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Changing Concepts in the Treatment of Tuberculosis
Changing Concepts in the Treatment of Tuberculosis GUSTAF A. HEDBERG
THE ERA OF REST AND COLI"APSE THERAPY .eOR at least a decade before 1947 the treatment of tuberculosis, particularly pulmonary tuberculosis, was rather well standardized. It was based on the principle of rest and support to the patient who had the disease. In most institutions emphasis was placed on continued strict rest in bed and actual physical immobilization over many consecutive months until the lesion had shown maximal improvement and signs of stabilizing. Following this a careful long-continued program of graduated exercise was carried out in the sanatorium and the patient was usually not discharged until he had reached an exercise level of 4 or more hours of aetivity in addition to going to the dining room. Most reactivations that occurred in the hospital took place during this period of gradually increasing exercise. In addition to the basic treatment of rest in bed, measures were directed toward the pulmonary disease; they were mainly collapse measures such as pneumothorax, pneumoperitoneum, interruption of the phrenic nerve, thoracoplasty, extrapleural plombage, oleothorax and so forth. In the earlier days of collapse therapy, pneumothorax was by far the most popular procedure, probably because of the simplicity of induction and maintenance of collapse by air injected into the pleural space. Complications such as effusion and empyema were common, resulting very often in conditions far more serious than the original tuberculosis. Later there was a trend toward "primary thoracoplasties" wherein permanent collapse was induced by rib resection without attempts at so-called reversible measures such as pneumothorax. Pneumoperitoneum reached its peak of popularity toward the end of this period in many institutions, mainly because it was considered a "harmless procedure" which would tend to keep the patient in the sanatorium. There was always great debate as to the actual value of phrenic-nerve interruptions. Only in rare instances was resection attempted for pulmonary tuberculosis and then usually in the cases of so-called destroyed lung or in cases in which thoracoplasty had failed. The operation in most cases was pneumonec-
1161
1162
Gustaf A. H edberg
tomy; occasionally lobectomy was performed. The operative danger as well as danger of "pread to the opposite lung was so great that resectional surgery was greatly limited in this period. INTRODUCTION OF
ANTl'fUBERCUI~OSIS
DUUeS
Since the advent of antimicrobial drugs and the improvement in anesthesia and pulmonary surgery, the concept of tuberculosis therapy has been continually changing. While a few patients were treated with streptomycin before 1947 it was not until this time that this agent became available to any general extent, and when it was first used little was known as to proper dosage, length of therapy and the like. I believe that originally most patients were overdosed with the drug. The original regimen used by most institutions consisted of 0.5 gram of the antibiotic given intramuscularly every 6 hours around the clock. Under thi" schedule of treatment there were frequent toxie complications, mainly those of vefltibular damage and of deafne"fl. Dihydrostreptomyein "eemed to have lefls toxicity so far as the vestibular apparatus was coneerned but deafness occurred with long-term heavy dosage of this drug. It was soon found that streptomycin and dihydrostreptomycin were not bactericidal agents but merely altered the metabolism of the tubercle bacilli to the extent that they were not able to multiply. It was found further that in a relatively high percentage of patients, particularly those with cavitary disease, the surviving strains of tubercle baeilli became resistant to the drug and that further administration of this agent was of no help. As a result of this knowledge there was a tendency of introduce collapse therapy or resection therapy, mainly thoracoplasty or resection, very early in the drug treatment of patients with pulmonary tuberculosis. Reactivation and spread to other parts of the body were eommon with this type of treatment. Many forgot that tuberculosis is a systemic disease with local manifestations that cannot be controlled by the excision or collapse of diseased parts alone. Short courses of treatment with ::ltreptomycin-that is, giving 1 gram of the drug a day for (j weeks and depending upon the patient's native resistance to complete the control of his disease-became the vogue for a short while. In 1949 para-aminosalicylic acid (PAS) became available in thi'l country as another antitubereulosis drug. It was found eventually that the combination of streptomycin and PAS not only proved to be of increased therapeutic effect but tended to delay the emergence of strains of tubercle bacilli that were resistant to either streptomycin or PAS. It was found that patients could be treated from 12 to 18 months with this combination of drugs before resistant strains developed. With long-term effective ehemotherapy it became possible to treat patients until maximal resolution had occurred, with reseetion of residual cavitary areas and with or without resection of residual nodular areas.
