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Medical Societies TUBERCULOSIS ASSOCIATION The ANNUAL PROVINCIAL MEETING OF THE TUBERCULOSIS ASSOCXATION Was held in Oxford on July 8, 9 and IO. The President, Mr J. E. H. Roberts, was in the chair. O n the first afternoon, the meeting was opened by PROFESSOR JOHN RYLE with an address on ' Tuberculosis as a Social Disease '. He said that preventive medicine in the past century had achieved control of the acute infections, but on the infective side there still remained tuberculosis, venereal disease, rheumatic fever and a few dangerous acute specific fevers. Perhaps further advances would bring control of the chronic infective diseases. O f these, tuberculosis had for aetiological factors, racial or familial pre-disposition, poor environment, a bias towards youth and the importance of the h u m a n carrier. The measures of control could be used preferably on a less limited scale than now, and, after detailing the methods, the speaker said that we had to aim at tl:eir extension and better co-ordination, with wider application of known principles. There must be a co-ordinated national health service. Education t o o - - o f the people, their leaders and their doctors--was necessary. These weapons were about to be used to better effect and in some remote generation the need for the T.A. (except for a residual historical section perhaps) would have departed with the conquest of the disease. Dr A. H. T. ROBB-SMITH (Oxford) followed with a paper o n ' D i s e a s e s of the Reticulo-endothelial system and their thoracic manifestations '. Demurring a little at the title, he differentiated between diseases of the reticuloendothelial system and those of reticular tissue, the former being a functional or physiological system, the latter an anatomico-histological tissue. In the thorax the latter was represented by the l~mph nodes, the phagocytic cells of the lung, the general connective tissue, the lympho epithelial organs (e.g., the tonsils). Accepting Maximow's theory of the persistence of a pleuri-potential mesenchymal cell in the adult organism, under suitable stimuli local reticular cells may produce a number of other mature differentiated cells. Progressive hyperplasias of the reticular tissue would include Hodgkin's disease, majority of leukaemias, mycosis fungoides and other forms of nonmalignant lymphademopathy. ' Reticulosarcoma ' would include malignant proliferations of the reticular cells (lym.phosarcoma and leuko-sarcoma, chloromata and certain ' endotheliomata ') and must show stromal destruction or blood-borne metastasis. The simple hyperplasia might become an infiltrative malignant process. Diseases of the reticular tissue only rarely showed their initial manifestations in the chest. Chronic lymphatic leukaemia might show moderate mediastinal lymph node enlargement, but rarely (Dr Robb-Smith showed x-ray of a case with foci of leukotic tissue in the lungs) elsewhere in the thorax. Other non-leukaemic reticuloses (except for Hodgkin's and Sarcoidosis) had no characteristic thoracic manifestations, tlaough all might enlarge lymph nodes or cause effusions. Lymphoid follicular reticulosis, not uncommon, occurring in late middle age, showed itself in generalised painless lymph node enlargement sometimes regressing spontaneously. O n the other hand, it was liable to cause serious effusions and limb oedema with death from cardiac compression. However, the masses were very radio-sensitive. With regard to Hodgkin's disease, there did not seem to be a marked age or sex
preponderance. Dr Robb-Smith spoke further on sarcoidosis (in the tuberculin-negative case there did not seem to be any alteration in reactions to different strains of Tuberculin) the lipoidoses and the sarcomata and showed slides and x-rays of these conditions. In the discussion that followed Dr LLOYD RUSBY (Hon. Sec.) asked i f ' endothelioma ' of the pleura still existed as an entity, and Dr A. STEPHEN HALL (Middlesex) mentioned the difficulty in producing a positive Mantoux test in sarcoidosis even after B.C.G. administration. Replying, Dr ROBB SMITH thought there was always the chance of carcinomatosis in pleural ' endothelioma '. The point about resistance to B.C.G. in sarcoidosis was obviously important. A discussion on ' E x t r a p l e u r a l P n e u m o t h o r a x ' was opened by the President, M r J. E. H. ROBERTS. In a few words on technique, he emphasised that pleura should be stripped to the hilum on mediastinal side, to the 8th or 9th ribs posteriorly and the 4th or 5th rib cartilage anteriorly. More frequent refills than weekly may be necessary. He reviewed the 5-year results of 33 cases published in 1938. Omitting 3 hopeless cases and 3 in which pleura was too adherent, in the other 27, 2 died of the operation (I massive haemorrhage, i pneumococcal bronchopneumonia) 4 are dead after one to four years, 6 have had thoracoplasty, IO are well and working, 5 untraced (though well for periods of half to four years). The morbidity of the operation was greater than modern thoracoplasty. Two main complications were haemorrhage within forty-eight hours and secondary pyogenic infection later (Hypovitaminosis C may be related to former). O f indications given in I938 , only where general condi[ion or contralateral disease precluded thoracoplasty, or where patient refused thoraeoplasty did they still hold good. Cases of limited disease were better with a limited thoracoplasty with apicolysis. Children or young people might now have a thoracoplasty if routine post-operative exercises were adequate. There was still the problem o f terminating cases of extrapleural pneumothorax and probably the lung could only expand at the expense o f the diseased area. An oleothorax might lead to perforation and sepsis. Mr. Roberts believed the pneumothorax should be converted to a thoracoplasty as soon as patient fit enough. Mr T. HOLMES SELLORS (London) thought we should not do an extrapleural pneumothorax now if we could get out of it. In a limited number of cases we can get away with it when a thoracoplasty is unjustifiable. Tuberculous infection of the space was c o m m o n - - n o t surprising when we know that 75 per cent of intercostal glands removed in apicolysis were infected with tuberculosis. Colonel JOHAN HOLST (Oslo) said E.P. should he done only when stripping is easy, i.e., no peripleuritis, and when thoracoplasty is contra-indicated, especially bilateral cases or with progressive disease. H e had had more postoperative haemorrhage in some cases done in England than in Norway. Fistulas were a danger where the E.P. ,a as terminated with an oleothorax. M r R. C. BROCK (London) had done 1oo cases up to the end of 1939 and only 8 since ; this indicated trend o f opinion. In a follow-up for four to six years : 50 per cent were good, 5~ per cent bad, poor or fatal. More immediate results: IO per cent died from the operation, 19 patients from extension of disease or other causes ; of remainder, 43 good, 6 fair, 37 poor operative results. O f 9 cases w h o
