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Observations on active domiciliary treatment of cases of pulmonary tuberculosis
June" 1950
131
Observations on Active Domiciliary Treatment of' Cases of Pulmonary Tuberculosis By JAMES CUTHBERT Baguley Sanatorium, Manchester hi this area, as in others, there is a grave and increasing shortage of nurses with consequent empty sanatorium beds and mounting, waiting lists. There is a lack o f beds outside Sanatoria for the untreatable, chronic cases of puhnonary tuberculosis, so for urgent public health reasons, such as their proximity to young children, those advanced cases often encroach on the beds which could be better used in dealing with patients who haye minimal disease. We observed that by the time many of the cases with minimal disease had waited nine or ten months for admission to sanatorium the lesions had progressed just to that extent to make all the methods of collapse at our command futile. This then was where domiciliary active therapy (D.A.T.) was thought to have a place in our armamentarium. It was hoped that, by treating the cases in their homes during the ten months' waiting period; the disease could at least be held where it was, if not improved, so that surgery c o u l d be available when finally .the patient was admitted to sanatorium in his tuim. Cases have been treated by domiciliary active therapy since September f948 and we h a v e already drawn certain conclusions. The whole problem is .bound up' with the question of the safety or otherwise of having an early artificial pneumothorax case at home and outside hospital. The following brief digression explains the position: The individual case records of 7,2o6 patients with pulmonary tuberculosis who had been in Baguley Sanatorium between January I, I9~9, and J a n u a r y I, I948, were studied. The field comprised 2,I57.patients who died in hospital and 5,o49 who were discharged or left the hospital for one reason or another. The incidence o f tuberculous empyema comprised i46 cases distributed as shown in Table I.
"I'AI~I.E I
.,Vumbers
Percentage of total
Artificial p n e u m o t h o r a x therapy
93
63"7
Spontaneous p n e m n o t h o r a x
..
44
3oq
Causes other t h a n spontaneous pneumothorax, i.e. operative removal of diseased lung and Pott's disease, etc . . . . .
9
6.2
Totals
146
I oo.o
Causes
It was further noted that artificial pneumothoraces which had either no adhesion section or no adhesion section within three months of the onset o f empyema, had the latter complication in 9"5 per cefit of cases. Similar artificial pneumothoraces which had adhesion section three months or less before the onset of empyema, show an empyema incidence of I8. 3 per cent, i.e. the use of a cautery on adhesions in artificial pneumothoraces d o n e on advanced cases appears to i n c r e a s e ' t h e risk of empyema if the artificial pneumothorax is maintained. Further probing of the ar[ificial pneumotlmrax position revealed that the material from wlfich the "cases arose was for the most part advanced, i.e. RB 2 and RB 3 cases (Ministry of Health)' comprised 82- 4 per cent of all the admissions for the nineteenyear period under review while RB I were 2 per cent and all"negative cases (mostly R A 2) were" 15.6 per cent of admissions. Table II reveals that most of the artificial pneumothoraces and most of tl~e,resulting. empyemas were in RB 2 and RB 3 cases. With those classes of cases i t was noted that where there was pyrexia at the induction of an artificial pneumottiorax, the trend was for the onset of empyema to be earlier than if there were no elevation of temperature. Also, as regards the onset of clear effusions sufficient to cover the hemi-. diaphragm, it was noted that, in proportion,
132
TUBERCLE TABLE I I
Case classification N u m b e r i i n each class calculated as a per cent of 7,206 cases studied, I9~ 9 1948 .. . Percentage of i o 4 empyemas in each c l a s s . . P e r c e n t a g e s of 6/o artificial pneumothoraces in each class . . . .
"RA x R A e R B t
15-6
_.e.