, Changing Concepts in Treatment of Tuberculosis
1163
[ In the meantime the number of treatment failures as a result of earlier therapy was considerable. Many drugs that had some anti tuberculosis effect, such as the thiosemicarbazones, were introduced. In 1951 viomycin became available and in 1952 isoniazid was added to the list of therapeutic agents. These two drugs are very effective and have helped salvage some of the patients who failed to respond to the earlier treatment with streptomycin and PAS. The details of antimicrobial therapy will be dealt with in another section. l' ATIENTS
_.
Table 1 RECEIVING SURGICAL TREATMENT
1944 1945 1946 1947 1948 1949 1950 1951 19521 953 -
~-
~-
~.
-
-'-
-
-- --
Collapse therap y Pneumothora x-initial. ..... 54 Pneumoperito neum-ini tial .. 6 Thoracoplast y* .... 11 Phreniclasis. 15 Total.
4 50 35 23 25 12 20 39 11 20 25 6 31 41 38 29 30 39 35 31 12 16 28 26 - - - - - - --- --- --- - - -- --- - ..... 86 136 134 76 86 101 93 -
Resection Pneumonecto my .. . ..... Lobectomy .. ........ Segmental or subsegmental. Total.
-- -- -
1
0 0
4 0 0
0 0
-
1 0 0
~-
2 3 0
3 4
-
1
0
16
8
10
11
5 1
--38 14
o o 1 o 1
-- -
3 2 0
3 8 9
2
11
4
12 51
48 0 0 - - - - - - - -- - - - - -- -- - - - - - - - ...... .... . 1 4 1 5 7 5 20 61 67 0
* As definitive treatment. Thoracoplasties carried out in conjunction with resection are not included. PRESENT STATUS OF TUBERCULOSIS THERAPY
The present status of the treatment of tuberculosis has not stabilized except possibly in regard to the emphasis of long-term chemotherapy. Indications for resection became quite broad, including in many institutions all residual cavitary and nodular lesions that could be palpated by the surgeon and removed without undue loss of normally functioning lung. More recently there has been a more conservative trend with regard to indications for surgical treatment, and more and more of the residual nodules are being treated medically only. In the institution with which I am connected there has been almost complete abandonment of collapse therapy, as shown in Table 1. For the past 2 years we have abandoned the principle of strict rest in bed except for toxic patients and those under orthopedic treatment. All are allowed a moderate amount of exercise including full bathroom privileges throughout their stay in the sanatorium. This has reduced the amount of disability from physical immobilization but at the same time has made it more difficult to convince the patient of the necessity for sanatorium treatment for his disease. It has become necessary to spend
1164
Gustaf A. H edberg
much more time in the individual education of the patient regarding the problems of his disease as it relates to himself and to his family and community. With chemotherapy, however, we have been able to shorten the hospital stay for the intelligent and co-operative patient by a program of postsanatorium outpatient treatment with drugs, although the total period of treatment has been lengthened. Such postsanatorium outpatient treatment is given under the supervision of the patient's private physician with the patient returning to the sanatorium at intervals of approximately 3 months for intensive laboratory studies including the inoculation of gastric specimens into culture media or guinea pigs. Three months after the prescribed course of treatment has been terminated the patient is again hospitalized for such studies. The factors taken into consideration in the matter of surgical treatment are the type of lesion present, whether there is residual cavitation and whether there is extensive nodular disease that is localized. The use of body section radiography is of great value in making these determinations. We prefer to delay operation until such time as the patient is not excreting tubercle bacilli, even to the extent of not being able to demonstrate the organism by inoculations of gastric specimens into guinea pigs or culture media. If the decision of the staff is in favor of resection, it is performed and the patient is kept on modified exercise for approximately 2 months thereafter. After this interval, exercise is increased over a period of approximately 2 months and the patient is considered for discharge, to continue his chemotherapy for a minimum of 12 months and in some cases up to 18 months depending upon residual known disease and other factors. As previously mentioned, there has been a trend in our institution during the past year toward more conservatism in recommending surgical treatment, as we have found in many resected specimens that we have been unable to demonstrate activity of the tuberculosis, either histologic ally or bacteriologically. I am personally being impressed by the fact that since 1951 no patient in our sanatorium who has taken a minimum of 100 grams of streptomycin with PAS as mentioned above and who has undergone resection has shown evidence of reactivation of his disease, while reactivation has occurred in a few patients treated by medical means alone. It is impossible to evaluate the results of treatment with any accuracy in such a changing trend of treatment as we have been undergoing during the past 5 years. There has been definite improvement in the status of the patients discharged from the sanatorium during these 5 years over that of the previous half of the decade, as shown in Table 2. We know that previous to the advent of chemotherapy with or without resectional surgery the reactivation rate among patients discharged as well or improved was considerable, approximating 33 per cent over a 5ycar follow-up period. We know that there has been a definite decrease
