Rest Therapy in Pulmonary Tuberculosis

Arnt

Rest Therapy in Pulmonary Tuberculosis iudi('" IiOlls and the limitation' BY after Cln-i ...t, employed oL which \\ e are gr'aduall! J, W, HUSTON, M,D. l'e~t therapy for the t reatmen t leu t uing more. Ashe" ille ,NC of his tu hereulous, pa tients, The axiom that "the repan and It remains th e time-proved uu-thod of the diseased t issue is best furthered of t rea t men t upon w hi« It we ~till depend. !I,\" courplel e rest of the diseased part' '\Tit h the addition of PIH. awl i ... jn:-.t as true today as it was when sur ot lu-t- . . nrgicul aids to lllal\.(, re . . t of t hr- geou- first cal led 0111' attention to it, (li~ea~ell area more effect ii P, an era of upplicntion in the tn-anuent of pulmon increuserl interest in the t u-a t inent of pul- .u-v t n herculosis by their success in tUt 1l1OlHU'.' tuberculosis IIPgCln. "'hen t lut reutuient of Lone and joint manifesta surgeon became J r.t.ivvly allied \\ it h the t ions of the disease. uuei uist in the care of t lle~e purieu t~, a The question t h ..r t HOW coufronts us h 1lI0l'C aggl'l'~sive treatment \\ a~ instituted. Ha ve we a t-rived at a period in the treat Over enthusiasm resulted, however, in meut of pulmonary tuberculosis wht:'rt iuany operations that pro\ ell to be ill IJ~ means of surgical procedures we can all vised; not only were thej not hel pf'ul, I-lafely immobilize the affected lung, and obtain a sat istuctory cure, while the pa hut some were dist invt lj harmful. "'-\ Ie" tient remains mobile and. carries on hl' yecll's ago a ]al'ge III Ull iri pal hospital reported that phrenicectomies were heing usual activities? Before concl usicns are dra wn we done on practically all patients enteriug the hospi tal. should review the results obtained o! At present there art' those advocating strict bed-rest, both with and without pneumothorax for minimal eases with a the surgical adjuncts which I regard il' vie» to permitting the patient to COIl- ndditicns to rest therapy. The physiological reasons for bed-rest t inue at work. There are to be found in uud the serious effects that result in tht our medical journals report- of the treat uren t of bilateral c.ivi ty tuberculosis by patient \\ 110 disregards the need for re~t meuns of bilateral pneumothorax in am- should a lso he considered. If, IJ.) resorting dh-oct ly to surgery, Ole bu lutorj paticnts. Other \\ riters vigorresults are as good as those obtained (Jll~l'y conrlenm the U~E' of surgical treatment uutll serial films show that Pl'O- through rest and its surgical ad [unrtthen hy all means we should resort tli gl'C:-'S cunuot Ill' expected 11.\ ~tl'kt hedl'l'::-'t. surgery and. relieve this vast army of suf "-Hh a d isregut (1 uf the importance ferers of much expense and loss of time But, if surgery and ambulatorj or pal ot :-.egl·l'gat ion a~ a mea n-, of checking the :-,pl'ead of the disease, IIIuch has been tially ambulatory treatment fails to meet \\ i-itten to encourage the family ph~'~ician the requirements for the majority of pa to edlTY on "home treatment", \\ hich tients, then great care should. he exercised usually must be (lone without the facili- in the type of treatment selected for the ties considered neces~aI'J for good work individual case. by the internist who specializes in the The tuberculous patient is ill only in care and treatment of the ttl berculous. proportion to the amount of tuberculo These divergent opinions serve to con- toxins that finds its way into the blood fuse both the patient and his phvsician, stream. If a tuberculous patient is given and make adv isable a review of OUf val'· tuberculin subcutaneously, in sufficient iOlll'\ thel>apeutie procer1uI'e~, ahout the amounts, both s;ystemic and focal symp G -\.LE:\" , ,,110 \\ ,1:-. lrm-n 1:10