RBe RB3RB2+RB
62
2o- 4
3
73
-~
3"2
73
23"8
3
82- 4 97
96-8
refills to positive pressures resulted in half as many effusions again as artificial pneumothoraces filled to a terminal negative pressure. Finally the radiological appearances o f the artificial pneumothoraces responsible for empyemata were analysed. It was possible to obtain the x-ray 0 f t h c artificial pneumo-" thorax which existed before the onset of 78 of the 93 cmpyemas due to artificial pncumothorax. Table I I I shows the radiological appearances of 5 main groups of artificial pncumothoraces into which the cases may be divided. Group ,I represents a 'free artificial pneumdthorax': There is concentric collapse of lung which comes freely away from the hilar region without apica! or mcdiastinal adhesions. Semi-aeration is present and no areas of gross opacity Or visible cavitation. Group / / . - H e r e there are adhesions visible between chest wall and lung, or apico-mcdiastinum and lung. Those cases have cavities, in some cases honeycomb" in type. There is, however, no 'ground-glass'like, milky opacity present. Group I I L - H e r e adhesions are present between the lung and chest wall and there is a 'ground-glass' opacity of a lobe or an entire lung but no visible cavities. Group IV has adhesions between lung and chest wall, 'ground-glass' opacity of a lobe or entire lung and a cavity or cavities visible on the x-ray. Group V is an apparently free artificial
June 1950
pne~lmothorax with 'ground - glass'- like upper lobe containing a cavity. It will be at once seen (Section A, Table III) that 74"4 per cent o f the empyemata arise from artificial pneumothoraces in Group IV. O f the 58 cases of empyemata from artificial pneumothoraces in Group'IV, 28 cases arose within six months and 30 cases longer than six months from artificial pneumothorax induction. Section B of Table I I I shows the results of an analysis of a sample of 2Ol artificial pneumothoraces in which empyema did not develop.. The majority (57"7 per cent) or x 16 cases are in Group IV. 67 had no fluid copious enough to cover the hemi-diaphragm or to warrant aspiration, while 49 developed non-purulent fluid. The table indicates how many of the artificial pneumothoraces lasted over one month but under six months and how many lasted over six months. Turning again to Section A of Table I I I we see that Group II artificial pneumothoraces accounted for the next high incidence of empyema (12 cases or I5- 4 per cent), Similarly section B shows that 25. 4 per .cent of the other artificial pneumothoraces were in this,group. Group I I I accounted for lO. 3 per cent of empyemas in the sample. 11 "4 per cent of all-other artificial pneumothoraces fell into this group. The free artificial ,pneumothoraces in Group I and Group V numbered together only i i cases or 5"5 per cent and no empyemata were found arising from this type of artificial pneumoth0rax. There is "no necessity to elaborate this further. A glance at Table III reveals the position better than words. Thug Groups II and IV between them accounted for the majority of artificial pneumothoraces. Similarly , most empyemas followed this type of artificial pneumothorax and most of the non-pui'ulent fluids. When they are analysed they are seen to have two things in common: (a) the presence of adhesions, and (b) the persis.tence of cavities. In other words, they" are contraselective artificial pnennlothoraces.
June
TUBERCLE
1950
133
TABLE I I I
Free. artificial pneitmolhorax
Duration A.P.T.
Adhesions visible Adhesions present Adhesions present Free artificial but no and and pneumothorax 'grolmd-glass' 'ground-glass' 'ground-glass' but collapsed opacity. All these opadty of a opacity of a and cases have cavities, lobe or entre lung lobe or entire hmg. "'ground-glass'sonic cases 'hone)'- but no visible Cavity obvious like upper lobe comb' in tape cavities on x-ray containing a cavity
Group I Group II Group III Group IV Group V of Under Over U n d e r Over Under Over Under Over Under Over 6 mths, 6 mths. 6 mths. 6 mths. 6 mths. 6 mths. 6 mths. 6 mths. 6 mths. 6 mths.
Section A Arrangementof 78 empyemas m groups according to the radiological appearances of their causal A.P.T.s Section B Analysis of sample, i,e. 2Ol A.P.T.s (not developing empyema) according to their radiol o g i c a l appearances
Percentages of A . P . T . s in each group
Nil
Nil
5
7
3
5
i2
8
I5"4%
6
Nil
1o
6
~r7
Io'3%
2
15
.37
x7
Flifid Nil
Fluids Fluids
Total 6
Total I2
Nil
3%
2
I2
~4 Total 39
25"4%
The most important group of cases, Group IV, has, in addition, that 'ground-glass'like milky radiological appearance around the vomica due to atelectasis. Clearly then the first criterion in choosing a case for domiciliary active therapy is that it should be radiologically suitable for collapse "therapy with the least risk of complications. It is dangerous to have cases in Groups II, I I I and IV above, in the home. This rules out many cases from the
28
3~
Nil
Nil
Nil
5
58 74"4%
3x
36
67
Fluids Fluids Fluids 5 I6 33 6 49 Total Total Total Total 3 20 47 69 Fluid
5 Nil
i
II"4%
57"7%
--
Fluids Nil Total 5
2'5%
start in which an artificial pneumothorax might be cautiously tried were,they under our constant eye in hospital. The patient must be. co-operative and understand the position and aim of treatment. It is insisted that the patient has his or her own bed, if not bedroom, and that there is someone at home who can cook and convey meals to the patient's bedroom~ At the outset Ipersonally surveyed the'patient's home conditions but found that pressure of
134
TUBERCLE