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went to thoracoplasty, 6 reached a good result. Risks were haemorrhage" and sepsis. Thoraeoplasty is the choice if patient is or can be made fit for it. If not, or sometimes if early acute disease, perhaps an E.P., with thoracoplasty as soon as possible. Lieut.-Colonel T. L. BADGER (U.S. Army) endorsed what previous speakers had said. Empyema and fistulae common. Used much less now in U.S.A. than previously. Dr F. H. YOUNG (London) stressed the advantage of E.P. over thoracoplasty in its avoidance of deformity, especially in women. Dr F. A. H. SIMMO~DS(Clare Hall) whilst agreeing with much of the above, thought the operation had justified itself; 22 out of 3 z cases operated on two to five years ago were now well and working. Patients seemed to do best when operated on in the sanatorium. Dr A. P. FORD (Herts) and others mentioned the value of the 'combined' (E.P. and A.P.) operation. Dr BRIAN THOMPSON (Ealing) thought the operation was under-estimated. After all, sputum-positive patients had only I chance in 8 of living ten years. Mr J. E. H. ROBERTS, in reply, said that Dr Brian Thompson's arguments were good for doing some form of collapse therapy, but not necessarily E.P. By contrast, of the first 5oo thoraeoplasties at Brompton 66 per cent were alive after five years. On Friday, June 9, a discussion on 'Tracheobronchial Tuberculosis, its frequency and treatment' was opened by Lieut.-Colonel T. L. BADGER (U.S. Army). He said that positive sputum or haemoptysis, dyspnoea or cyanosis, not accounted for by the extent of parenchymal lesion pointed towards bronchial tuberculosis. In the adult, it was usually secondary to disease in the lung, and bronchoscopy in the living showed it in IO to 2o per cent of sanatorium cases. However, it must be present with greater frequency throughout the smaller bronchioles, as shown by post-mortem studies. Probably, direct implantation of tubercle bacilli from heavily laden sputum was the most common cause and the posterior wall of the bronchus was most frequently involved. Small tubercles growing between the aeini cause dilatation of the mucous glands from duct obstruction. Diffuse inflammation and ~welling encroach on the bronchial lumen and further caseation may proceed to ulceration. Healing may cause scarring and fibrotic stenosis, with resultant atelectasis. Biopsy may be necessary to differentiate from neoplasms, non-tuberculous granulomata, etc. In the presence of tubercle bacilli in sputum or gastric contents, tuberculous bronchitis may sometimes be diagnosed clinically or radiologically. Overexposed films or laminography may help. The speaker said that tuberculous bronchitis tended to reflect the progress of the pulmonary disease. 8o per cent heal spontaneously where pulmonary lesions progress favorably. The treatment of the latter is more important than any local treatment of the bronchial lesions. Local caustics were of little value, though electrocautery of local obstructing lesions may occasionally relieve suffocation and atelectasis especially in children. Bronchoscopy was not without complications (e.g. secondary fever, minimal infiltrative spread or small lobular atelectasis.) An artificial pneumothorax causes shortening of bronchi (thus thickening mucous membranes), and kinking of a bronchus may follow rotation of the lung, especialIy with adhesions present. Obstruction may result in the oedematous bronchus. Bronchoscopy is indicated before starting collapse therapy, where minimal lung lesions inadequately account for persistently positive sputum, haemoptysis, bronchogenie
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spreads, wheezing type of respiration, or areas of ateleetasis. If bronchial lesions are found, a month of absolute bed rest should precede the induction of collapse. Drolet failed to find improvement in the U.S.A. in tuberculosis mortality since 1931 despite widespread collapse measures. Perhaps tuberculous tracheobronchitis with its sequelae is a more significant detriment to successful collapse than we know. Mr F. C. OmUEROD (London) who followed, mentioned that Eppinger in I88O wrote the first real classification of the condition. The paucity of symptoms combined with the necessity for performing bronchoscopy for diagnosis (reluctantly advised in tuberculous patients in this country) reduced opportunities for seeing many cases. He detailed possible symptoms and discussed the incidence. Warren, Hammond and Turtle in a large series of endoscopies, found tracheo-bronchial lesions in 13 per cent of unselected, 57 per cent of more advanced cases selected for thoracoplasty. Lesions are always associated with phthisis and a positive sputum. Though possibly sputum- or lymph-borne, infection may be due to direct spread. Usually lung lesions are advanced but may be minimal at first or even quiescent. Often there is a tuberculous laryngitis. The disease usually begins in the intercartilaginous membranous zones and less often on the posterior membranous wall. There may be ulceration, commonest in smaller bronchioles or trachea (in latter site multiple and tend to coalesce) or tuberculous granulation--usually in larger bronchi or trachea. Granulation tissue causes obstruction with cavity formation or bronchiectasis. Similar symptoms will be given by tuberculous mediastinal glands eroding into the bronchi. As regards treatment, rest and treatment of lung disease most important. Local treatment--silver nitrate, galvano-cautery, diathermy--was of doubtful value, and the two latter difficult to control, diathermy sometimes causing cartilage necrosis. Granulation tissue may be curetted or lifted away and the raw area cauterized. Dr H. V. MORLOCK (London) asked how often it was justifiable to bronchoscope tuberculous patients; he had found tracheo-bronchial lesions in only about 5 per cent, and probably less than 5 per cent of A.P.s failed because of existence of such lesions. Apart from removal of granulomatous tissue, local treatment disappointing. Captain METZER (R.C.A.M.C.) thought that cough was often a prominent symptom. Cases of thoracoplasty might retain a plus sputum due to bronchial ulceration, and might respond to bronehoscopic treatment. Collapse therapy might aggravate such a lesion; despite that, usually necessary to carry on with A.P. after period of rest. Wing Commander E. H. HUDSON regarded cases of granulomatous obstruction as open to treatment and glands pointing into a bronchus might be aspirated through an operating bronchoscope. Mr V. C. THOMPSON (London) recalled an incidence of I I per cent in a U.S. Sanatorium he visited, a figure he had not found in England. Dr J. V. HURFORD (High Wood) referred to cases in children where a bronchus was blocked by granulomatous tissue; removal of this had not seemed to cure the complicating atelectasis. Dr L. E. HOUGHTON (Harefield) recalled the occurrence of lobar collapse after A.P. induction, especially in the acute exudative lesion: a subsequent tuberculous empyema seemed more liable. What was the state of the bronchi in such cases? Dr H. V. MORLOCK and Mr T. HOLMES S~LLORS (London) also referred to 'black lobes' the latter saying that there was often a bronchial lesion in the 'case with a large cavity at the apex of the lower lobe'. THE PR~SmENT thought there was scope for dilatation
