of tlze He~rt clnd Lungs, Victoria Park.
THlg predilection of the primary lesion of adult phthisis for the apical region of one lung has been recognised almost as long as the disease itself. Laennec, who, by the introduction of the stethoscope and the correlation of clinical and post-mortem findings, laid the foundations of modern phthisiology, asserted that tubercles are almost always developed primarily in the summits of the superior lobes. In addition he drew attention to the development of secondary eruptions spreading towards the base. L a t e r writers have confirmed this description and, although a type of pulmonary tuberculosis commencing at the base has been found to occur, it is generally regarded as a rarity, and the spread of lesions in the primarily affected lung is held to be from apex to base. The distribution of secondary foci in the opposite lung has been less carefully s t u d i e d - - p r o b a b l y because bilateral pulmonary tuberculosis is generally regarded as a hopeless condition and less w o r t h y of investigation than the early case. Fowler's study of " The Localisation of the Lesions of P h t h i s i s " is still the best account of the spread of the tuberculous process. H e concludes, as ~ result of analysis of post-mortem records, that this spread follows a definite line of march. His description of the spread from apex to base in the primarily affected lung is substantially the same as that of previous writers. I n discussing extension to the opposite lung, however, he describes three sites of secondary infection. The first two are the same as the common situations of the primary lesions, i.e., (i) 189 in. below the summit of the lung and rather near to the posterior and external borders, and (ii) at a point corresponding on the chest wall with the first and second interspaces below the outer third of the clavicle. The third site is close to the interlobar septum about midway between its upper and lower extremities and corresponds on the chest wall to the upper part of the axilla. The essentially apical character of adult phthisis is so much stressed by most teachers that clinical examination of the tuberculous patient is usually directed mainly to the apices and in consequence physical signs of disease in other situations are hkely to be overlooked. Fowler's third type of spread has thus often not been recognised. The increasing importance of artificial pneumothorax in the therapy of puhnonary tuberculosis has necessitated the closer examination of the socalled sound lung. While considering cases from this point of view, we have been impressed with the frequency of radiological evidence of infection 7
102
T~BERCLL
[December, 1928
of the midzone of the sound lung and have been led to analyse a series of 292 consecutive cases of pulmonary tuberculosis admitted to Victoria Park. As a result of X-ray examination we classified 106 as unilateral and 186 as bilateral. Of these latter 82 were cases of far advanced disease and we were unable to determine the mode of spread, 58 were cases where there was apical involvement only of the second lung, 46 showed infection of the midzone only of the second lung. The term " m i d z o n e " has been used because radiologically the pneumonic spread has taken place in the middle field of the skiagram, where it is difficult to decide if it is the lower part of the upper lobe or the upper part of the lower lobe which is affected. I n this series of the two cases which came to autopsy, one had the spread in the upper lobe, while the other was in the lower lobe. The radiological appearances in these 46 cases were strikingly uniform. The primarily affected lung in all eases showed evidence of chronic fibroid tuberculosis with cavitation. I n the opposite lung the appearances were those of patches of bronchopneumonia in the midzone. These patches occupied a wedge-shaped zone, varying in extent, with the base at the periphery and the apex towards the hilum. A s u m m a r y of the chief clinical features of these cases appears in the table on p. 103. M.any of the cases have been observed for a few months only and none has been watched longer t h a n eighteen months. Results of t r e a t m e n t have therefore been expressed as : (1) Good progress where the resting temperature and pulse have become normal and the patient has gained w e i g h t ; (2) fair progress where there has been general improvement but some untoward symptom has remained, e.g., temperature occasionally irregular, gain in weight u n s a t i s f a c t o r y ; (3) worse, and (4) died. It is worth noting that sputum was present in all these cases and in all was sputum positive on some occasion. A few cases became sputum negative under t r e a t m e n t , but the period of observation was too short to allow of frequent re-examination, and so tabulation of these cases has not been attempted. The table on p. 103 does not bring out any striking causative factor for the pneumonic spread in the sound lung, other t h a n the presence of cavitation in the previously affected lung and sputum containing tubercle bacilli~ and these two factors would seem to be the main ones in the mtiology. This would, therefore, suggest that the pathology of the spread is an ~spiration bronchopneumonia. The following facts support this view : ~ (1) The presence of a cavity containing tubercle bacilli. (2) The radiological appearance. (3) I n 15 of our cases the condition followed an hsemoptysis. (4) If Renke's theory of primary, secondary and tertiary stage is accepted, the process in the sound lung has already reached the tertiary stage, so t h a t a fresh spread in the midzone of the " sound " lung is most likely to be an aspiration spread. (5) T h a t in four of our cases the spread followed the starting of an artificial pneumothorax in the cavity-containing lung (artificial pneumothorax often at first leading to an increase in the sputum). (6) Post-mortem examination in two cases showed this process to be present.