work ofici~ prevented this and the health visitor now visits the homes and reports on conditions. At first glance one would think that the scheme will bc of no help to patients 9in poor social conditions but will only help their better-off fellows. This is not so. We have drawn patients from all classes provided they have.a bed to themselves, that they are co-operative and that there is someone else at home to fetch and carry for them. Health visitors pay unexpected calls on patients suspected of not co-operating. So far only one such patient has been caught out. The majority are only too keen to have the treatment. The case is chosen, interviewed at the Clinic and the method of the proposed treatment during his w a i t i n g period for ,'{dmission to sanatorium, explained. At first we delayed treatment tintil the case had produced a positive sputum result, often after laryngeal swab culture and a lapse of several weeks. Lately several cases have had treatment Commenc6d on radiological and Clinical evidence while laryngeal swabs and gastric lavages have been taken during the morning that the patient is in hospital for the first treatment. This saves time. A letter to the General Practitioner explains the scheme and h e is asked to communicate with the sanatorium at once, by telephone, should any complications arise as a result of the treatment. The surgeon is contacted and the case is admitted to hospital by ambulance on the morning that the phrenic nerve crush can be done. The newcomer is placed in a cubicle beside a sensible, old-term patient, who explains the ways of the institution and preycnts alarm. That first day an x-ray is taken, the weigh.t, history and blood sedimentation rate recorded, a pncumopcritoncum induced and a phrcnic nerve crush done. The following day, after pneumopcritoncu'm refill and early morning gastric lavage if sputum is negative, the patient is taken hbme by anabulance to bed. They return by ambulance in three days
June
1950
for a refill and removal of stitches and thereafter come up weekly as sitting cases in an ambulance with other D.A.T. cases, in time for screening sessions, after which they have a refili and are conveyed home again. Domiciliary cases are instructed to chart their own temperatures and produce the charts when up for refills. They have peri6dic blood sedimentation rates, weight records weekly, sputum tests and x-rays as required. When the time is considered ripe they are admitted for approximately five days for artificial pneumothorax induction and then return home and come up for weekly refills by ambulance. In all cases they are admitted within two or three weeks ofinduction or as soon as there is sufficient space, for thoracoscopy and adhesion section, and'tilts entails a further five or six days in hosbital. The pneumoperitoneum is abandoned if a good free artificial pneumothorax is obtained. Finally the patient is admitted, often with an established free artificial pneumothorax, when the turn on the list comes round or at anytime, at once, ira complication develops. It may well bc asked why we insist on a ph'renic crush and pneumoperitoneum at the onset" and why we do not embark on an artificial pneumothorax at once. There are two good reasons: (a) those early'cases often have some pyrexia and 'soft' disease and i t is better to let this settle and prepare the lung for safe r artificial pneumothorax therapy with a phrenie crush and pneumopcritoneum for a few months; (b) to ascertain if the patient is ~mentally suitable for domiciliary activ6 therapy. I feel that an artificial pneumothorax might be iziduced and the patient, away from daily hospital, contact, might give it up and later rue the day he or she cannot have another artificial pneumothorax when finally admitted. The following case vividly illustrates the importance of a testing spell with pneumoperitoneum: A married woman (30 years) with 2 clfildren and living apart f r o m h e r husband was found to have pulmonary tuberculosis.
June
1950
TUBERCLE
The lesion consisted of two, smallish right mid-zone cavities with surrounding infiltra{ion. She was non-toxic. It was arranged that her children should stay with the patient's sister who lived near-by and that the sister would ~6ok and carry meals to the patient. She had a right phrcnic nerve crush and pneumoperitoneum induction in J u l y 1949. In August 1949 the patient complained of abdominal pain when up for refill and was admitted at once. During the following two days she developcd a profound maniacal statc for which she required certification and removal to a inental home. The pneumoperitoneum was discontinued there. In early December 1949 the patient was discharged, apparently sane. The fact 6f having to be separated from her children had upset her originally but now she was reconciled to it. Her right mid-zone had improved though the two cavities persisted. and she was admitted to the sanatorium where I was able to induce a good artificial pneumothorax.
135
peritoneum w c r c d o n e ill all attcinpt to hold the disease in situ, as it were, so that the cases might have major surgery when they wcrc admitted. In each case thoracoplasty was done within a few days of their final admission and one man took his discharge as soon as his second and last stage was completed. The other did not stay long either. It was felt that those major surgical cases must live in the atmosphere of a sanatorium for a period before the operation in order to become imbued with the idea of physiotherapy and sanatorium regime, etc. (3) There is a very marked psychological effect for the better in our patients.having domiciliary active therapy. They like the weekly jaunt to hospital by the ambulance which picks several of them up in its round. They benefit by the gossip with their fellows and the in-patients they meet, they are cheered by a warm cup of tea, and they recognize that something is being done for them. Wc finally admit all cases to assess their capabilities in terms of hours up daily and capacity for exercise and to complete their Some Observations education as regards the necessity for (i) The charting of morning and