Changing Concepts in Treatment of Tuberculosis
1165
in the reaetivation rate after discharge from the sanatorium but it is impossible to give a comparative figure without waiting a few more years. The Continuing Need for Sanatorium Care
One might ask why sanatorium care is necessary with present definitive treatment. Why might we not start a patient on antimicrobial therapy at home and hospitalize him only for periodic intensive study and during the period of surgical treatment if such is deemed necessary? There are two main reasons for hospitalization during the active period of a person's tuberculosis even though his condition may be improving. First, patients with active tubereulosis are an actual or potential public health menace. Even with intensive drug treatment tubercle Table 2 STATUS OF PATII,NTtl AT DISCHARGE WELL OH IMPROVED YEAR
--
UNIMPROV~;[)
OR DEAD TOTAL
------~--
Cases
Per cent
Cases
190 144 177 137 181 219 192 186 203 206
71.2 71.6 81.6 77.8 81.2 85.5 84.6 1\3.0 Ul.4 85.5
77 57 40 :39 42 37 :35 38
Per cent ------
1944 1945 1946 1947 1948 194H 1950 HI51
1952 1953
In
35 ~-~~--
28.8 28.4 18.4 22.2 18.8 14.5 15.4 17.0 8.6 14.5
~---
~----
267 201 217 176 223 256 227 224 222 241 ~---~--~
bacilli can be reeovered from the average patient's pulmonary secretions for many months. Therefore he should be removed from environments wherein he might infect others. Second, it has not been proved that drugs alone "cure" tuberculosis; a certain amount of rest and support are necessary in order to promote the patient's innate ability to heal his disease. Further, all the drugs used have toxic potentialities and some are difficult to take. Toxic manifestations aside from deafness and vertigo usually occur relatively early in the course of treatment and often are asymptomatic, requiring routine repetition of laboratory studies. The patient must be taught the importance of taking the prescribed doses of the drugs even though the side effects such as gastrointestinal upsets are to be expected and tolerated in the interest of accomplishing the goal of "curing" the disease. Until such time as a "miracle drug" capable of killing the tubercle bacilli in short order becomes available, considerable hospitalization during the active stage is necessary.
1166
Gustaf A. H cdbcrg
Two age groups have increased in the sanatorium population-the very young and the very old. The proportion of men more than 60 years of age is steadily increasing. In this group resection is seldom considered in the treatment of tuberculosis, because of the increased surgical risk. Long-term chemotherapy has shown encouraging results even when used alone. Most of these elderly men are best treated by hospitalization during the entire period of treatment as they need the additional protection afforded them in the sanatorium. Most could not be depended upon to take medications properly in an outpatient program. Because of the hesitancy in performing resection a considerable number do not get well but continue on as chronic active cases, certainly a dangerous group to have in the community. The very young present a problem best handled in its entirety by hospitalization. Active primary tuberculosis responds to antimicrobial therapy. There usually is rapid conversion of the bacteriologic findings under such treatment but relatively slow improvement in the pulmonary and glandular lesions as studied by serial roentgenograms. If rest and moderation of activities are factors in recovery from tuberculosis, the child can receive this best in a regulated institution. In addition, if the child is of school age, education is provided in a good sanatorium. WHAT OF THE FUTURE?
The present treatment of tuberculosis has far from stabilized. Many questions plague the physician in charge of treatment. Are we depending too much on the bacteriologic and pathologic observations made on surgical specimens in reversing to some extent the indications for resection? Have we dropped some of the earlier procedures too quickly? Should we reconsider pneumothorax in conjunction with drug therapy, especially for the limited cavitary lesion, rather than completely abandon this previously valued procedure in favor of resection? Cautious reinvestigation of these questions is in order. The future treatment of tubereulosis may change as radically as that of the past few years. If a truly bactericidal drug were made available the treatment of the tubereulous infection as well as the disease would be in order-aetual sterilization of an individual of the dormant baeilli whieh have the eonstant potentiality of produeing the disease. In the meantime the problem of tuberculosis remains that of the community as well as that of the individual. More thorough search for the unknown cases must be instituted by every practieal means. Those with known apparently inactive tuberculosis must be checked by periodic roentgenograms and sputum studies, and ideally all persons with positive tuberculin reactions should be followed by periodic roentgenograms in order to find the disease in its earliest stages with reduction of further infection of the community and insurance of the best results to the diseased person.
