- Email: [email protected]
Cavitation in pulmonary tuberculosis
106 [16] [H3J [17] [17J [18] [18J [19] [19J [20] [20J [21J [22J [23J [24J [25] [25J
TUBEROLE
[December, 1935
DURAND, R., H., KOUlULSllY, R. and BEKDA. BENDA. R. O. R. Soc. Biol., 1928, 99, 30. DURAKD, DUHAND, H. and BENDA, R. Ibid., 1928, 99, ~8. SERGENT, E., DUHAKD, ARLOING, F. and THIh'EKOT, THIh'ENOT, W. Ibid., 1928, 99, 13G. ARLOIKG, NI~GRE, L., BOQUET, A. and YALTIS, J. Ibid., 99,45. NI::GRE, L. and YALTIS, J. Ibid., 1931, 107, 774. NEGRE, L. and VALTIS, J. Ibid., 1931, 107, 774. Ni:GIm, Ni:GRE, L. and SAENZ, A. Ibid., 1931, 107, 942. VAN DEINSE, DEmSE, F. Ibid., 1931, 107, 1058 and 1212. VAK SANARELLI. G. Ibid., 1931, 107, 443. SAKARELLI, NINNI, 111. C. Ibid., 1931, 107, G15. NIKKI,
CAVITATION IN PULMONARY TUBERCULOSIS. A HEVIEW OF ONE HUNDRED CASES. By R. Y. KEERS, l\I.D. Tor-na-Dee Sanatorilllll. Sanatorillm. Late Assistant Physician, Tor-na·Dee
UNTIL comparatively recently, cavity formation in the course of pulUKTIL monary tuberculosis was regarded as a final and incurable stage of the disease. Statistics published within the past few years, however, indicate that, with adequate treatment, closure of a cavity and restoration of the patient's working capacity is possible and that, in aDo considerable proportion of cases, this can be brought about without resort to collapse therapy. Thus the analysis of the cases with cavities given in the annual report of the Trudeau Sanatorium in HJ31 [1] showed that cavities, as seen by X-rays, disappeared with about the same frequency under ordinary general and resting treatment as in those cases receiving collapse therapy, the figures being 77 per cent. in the first group and 79 per cent. in the second. It should be noted, however, that collapse treatment was applied only to those patients who, after a preliminary period of general treatment, failed to show a natural tendency to healing. Again, l\Iacl\Iahon and Kerper [2J investigating a series of 296 cases with cavitation at Loomis Sanatorium found that 22 per cent. secured spontaneous closure and that of those receiving collapse therapy 34 per cent. obtained obliteration of the cavity. Altogether, using all forms of treatment, closure was obtained in 39 per cent., and an additional 25 per cent. were much improved. On the other hand, much less satisfactory results are given by Barnes and Barne~ Barne~ [3J who, in a series of 1,454 cases with cavitation, found a mortality of 80 per cent. within a period of one year, and 'Watt [4J, analysing the results in 109 cases treated without collapse, found that at the end of five years, 82 per cent. were dead, 7 per cent. were alive but unfit for work, and only 11 11 per cent. were working. The discrepancy in these two sets of figures calls for some explanation, for example, a difference in the economic status of the patients admitted to the various institutions or variations in the interpretation of the criteria of cavitation. But the most probable explanation is, that the
December, 1935]
107
TUBERCULOSIS CAVITATION IN PULMONARY TUDERCULOSIS
authors quoted have not differentiated in their figures between the various types of cavities which occur at different stages of the disease. ''Nohlers [6 [6]J have laid stress upon this latter distincJJ acquerod [51 and ·Wohlers tion and pointed out its importance in prognosis, and the former has ilevised a useful classification based largely upon the radiological appearances. clevised He describes three stages in the development of the cavity commencing iII-defined outline, passing on with a circular shadow Ehadow with a comparatively ill-defined to the second stage where there is a well-defined ring, but with little surrounding fibrosis and induration, and ending with the typical thickwalled cavity seen in the chronic case of some years' duration. Potte'nger [7] [7J has also drawn attention to the importance of the Potte-nger thickness of the cavity wall and the amount 'of surrounding fibrosis in considering the prognosis in these cases, and says that "the healing of early cavities depends primarily on the patient's ability to marshal an adequate defence, both specific and non-specific, and secondarily is a question of mechanics. The healing of the late cavity is primarily a mechanical problem .. the fact that the disease has become chronic denotes resistance." The following figures have been compiled from the case-records in Tor-na-Dee Sanatorium, an attempt having been made to group the cases acqueiod's classification and to obtain some idea of the according to J acquer·od's prognosis in each type of cavity. Altogether 100 consecutive cases of cavitation were taken, covering a period from the end of 1924 until the 1£130. 'I'heir subsequent progress was followed up until the beginning of 1930. end of 1932, thus giving a period of after-history varying from seven to two years. Of the total it was found that at the end of 1932,49 were alive and 51 were dead. Taking the survivors first, all except 8 had bilateral disease, and 5 had bilateral excavation. Excluding these 5, the remaining 44 were equally divided as regards the side of the main lesion, 22 having left-sided cavi.ties and 22 right-sided. Treatment had as its basis rest in bed with the usual hygienic and dietetic regime of a sanatorium. In suitable cases, this was supplemented by one or other of the various forms of collapse therapy, and the results of . treatment are embodied in the following tables. WHICH ARTIFICIAL PXEUMOTHORAX PNEUMOTHORAX WAS ATTE)IPTI:D; IT TABLE A.·-TwENTY-ONE CASES IN WlIICli WILL BE SEEN TliAT THAT AN EFFECTIVE COLLAPSE WAS ONLY OBTAINED IN SEVEN BEVEN INSTANCES.