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of the incompletely stenosed bronchus with successive sizes of bougies. With Mr Ormerod, he disliked the use of diathermy. Lieut.-Colonel T. L. BADOER, replying, was against routine bronchoscopy. He stressed the importance of considering the patient as a whole. Many cases of traeheobronchitis got well spontaneously. An A.P. may lead to collapse of the 'wrong' lobe due to ulceration in its bronchus, and in 'black lobes' he thought there was probably lymphatic interruption, possibly accounting for empyema incidence, whilst he agreed about the 'cavity in the upper pole of the lower lobe'. Atelectasis in children was due to pressure of glands more often than to granulomatous obstruction. Dr F. A. H. SIMmONDS (Clare Hall) followed with a paper on 'The Use of Pneumo-peritoneum in the Treatment of Pulmonary Tuberculosis'. He proposed to deal with its effects (in his cases after a phrenic paralysis) on lung disease. The indications were: to improve lung rest in non-cavitary lesion; to replace A.P. when latter impossible, or thoracoplasty in the poor risk case; with rest as a preliminary to future thoracoplasty; or as a preliminary to A.P. in the toxic case with acute lung disease and tense soft walled cavities. This treatment had not been used for longer than a mean period of twenty-three weeks. As regards technique, high pressures were unwise and unnecessary. Usually, air was introduced through abdominal wall about i in. below left costal margin, where adhesions were less likely. Initially 6oo to i,ooo e.c. and afterwards about I,OOO c.c. weekly, using pneumothorax needles. Insertion of air in abdominal wall or adhesions accounted for complete or partial failures. In 15 cases the average rise of diaphragm was 2.6 cm. after phrenic crush and a 4"6 cm. more with pneumo-peritoneum (x-rays shown). A tight binder might raise the diaphragm further. Of complications, Dr Simmonds mentioned initial shoulder pain and abdominal fullness (soon pass off) puncture of bowel (i case) filled in midline below umbilicus, air embolism (rare), mediastinal emphysema, peritoneal effusion (I case of each). Of 48 cases, of which 3 abandoned, successful results (i.e. rendered fit for collapse therapy or enabled to avoid it) occurred in 5 of 14 'poor choice' and in 18 of 31 'fair or good choice' cases. Lower zone cavities were most favourable influenced. In the subsequent discussion, Lieutenant G. DAY (R.A.M.C.) referred to the improvement in general condition and x-ray appearances which followed the treatment; Dr M. C. WmKINSON (Black Notley) mentioned its use in the puerperium--he regarded it as unnecessary; and Dr A. S. HALL (Middlesex) thought it might be most useful in cavities at apex of lower lobe. Captain E. G. KIRBY (U.S. Army) said pneumoperitoneum had been used in over I,OOO cases in his Sanatorium and in many cases was the treatment of choice. It seemed to improve the old fibroid type with emphysema and might be used where a cavity remained 9fter thoracoplasty. It should be carried on for two to three years after cavity closure. An immobile diaphragm, a large hernia, and abdominal adhesions were preventing factors. In the afternoon, an interesting radiological demonstration by Dr F. H. KEMP (Oxford) was followed by a paper by Dr ALINE STEWART (Oxford) on 'Some Observations on Systemic Diseases complicated by Tuberculosis'. She spoke on the part which the general physician should play in future schemes for tuberculosis. Her choice was a scheme in which the large general hospital worked in close collaboration with outlying sanatoria. Staff appointments should work both ways (the hospital staff consulting in the Sanatoria, the physicians of the latter
July I943
acting as specialists to the general hospital). Combined rounds would occur in each institution. There would be interchange of staff other than medical, and students would 'walk the Sanatorium'. The hospital would take part in early diagnosls--through outpatients or attached dispensary- and early inpatient investigation. Dr Stewart discussed the question of tuberculosis complicated by other diseases. She quoted Himsworth's figures for occurrence of pulmonary tuberculosis in his diabetic clinic and his dictum that--'it is far better for a diabetic with tuberculosis to be treated in a general ward of a London hospital than to go to a Sanatorium'. This applied to other associated diseases, e.g. peptic ulceration, the anaemias and thyrotoxicosis. Finally, the speaker alluded to the value of collaboration in research. In the subsequent discussion, Dr PETER EDWARDS (Cheshire Joint Sanatorium) said that the Dispensary should be a part of a general hospital but the patient should not have treatment in the latter. He favoured the large Sanatorium (I,ooo beds) with first-class men and all facilities. THE PRESIDENT, whilst thinking that Dr Stewart had in mind two fictitious persons--the inefficient medical superintendent and the ideal general physician--voiced the general desire for collaboration and this was supported further by Dr JESSEL (Lanes.) who thought that no tuberculosis officer could be successful without knowledge of general medicine. Dr F. A. H. SIMMONDS (Clare Hall) thought patients probably should be admitted to the Sanatorium through the general hospital and it was bad to hurry them through the latter, though diabetes could be treated and thoracic surgery performed in the Sanatorium. Dr H. V. MORLOCK (London) pointed out the importance of keeping the tuberculous patient under one control throughout his institutional career. Dr A. S. HALL (Middlesex) said that many T.O.s and chest physicians were already attached to general hospitals; into the medical wards of the latter should be admitted cases for diagnosis in which tuberculosis was not certain though suspected. Mr PRinK THOMAS (London), alluding to the dangers of specialisatlon and also of too general an outlook, wanted a plan whereby the whole of chest diseases were handled by one group of physicians. In a short reply Dr A. STEWART indicated that she also was in favour of treating the tuberculosis patient in the special hospital. Later, Lieut.-Colonel YALE KNEELAND (U.S. Army) introduced a discussion on 'Differential diagnosis between Pulmonary Tuberculosis and the Atypical Pneumonias, with particular reference to Virus Pneumonia'. He mentioned first the appearance of a primary bronchopneumonia in young adults which appeared in epidemic form in U.S.A. in I938 and characterized by incubation period of average eighteen days, gradual onset, dry cough, fairly severe systemic disturbance, inconspicuous physical signs and a fever lasting two weeks. There was no response to sulphonamides (pneumococci rare in sputum) but quite extensive shadows in the x-ray. In I94I , similar atypical pneumonias occurred in U.S. training camps and resembled previous outbreaks. The lower lobe was commonest involved and lesions bilateral in 48 out of I83 cases. The cause might be a filterable virus, though a few cases were associated with sinusitis and a few infected with psittacosis. Lieut.-Colonel TURNER (U.S. Army) mentioned the value as a test of changes in the cold agglutinlns. Lieut.ColoneI DREW (R.A.M.C.) had seen 64 cases since I94I and thought the cause might be a virus or group of viruses; he had found psittacosis virus in 5 cases. The-hilar glands were often enlarged and the E.S.R. raised. X-ray shadows disappeared in a fortnight. Ambulant cases occurred and
July I943
TUBERCLE