evening regular rest, etc. (4) It has bccn my experience that the tcmpcraturcs by tile patients is of value. In one case we noted a sharp rise of temperature ideal types of case for D.A.T. arc few. Perof two days' duration when t h e Patient was haps our standards in artificial pneuino9up for pneum6peritonefini refill and in the thorax therapy are too strict but I do not absence of clinical signs of peritoneal effusion think so. The fact remains that the majority nevertheless admitted the patient. A peri- of case~ of pulmonary tuberculosis are so far toneal effusion appeared in a week but advanced by the time they are first diagnosed that artificial pneumothorax would be absorbed eventually. In another recent case a girl of 19 years dangerous and many of them require the had reached tile stage of having a good, free more extensive surgical collapse measures. right artificial pneumothorax with no effu- This fact "considei:ably limits the numbers sion. The radiological appearances could not for whom the scheme is suitable. (5) It is essential that the physician explain her persistent slight evening rise of temperature. She, too, was admitted and an running'a D.A.T. scheme should have close early tuberculous lesion of the lower lumbar liaison and co-operation from the surgical spine discovered with cold abscess just tea.m. I have been fortunate in having had palpable above the upper half of Poupart's the phrenic crush operations done within a few days of my request. Similarly there has ligament. (o) We had two cases v?ith localized been no delay in obtaining thoracoscopy. apical cavities in which it was dccidcd it Efficient artificial pneumothorax therapy was unwise to try artificial pncumothorax cannot be done where cases have to wait therapy. Phrenic nerve crush and pneumo- weeks or months for adhesion sections. Thus
136
June 1950
TUBERCLE
the scheme can best be worked only in places where prompt surgical measures are forthcoming when they are required. (6) T h e sanatorium nursing staff appreciate the fact t!mt they can handle those early cases and ofie of the sisters often asks me " W h e n are we going to get some more D.A.T. cases?" (7) As regards the numbers that can be handled, I should say approximately i.o or 15 per h o u r is a good average if one allows for the taking of blood sedimentation rates and new case histories when they crop up. (8) L a s t l y , I believe that the team responsib!e for running the scheme should have the final say in choosing the cases if they are submitted by several clinicians. Workers in the field have varying ideas about the capabilities of artificial p n e u m o t h o r a x and the ideal type of case for that therapy. Would it not be better to admit those cases with priority rather than r u n this scheme with the cost of an!bulance journeys, etc.? I think it would be better to admit those cases at once but the fact remains that we are so pressed with the advanced, untreatable cases who on public health grounds require segregation, that the early cases are squeezed out of the sanatorium. T h e D.A.T. scheme is a second-best ahernativc to sanatorium treatment bt/t is, nevertheless, of proved value. Some m a y ask if our cases arc, not so minimal (even though tubercle bacilli positive) that the v a s t majority would get better thenaselves. I think not. Hcllcr's (i947) classical work bears me out as well as my own observations that most of the 'positive' cases, unless receiving a good artificial p n e u m o t h o r a x or equivalent collapse, usnally relapse.
Summary (a) T h e reasons w h y domiciliary active therapy is required are mentioned with a brief description of a schenae which takes a patient through the stages of phrenic nerve crush, p n c u m o p e r i t o n c u m , artificial pneumothorax induction and adhesion section
with an avc,'agc of clcvcn nights in hospital. It is felt that the safety of the scheme hinges on the type of case that is picked for artificial p n e u m o t h o r a x therapy and for that reason the case records of 7,.oo6 patients over a nineteen-year period are reviewed a n d the complications of 703 artificial p n c u m o t h o races noted. Especial emphasis is placed on the type of artificial pncumothorax which causes complications and which, in .my Olfinion , it is dangerous to keep resting at holnc. (b) Reasons arc given why wc consider it better to start D.A.T. with a spell of p n c u m o p c r i t o n c u m therapy combincd with phrcnic nerve crush. (c) Some observations arc m a d e arising from our cxpcricncc with D.A.T. (d) It is considered tlmt the scheme has a definite place in our a r m a m c n t a r i u m as things stand today and that some form o f collapse therapy is bcttcr than none in the minimal, sputum-positive case. M y thanks arc d u c to Dr H. G. T r a y c r arid the surgical and nursing tcams in Bagulcy S a n a t o r i u m for their hclp and to the physicians at the Manchester Chest Clinic for collecting suitable cases for domiciliary, active, treatment. Bibliography Heller, R. (19.t.7) Tubercle, xxv:;, No. 3. Ministry of tteahh. 93,"o5/9h3. May 19t 7. Rev. Sect. I of appemllx to Mere. ~37/T (revised).
(Co'nlimted
from page 130.)
[16] Gottschall, Russell, and Bunney, William Edward 0938) A diluent for stabilizing tuberculin 'O.T.' diluted for tile Mantoux test, 07. hmnun., xxxw, lo3-115. [17] Wong,Sam C., and Ouyang, George (x94o) Studies on stability of dilute purified tuberculins, Proc. Soc. E.q,. Biol. and ,lied., XLV,83-86.. [zSI Holm,johannes, and I.ind, Poul (191~7) Standardization of tuberculin, Public Health Reporls, LXII, 18•-201.
[I9] Ilanan, Ernest B., and Ericks, Waher P. 0937) Precipitation of water soluble tuberculoprotein by hydrogen-lon conccntratlon, Amer. Rev. Tuberc., xxxxa, -044-9. [-00] Clark, W. M. (t 920) The Determinationof I lydrogen Ions. Williams & WilklnsCo., p. 83.