Result
Effective Ineffectiye Ineffective Failed
Type of cavity
,
,
A
1st ~tage
2
1
3
2nd Stage 1
3rd Stage
Total
4 2
4 3 4
7 8
7
11
21
G
Of the 14 cases in this table in which A.P. failedor.was failed or.was ineffective, six proceeded to phrenic evulsion, followed by thoracoplasty, and one to thoracoplasty without a preliminary evulsion. The results in this operative group are shown in Table B. B. .. . ·.
108
[December, 1935
TUBEROLE
n.
TABLE
Type of cavity
Result
Arrested Improved Unimproved or worse
r-,_ _ _
1st Stage
,
__. _ __.
-'A~ 'A~
3rd Stage
Sta;;e 2nd Su;;e
3 1
Total
3
1
1
2
3
1
6
7
RE~IAINING SEYEN CASES IN TABLE A RECEIYED RECEIVED GENERAL RESTING TABLE C.-THE RE~IAINING TREAT~IE~T WITHOUT FURTHER FURTIIER COLLAPSE. TREAT~IE~T
Result
Arrested Improved Unimproved or worse
at ca C,,,"ity Type or ,-itr
,,r-_ _ _
1st Stage
-'A~
A
3rd Suge Srd Stage
2 1
2
5
1
,
_ _ _ __.,
2nd Stage
.
Total
2
1
1 4
1
7
. Twenty-eight remained of the survIvmg group who were regarded as unsuitable for collapse therapy for various reasons and who received general resting treatment, supplemented in certain instances by sanocrysin or collosol calcium. The results in this group are shown in Table D. D.
TABLE
Type cavity Type er er cavitr
Result
Arrested Improved Unimproved or worse
,r-_ _ _ _ A _ _ _ __. I -'A~
1st Stage
2nd Stage
3rd St;he
Total
2
11
6
6 9
7
6
15
28
5 4 4 5 4 11 5
13
Taking the entire group of 49 patients who were alive at the end of 1932, the results of all forms of treatment are summarised in Table E. E.
TABLE
Type of cavity
Result
Arrested Improved Unimproyed or worse UnimproYed
,~
I
___
1st stage
7
33 10
-,A~
A
7 2 44
13
,
_ _ _ _ _-.,
2nd Stage
3rd Stage
11 6
Total
9 9
25 8 16
26
49
In assigning the cases to their various groups of "arrested," "improved," &c., the following criteria were utilised. " Arrested" this term was used solely in respect of those patients who were able to lead a reasonably normal life, carry out their full work and were either sputum free or negative for tubercle bacilli.
December, 1935]
109
CAVITATION IN PULMONARY TUBERCU.LOSIS
Provided that the working capacity was unimpaired and the sputum T.E. negative, complete obliteration of the cavity as shown on the radiogram was not considered an essential qualification for admission to this group. " Improved" . . . this group includes those who were able for ordinary work but were still T.B. positive, those who were able for ordinary work but subject to occasional exacerbations of the pulmonary condition, and those who were able for light work. " Unimproved or worse" this comprises the remainder who were either unable to work or were living a life of chronic invaliJism. As regards the side on which the cavity was located, the right sided group gave the following results: Arrested, 10; improved, 4; unimproved or worse, 8; while the left sided cases were: arrested, 12; improved, 3; unimproved or worse, 7. Of the five patients with bilateral excavation, two secured arrest of the disease, one was improved and two were unimproved or worse. In the two instances in which the cavity was situated in the lower lobe, the H)32. patients were definitely worse at the end of HJ32. Turning now to the 51 patients who were dead at the end of 1932, HJ32, it was found that all except five had bilateral disease, while nine had bilateral excavation. The unilateral cavities were distributed thus, 25 on the right side and 17 on the left. Artificial pneumothorax was attempted in 11 cases with the results shown in Table AI. TABLE
Result
Effective Ineffective Failed .•
AI. of cavity Type or
,
A
1st Stage
2
~nd
Stage
\
3rd Stlge Stage
Total
2
1
1 I
2 3
5
3
3
5
11
6
Of these 11 cases in which pneumothorax was unsuccessful, one proceeded to thoracocplasty, but died ten days after the operation from cardiac failure, whilst 10 received general resting treatment without further collapse and are dealt with in Table 01. TABLE
01. of cavity Type of
Result
Died in Sanatorium Died after discharge Dicd
,,-_ _~A'A _ _---.,\
r
Stacie 1st Stage
33
3
2nd ~nd Stage
2 2 1
3
\
3rd Stage
44
4
Total !) !l I
10
Table Dl shows the results of general resting treatment in the remaining 39 cases who were regarded as unsuitable for collapse treatment for various reasons.