THE ERA OF REST AND COLI"APSE THERAPY .eOR at least a decade before 1947 the treatment of tuberculosis, particularly pulmonary tuberculosis, was rather well standardized. It was based on the principle of rest and support to the patient who had the disease. In most institutions emphasis was placed on continued strict rest in bed and actual physical immobilization over many consecutive months until the lesion had shown maximal improvement and signs of stabilizing. Following this a careful long-continued program of graduated exercise was carried out in the sanatorium and the patient was usually not discharged until he had reached an exercise level of 4 or more hours of aetivity in addition to going to the dining room. Most reactivations that occurred in the hospital took place during this period of gradually increasing exercise. In addition to the basic treatment of rest in bed, measures were directed toward the pulmonary disease; they were mainly collapse measures such as pneumothorax, pneumoperitoneum, interruption of the phrenic nerve, thoracoplasty, extrapleural plombage, oleothorax and so forth. In the earlier days of collapse therapy, pneumothorax was by far the most popular procedure, probably because of the simplicity of induction and maintenance of collapse by air injected into the pleural space. Complications such as effusion and empyema were common, resulting very often in conditions far more serious than the original tuberculosis. Later there was a trend toward "primary thoracoplasties" wherein permanent collapse was induced by rib resection without attempts at so-called reversible measures such as pneumothorax. Pneumoperitoneum reached its peak of popularity toward the end of this period in many institutions, mainly because it was considered a "harmless procedure" which would tend to keep the patient in the sanatorium. There was always great debate as to the actual value of phrenic-nerve interruptions. Only in rare instances was resection attempted for pulmonary tuberculosis and then usually in the cases of so-called destroyed lung or in cases in which thoracoplasty had failed. The operation in most cases was pneumonec-
1161
1162
Gustaf A. H edberg
tomy; occasionally lobectomy was performed. The operative danger as well as danger of "pread to the opposite lung was so great that resectional surgery was greatly limited in this period. INTRODUCTION OF
ANTl'fUBERCUI~OSIS
DUUeS
Since the advent of antimicrobial drugs and the improvement in anesthesia and pulmonary surgery, the concept of tuberculosis therapy has been continually changing. While a few patients were treated with streptomycin before 1947 it was not until this time that this agent became available to any general extent, and when it was first used little was known as to proper dosage, length of therapy and the like. I believe that originally most patients were overdosed with the drug. The original regimen used by most institutions consisted of 0.5 gram of the antibiotic given intramuscularly every 6 hours around the clock. Under thi" schedule of treatment there were frequent toxie complications, mainly those of vefltibular damage and of deafne"fl. Dihydrostreptomyein "eemed to have lefls toxicity so far as the vestibular apparatus was coneerned but deafness occurred with long-term heavy dosage of this drug. It was soon found that streptomycin and dihydrostreptomycin were not bactericidal agents but merely altered the metabolism of the tubercle bacilli to the extent that they were not able to multiply. It was found further that in a relatively high percentage of patients, particularly those with cavitary disease, the surviving strains of tubercle baeilli became resistant to the drug and that further administration of this agent was of no help. As a result of this knowledge there was a tendency of introduce collapse therapy or resection therapy, mainly thoracoplasty or resection, very early in the drug treatment of patients with pulmonary tuberculosis. Reactivation and spread to other parts of the body were eommon with this type of treatment. Many forgot that tuberculosis is a systemic disease with local manifestations that cannot be controlled by the excision or collapse of diseased parts alone. Short courses of treatment with ::ltreptomycin-that is, giving 1 gram of the drug a day for (j weeks and depending upon the patient's native resistance to complete the control of his disease-became the vogue for a short while. In 1949 para-aminosalicylic acid (PAS) became available in thi'l country as another antitubereulosis drug. It was found eventually that the combination of streptomycin and PAS not only proved to be of increased therapeutic effect but tended to delay the emergence of strains of tubercle bacilli that were resistant to either streptomycin or PAS. It was found that patients could be treated from 12 to 18 months with this combination of drugs before resistant strains developed. With long-term effective ehemotherapy it became possible to treat patients until maximal resolution had occurred, with reseetion of residual cavitary areas and with or without resection of residual nodular areas.