TUBERCLE.
DECEi~IBER, 1928.
PLATE
Case No. 14.
Cavity, right upper lobe.
I.
Bronehopneumonie spread in left " m i d z o n e . "
To illustrate article, " A s p i r a t i o n Bronchopneumonia of the Secondarily Affected Lung in Adult P h t h i s i s , " by T. F. LANDRETH and H. u hIORLOCK.
Face p. ]02.
TUBERCLE.
DECEMBER, 1928.
PLATE II.
Case No. 14.
After treatment by sanocrysin, showing absorption and fibrosis of bronchopneumonic spread in left " m i d z o n e . "
December, 1928]
ASPIRATIONJ3RONCItOPNEUMONI&
103
It, therefore, seems logical to conclude with Matson, Matson and Bisaillon, that " cavity cases with abundant expectoration should be subjected to early pneumothorax treatment in order that aspiration spread to the opposite lung should be prevented." The clinical picture has no~ been as uniform as the radiological appearances of these cases. The majority of the patients have come into
No.
S~'x Ptg~,
Physical s i g n s ot
N~te of i m i m l l e s i o n
~econdsly
H~emoptyms or p l e m ~,~
T1 e a t n l e l l t
I{~sult
leslolls i
M hi F F M F F 8 9 10 11 12 13 14 15 16
F hi F 25I F M M M F
I7 18 19
F F hi
20 21 22 23
hi M hi
24 25 26 27 "28 "29 30 31 32 33 3~ 35 36 37
F F hi hi F F 5][ F F F M F F
38 39 40 41 42 43 44
F M hi: M
45 4:6
F F
F
36 25 33 16 3~
i
i~ u p p e r lobe c a v i t y 1r ,, ., ,, :
+ + ~+ +
tL IL
,. . . . . ,, ,,
,,
R.
,,
,,
,,
g . 4 weeks ago H. 3 ,, H . 18 ,,
General A.P... Sanoe rysin
H . 9, m o n t h s a g o
+ A b: Good A.P. Died Sanoerysin .. Good Sound lung affected following A.P.
K. 2 m o n t h s a g o
General"
..
A.P.
..
General'" A.P. General" " Sanoerysin
.. .. .. ..
it. 3 weeks ago H. 7 Sound lung affeetod"following" ' A.P. A.P .
L. g. L. [4. 29 2O 35 29 27 25 32 2l 18 15 19 17 17 15
,, ,, ,, ,,
,, ,, ,, ,,
,, ,. ,, ,,
+ + + + § + +
Hi. 3 m o n t h s a g o , H . a n d P. 2 m o n t h s ago i P . 9, m o n t h s a g o i I t . 1 y e a r ago K. 2 m o n t h s ago H . a n d P. 4 w e e k s ago P. 2 m o n t h s ago H . 1 y e a r ago H. 4 m o n t h s a g o
tL
.,
,,
,,
+
I{, 5 w e e k s ago
.
.
,,
+ + + +
....
P. P. 3 m o n t h s a g o - -
- -
- -
- -
+
--
+
--
+
- -
- -
L~
L.
,~
,,
,,
,,
"Good ~Vorse Poor
Good Fair Died Fair
.
Good
Sanocrysin .. A.P.and sanocr. General .. Sanocrysin .~
Fair Good
A.P.. General Sanocrysin General
.. .. ..
A.e'.'abandonei] General
..
Poor Improved Worse Good Worse Imp'loved
].s.q.
H. 6monthsago
I~
I.S.Q. Improved
:: aui' ano 'r"
' A.P'.'
~,
,,
+ +
m
..
..
General A.P. Sanocrysin .. A.P. unsuccessful Sanocrysin .. A.P. a n d sanoer. Sanoerysin .. General .. ,~
19 35
.
It . . . . . . .
17 22 16 24 "25 16
..
..
Poor Good Improved Good. Worso p,
Fair Good ~P
..
Sanocrysin Sound lung s fected following A.P. General ..
D~ed
Worse
Good
104
TUBERCLe.