llO 110
[December, 1935
TUDEROLE Dl.
TADLE
of c.wity Type or
firsnlt firsult
Died in sanatorium Died after discharge
,r-_ _ _~ ~A~ _ _____" '-, A ~_ --"
I.t lSh;:. l:lh;:e let
Tot.1
2nd Sta.e
3nl St.ge 3rd St•••
3
11
23 16
28
30
6
2
17
!J
2
Table El summarises the results in the entire group. El.
TABLE
Typ. Typo or ca,"ity ca"ity
Result nesult
Died in sanatorium Died after discharge
.,r-_ _ _
St.;;e 1st Staoe
~A'-
A
_ _ ___.,,
2nd l:;t:lge ~ube
3ru I-iu.;;e I-it:lge
Tot.1 Total
2
8 4
2~
12
33 18
5
12
34
51
33
One case is included here which had a thoracoplasty without a preliminary attempt at pneumothorax. ~'he operation was successful, but the patient died of pneumonia a year later, having been previously in good health. The final table I!' is appended to show the results of each form of treatment in each type of cavity and deals with the entire group of 100 cases. The only explanatory note necessary concerns the column headed "A.P." which includes all those cases in which pneumothorax was attempted. As shown in Tables A and Al the collapse was properly effective in only 7 cases, so that, strictly speaking, the remaining cases in this column received general treatment only. TADLE F. Form or of
T~fe
Result nesult
<,,'ity <"'ity
1st { Stage 2nd Stage
3rd Stage
I
1
I
Arrested Improved Worse Dead .. Arrested ., Improved Worse Dead Arrested ., .. Impro\'ed \Vor.e \Vorse Dead Total
A.P.
2
tre3tm~nt tre3tm~nt
Thoraro· pl .. ty plasty
1 3
ne5tin.; ne5tin,;
Total
5
7
'2 2 4 1 1 !J
2 3
1
,1
11 ,1
3 1 2 2
5 6 28 28
3 5 7 2 4 12 11 6 !J 3-1 3·1
24
0
67
100
3
1
,1
Total or typo or of c,,'ity ca"ity
tI ,
II
15
25
60'
f , --------------" ------ - - - - - - SU~DIAnY.
As a basis for investigation, 100 consecutive cases of pulmonary tuber~'hey had been admitted culosis showing cavity {ormation formation were taken. ~'hey H)24 and Ul30, and their to Tor-na-Dee Sanatorium between the years l!J24 subsequent fate was ascertained at the end of 1932, when 51 were found to be dead and ,19 alive. 1'hirteen had unilateral and 87 bilateral disease.
H)35] December, Hl35]
111
CAVITATION IN rULlIONAHY TUllEHCULOSIS
Fourteen of these had bilateral excavation and of this group only two secured arrest, one was improved, two were unimproved or worse and nine were dead. ullilateral cavities, 47 had excavation As regards the situation of the unilateral left .. on the right side and 39 on the left.. Here the results were:Right side Left side
Arre.ted Arrested
(21·3 per cent.) 10 (21'3 (30·7 12 (30'7 " )
Impro\-ed
UnimproHd
(S-5 per cent.) 4 (8-5 (7 6 3 (7'6 " )
S 8 (17 per cent.) (17°9.. 7 (17'9.. )
0
De,,\ De",
25 17
In 10 cases there were cavities in the lower lobe and of these only two were alive and ,vere unimproved. Of this group of 10, however, there were only two which were regarded as suitable for collapse treatment and in one of these artificial pneumothorax failed, while the second died from cardiac failure following thoracoplasty. In the matter of treatment, artificial pneumothorax was attempted in 32 cases which were made up as follows:Staga First Stage Second II Third "
C~vities C~vities
6
10 16
An effective collapse was only obtained in seven instances, two first stage, one second stage and four third stage cases securing arrest thereby. Nine cases, made up of one second stage and eight third stage cavities, r.l'hree of these secured arrest, one was were treated by thoracoplasty. rr'hree improved, three were unimproved and two were dead. Including the 17 cases where artificial pneumothorax failed and where further attempts at collapse were abandoned, 84 cases altogether received general resting treatment. They were made up as follows : First Stage Cl\vities Second " Third
•.