, Changing Concepts in Treatment of Tuberculosis
1163
[ In the meantime the number of treatment failures as a result of earlier therapy was considerable. Many drugs that had some anti tuberculosis effect, such as the thiosemicarbazones, were introduced. In 1951 viomycin became available and in 1952 isoniazid was added to the list of therapeutic agents. These two drugs are very effective and have helped salvage some of the patients who failed to respond to the earlier treatment with streptomycin and PAS. The details of antimicrobial therapy will be dealt with in another section. l' ATIENTS
_.
Table 1 RECEIVING SURGICAL TREATMENT
1944 1945 1946 1947 1948 1949 1950 1951 19521 953 -
~-
~-
~.
-
-'-
-
-- --
Collapse therap y Pneumothora x-initial. ..... 54 Pneumoperito neum-ini tial .. 6 Thoracoplast y* .... 11 Phreniclasis. 15 Total.
4 50 35 23 25 12 20 39 11 20 25 6 31 41 38 29 30 39 35 31 12 16 28 26 - - - - - - --- --- --- - - -- --- - ..... 86 136 134 76 86 101 93 -
Resection Pneumonecto my .. . ..... Lobectomy .. ........ Segmental or subsegmental. Total.
-- -- -
1
0 0
4 0 0
0 0
-
1 0 0
~-
2 3 0
3 4
-
1
0
16
8
10
11
5 1
--38 14
o o 1 o 1
-- -
3 2 0
3 8 9
2
11
4
12 51
48 0 0 - - - - - - - -- - - - - -- -- - - - - - - - ...... .... . 1 4 1 5 7 5 20 61 67 0
* As definitive treatment. Thoracoplasties carried out in conjunction with resection are not included. PRESENT STATUS OF TUBERCULOSIS THERAPY
The present status of the treatment of tuberculosis has not stabilized except possibly in regard to the emphasis of long-term chemotherapy. Indications for resection became quite broad, including in many institutions all residual cavitary and nodular lesions that could be palpated by the surgeon and removed without undue loss of normally functioning lung. More recently there has been a more conservative trend with regard to indications for surgical treatment, and more and more of the residual nodules are being treated medically only. In the institution with which I am connected there has been almost complete abandonment of collapse therapy, as shown in Table 1. For the past 2 years we have abandoned the principle of strict rest in bed except for toxic patients and those under orthopedic treatment. All are allowed a moderate amount of exercise including full bathroom privileges throughout their stay in the sanatorium. This has reduced the amount of disability from physical immobilization but at the same time has made it more difficult to convince the patient of the necessity for sanatorium treatment for his disease. It has become necessary to spend
1164
Gustaf A. H edberg
much more time in the individual education of the patient regarding the problems of his disease as it relates to himself and to his family and community. With chemotherapy, however, we have been able to shorten the hospital stay for the intelligent and co-operative patient by a program of postsanatorium outpatient treatment with drugs, although the total period of treatment has been lengthened. Such postsanatorium outpatient treatment is given under the supervision of the patient's private physician with the patient returning to the sanatorium at intervals of approximately 3 months for intensive laboratory studies including the inoculation of gastric specimens into culture media or guinea pigs. Three months after the prescribed course of treatment has been terminated the patient is again hospitalized for such studies. The factors taken into consideration in the matter of surgical treatment are the type of lesion present, whether there is residual cavitation and whether there is extensive nodular disease that is localized. The use of body section radiography is of great value in making these determinations. We prefer to delay operation until such time as the patient is not excreting tubercle bacilli, even to the extent of not being able to demonstrate the organism by inoculations of gastric specimens into guinea pigs or culture media. If the decision of the staff is in favor of resection, it is performed and the patient is kept on modified exercise for approximately 2 months thereafter. After this interval, exercise is increased over a period of approximately 2 months and the patient is considered for discharge, to continue his chemotherapy for a minimum of 12 months and in some cases up to 18 months depending upon residual known disease and other factors. As previously mentioned, there has been a trend in our institution during the past year toward more conservatism in recommending surgical treatment, as we have found in many resected specimens that we have been unable to demonstrate activity of the tuberculosis, either histologic ally or bacteriologically. I am personally being impressed by the fact that since 1951 no patient in our sanatorium who has taken a minimum of 100 grams of streptomycin with PAS as mentioned above and who has undergone resection has shown evidence of reactivation of his disease, while reactivation has occurred in a few patients treated by medical means alone. It is impossible to evaluate the results of treatment with any accuracy in such a changing trend of treatment as we have been undergoing during the past 5 years. There has been definite improvement in the status of the patients discharged from the sanatorium during these 5 years over that of the previous half of the decade, as shown in Table 2. We know that previous to the advent of chemotherapy with or without resectional surgery the reactivation rate among patients discharged as well or improved was considerable, approximating 33 per cent over a 5ycar follow-up period. We know that there has been a definite decrease