the existence of the syndrome must be remembered in mass radiography reviews. Flt.-Lieutenant F. TEMPLE CLIW agreed that the atypical pneumonias were quite common and often symptomless. The sedimentin index was useful in diagnosis. Lieutenant G. DAY (R.A.M.C.) remarked that in his cases the clinical course was almost exactly eleven days. The sedimentin index was highest on admission and levelled out to normal about the twenty-eighth day, whilst in ordinary pneumonias it was high at first and went up for the first week, then came down more slowly. Even when patient was doing well, he might still relapse, showing a patch in another lung area. Dr C. H. C. TOOSSAINT (Bermondsey) suggested a return to the name 'Pneumonitis'. Lieut.-Colonel SIENIEWmZ (R.C.A.M.C.) pointed out that apical shadows might persist longer than two weeks and it was important to exclude primary tuberculosis. In a short reply Lieut.-Colonel KNE~LAND thought persistent shadows were rare. In recent years the disease appeared to have assumed much greater proportions. The last day was devoted to two papers on an 'Experiment on Tuberculosis case Finding' (Dr. C. H. C. TousSAINT and Dr E. K. PRITCHARD) followed by the Annual Meeting. Dr C. H. TROUSSAINT (Bermondsey) began by pointing out that still 50 per cent of all deaths from pulmonary tuberculosis occurred within one year following notification. Consistent with this, far too many cases enter Sanatorium in advanced stages of the disease. H e believed that most patients who come under treatment in a moderately advanced state are cases in w h o m the onset was comparatively sudden. Often a short acute febrile attack with indefinite symptoms. The pyrexia goes but cough continues. Morlock had pointed out that many cases were first diagnosed as 'influenza' and that the classical constitutional symptoms were in reality quite late in time. Soft rapidly-spreading lesions, not preceded by small hard lesions, arose comparatively suddenly. They must be treated at the earliest possible moment. But there was a delay between onset of symptoms and consultation with general practitioner and a further delay (average three to two months: Lissant Cox) before the case is referred to the tuberculosis officer. After detailing the steps leading up to it, Dr Tonssaint outlined the scheme adopted in Bermondsey and Southwark. In December 1942 , certain practitioners were asked to send up for x-ray any patient with minor symptoms which might be due to thoracic disease. In June, 1943, the scheme was extended to all general practitioners (slides of cases and results). (In 1,ii1 cases x-rayed, there were 463 abnormalities, of which there were 31 cases of active tuberculosis--including 6 pleural effusions.) There was a high percentage of abnormalities and a number of early unilateral lesions in the cases of tuberculosis. Also a high proportion of cardiac abnormalities. It was necessary to bring to the notice of the general practitioner cases that might have been referred for x-ray sooner and also to applaud them for finding the really early case, the aim being to increase co-operation. The clinical experience of the tuberculosis officer was maintained if he had some beds at his disposal. For instructional purposes a selection of the early lesions discovered should be admitted to a teaching hospital (in this case, Guy's). I n summarizing, the speaker believed that such an investigation would provide better results than mass radiology of the normal civilian population. Dr E. K. PRITCHARD (Southwark) said there was not only a delay between first consultation with the general
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practitioner and definite diagnosis, but also between the latter and sanatorium treatment. Their aim had been to shorten the interval before the tuberculosis officer saw a case. In interesting the general practitioners, a letter had been sent to each practitioner and followed up by personal contact. Dr. Pritchard read the letter which was sent to practitioners and the list of conditions (cough, bronchitis, influenza, P.U.O., loss of weight, etc.) which they were told warranted an early x-ray. Cases which a miniatute radiograph would find might be put in two groups, the misdiagnosed and the symptomless (the latter really very rare and usually due to bad history taking). It was unlikely that in civil life there would be the IOO per cent attendance for miniature radiography that could be obtained in the Services, and probably it would be most useful in assessing those patients who were sufficiently worried about their health to consult their doctors. (A machine situated in a convenient area might serve five or six London boroughs.) However, the BermondseySouthwark 'experiment' was worked with a dispensary x-ray plant, taking up to twenty films an hour and staffed by a 'shepherd' (to usher patients in and out and check names, etc.) a cassette-changer and a radiographer. Dr Pritchard spoke about necessary apparatus and materials, stressing necessary cooling of an x-ray tube when a m a x i m u m of twenty exposures an hour were taken. Regarding cost, in a borough of ioo,ooo population, booo to 2,000 x-rays a year (costing about s per I,OOO) would be necessary. It was valuable to extend the scheme to examination of contacts. O n the subject of beds, the early case required immediate admission and, at first, more accommodation would be needed for observation cases, but in time the effect of getting early cases would be to relieve pressure on sanatorium beds. Dr M. M. SCOTT (S. London) spoke as a general practitioner who had co-operated in the scheme from the start. Though he had not had a patient refuse to go for x-ray ('a general check-up' was a useful phrase), the public still regarded tuberculosis as a foul disease which hindered the getting of employment, and it did not realize the varying prognosis. The overworked general practitioner got much moral comfort from such a scheme. He was all in favour of closer co-operation between tuberculosis officers and general practitioners. Dr G. JESSEL (Lancs.) pointed out that the dispensary found other conditions than tuberculosis; 75 per cent of cases in Lancashire dispensaries were non-tuberculous. The dimculty in mass radiography would be to hit on the right moment when the lesion occurred in the individual. Dr N. J. ENOLAND (Oxford) cautioned that a single clear x-ray did not mean that tuberculosis was eliminated. Dr FOSTER CARTER (Brompton) said that x-ray facilities were very poor in some areas and that improved casefinding must mean more beds. Dr F. R. G. HEAF (London) asked why general practitioners did not more often test sputa for tuberculosis. With regard to beds, the shortage was rather of people to staff them. Dr A. S. HALL (Middlesex) had circularized general practitioners in his area, suggesting that patients should be sent to his dispensary for either (a) full examination, or (b) x-ray only. O f a large number sent, 5"7 per cent had tuberculosis. Flt.-Lieutenant F. TEMPLE CLIVE said that of cases found in the R.A.F. a third had symptoms and twothirds physical signs. Dr J. WATT (Godalming) thought that the work of the speakers was definitely pioneer and emphasized both the necessity for going after the early case and also the point that 'there is no early stage'. THE PRESIDENT stressed that the negative x-ray does not necessarily mean good health and instanced eaHy carcinoma of bronchus.