13 23 4S 48
(17·8 per cent.) secured arrest, seven (8·3 Fifteen (17'8 (8'3 per cent.) were im(15·4 per cent.) were unimproved and ,19 (58'3 (58·3 per cent.) were proved, 13 (15'4 dead. 'rhe sub-groups of the latter were made up thus : Arrested Improved .. Unimproved •. Dead
st.lse First suse
5 (37'6 (37·6 per cent.) 07 33 (23 (23'07 5 (37'6 (37·6 0
" .. "
Second "tage sta~e
66 (26-08 (26-08 per cent.) cento) 2 (8'6 (S06 2 )) (13·01 3 (13'01 ) (51·7 12 (51'7 )
Third .t.lge suge
(S03 per cent.) cento) 44 (8'3 55 (lO (10··!.. 1.. )) (14·5.. 7 (14'5" ) 32 (06'6.. )) (06·6" o0
Altogether, of the total 100 cases, there were 15 first stage cavities, 60 third stage. -25 second stage, and 60 (46·6 per cenL) cent.) secured arrest, three Of the first stage cases seven (46'6 (19·9 per cent.) were alive but unimproved, and five (33'3 (33·3 per cent.) were (19'9 dead. Of the second stage, seven (28 per cent.) secured arrest, two (8 per cent.) four (16 per cent.) were unimproved, and 12 (48 per cent.) were improved, foul' were dead. (18·3 pel' per cent.) secured arrest, six (10 per Of the third stage group, 11 (18'3
112
TUDE ROLE
lDecember, 1905
cent.) were improved, nine (15 per cent.) were unimproved, and 34. \yere dead. (50·0 per cent.) \vere One further point brought out by the investigation was that of the 51 cases who had died, 10 (19·0 per cent.) had had fatal hmmorrhages. Of these 10, eight had third stage cavities.and two second stage. CONCLUSIONS. c1o~~ly reJ~ted to the (1) The prognosIs Ill. cases with excavation is clo~~ly type of lesion, the outlook in first stage cavities being very much better lS·3 per cent. than in the third stage,' 40·0 per cent. arrested as opposed to 18·3 2S per cent. The second stage group occupies an ·intermediate position with 28 arrested. (2) Left-sided cavities appear to have a better prognosis than those located in the right lung-:30·7 per cent. arrested as against 21·3 per cent. (3) 'Where the cavity is situated in the lower lobe the outlook is serious unless it can be effectively dealt with by collapse therapy. (,.1) Under resting tr~atme'Iit tr~atme'Iit (tiono, ('.1) alone, first stage lesions give the best prognosis (37·0 per cent. arrested), while the outlook in the third stage group with a figure of only S·3 8'3 per cent. arrested is very grave, as is to be expected. (5) Artificial pneumothorax as a method of treatment has been unexpectedly disappointing due, mainly, to pleural adhesions preventing effective collapse. The result of this treatm'ent would probably be improved by its application as soon as breaking down is detected, even in the absence of any gross systemic disturbance. (6) Phrenicectomy is of limited value in cases of excavation, and in none of these under review was this operation' alone sufficient to secure obliteration of the cavity. (7) In carefully selected third stage cases, thoracoplasty is more likely to produce benefit than any of the other methods of collapse. (S) An uncollapsed chronic cavity is.a (8) is.n. potential source of severe (1£1'0 per hmmoptysis, and of the 51 deaths recorded in this series, ten (Hl·(j cent.) were the result of a fatal hmmorrhage. . I wish to express my thanks to Dr. J. 1\1. Johnston for permission to ~'or-na-Dee .Sanatorium and for much helpful use the case records at ~'or-na-Dee l\Iaso~ for her assistance in the final checking criticism, also to Dr. A. T. l\Iaso~ of figures. REFERENCES.