131
Observations on Active Domiciliary Treatment of' Cases of Pulmonary Tuberculosis By JAMES CUTHBERT Baguley Sanatorium, Manchester hi this area, as in others, there is a grave and increasing shortage of nurses with consequent empty sanatorium beds and mounting, waiting lists. There is a lack o f beds outside Sanatoria for the untreatable, chronic cases of puhnonary tuberculosis, so for urgent public health reasons, such as their proximity to young children, those advanced cases often encroach on the beds which could be better used in dealing with patients who haye minimal disease. We observed that by the time many of the cases with minimal disease had waited nine or ten months for admission to sanatorium the lesions had progressed just to that extent to make all the methods of collapse at our command futile. This then was where domiciliary active therapy (D.A.T.) was thought to have a place in our armamentarium. It was hoped that, by treating the cases in their homes during the ten months' waiting period; the disease could at least be held where it was, if not improved, so that surgery c o u l d be available when finally .the patient was admitted to sanatorium in his tuim. Cases have been treated by domiciliary active therapy since September f948 and we h a v e already drawn certain conclusions. The whole problem is .bound up' with the question of the safety or otherwise of having an early artificial pneumothorax case at home and outside hospital. The following brief digression explains the position: The individual case records of 7,2o6 patients with pulmonary tuberculosis who had been in Baguley Sanatorium between January I, I9~9, and J a n u a r y I, I948, were studied. The field comprised 2,I57.patients who died in hospital and 5,o49 who were discharged or left the hospital for one reason or another. The incidence o f tuberculous empyema comprised i46 cases distributed as shown in Table I.
"I'AI~I.E I
.,Vumbers
Percentage of total
Artificial p n e u m o t h o r a x therapy
93
63"7
Spontaneous p n e m n o t h o r a x
..
44
3oq
Causes other t h a n spontaneous pneumothorax, i.e. operative removal of diseased lung and Pott's disease, etc . . . . .
9
6.2
Totals
146
I oo.o
Causes
It was further noted that artificial pneumothoraces which had either no adhesion section or no adhesion section within three months of the onset o f empyema, had the latter complication in 9"5 per cefit of cases. Similar artificial pneumothoraces which had adhesion section three months or less before the onset of empyema, show an empyema incidence of I8. 3 per cent, i.e. the use of a cautery on adhesions in artificial pneumothoraces d o n e on advanced cases appears to i n c r e a s e ' t h e risk of empyema if the artificial pneumothorax is maintained. Further probing of the ar[ificial pneumotlmrax position revealed that the material from wlfich the "cases arose was for the most part advanced, i.e. RB 2 and RB 3 cases (Ministry of Health)' comprised 82- 4 per cent of all the admissions for the nineteenyear period under review while RB I were 2 per cent and all"negative cases (mostly R A 2) were" 15.6 per cent of admissions. Table II reveals that most of the artificial pneumothoraces and most of tl~e,resulting. empyemas were in RB 2 and RB 3 cases. With those classes of cases i t was noted that where there was pyrexia at the induction of an artificial pneumottiorax, the trend was for the onset of empyema to be earlier than if there were no elevation of temperature. Also, as regards the onset of clear effusions sufficient to cover the hemi-. diaphragm, it was noted that, in proportion,
132
TUBERCLE TABLE I I
Case classification N u m b e r i i n each class calculated as a per cent of 7,206 cases studied, I9~ 9 1948 .. . Percentage of i o 4 empyemas in each c l a s s . . P e r c e n t a g e s of 6/o artificial pneumothoraces in each class . . . .
"RA x R A e R B t
15-6
_.e.