preponderance. Dr Robb-Smith spoke further on sarcoidosis (in the tuberculin-negative case there did not seem to be any alteration in reactions to different strains of Tuberculin) the lipoidoses and the sarcomata and showed slides and x-rays of these conditions. In the discussion that followed Dr LLOYD RUSBY (Hon. Sec.) asked i f ' endothelioma ' of the pleura still existed as an entity, and Dr A. STEPHEN HALL (Middlesex) mentioned the difficulty in producing a positive Mantoux test in sarcoidosis even after B.C.G. administration. Replying, Dr ROBB SMITH thought there was always the chance of carcinomatosis in pleural ' endothelioma '. The point about resistance to B.C.G. in sarcoidosis was obviously important. A discussion on ' E x t r a p l e u r a l P n e u m o t h o r a x ' was opened by the President, M r J. E. H. ROBERTS. In a few words on technique, he emphasised that pleura should be stripped to the hilum on mediastinal side, to the 8th or 9th ribs posteriorly and the 4th or 5th rib cartilage anteriorly. More frequent refills than weekly may be necessary. He reviewed the 5-year results of 33 cases published in 1938. Omitting 3 hopeless cases and 3 in which pleura was too adherent, in the other 27, 2 died of the operation (I massive haemorrhage, i pneumococcal bronchopneumonia) 4 are dead after one to four years, 6 have had thoracoplasty, IO are well and working, 5 untraced (though well for periods of half to four years). The morbidity of the operation was greater than modern thoracoplasty. Two main complications were haemorrhage within forty-eight hours and secondary pyogenic infection later (Hypovitaminosis C may be related to former). O f indications given in I938 , only where general condi[ion or contralateral disease precluded thoracoplasty, or where patient refused thoraeoplasty did they still hold good. Cases of limited disease were better with a limited thoracoplasty with apicolysis. Children or young people might now have a thoracoplasty if routine post-operative exercises were adequate. There was still the problem o f terminating cases of extrapleural pneumothorax and probably the lung could only expand at the expense o f the diseased area. An oleothorax might lead to perforation and sepsis. Mr. Roberts believed the pneumothorax should be converted to a thoracoplasty as soon as patient fit enough. Mr T. HOLMES SELLORS (London) thought we should not do an extrapleural pneumothorax now if we could get out of it. In a limited number of cases we can get away with it when a thoracoplasty is unjustifiable. Tuberculous infection of the space was c o m m o n - - n o t surprising when we know that 75 per cent of intercostal glands removed in apicolysis were infected with tuberculosis. Colonel JOHAN HOLST (Oslo) said E.P. should he done only when stripping is easy, i.e., no peripleuritis, and when thoracoplasty is contra-indicated, especially bilateral cases or with progressive disease. H e had had more postoperative haemorrhage in some cases done in England than in Norway. Fistulas were a danger where the E.P. ,a as terminated with an oleothorax. M r R. C. BROCK (London) had done 1oo cases up to the end of 1939 and only 8 since ; this indicated trend o f opinion. In a follow-up for four to six years : 50 per cent were good, 5~ per cent bad, poor or fatal. More immediate results: IO per cent died from the operation, 19 patients from extension of disease or other causes ; of remainder, 43 good, 6 fair, 37 poor operative results. O f 9 cases w h o
July 1943
TUBERCLE
went to thoracoplasty, 6 reached a good result. Risks were haemorrhage" and sepsis. Thoraeoplasty is the choice if patient is or can be made fit for it. If not, or sometimes if early acute disease, perhaps an E.P., with thoracoplasty as soon as possible. Lieut.-Colonel T. L. BADGER (U.S. Army) endorsed what previous speakers had said. Empyema and fistulae common. Used much less now in U.S.A. than previously. Dr F. H. YOUNG (London) stressed the advantage of E.P. over thoracoplasty in its avoidance of deformity, especially in women. Dr F. A. H. SIMMO~DS(Clare Hall) whilst agreeing with much of the above, thought the operation had justified itself; 22 out of 3 z cases operated on two to five years ago were now well and working. Patients seemed to do best when operated on in the sanatorium. Dr A. P. FORD (Herts) and others mentioned the value of the 'combined' (E.P. and A.P.) operation. Dr BRIAN THOMPSON (Ealing) thought the operation was under-estimated. After all, sputum-positive patients had only I chance in 8 of living ten years. Mr J. E. H. ROBERTS, in reply, said that Dr Brian Thompson's arguments were good for doing some form of collapse therapy, but not necessarily E.P. By contrast, of the first 5oo thoraeoplasties at Brompton 66 per cent were alive after five years. On Friday, June 9, a discussion on 'Tracheobronchial Tuberculosis, its frequency and treatment' was opened by Lieut.-Colonel T. L. BADGER (U.S. Army). He said that positive sputum or haemoptysis, dyspnoea or cyanosis, not accounted for by the extent of parenchymal lesion pointed towards bronchial tuberculosis. In the adult, it was usually secondary to disease in the lung, and bronchoscopy in the living showed it in IO to 2o per cent of sanatorium cases. However, it must be present with greater frequency throughout the smaller bronchioles, as shown by post-mortem studies. Probably, direct implantation of tubercle bacilli from heavily laden sputum was the most common cause and the posterior wall of the bronchus was most frequently involved. Small tubercles growing between the aeini cause dilatation of the mucous glands from duct obstruction. Diffuse inflammation and ~welling encroach on the bronchial lumen and further caseation may proceed to ulceration. Healing may cause scarring and fibrotic stenosis, with resultant atelectasis. Biopsy may be necessary to differentiate from neoplasms, non-tuberculous granulomata, etc. In the presence of tubercle bacilli in sputum or gastric contents, tuberculous bronchitis may sometimes be diagnosed clinically or radiologically. Overexposed films or laminography may help. The speaker said that tuberculous bronchitis tended to reflect the progress of the pulmonary disease. 8o per cent heal spontaneously where pulmonary lesions progress favorably. The treatment of the latter is more important than any local treatment of the bronchial lesions. Local caustics were of little value, though electrocautery of local obstructing lesions may occasionally relieve suffocation and atelectasis especially in children. Bronchoscopy was not without complications (e.g. secondary fever, minimal infiltrative spread or small lobular atelectasis.) An artificial pneumothorax causes shortening of bronchi (thus thickening mucous membranes), and kinking of a bronchus may follow rotation of the lung, especialIy with adhesions present. Obstruction may result in the oedematous bronchus. Bronchoscopy is indicated before starting collapse therapy, where minimal lung lesions inadequately account for persistently positive sputum, haemoptysis, bronchogenie