SanatOl:iuID, Forty-Seventh Annual Report, 1931. [1] Trudeau Sanator:iuID, H. Amer. JOIlTll. JOllnz. Med. Sciences, [2] MACMAHON, B. T., and KEUPER, E. H. August, 1933, p. 170. [3] BARNES, H. L., und BARNES. L. R. P. Amer. Rev. of Tllb., Tub., 1928, 18, 412. Tubercle, 1934, [4] WATT, J. Proceedings of' the Tuberculosis Association, Tllbercle, 15, 179. I JACQUEIWD, M. "Etude Clinique et ot RUdiologique [5] JACQUEROD, Rudiologique des Cavernes Tuberculeuses." Paris: Masson et Cia. 1928. . [6] WOIILEUS, H. An. de Ned., }Jed., 1930, 28, 397. [7J POTTENGER. POTTENGEH, F. M. Amer. Rev. Rcv. of T1ib~ 1932,' 26, 215 .. 215.. [7]
TUBEROLE
[December, 1935
DURAND, R., H., KOUlULSllY, R. and BEKDA. BENDA. R. O. R. Soc. Biol., 1928, 99, 30. DURAKD, DUHAND, H. and BENDA, R. Ibid., 1928, 99, ~8. SERGENT, E., DUHAKD, ARLOING, F. and THIh'EKOT, THIh'ENOT, W. Ibid., 1928, 99, 13G. ARLOIKG, NI~GRE, L., BOQUET, A. and YALTIS, J. Ibid., 99,45. NI::GRE, L. and YALTIS, J. Ibid., 1931, 107, 774. NEGRE, L. and VALTIS, J. Ibid., 1931, 107, 774. Ni:GIm, Ni:GRE, L. and SAENZ, A. Ibid., 1931, 107, 942. VAN DEINSE, DEmSE, F. Ibid., 1931, 107, 1058 and 1212. VAK SANARELLI. G. Ibid., 1931, 107, 443. SAKARELLI, NINNI, 111. C. Ibid., 1931, 107, G15. NIKKI,
CAVITATION IN PULMONARY TUBERCULOSIS. A HEVIEW OF ONE HUNDRED CASES. By R. Y. KEERS, l\I.D. Tor-na-Dee Sanatorilllll. Sanatorillm. Late Assistant Physician, Tor-na·Dee
UNTIL comparatively recently, cavity formation in the course of pulUKTIL monary tuberculosis was regarded as a final and incurable stage of the disease. Statistics published within the past few years, however, indicate that, with adequate treatment, closure of a cavity and restoration of the patient's working capacity is possible and that, in aDo considerable proportion of cases, this can be brought about without resort to collapse therapy. Thus the analysis of the cases with cavities given in the annual report of the Trudeau Sanatorium in HJ31 [1] showed that cavities, as seen by X-rays, disappeared with about the same frequency under ordinary general and resting treatment as in those cases receiving collapse therapy, the figures being 77 per cent. in the first group and 79 per cent. in the second. It should be noted, however, that collapse treatment was applied only to those patients who, after a preliminary period of general treatment, failed to show a natural tendency to healing. Again, l\Iacl\Iahon and Kerper [2J investigating a series of 296 cases with cavitation at Loomis Sanatorium found that 22 per cent. secured spontaneous closure and that of those receiving collapse therapy 34 per cent. obtained obliteration of the cavity. Altogether, using all forms of treatment, closure was obtained in 39 per cent., and an additional 25 per cent. were much improved. On the other hand, much less satisfactory results are given by Barnes and Barne~ Barne~ [3J who, in a series of 1,454 cases with cavitation, found a mortality of 80 per cent. within a period of one year, and 'Watt [4J, analysing the results in 109 cases treated without collapse, found that at the end of five years, 82 per cent. were dead, 7 per cent. were alive but unfit for work, and only 11 11 per cent. were working. The discrepancy in these two sets of figures calls for some explanation, for example, a difference in the economic status of the patients admitted to the various institutions or variations in the interpretation of the criteria of cavitation. But the most probable explanation is, that the
December, 1935]
107
TUBERCULOSIS CAVITATION IN PULMONARY TUDERCULOSIS
authors quoted have not differentiated in their figures between the various types of cavities which occur at different stages of the disease. ''Nohlers [6 [6]J have laid stress upon this latter distincJJ acquerod [51 and ·Wohlers tion and pointed out its importance in prognosis, and the former has ilevised a useful classification based largely upon the radiological appearances. clevised He describes three stages in the development of the cavity commencing iII-defined outline, passing on with a circular shadow Ehadow with a comparatively ill-defined to the second stage where there is a well-defined ring, but with little surrounding fibrosis and induration, and ending with the typical thickwalled cavity seen in the chronic case of some years' duration. Potte'nger [7] [7J has also drawn attention to the importance of the Potte-nger thickness of the cavity wall and the amount 'of surrounding fibrosis in considering the prognosis in these cases, and says that "the healing of early cavities depends primarily on the patient's ability to marshal an adequate defence, both specific and non-specific, and secondarily is a question of mechanics. The healing of the late cavity is primarily a mechanical problem .. the fact that the disease has become chronic denotes resistance." The following figures have been compiled from the case-records in Tor-na-Dee Sanatorium, an attempt having been made to group the cases acqueiod's classification and to obtain some idea of the according to J acquer·od's prognosis in each type of cavity. Altogether 100 consecutive cases of cavitation were taken, covering a period from the end of 1924 until the 1£130. 'I'heir subsequent progress was followed up until the beginning of 1930. end of 1932, thus giving a period of after-history varying from seven to two years. Of the total it was found that at the end of 1932,49 were alive and 51 were dead. Taking the survivors first, all except 8 had bilateral disease, and 5 had bilateral excavation. Excluding these 5, the remaining 44 were equally divided as regards the side of the main lesion, 22 having left-sided cavi.ties and 22 right-sided. Treatment had as its basis rest in bed with the usual hygienic and dietetic regime of a sanatorium. In suitable cases, this was supplemented by one or other of the various forms of collapse therapy, and the results of . treatment are embodied in the following tables. WHICH ARTIFICIAL PXEUMOTHORAX PNEUMOTHORAX WAS ATTE)IPTI:D; IT TABLE A.·-TwENTY-ONE CASES IN WlIICli WILL BE SEEN TliAT THAT AN EFFECTIVE COLLAPSE WAS ONLY OBTAINED IN SEVEN BEVEN INSTANCES.