RBe RB3RB2+RB
62
2o- 4
3
73
-~
3"2
73
23"8
3
82- 4 97
96-8
refills to positive pressures resulted in half as many effusions again as artificial pneumothoraces filled to a terminal negative pressure. Finally the radiological appearances o f the artificial pneumothoraces responsible for empyemata were analysed. It was possible to obtain the x-ray 0 f t h c artificial pneumo-" thorax which existed before the onset of 78 of the 93 cmpyemas due to artificial pncumothorax. Table I I I shows the radiological appearances of 5 main groups of artificial pncumothoraces into which the cases may be divided. Group ,I represents a 'free artificial pneumdthorax': There is concentric collapse of lung which comes freely away from the hilar region without apica! or mcdiastinal adhesions. Semi-aeration is present and no areas of gross opacity Or visible cavitation. Group / / . - H e r e there are adhesions visible between chest wall and lung, or apico-mcdiastinum and lung. Those cases have cavities, in some cases honeycomb" in type. There is, however, no 'ground-glass'like, milky opacity present. Group I I L - H e r e adhesions are present between the lung and chest wall and there is a 'ground-glass' opacity of a lobe or an entire lung but no visible cavities. Group IV has adhesions between lung and chest wall, 'ground-glass' opacity of a lobe or entire lung and a cavity or cavities visible on the x-ray. Group V is an apparently free artificial
June 1950
pne~lmothorax with 'ground - glass'- like upper lobe containing a cavity. It will be at once seen (Section A, Table III) that 74"4 per cent o f the empyemata arise from artificial pneumothoraces in Group IV. O f the 58 cases of empyemata from artificial pneumothoraces in Group'IV, 28 cases arose within six months and 30 cases longer than six months from artificial pneumothorax induction. Section B of Table I I I shows the results of an analysis of a sample of 2Ol artificial pneumothoraces in which empyema did not develop.. The majority (57"7 per cent) or x 16 cases are in Group IV. 67 had no fluid copious enough to cover the hemi-diaphragm or to warrant aspiration, while 49 developed non-purulent fluid. The table indicates how many of the artificial pneumothoraces lasted over one month but under six months and how many lasted over six months. Turning again to Section A of Table I I I we see that Group II artificial pneumothoraces accounted for the next high incidence of empyema (12 cases or I5- 4 per cent), Similarly section B shows that 25. 4 per .cent of the other artificial pneumothoraces were in this,group. Group I I I accounted for lO. 3 per cent of empyemas in the sample. 11 "4 per cent of all-other artificial pneumothoraces fell into this group. The free artificial ,pneumothoraces in Group I and Group V numbered together only i i cases or 5"5 per cent and no empyemata were found arising from this type of artificial pneumoth0rax. There is "no necessity to elaborate this further. A glance at Table III reveals the position better than words. Thug Groups II and IV between them accounted for the majority of artificial pneumothoraces. Similarly , most empyemas followed this type of artificial pneumothorax and most of the non-pui'ulent fluids. When they are analysed they are seen to have two things in common: (a) the presence of adhesions, and (b) the persis.tence of cavities. In other words, they" are contraselective artificial pnennlothoraces.
June
TUBERCLE
1950
133
TABLE I I I
Free. artificial pneitmolhorax
Duration A.P.T.
Adhesions visible Adhesions present Adhesions present Free artificial but no and and pneumothorax 'grolmd-glass' 'ground-glass' 'ground-glass' but collapsed opacity. All these opadty of a opacity of a and cases have cavities, lobe or entre lung lobe or entire hmg. "'ground-glass'sonic cases 'hone)'- but no visible Cavity obvious like upper lobe comb' in tape cavities on x-ray containing a cavity
Group I Group II Group III Group IV Group V of Under Over U n d e r Over Under Over Under Over Under Over 6 mths, 6 mths. 6 mths. 6 mths. 6 mths. 6 mths. 6 mths. 6 mths. 6 mths. 6 mths.
Section A Arrangementof 78 empyemas m groups according to the radiological appearances of their causal A.P.T.s Section B Analysis of sample, i,e. 2Ol A.P.T.s (not developing empyema) according to their radiol o g i c a l appearances
Percentages of A . P . T . s in each group
Nil
Nil
5
7
3
5
i2
8
I5"4%
6
Nil
1o
6
~r7
Io'3%
2
15
.37
x7
Flifid Nil
Fluids Fluids
Total 6
Total I2
Nil
3%
2
I2
~4 Total 39
25"4%
The most important group of cases, Group IV, has, in addition, that 'ground-glass'like milky radiological appearance around the vomica due to atelectasis. Clearly then the first criterion in choosing a case for domiciliary active therapy is that it should be radiologically suitable for collapse "therapy with the least risk of complications. It is dangerous to have cases in Groups II, I I I and IV above, in the home. This rules out many cases from the
28
3~
Nil
Nil
Nil
5
58 74"4%
3x
36
67
Fluids Fluids Fluids 5 I6 33 6 49 Total Total Total Total 3 20 47 69 Fluid
5 Nil
i
II"4%
57"7%
--
Fluids Nil Total 5
2'5%
start in which an artificial pneumothorax might be cautiously tried were,they under our constant eye in hospital. The patient must be. co-operative and understand the position and aim of treatment. It is insisted that the patient has his or her own bed, if not bedroom, and that there is someone at home who can cook and convey meals to the patient's bedroom~ At the outset Ipersonally surveyed the'patient's home conditions but found that pressure of
134
TUBERCLE