Changing Concepts in Treatment of Tuberculosis
1165
in the reaetivation rate after discharge from the sanatorium but it is impossible to give a comparative figure without waiting a few more years. The Continuing Need for Sanatorium Care
One might ask why sanatorium care is necessary with present definitive treatment. Why might we not start a patient on antimicrobial therapy at home and hospitalize him only for periodic intensive study and during the period of surgical treatment if such is deemed necessary? There are two main reasons for hospitalization during the active period of a person's tuberculosis even though his condition may be improving. First, patients with active tubereulosis are an actual or potential public health menace. Even with intensive drug treatment tubercle Table 2 STATUS OF PATII,NTtl AT DISCHARGE WELL OH IMPROVED YEAR
--
UNIMPROV~;[)
OR DEAD TOTAL
------~--
Cases
Per cent
Cases
190 144 177 137 181 219 192 186 203 206
71.2 71.6 81.6 77.8 81.2 85.5 84.6 1\3.0 Ul.4 85.5
77 57 40 :39 42 37 :35 38
Per cent ------
1944 1945 1946 1947 1948 194H 1950 HI51
1952 1953
In
35 ~-~~--
28.8 28.4 18.4 22.2 18.8 14.5 15.4 17.0 8.6 14.5
~---
~----
267 201 217 176 223 256 227 224 222 241 ~---~--~
bacilli can be reeovered from the average patient's pulmonary secretions for many months. Therefore he should be removed from environments wherein he might infect others. Second, it has not been proved that drugs alone "cure" tuberculosis; a certain amount of rest and support are necessary in order to promote the patient's innate ability to heal his disease. Further, all the drugs used have toxic potentialities and some are difficult to take. Toxic manifestations aside from deafness and vertigo usually occur relatively early in the course of treatment and often are asymptomatic, requiring routine repetition of laboratory studies. The patient must be taught the importance of taking the prescribed doses of the drugs even though the side effects such as gastrointestinal upsets are to be expected and tolerated in the interest of accomplishing the goal of "curing" the disease. Until such time as a "miracle drug" capable of killing the tubercle bacilli in short order becomes available, considerable hospitalization during the active stage is necessary.
1166
Gustaf A. H cdbcrg
Two age groups have increased in the sanatorium population-the very young and the very old. The proportion of men more than 60 years of age is steadily increasing. In this group resection is seldom considered in the treatment of tuberculosis, because of the increased surgical risk. Long-term chemotherapy has shown encouraging results even when used alone. Most of these elderly men are best treated by hospitalization during the entire period of treatment as they need the additional protection afforded them in the sanatorium. Most could not be depended upon to take medications properly in an outpatient program. Because of the hesitancy in performing resection a considerable number do not get well but continue on as chronic active cases, certainly a dangerous group to have in the community. The very young present a problem best handled in its entirety by hospitalization. Active primary tuberculosis responds to antimicrobial therapy. There usually is rapid conversion of the bacteriologic findings under such treatment but relatively slow improvement in the pulmonary and glandular lesions as studied by serial roentgenograms. If rest and moderation of activities are factors in recovery from tuberculosis, the child can receive this best in a regulated institution. In addition, if the child is of school age, education is provided in a good sanatorium. WHAT OF THE FUTURE?
The present treatment of tuberculosis has far from stabilized. Many questions plague the physician in charge of treatment. Are we depending too much on the bacteriologic and pathologic observations made on surgical specimens in reversing to some extent the indications for resection? Have we dropped some of the earlier procedures too quickly? Should we reconsider pneumothorax in conjunction with drug therapy, especially for the limited cavitary lesion, rather than completely abandon this previously valued procedure in favor of resection? Cautious reinvestigation of these questions is in order. The future treatment of tubereulosis may change as radically as that of the past few years. If a truly bactericidal drug were made available the treatment of the tubereulous infection as well as the disease would be in order-aetual sterilization of an individual of the dormant baeilli whieh have the eonstant potentiality of produeing the disease. In the meantime the problem of tuberculosis remains that of the community as well as that of the individual. More thorough search for the unknown cases must be instituted by every practieal means. Those with known apparently inactive tuberculosis must be checked by periodic roentgenograms and sputum studies, and ideally all persons with positive tuberculin reactions should be followed by periodic roentgenograms in order to find the disease in its earliest stages with reduction of further infection of the community and insurance of the best results to the diseased person.