Result
Effective Ineffectiye Ineffective Failed
Type of cavity
,
,
A
1st ~tage
2
1
3
2nd Stage 1
3rd Stage
Total
4 2
4 3 4
7 8
7
11
21
G
Of the 14 cases in this table in which A.P. failedor.was failed or.was ineffective, six proceeded to phrenic evulsion, followed by thoracoplasty, and one to thoracoplasty without a preliminary evulsion. The results in this operative group are shown in Table B. B. .. . ·.
108
[December, 1935
TUBEROLE
n.
TABLE
Type of cavity
Result
Arrested Improved Unimproved or worse
r-,_ _ _
1st Stage
,
__. _ __.
-'A~ 'A~
3rd Stage
Sta;;e 2nd Su;;e
3 1
Total
3
1
1
2
3
1
6
7
RE~IAINING SEYEN CASES IN TABLE A RECEIYED RECEIVED GENERAL RESTING TABLE C.-THE RE~IAINING TREAT~IE~T WITHOUT FURTHER FURTIIER COLLAPSE. TREAT~IE~T
Result
Arrested Improved Unimproved or worse
at ca C,,,"ity Type or ,-itr
,,r-_ _ _
1st Stage
-'A~
A
3rd Suge Srd Stage
2 1
2
5
1
,
_ _ _ __.,
2nd Stage
.
Total
2
1
1 4
1
7
. Twenty-eight remained of the survIvmg group who were regarded as unsuitable for collapse therapy for various reasons and who received general resting treatment, supplemented in certain instances by sanocrysin or collosol calcium. The results in this group are shown in Table D. D.
TABLE
Type cavity Type er er cavitr
Result
Arrested Improved Unimproved or worse
,r-_ _ _ _ A _ _ _ __. I -'A~
1st Stage
2nd Stage
3rd St;he
Total
2
11
6
6 9
7
6
15
28
5 4 4 5 4 11 5
13
Taking the entire group of 49 patients who were alive at the end of 1932, the results of all forms of treatment are summarised in Table E. E.
TABLE
Type of cavity
Result
Arrested Improved Unimproyed or worse UnimproYed
,~
I
___
1st stage
7
33 10
-,A~
A
7 2 44
13
,
_ _ _ _ _-.,
2nd Stage
3rd Stage
11 6
Total
9 9
25 8 16
26
49
In assigning the cases to their various groups of "arrested," "improved," &c., the following criteria were utilised. " Arrested" this term was used solely in respect of those patients who were able to lead a reasonably normal life, carry out their full work and were either sputum free or negative for tubercle bacilli.
December, 1935]
109
CAVITATION IN PULMONARY TUBERCU.LOSIS
Provided that the working capacity was unimpaired and the sputum T.E. negative, complete obliteration of the cavity as shown on the radiogram was not considered an essential qualification for admission to this group. " Improved" . . . this group includes those who were able for ordinary work but were still T.B. positive, those who were able for ordinary work but subject to occasional exacerbations of the pulmonary condition, and those who were able for light work. " Unimproved or worse" this comprises the remainder who were either unable to work or were living a life of chronic invaliJism. As regards the side on which the cavity was located, the right sided group gave the following results: Arrested, 10; improved, 4; unimproved or worse, 8; while the left sided cases were: arrested, 12; improved, 3; unimproved or worse, 7. Of the five patients with bilateral excavation, two secured arrest of the disease, one was improved and two were unimproved or worse. In the two instances in which the cavity was situated in the lower lobe, the H)32. patients were definitely worse at the end of HJ32. Turning now to the 51 patients who were dead at the end of 1932, HJ32, it was found that all except five had bilateral disease, while nine had bilateral excavation. The unilateral cavities were distributed thus, 25 on the right side and 17 on the left. Artificial pneumothorax was attempted in 11 cases with the results shown in Table AI. TABLE
Result
Effective Ineffective Failed .•
AI. of cavity Type or
,
A
1st Stage
2
~nd
Stage
\
3rd Stlge Stage
Total
2
1
1 I
2 3
5
3
3
5
11
6
Of these 11 cases in which pneumothorax was unsuccessful, one proceeded to thoracocplasty, but died ten days after the operation from cardiac failure, whilst 10 received general resting treatment without further collapse and are dealt with in Table 01. TABLE
01. of cavity Type of
Result
Died in Sanatorium Died after discharge Dicd
,,-_ _~A'A _ _---.,\
r
Stacie 1st Stage
33
3
2nd ~nd Stage
2 2 1
3
\
3rd Stage
44
4
Total !) !l I
10
Table Dl shows the results of general resting treatment in the remaining 39 cases who were regarded as unsuitable for collapse treatment for various reasons.