[December, 1928
hospital with the history and symptoms of an acute illness supervening on an old fibroid phthisis. I n some the history of such an acute exacerbation was lacking. The physical signs of this secondary spread were present in 55 per cent. of our cases. The signs most commonly found were impairment of percussion note and crepitations. Occasionally bronchial breathing was present. The usual position was in the axilla, around the nipple area and occasionally at the angle of the scapula. I n a proportion of the cases physical signs were only detected after a skiagram had called attention to this area. A history of pain suggesting pleurisy was obtained in seven cases, but in no case was a rub heard. There were no cases of pleural effusion. May calls attention to the occasional appearance of pleural effusions in these bronchopneumonic spreads. The course of the disease in these cases has been extremely variable and appears to depend on the treatment adopted. These cases have not been followed for a sufficient length of time to w a r r a n t our drawing any conclusions except as to immediate prognosis. Fifteen cases were treated on ordinary sanatorium lines and of these nine have progressed satisfactorily and six have become worse. T w e n t y cases have been associated with artificial pneumothorax treatment. I n four of these cases the spread followed t r e a t m e n t . Satisfactory collapse was not obtained in any of these cases, two are doing badly and two are dead. Including the above, 16 have been treated by artificial pneumothorax alone and of these three are dead, seven are worse and four are making satisfactory progress, two are in statue quo. F o u r have been treated by a combination of artificial pneumothorax and sanocrysin, and all have made good progress. Eleven have been treated by sanocrysin alone, and of these nine have improved and two became worse. The above figures, although small in numbers, support Riviere's assertion of the danger of pneumothorax in cases with axillary signs in the contralateral lung, and also his teaching t h a t the axilla area in the sound lung in pneumothorax cases must be carefully watched. Sanatorium treatment alone has produced several satisfactory results, and in some clearing of the original opacities in the X-ray film has occurred. I n these cases presumably resolution of the pneumonic process as described by Jacquerod has occurred. T r e a t m e n t by sanocrysin has been encouraging, and on theoretical grounds a pneumonic type of disease such as is here described would appear to be suitable for chemotherapeutic methods. Gravesen has reported several happy results from the combination of sanocrysin t r e a t m e n t of the pneumonic condition with later collapse of the primarily affected lung. This plan appears to the writers to be the logical scheme of treatment. CONCLUSmNS. (1) The spread of pulmonary tuberculosis to the axillary region of the second lung is more common than is generally realised. (2) Clinical examination of the tuberculous patient should be directed
December, 1928]
ASPIRATIONBRONCHO:PNEUMONIA
105
to the axillee, particularly in cases with recent symptoms who have signs of old disease at one apex. (3) The type of spread is a bronchopneumonia resulting from the aspiration of infected sputum, and therefore early pneumothorax is necessary in cavity cases with m u c h sputum. (4) Prognosis in such cases, though grave, is not hopeless, and resolution of the pneumonic process may occur. (5) T r e a t m e n t of tbo pneumonic process by sanocrysin, followed by collapse of the excavated lung, appears to be the best form of treatment. W e wish to t h a n k the honorary staff of the Victoria P a r k Hospital for their kind permission to use the notes and skiagrams of their series, also Dr. Clive :Riviere and Dr. d. V. Sparks for helpful criticism. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12]
]~EFERENCES. LA~N~EC,R.T. " Trait~ d'Auscultation M~di~te," 1819. WALS~F~,W . H . " Dmeases of the Lungs," Fourth Edition, 1871, p. 415. KLSGSTONFOWnaR, Sir J. " Localisation of the Lesions of Phthisis," 188S. WESSLEa, H., and JncH~s, L. " Clinical Roentgenology of Diseases of the Chest," 1923. RANCI~E,K . E . Miinch. ~ned. Wochenschr., 1908, 1173. MATsoN, R. W., MATSON, R. C., and BESAILLON, M. Amer. Rev. T~tb., 1924-9~5, t0, 562. ANDREWS, PETER. Amer. Rev. Tub., 1924-25, t0, 583. R[VIERE, CLIVE. "Treatment of Pulr.lonary Tuberculosis by Artificial Pneumothorax," 1927. JACQUE~OD, ~i. " Natural Processes of Healing in Tuberculosis," 199.6. SEOHE~, K. " S~nocrysin Treatment," 1926. GRAVESE~,J. Proc. Roy. Soc. Med., 1927-28, 2t, Elec~.-Therap. Section, 11P, MAy, W. Zettschr. f. 7'uberk., 199.8, 50, 131. THE
C A U S E S OF B R E A K D O W N I N H E A L T H PULS[0NA]~Y TUBERCULOSIS.
IN
By F. R. \u M.D., M.R.C.P. Late 3fedical Director, Crooksb~try SaTzr~tori~t~. I SUPPOSE t h a t we are all agreed that pulmonary tuberculosis is a local manifestation of a general disease caused by infection with the tubercle bacillus. About 1 per cent. of our present population are affected with some form of tuberculosis, chiefly pulmonary. Our object is to discuss the reasons w h y 99 per cent. escape and 1 per cent. breaks down with tubercle. Dzfection alone D~adequate. Were we dealing with one of the infective fevers we should account for the small n u m b e r who fall ill by assuming that they alone have been infected; but in tuberculosis this explanation is inadequate, for the following reasons : - (1) M:~ny are infected who do not fall ill. Post-mortem e x a m i n a t i o n s and the results of the tuberculin test prove that the large majority of our present population become infected with tubercle. Probably quite 90 per cent. of our aclul~ population have been infected in this w a y - - a vastly l a r g e r number t h a n of those who develop the disease.