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1937

] )J~EA~E~ OF 'l'HE CHBRT

toms will result. Headache, fever, general aching over the body. nausea and vomiting are complained of, and an examination of the chest "ill show congestion, rules, and other signs of increased activity in the affected area, The tuberculous patient can duplicate these signs and symptoms any time that he indulges in a sufficient amount of exercise, Just as there are different degrees of reaction to various-sized doses of tuberculin; so there are moderate or severe symptoms that follow different amounts of physlcal exercise, Some years ago only the toxic fever ease was considered a subject for bed rest. Following the loss of fever the patient was allowed up and more or less mobile, Now, however, w e have learned that progress continues most rapidly if rest is uninterrupterl : that mohili tv of the patient Intet-fer-es with repair work and all too frequently leads to advancement of t he disease. 'Ve have learned that all r-l in icnl cases, however mild, should he placed at strict bed-rest because the same mechanism is required for the healing of the minimal as is required for the more advanced easp, Occasionally we see recover-ies w ith a Ip",,~ strict regime, and w e know that so me patients recover without any trea t men t just as some do in other infections, Il11t no patient can afford to exper-iment for the purpose of learning whether 01' not he be in that class, Pottenger, in a palJcr on The Physiological Basis of Rest as a Therapeutic )[easure in Pulmonary Tuberculosis! says: "Twenty per cent more effort is required to sit quiet ly in a chair than to lie in heel; one hundred per cent more is required to walk a bout and three to four hundred per cent more for strenuous exercise, "Two hundred fifty to three hundred c.c. of air is required per minute while at rest, and for moderate exercise six hundred to sixteen hundred c.c. "The healthy pulse rate, while resting,

is from seventy to eigh t~ ; under moderate exercise from one hundred to one hundred twen ty. and for strenuous exercise a rate of one hundre-d fifty to two hundred is necessary, . "The heart output is four or five liters per minnte while the borlv is at rest arul twenty liters when at work. The hloorl pressure must rise fifty to sixty mm to maintain sufficient oxygen for exercise. "Under normal conditions the Increased output of the heart is accomplished lJ.'greater ventr-icular activity with a relative increase in rate whi1~ in the tuber culous patient response is mainly by increased hern-t rate and is deficient in ventr-icula r response." Even when the patient lies, quietly in bed the respiratory rate is more than 1000 per honr, and "hen he stands on his feet the respiratory arid circulatory load is markedly increased: there is more movement of the diseased area; lymph flow is stimulated, and a greater volume of pulmonary hlood carries into the goenoral circulation increasing amonnts of tuhercnlotoxins. On the other hand. slowing of the pulmonary circulation and intl'easing stasis of the lymph lessen the amount of toxin'S carried in the blood stream and favor healing. ~erial films show that absorption of exudates and debris takes place when the affected area is sufficiently immobile ~ \.hsorption is hindered, or prevented, if the patient is tuherculinizerl hy the frequent flooding of the circulation hy toxins, Cough and sputum are reduced fiR immobilization becomes effective. but aggravated by increase of respiratory and r-irculatorv effort. Strict bed-rest gives splendid results for the early involvement, and no other form of treatment should he considered for the exudative type unless the allergic response has been so severe that necrosis of tissue and cavitation has taken place. \\~ith Len-rest alone many moderately advanced cases do welt and small cavities ma v disappear, hut, if the cavity is more than t" 0 centimeters in diameter, or has 9

DISE~\.SES

OF 'rHE CHEST

thickened walls, bed-rest will prove insufficient. If the lung is not adherent to the chest wall a collapse by pneumothorax closes cavities, immobilizes the diseased area, and favors healing by fibrosis. Rarely do we find a case that is free from adhesions, but, by maintaining an even pressure through frequent refills of ~50 to 350 c.c, of air. we may gradually produce an effective collapse. Pleural effusion is not so frequent a complication where small refills are repeated at intervals that keep the presRUl'C as uniform as possible. If an r-ff'usion occurs, the fluid should Ill' removed am] replaced hy ail'. Often we again get a drv pleural cavity, hut, if the fluid is allowed to remain, we frequently 'lose the pneumothorax. Adhesions that prevent collapse may be severed hy pneumolysis. if they he accessible, or we may consider reducing the tension of an adhesion by phrenicectomy. Certain thick-walled cavities in the f'ii-st interspace area are recognized by the experienced observer as being unsuitable for closure hy pneumothorax. He recognizes the fact that such areas tightly adhere to the pleural nome, and, although the remainder of the lung may he nicely collapsed hy ga~, the cavity will remain open. He may choose to do a partial thoracoplasty with or without the collapse of the remainder of the lnng by penumothnrax, depending on the amount of pathology present. 'Vith an extensive involvement through a greater portion of the lung the complete thoracoplasty would he Indicated. In 1916, ebb 2 first pointed out the advantages of postural rest, and the use of shot-hags. For a cavity in the upper part of the chest a shot-bag of about three pounds may he placed over the affected area so that movement of that part will he reduced to the minimum. Air in that portion of the lung is reduced, atelectusis of some degree takes place, and a collapse of the cavity tends to follow. For im olvements lower in the lung