llO 110
[December, 1935
TUDEROLE Dl.
TADLE
of c.wity Type or
firsnlt firsult
Died in sanatorium Died after discharge
,r-_ _ _~ ~A~ _ _____" '-, A ~_ --"
I.t lSh;:. l:lh;:e let
Tot.1
2nd Sta.e
3nl St.ge 3rd St•••
3
11
23 16
28
30
6
2
17
!J
2
Table El summarises the results in the entire group. El.
TABLE
Typ. Typo or ca,"ity ca"ity
Result nesult
Died in sanatorium Died after discharge
.,r-_ _ _
St.;;e 1st Staoe
~A'-
A
_ _ ___.,,
2nd l:;t:lge ~ube
3ru I-iu.;;e I-it:lge
Tot.1 Total
2
8 4
2~
12
33 18
5
12
34
51
33
One case is included here which had a thoracoplasty without a preliminary attempt at pneumothorax. ~'he operation was successful, but the patient died of pneumonia a year later, having been previously in good health. The final table I!' is appended to show the results of each form of treatment in each type of cavity and deals with the entire group of 100 cases. The only explanatory note necessary concerns the column headed "A.P." which includes all those cases in which pneumothorax was attempted. As shown in Tables A and Al the collapse was properly effective in only 7 cases, so that, strictly speaking, the remaining cases in this column received general treatment only. TADLE F. Form or of
T~fe
Result nesult
<,,'ity <"'ity
1st { Stage 2nd Stage
3rd Stage
I
1
I
Arrested Improved Worse Dead .. Arrested ., Improved Worse Dead Arrested ., .. Impro\'ed \Vor.e \Vorse Dead Total
A.P.
2
tre3tm~nt tre3tm~nt
Thoraro· pl .. ty plasty
1 3
ne5tin.; ne5tin,;
Total
5
7
'2 2 4 1 1 !J
2 3
1
,1
11 ,1
3 1 2 2
5 6 28 28
3 5 7 2 4 12 11 6 !J 3-1 3·1
24
0
67
100
3
1
,1
Total or typo or of c,,'ity ca"ity
tI ,
II
15
25
60'
f , --------------" ------ - - - - - - SU~DIAnY.
As a basis for investigation, 100 consecutive cases of pulmonary tuber~'hey had been admitted culosis showing cavity {ormation formation were taken. ~'hey H)24 and Ul30, and their to Tor-na-Dee Sanatorium between the years l!J24 subsequent fate was ascertained at the end of 1932, when 51 were found to be dead and ,19 alive. 1'hirteen had unilateral and 87 bilateral disease.
H)35] December, Hl35]
111
CAVITATION IN rULlIONAHY TUllEHCULOSIS
Fourteen of these had bilateral excavation and of this group only two secured arrest, one was improved, two were unimproved or worse and nine were dead. ullilateral cavities, 47 had excavation As regards the situation of the unilateral left .. on the right side and 39 on the left.. Here the results were:Right side Left side
Arre.ted Arrested
(21·3 per cent.) 10 (21'3 (30·7 12 (30'7 " )
Impro\-ed
UnimproHd
(S-5 per cent.) 4 (8-5 (7 6 3 (7'6 " )
S 8 (17 per cent.) (17°9.. 7 (17'9.. )
0
De,,\ De",
25 17
In 10 cases there were cavities in the lower lobe and of these only two were alive and ,vere unimproved. Of this group of 10, however, there were only two which were regarded as suitable for collapse treatment and in one of these artificial pneumothorax failed, while the second died from cardiac failure following thoracoplasty. In the matter of treatment, artificial pneumothorax was attempted in 32 cases which were made up as follows:Staga First Stage Second II Third "
C~vities C~vities
6
10 16
An effective collapse was only obtained in seven instances, two first stage, one second stage and four third stage cases securing arrest thereby. Nine cases, made up of one second stage and eight third stage cavities, r.l'hree of these secured arrest, one was were treated by thoracoplasty. rr'hree improved, three were unimproved and two were dead. Including the 17 cases where artificial pneumothorax failed and where further attempts at collapse were abandoned, 84 cases altogether received general resting treatment. They were made up as follows : First Stage Cl\vities Second " Third
•.