work ofici~ prevented this and the health visitor now visits the homes and reports on conditions. At first glance one would think that the scheme will bc of no help to patients 9in poor social conditions but will only help their better-off fellows. This is not so. We have drawn patients from all classes provided they have.a bed to themselves, that they are co-operative and that there is someone else at home to fetch and carry for them. Health visitors pay unexpected calls on patients suspected of not co-operating. So far only one such patient has been caught out. The majority are only too keen to have the treatment. The case is chosen, interviewed at the Clinic and the method of the proposed treatment during his w a i t i n g period for ,'{dmission to sanatorium, explained. At first we delayed treatment tintil the case had produced a positive sputum result, often after laryngeal swab culture and a lapse of several weeks. Lately several cases have had treatment Commenc6d on radiological and Clinical evidence while laryngeal swabs and gastric lavages have been taken during the morning that the patient is in hospital for the first treatment. This saves time. A letter to the General Practitioner explains the scheme and h e is asked to communicate with the sanatorium at once, by telephone, should any complications arise as a result of the treatment. The surgeon is contacted and the case is admitted to hospital by ambulance on the morning that the phrenic nerve crush can be done. The newcomer is placed in a cubicle beside a sensible, old-term patient, who explains the ways of the institution and preycnts alarm. That first day an x-ray is taken, the weigh.t, history and blood sedimentation rate recorded, a pncumopcritoncum induced and a phrcnic nerve crush done. The following day, after pneumopcritoncu'm refill and early morning gastric lavage if sputum is negative, the patient is taken hbme by anabulance to bed. They return by ambulance in three days
June
1950
for a refill and removal of stitches and thereafter come up weekly as sitting cases in an ambulance with other D.A.T. cases, in time for screening sessions, after which they have a refili and are conveyed home again. Domiciliary cases are instructed to chart their own temperatures and produce the charts when up for refills. They have peri6dic blood sedimentation rates, weight records weekly, sputum tests and x-rays as required. When the time is considered ripe they are admitted for approximately five days for artificial pneumothorax induction and then return home and come up for weekly refills by ambulance. In all cases they are admitted within two or three weeks ofinduction or as soon as there is sufficient space, for thoracoscopy and adhesion section, and'tilts entails a further five or six days in hosbital. The pneumoperitoneum is abandoned if a good free artificial pneumothorax is obtained. Finally the patient is admitted, often with an established free artificial pneumothorax, when the turn on the list comes round or at anytime, at once, ira complication develops. It may well bc asked why we insist on a ph'renic crush and pneumoperitoneum at the onset" and why we do not embark on an artificial pneumothorax at once. There are two good reasons: (a) those early'cases often have some pyrexia and 'soft' disease and i t is better to let this settle and prepare the lung for safe r artificial pneumothorax therapy with a phrenie crush and pneumopcritoneum for a few months; (b) to ascertain if the patient is ~mentally suitable for domiciliary activ6 therapy. I feel that an artificial pneumothorax might be iziduced and the patient, away from daily hospital, contact, might give it up and later rue the day he or she cannot have another artificial pneumothorax when finally admitted. The following case vividly illustrates the importance of a testing spell with pneumoperitoneum: A married woman (30 years) with 2 clfildren and living apart f r o m h e r husband was found to have pulmonary tuberculosis.
June
1950
TUBERCLE
The lesion consisted of two, smallish right mid-zone cavities with surrounding infiltra{ion. She was non-toxic. It was arranged that her children should stay with the patient's sister who lived near-by and that the sister would ~6ok and carry meals to the patient. She had a right phrcnic nerve crush and pneumoperitoneum induction in J u l y 1949. In August 1949 the patient complained of abdominal pain when up for refill and was admitted at once. During the following two days she developcd a profound maniacal statc for which she required certification and removal to a inental home. The pneumoperitoneum was discontinued there. In early December 1949 the patient was discharged, apparently sane. The fact 6f having to be separated from her children had upset her originally but now she was reconciled to it. Her right mid-zone had improved though the two cavities persisted. and she was admitted to the sanatorium where I was able to induce a good artificial pneumothorax.
135
peritoneum w c r c d o n e ill all attcinpt to hold the disease in situ, as it were, so that the cases might have major surgery when they wcrc admitted. In each case thoracoplasty was done within a few days of their final admission and one man took his discharge as soon as his second and last stage was completed. The other did not stay long either. It was felt that those major surgical cases must live in the atmosphere of a sanatorium for a period before the operation in order to become imbued with the idea of physiotherapy and sanatorium regime, etc. (3) There is a very marked psychological effect for the better in our patients.having domiciliary active therapy. They like the weekly jaunt to hospital by the ambulance which picks several of them up in its round. They benefit by the gossip with their fellows and the in-patients they meet, they are cheered by a warm cup of tea, and they recognize that something is being done for them. Wc finally admit all cases to assess their capabilities in terms of hours up daily and capacity for exercise and to complete their Some Observations education as regards the necessity for (i) The charting of morning and