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the patient is placed on a firm pillow on the affected side. a similar effect Of curring when the weight of the horh restricts movement of the affected are: Placing the patient on the affected sid~ has been of value to me in some cases an~ the use of the shot-bag in the upper lob has closed cavities for me, but the treat ment must be continued over a long period of time if the cavity is to remain closes The use of either posture or shot-bags i\ justified when a pneumothorax is impos sihle and the patient's general condition forbids the use of thoracoplasty as tOil hazardous, hut pneumothorax and thoro coplasty are the operations upon whirl we must place onr reliance for effectiu results. Phrenicectomv, formerly tried for TIn merous types of lesions, has been disap pointing'. Corrylos" reports that in ~e lected basal lesions phrenicectomy is "lUI cessful in but 16 per cent of the cases and that he is convinced that the reportel successes of enthuslastic supporters 01 the operation are due to their use of it in benign, acute, exudative tuberculosis, ano that the patients recovered. not hecauof, but in spite of phrenicectomies. Good serial stereoscopic films a rr 01 the utmost importance. not only for diae nosis, hut for following the prozress o the case, and to determine the IlPPo. for surgical intervention, In a large percentage of cases snitabl fOJ' pneumothorax, an active lesion ,found in the opposite lung. In such case we have no choice but to maintan strict bed-rest and at the same time carr' on the pnenmothorax. Only infrequently do we get a perfet collapse by pneumothorax. but, if th cavity ts closed, and the sputum remaincontin nouslv neg-ative, it is effective. \ posit ive sputum means an unsa tisfactor pneumothorax. The location of the cavity and the siz of the hronchus into which it drains rlr terurines the effedivene...s with which" lllay collapse the cavity. (Continued to page 26)

193; Rest 'I'herapy in Pulmonary Tuberculesis-e-r Contmued from page 10) HNl-re~t lr('(ll1Plltl.\ inu kflf., effedh p a pu: t ial pnenurot lror.rx which i~ iueffective if the patient i~ mubi le Pneumolysis \\ ill allow a more complete collapse, hut f'requent ly tln- nrlhesion that 11011.18 the til\ ity opeu iH l'-,O hwatP41 t hn t it cannot be l·e
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References 1. Pottenger-s-Annuls of ClilIlcal jIed

iciue, September, 1924. :!. Ge1'411<.1 H. Webh - Colorado )!el! i.-ine, .May, 19:33. a. Coryllos-c-The Quarterly Bulletin iiI ~pa View H ospita I, October, 19i1:"). ::

PULfyIONARY CONDIr-fIONS The field of therapeutic application of intravenous medication has yet to be explored.

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afford physicians an opportunity to test out the value of well established remedies by a more modern and scientific method. The unerring accuracy of composition and uniformity of Loeser solutions furnish a means of safe and exact determination of therapeutic value. WE Offer:-

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GUAIACOL 02 gm and Iodme 45 Mg 1.'120 C c GUAIACALX GUaiacol 4 Gm and Calcium 90 Mg. in 20 c c CALCIUM CHLORIDE 25 Gm. m 5 c c -5'7(.' in 10 c c and 10% In 10 c c CALCIUM GLUCONATE 10% in 10 c c -10 t /o 111 5 c c CALCIUM GUAIACOL Sulphonate .66 Gm 1ll 20 c c SODIUM IODIDE 2 Gm. Guaiacol 0 2 Gm. in 20 c c HEMATONIC Iron and Arsenic 64 Mg Colloidal Iron Cacodylate 5 c c LITERATURE AND COMPLETE LIST ON REQUEST

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Actin-, agg ressive treatment herculou« h.rs shortened the disuhilitj awl runde recovery tuin, ~ul'gieal adjuncts h a ve covery possible for many who

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