13 23 4S 48
(17·8 per cent.) secured arrest, seven (8·3 Fifteen (17'8 (8'3 per cent.) were im(15·4 per cent.) were unimproved and ,19 (58'3 (58·3 per cent.) were proved, 13 (15'4 dead. 'rhe sub-groups of the latter were made up thus : Arrested Improved .. Unimproved •. Dead
st.lse First suse
5 (37'6 (37·6 per cent.) 07 33 (23 (23'07 5 (37'6 (37·6 0
" .. "
Second "tage sta~e
66 (26-08 (26-08 per cent.) cento) 2 (8'6 (S06 2 )) (13·01 3 (13'01 ) (51·7 12 (51'7 )
Third .t.lge suge
(S03 per cent.) cento) 44 (8'3 55 (lO (10··!.. 1.. )) (14·5.. 7 (14'5" ) 32 (06'6.. )) (06·6" o0
Altogether, of the total 100 cases, there were 15 first stage cavities, 60 third stage. -25 second stage, and 60 (46·6 per cenL) cent.) secured arrest, three Of the first stage cases seven (46'6 (19·9 per cent.) were alive but unimproved, and five (33'3 (33·3 per cent.) were (19'9 dead. Of the second stage, seven (28 per cent.) secured arrest, two (8 per cent.) four (16 per cent.) were unimproved, and 12 (48 per cent.) were improved, foul' were dead. (18·3 pel' per cent.) secured arrest, six (10 per Of the third stage group, 11 (18'3
112
TUDE ROLE
lDecember, 1905
cent.) were improved, nine (15 per cent.) were unimproved, and 34. \yere dead. (50·0 per cent.) \vere One further point brought out by the investigation was that of the 51 cases who had died, 10 (19·0 per cent.) had had fatal hmmorrhages. Of these 10, eight had third stage cavities.and two second stage. CONCLUSIONS. c1o~~ly reJ~ted to the (1) The prognosIs Ill. cases with excavation is clo~~ly type of lesion, the outlook in first stage cavities being very much better lS·3 per cent. than in the third stage,' 40·0 per cent. arrested as opposed to 18·3 2S per cent. The second stage group occupies an ·intermediate position with 28 arrested. (2) Left-sided cavities appear to have a better prognosis than those located in the right lung-:30·7 per cent. arrested as against 21·3 per cent. (3) 'Where the cavity is situated in the lower lobe the outlook is serious unless it can be effectively dealt with by collapse therapy. (,.1) Under resting tr~atme'Iit tr~atme'Iit (tiono, ('.1) alone, first stage lesions give the best prognosis (37·0 per cent. arrested), while the outlook in the third stage group with a figure of only S·3 8'3 per cent. arrested is very grave, as is to be expected. (5) Artificial pneumothorax as a method of treatment has been unexpectedly disappointing due, mainly, to pleural adhesions preventing effective collapse. The result of this treatm'ent would probably be improved by its application as soon as breaking down is detected, even in the absence of any gross systemic disturbance. (6) Phrenicectomy is of limited value in cases of excavation, and in none of these under review was this operation' alone sufficient to secure obliteration of the cavity. (7) In carefully selected third stage cases, thoracoplasty is more likely to produce benefit than any of the other methods of collapse. (S) An uncollapsed chronic cavity is.a (8) is.n. potential source of severe (1£1'0 per hmmoptysis, and of the 51 deaths recorded in this series, ten (Hl·(j cent.) were the result of a fatal hmmorrhage. . I wish to express my thanks to Dr. J. 1\1. Johnston for permission to ~'or-na-Dee .Sanatorium and for much helpful use the case records at ~'or-na-Dee l\Iaso~ for her assistance in the final checking criticism, also to Dr. A. T. l\Iaso~ of figures. REFERENCES.
SanatOl:iuID, Forty-Seventh Annual Report, 1931. [1] Trudeau Sanator:iuID, H. Amer. JOIlTll. JOllnz. Med. Sciences, [2] MACMAHON, B. T., and KEUPER, E. H. August, 1933, p. 170. [3] BARNES, H. L., und BARNES. L. R. P. Amer. Rev. of Tllb., Tub., 1928, 18, 412. Tubercle, 1934, [4] WATT, J. Proceedings of' the Tuberculosis Association, Tllbercle, 15, 179. I JACQUEIWD, M. "Etude Clinique et ot RUdiologique [5] JACQUEROD, Rudiologique des Cavernes Tuberculeuses." Paris: Masson et Cia. 1928. . [6] WOIILEUS, H. An. de Ned., }Jed., 1930, 28, 397. [7J POTTENGER. POTTENGEH, F. M. Amer. Rev. Rcv. of T1ib~ 1932,' 26, 215 .. 215.. [7]