I2 5
spreads, wheezing type of respiration, or areas of ateleetasis. If bronchial lesions are found, a month of absolute bed rest should precede the induction of collapse. Drolet failed to find improvement in the U.S.A. in tuberculosis mortality since 1931 despite widespread collapse measures. Perhaps tuberculous tracheobronchitis with its sequelae is a more significant detriment to successful collapse than we know. Mr F. C. OmUEROD (London) who followed, mentioned that Eppinger in I88O wrote the first real classification of the condition. The paucity of symptoms combined with the necessity for performing bronchoscopy for diagnosis (reluctantly advised in tuberculous patients in this country) reduced opportunities for seeing many cases. He detailed possible symptoms and discussed the incidence. Warren, Hammond and Turtle in a large series of endoscopies, found tracheo-bronchial lesions in 13 per cent of unselected, 57 per cent of more advanced cases selected for thoracoplasty. Lesions are always associated with phthisis and a positive sputum. Though possibly sputum- or lymph-borne, infection may be due to direct spread. Usually lung lesions are advanced but may be minimal at first or even quiescent. Often there is a tuberculous laryngitis. The disease usually begins in the intercartilaginous membranous zones and less often on the posterior membranous wall. There may be ulceration, commonest in smaller bronchioles or trachea (in latter site multiple and tend to coalesce) or tuberculous granulation--usually in larger bronchi or trachea. Granulation tissue causes obstruction with cavity formation or bronchiectasis. Similar symptoms will be given by tuberculous mediastinal glands eroding into the bronchi. As regards treatment, rest and treatment of lung disease most important. Local treatment--silver nitrate, galvano-cautery, diathermy--was of doubtful value, and the two latter difficult to control, diathermy sometimes causing cartilage necrosis. Granulation tissue may be curetted or lifted away and the raw area cauterized. Dr H. V. MORLOCK (London) asked how often it was justifiable to bronchoscope tuberculous patients; he had found tracheo-bronchial lesions in only about 5 per cent, and probably less than 5 per cent of A.P.s failed because of existence of such lesions. Apart from removal of granulomatous tissue, local treatment disappointing. Captain METZER (R.C.A.M.C.) thought that cough was often a prominent symptom. Cases of thoracoplasty might retain a plus sputum due to bronchial ulceration, and might respond to bronehoscopic treatment. Collapse therapy might aggravate such a lesion; despite that, usually necessary to carry on with A.P. after period of rest. Wing Commander E. H. HUDSON regarded cases of granulomatous obstruction as open to treatment and glands pointing into a bronchus might be aspirated through an operating bronchoscope. Mr V. C. THOMPSON (London) recalled an incidence of I I per cent in a U.S. Sanatorium he visited, a figure he had not found in England. Dr J. V. HURFORD (High Wood) referred to cases in children where a bronchus was blocked by granulomatous tissue; removal of this had not seemed to cure the complicating atelectasis. Dr L. E. HOUGHTON (Harefield) recalled the occurrence of lobar collapse after A.P. induction, especially in the acute exudative lesion: a subsequent tuberculous empyema seemed more liable. What was the state of the bronchi in such cases? Dr H. V. MORLOCK and Mr T. HOLMES S~LLORS (London) also referred to 'black lobes' the latter saying that there was often a bronchial lesion in the 'case with a large cavity at the apex of the lower lobe'. THE PR~SmENT thought there was scope for dilatation
I26
TUBE R C L E
of the incompletely stenosed bronchus with successive sizes of bougies. With Mr Ormerod, he disliked the use of diathermy. Lieut.-Colonel T. L. BADOER, replying, was against routine bronchoscopy. He stressed the importance of considering the patient as a whole. Many cases of traeheobronchitis got well spontaneously. An A.P. may lead to collapse of the 'wrong' lobe due to ulceration in its bronchus, and in 'black lobes' he thought there was probably lymphatic interruption, possibly accounting for empyema incidence, whilst he agreed about the 'cavity in the upper pole of the lower lobe'. Atelectasis in children was due to pressure of glands more often than to granulomatous obstruction. Dr F. A. H. SIMmONDS (Clare Hall) followed with a paper on 'The Use of Pneumo-peritoneum in the Treatment of Pulmonary Tuberculosis'. He proposed to deal with its effects (in his cases after a phrenic paralysis) on lung disease. The indications were: to improve lung rest in non-cavitary lesion; to replace A.P. when latter impossible, or thoracoplasty in the poor risk case; with rest as a preliminary to future thoracoplasty; or as a preliminary to A.P. in the toxic case with acute lung disease and tense soft walled cavities. This treatment had not been used for longer than a mean period of twenty-three weeks. As regards technique, high pressures were unwise and unnecessary. Usually, air was introduced through abdominal wall about i in. below left costal margin, where adhesions were less likely. Initially 6oo to i,ooo e.c. and afterwards about I,OOO c.c. weekly, using pneumothorax needles. Insertion of air in abdominal wall or adhesions accounted for complete or partial failures. In 15 cases the average rise of diaphragm was 2.6 cm. after phrenic crush and a 4"6 cm. more with pneumo-peritoneum (x-rays shown). A tight binder might raise the diaphragm further. Of complications, Dr Simmonds mentioned initial shoulder pain and abdominal fullness (soon pass off) puncture of bowel (i case) filled in midline below umbilicus, air embolism (rare), mediastinal emphysema, peritoneal effusion (I case of each). Of 48 cases, of which 3 abandoned, successful results (i.e. rendered fit for collapse therapy or enabled to avoid it) occurred in 5 of 14 'poor choice' and in 18 of 31 'fair or good choice' cases. Lower zone cavities were most favourable influenced. In the subsequent discussion, Lieutenant G. DAY (R.A.M.C.) referred to the improvement in general condition and x-ray appearances which followed the treatment; Dr M. C. WmKINSON (Black Notley) mentioned its use in the puerperium--he regarded it as unnecessary; and Dr A. S. HALL (Middlesex) thought it might be most useful in cavities at apex of lower lobe. Captain E. G. KIRBY (U.S. Army) said pneumoperitoneum had been used in over I,OOO cases in his Sanatorium and in many cases was the treatment of choice. It seemed to improve the old fibroid type with emphysema and might be used where a cavity remained 9fter thoracoplasty. It should be carried on for two to three years after cavity closure. An immobile diaphragm, a large hernia, and abdominal adhesions were preventing factors. In the afternoon, an interesting radiological demonstration by Dr F. H. KEMP (Oxford) was followed by a paper by Dr ALINE STEWART (Oxford) on 'Some Observations on Systemic Diseases complicated by Tuberculosis'. She spoke on the part which the general physician should play in future schemes for tuberculosis. Her choice was a scheme in which the large general hospital worked in close collaboration with outlying sanatoria. Staff appointments should work both ways (the hospital staff consulting in the Sanatoria, the physicians of the latter
July I943
acting as specialists to the general hospital). Combined rounds would occur in each institution. There would be interchange of staff other than medical, and students would 'walk the Sanatorium'. The hospital would take part in early diagnosls--through outpatients or attached dispensary- and early inpatient investigation. Dr Stewart discussed the question of tuberculosis complicated by other diseases. She quoted Himsworth's figures for occurrence of pulmonary tuberculosis in his diabetic clinic and his dictum that--'it is far better for a diabetic with tuberculosis to be treated in a general ward of a London hospital than to go to a Sanatorium'. This applied to other associated diseases, e.g. peptic ulceration, the anaemias and thyrotoxicosis. Finally, the speaker alluded to the value of collaboration in research. In the subsequent discussion, Dr PETER EDWARDS (Cheshire Joint Sanatorium) said that the Dispensary should be a part of a general hospital but the patient should not have treatment in the latter. He favoured the large Sanatorium (I,ooo beds) with first-class men and all facilities. THE PRESIDENT, whilst thinking that Dr Stewart had in mind two fictitious persons--the inefficient medical superintendent and the ideal general physician--voiced the general desire for collaboration and this was supported further by Dr JESSEL (Lanes.) who thought that no tuberculosis officer could be successful without knowledge of general medicine. Dr F. A. H. SIMMONDS (Clare Hall) thought patients probably should be admitted to the Sanatorium through the general hospital and it was bad to hurry them through the latter, though diabetes could be treated and thoracic surgery performed in the Sanatorium. Dr H. V. MORLOCK (London) pointed out the importance of keeping the tuberculous patient under one control throughout his institutional career. Dr A. S. HALL (Middlesex) said that many T.O.s and chest physicians were already attached to general hospitals; into the medical wards of the latter should be admitted cases for diagnosis in which tuberculosis was not certain though suspected. Mr PRinK THOMAS (London), alluding to the dangers of specialisatlon and also of too general an outlook, wanted a plan whereby the whole of chest diseases were handled by one group of physicians. In a short reply Dr A. STEWART indicated that she also was in favour of treating the tuberculosis patient in the special hospital. Later, Lieut.-Colonel YALE KNEELAND (U.S. Army) introduced a discussion on 'Differential diagnosis between Pulmonary Tuberculosis and the Atypical Pneumonias, with particular reference to Virus Pneumonia'. He mentioned first the appearance of a primary bronchopneumonia in young adults which appeared in epidemic form in U.S.A. in I938 and characterized by incubation period of average eighteen days, gradual onset, dry cough, fairly severe systemic disturbance, inconspicuous physical signs and a fever lasting two weeks. There was no response to sulphonamides (pneumococci rare in sputum) but quite extensive shadows in the x-ray. In I94I , similar atypical pneumonias occurred in U.S. training camps and resembled previous outbreaks. The lower lobe was commonest involved and lesions bilateral in 48 out of I83 cases. The cause might be a filterable virus, though a few cases were associated with sinusitis and a few infected with psittacosis. Lieut.-Colonel TURNER (U.S. Army) mentioned the value as a test of changes in the cold agglutinlns. Lieut.ColoneI DREW (R.A.M.C.) had seen 64 cases since I94I and thought the cause might be a virus or group of viruses; he had found psittacosis virus in 5 cases. The-hilar glands were often enlarged and the E.S.R. raised. X-ray shadows disappeared in a fortnight. Ambulant cases occurred and
July I943
TUBERCLE
the existence of the syndrome must be remembered in mass radiography reviews. Flt.-Lieutenant F. TEMPLE CLIW agreed that the atypical pneumonias were quite common and often symptomless. The sedimentin index was useful in diagnosis. Lieutenant G. DAY (R.A.M.C.) remarked that in his cases the clinical course was almost exactly eleven days. The sedimentin index was highest on admission and levelled out to normal about the twenty-eighth day, whilst in ordinary pneumonias it was high at first and went up for the first week, then came down more slowly. Even when patient was doing well, he might still relapse, showing a patch in another lung area. Dr C. H. C. TOOSSAINT (Bermondsey) suggested a return to the name 'Pneumonitis'. Lieut.-Colonel SIENIEWmZ (R.C.A.M.C.) pointed out that apical shadows might persist longer than two weeks and it was important to exclude primary tuberculosis. In a short reply Lieut.