evening regular rest, etc. (4) It has bccn my experience that the tcmpcraturcs by tile patients is of value. In one case we noted a sharp rise of temperature ideal types of case for D.A.T. arc few. Perof two days' duration when t h e Patient was haps our standards in artificial pneuino9up for pneum6peritonefini refill and in the thorax therapy are too strict but I do not absence of clinical signs of peritoneal effusion think so. The fact remains that the majority nevertheless admitted the patient. A peri- of case~ of pulmonary tuberculosis are so far toneal effusion appeared in a week but advanced by the time they are first diagnosed that artificial pneumothorax would be absorbed eventually. In another recent case a girl of 19 years dangerous and many of them require the had reached tile stage of having a good, free more extensive surgical collapse measures. right artificial pneumothorax with no effu- This fact "considei:ably limits the numbers sion. The radiological appearances could not for whom the scheme is suitable. (5) It is essential that the physician explain her persistent slight evening rise of temperature. She, too, was admitted and an running'a D.A.T. scheme should have close early tuberculous lesion of the lower lumbar liaison and co-operation from the surgical spine discovered with cold abscess just tea.m. I have been fortunate in having had palpable above the upper half of Poupart's the phrenic crush operations done within a few days of my request. Similarly there has ligament. (o) We had two cases v?ith localized been no delay in obtaining thoracoscopy. apical cavities in which it was dccidcd it Efficient artificial pneumothorax therapy was unwise to try artificial pncumothorax cannot be done where cases have to wait therapy. Phrenic nerve crush and pneumo- weeks or months for adhesion sections. Thus
136
June 1950
TUBERCLE
the scheme can best be worked only in places where prompt surgical measures are forthcoming when they are required. (6) T h e sanatorium nursing staff appreciate the fact t!mt they can handle those early cases and ofie of the sisters often asks me " W h e n are we going to get some more D.A.T. cases?" (7) As regards the numbers that can be handled, I should say approximately i.o or 15 per h o u r is a good average if one allows for the taking of blood sedimentation rates and new case histories when they crop up. (8) L a s t l y , I believe that the team responsib!e for running the scheme should have the final say in choosing the cases if they are submitted by several clinicians. Workers in the field have varying ideas about the capabilities of artificial p n e u m o t h o r a x and the ideal type of case for that therapy. Would it not be better to admit those cases with priority rather than r u n this scheme with the cost of an!bulance journeys, etc.? I think it would be better to admit those cases at once but the fact remains that we are so pressed with the advanced, untreatable cases who on public health grounds require segregation, that the early cases are squeezed out of the sanatorium. T h e D.A.T. scheme is a second-best ahernativc to sanatorium treatment bt/t is, nevertheless, of proved value. Some m a y ask if our cases arc, not so minimal (even though tubercle bacilli positive) that the v a s t majority would get better thenaselves. I think not. Hcllcr's (i947) classical work bears me out as well as my own observations that most of the 'positive' cases, unless receiving a good artificial p n e u m o t h o r a x or equivalent collapse, usnally relapse.
Summary (a) T h e reasons w h y domiciliary active therapy is required are mentioned with a brief description of a schenae which takes a patient through the stages of phrenic nerve crush, p n c u m o p e r i t o n c u m , artificial pneumothorax induction and adhesion section
with an avc,'agc of clcvcn nights in hospital. It is felt that the safety of the scheme hinges on the type of case that is picked for artificial p n e u m o t h o r a x therapy and for that reason the case records of 7,.oo6 patients over a nineteen-year period are reviewed a n d the complications of 703 artificial p n c u m o t h o races noted. Especial emphasis is placed on the type of artificial pncumothorax which causes complications and which, in .my Olfinion , it is dangerous to keep resting at holnc. (b) Reasons arc given why wc consider it better to start D.A.T. with a spell of p n c u m o p c r i t o n c u m therapy combincd with phrcnic nerve crush. (c) Some observations arc m a d e arising from our cxpcricncc with D.A.T. (d) It is considered tlmt the scheme has a definite place in our a r m a m c n t a r i u m as things stand today and that some form o f collapse therapy is bcttcr than none in the minimal, sputum-positive case. M y thanks arc d u c to Dr H. G. T r a y c r arid the surgical and nursing tcams in Bagulcy S a n a t o r i u m for their hclp and to the physicians at the Manchester Chest Clinic for collecting suitable cases for domiciliary, active, treatment. Bibliography Heller, R. (19.t.7) Tubercle, xxv:;, No. 3. Ministry of tteahh. 93,"o5/9h3. May 19t 7. Rev. Sect. I of appemllx to Mere. ~37/T (revised).
(Co'nlimted
from page 130.)
[16] Gottschall, Russell, and Bunney, William Edward 0938) A diluent for stabilizing tuberculin 'O.T.' diluted for tile Mantoux test, 07. hmnun., xxxw, lo3-115. [17] Wong,Sam C., and Ouyang, George (x94o) Studies on stability of dilute purified tuberculins, Proc. Soc. E.q,. Biol. and ,lied., XLV,83-86.. [zSI Holm,johannes, and I.ind, Poul (191~7) Standardization of tuberculin, Public Health Reporls, LXII, 18•-201.
[I9] Ilanan, Ernest B., and Ericks, Waher P. 0937) Precipitation of water soluble tuberculoprotein by hydrogen-lon conccntratlon, Amer. Rev. Tuberc., xxxxa, -044-9. [-00] Clark, W. M. (t 920) The Determinationof I lydrogen Ions. Williams & WilklnsCo., p. 83.