-Colonel KNE~LAND thought persistent shadows were rare. In recent years the disease appeared to have assumed much greater proportions. The last day was devoted to two papers on an 'Experiment on Tuberculosis case Finding' (Dr. C. H. C. TousSAINT and Dr E. K. PRITCHARD) followed by the Annual Meeting. Dr C. H. TROUSSAINT (Bermondsey) began by pointing out that still 50 per cent of all deaths from pulmonary tuberculosis occurred within one year following notification. Consistent with this, far too many cases enter Sanatorium in advanced stages of the disease. H e believed that most patients who come under treatment in a moderately advanced state are cases in w h o m the onset was comparatively sudden. Often a short acute febrile attack with indefinite symptoms. The pyrexia goes but cough continues. Morlock had pointed out that many cases were first diagnosed as 'influenza' and that the classical constitutional symptoms were in reality quite late in time. Soft rapidly-spreading lesions, not preceded by small hard lesions, arose comparatively suddenly. They must be treated at the earliest possible moment. But there was a delay between onset of symptoms and consultation with general practitioner and a further delay (average three to two months: Lissant Cox) before the case is referred to the tuberculosis officer. After detailing the steps leading up to it, Dr Tonssaint outlined the scheme adopted in Bermondsey and Southwark. In December 1942 , certain practitioners were asked to send up for x-ray any patient with minor symptoms which might be due to thoracic disease. In June, 1943, the scheme was extended to all general practitioners (slides of cases and results). (In 1,ii1 cases x-rayed, there were 463 abnormalities, of which there were 31 cases of active tuberculosis--including 6 pleural effusions.) There was a high percentage of abnormalities and a number of early unilateral lesions in the cases of tuberculosis. Also a high proportion of cardiac abnormalities. It was necessary to bring to the notice of the general practitioner cases that might have been referred for x-ray sooner and also to applaud them for finding the really early case, the aim being to increase co-operation. The clinical experience of the tuberculosis officer was maintained if he had some beds at his disposal. For instructional purposes a selection of the early lesions discovered should be admitted to a teaching hospital (in this case, Guy's). I n summarizing, the speaker believed that such an investigation would provide better results than mass radiology of the normal civilian population. Dr E. K. PRITCHARD (Southwark) said there was not only a delay between first consultation with the general
i2 7
practitioner and definite diagnosis, but also between the latter and sanatorium treatment. Their aim had been to shorten the interval before the tuberculosis officer saw a case. In interesting the general practitioners, a letter had been sent to each practitioner and followed up by personal contact. Dr. Pritchard read the letter which was sent to practitioners and the list of conditions (cough, bronchitis, influenza, P.U.O., loss of weight, etc.) which they were told warranted an early x-ray. Cases which a miniatute radiograph would find might be put in two groups, the misdiagnosed and the symptomless (the latter really very rare and usually due to bad history taking). It was unlikely that in civil life there would be the IOO per cent attendance for miniature radiography that could be obtained in the Services, and probably it would be most useful in assessing those patients who were sufficiently worried about their health to consult their doctors. (A machine situated in a convenient area might serve five or six London boroughs.) However, the BermondseySouthwark 'experiment' was worked with a dispensary x-ray plant, taking up to twenty films an hour and staffed by a 'shepherd' (to usher patients in and out and check names, etc.) a cassette-changer and a radiographer. Dr Pritchard spoke about necessary apparatus and materials, stressing necessary cooling of an x-ray tube when a m a x i m u m of twenty exposures an hour were taken. Regarding cost, in a borough of ioo,ooo population, booo to 2,000 x-rays a year (costing about s per I,OOO) would be necessary. It was valuable to extend the scheme to examination of contacts. O n the subject of beds, the early case required immediate admission and, at first, more accommodation would be needed for observation cases, but in time the effect of getting early cases would be to relieve pressure on sanatorium beds. Dr M. M. SCOTT (S. London) spoke as a general practitioner who had co-operated in the scheme from the start. Though he had not had a patient refuse to go for x-ray ('a general check-up' was a useful phrase), the public still regarded tuberculosis as a foul disease which hindered the getting of employment, and it did not realize the varying prognosis. The overworked general practitioner got much moral comfort from such a scheme. He was all in favour of closer co-operation between tuberculosis officers and general practitioners. Dr G. JESSEL (Lancs.) pointed out that the dispensary found other conditions than tuberculosis; 75 per cent of cases in Lancashire dispensaries were non-tuberculous. The dimculty in mass radiography would be to hit on the right moment when the lesion occurred in the individual. Dr N. J. ENOLAND (Oxford) cautioned that a single clear x-ray did not mean that tuberculosis was eliminated. Dr FOSTER CARTER (Brompton) said that x-ray facilities were very poor in some areas and that improved casefinding must mean more beds. Dr F. R. G. HEAF (London) asked why general practitioners did not more often test sputa for tuberculosis. With regard to beds, the shortage was rather of people to staff them. Dr A. S. HALL (Middlesex) had circularized general practitioners in his area, suggesting that patients should be sent to his dispensary for either (a) full examination, or (b) x-ray only. O f a large number sent, 5"7 per cent had tuberculosis. Flt.-Lieutenant F. TEMPLE CLIVE said that of cases found in the R.A.F. a third had symptoms and twothirds physical signs. Dr J. WATT (Godalming) thought that the work of the speakers was definitely pioneer and emphasized both the necessity for going after the early case and also the point that 'there is no early stage'. THE PRESIDENT stressed that the negative x-ray does not necessarily mean good health and instanced eaHy carcinoma of bronchus.