- Email: [email protected]
The pneumothorax treatment of pulmonary tuberculosis
114
TUBERCLE
[December. 1919
.. Valeur semeilogique de Ill. Tuberculose fibreuse dans Ill. recherche de la Syphilis," Proqres Medical, April 26, 1913. .. Formes scrofuloides de Ill. Syphilis." Bulletin medical, May 28, 1913. See also.. Syphilis de l'appareil respiratoire sous-larynge " in the "Precis de Syphiligraphie du Professeur Gaucher" (Doin}, 1909.
THE P~EUMOTHORAX TREATMENT OF TUBERCULOSIS.l
PULMONARY
By CLIVE RIVIERE, M.D., F.RC.P. Physician, City of London Hospital for Diseases of the Chest. THE treatment of pulmonary tuberculosis by artificial pneumothorax has now achieved a fair hold in this country, and there can be few dealing with tuberculous cases who have not by now acquired some knowledge of its theory and practice. Since the subject is too wide to be covered in a single lecture, I shall presume at least a. nodding acquaintance with it on your part, and devote my time to such points as suggest themselves to me on account of their special interest or importance. Having published a small text-book on the subject some two years since. I am, perhaps, especially -desirous of laying stress on points which I then too lightly emphasised, but also of bringing forward certain matters which have forced themselves on my notice recently. I will not remind you here of the history of collapse of the lung in the treatment of tuberculosis, nOL' go into theories of its effects. I am anxious to stick to practical points! I will, therefore, wander over the headlines of the subject, anti pick out such points as may suit my present purpose.
INDICATIONS AND CONTRA-INDICATIONS.
Artificial pneumothorax stands apart from other methods of treating pulmonary tuberculosis especially in one particular namely, in the possession of more definite and clear - cut indications and contraindications. One of the unsatisfactory features about tuberculosi~ treatment in general is the very imperfect knowledge we have acquirel1 of the applicability of individual methods and remedies to individual cases. In spite of the variety that exists among cases in type, actiVit)". amount and location of disease, and other elements in the response of the individual's tissues, but very little is definitely known of the therapeutic indications which should be based upon them. True, the experienced physician acquires in process of time a certain intuition as to the therapeutic requirements of particular cases, but the grOunds on which it rests seldom become sufficiently clear and defined to enable him to hand on the results of his experience to others. No doubt our knowledge of the disease, and Qf the various actions of the remedies I
A lecture delivered at the Royal Institute of Public Health on November 13, 1919,
FIG. 2 -From same case as Fig. I, showing strained mediastinum. There is some fluid in right pleural cavi~y. right lung has disappeared from view, and half the width of the spine is uncovered on the right side.
FIG. a.-Arrow points to elliptical shadow of pleural pocket encroaching on the right lung. Collapsed left lung is adherent in many places.
December. UH9]
'l'UnnnCL£
115
we use, is still too imperfect to allow of our dovetailing them one into the other with any great accuracy, but still one cannot but feel that some clear thinking on the subject might enable us to " make the punishment fit the crime" more accurately. At present the treatment sheets over the beds of the average tuberculosis ward are, to say the least, a most uninspiring spectacle! Now the choice of pneumothorax treatment implies at the outset the fulfilment of two necessary conditions: (1) That one lung is so much diseased that its recovery under any known treatment while in an expanded and functioning state is despaired of. (2) That the other lung is a fairly good organ and not the seat of active tuberculosis. Outside these indications there still lies one class of case which calls for pneumothorax treatment on its own account, namely, hmmoptysis of a recurrent or dangerous type. Evidence of Hiius Tuberculosis.
Now the application of these axioms reduces the treatment in practice very largely to a particular class of case, namely to that with evidence of disease over the greater part of one lung. the other lung being comparatively free and generally appearing to be quite clear on the surface. These are undoubtedly cases of "central lung" or "hilus" tuberculosis in which disease has not been recognised as serious till it has reached the surface and rapidly spread over it. That they are not cases of " apical phthisis" will generally be borne in on you, when you have had a good deal of pneumothorax experience, by the beha.viour of the opposite lung. For .you ~ill fin~ that the area~ giving ~nxiety (and perhaps definite physical SIgns) WIll generally be 10 the neIghbourhood of the nipple in front, not at the apex, and it is just at this point that hilus disease so commonly comes within reach of the stethoscope. Now in these cases of apparent one-sided tuberculosis you must always be prepared to find extensive deep disease in the opposite (and apparently healthy) lung. I know no certain mea~s of ~eciding about this except the use of the X-rays, but ther~ .a re certain po~nts that may be of assistance. Thus the general condition of the patient may be too good to allow of more disease than is already obvious to the stethoscope. In particular his colour and breathing may be too good to be compatible with active disease on both sides of the che~t. Dyspnooa may be of a kind which is removable by collapse of the diseased lung (probably through the closing of its useless capillary channel~, ~nd the diversion ?f their blo~d into the functioning lung whereby anoxremia IS reduced); but If dyspncea IS marked, and particularly if it is accompanied by cyanosis, the probability is great that the" good .. lung is the seat of serious deep disease. I remember a patient with this condition being sent to me by a sanatorium physician for my opinion as to the advisability of a pneumothorax. The dyspncoa was marked, and was attributed by the physician to his cardiac condition, but I felt convinced there was extensive deep disease in what was called the" good lung," this being, indeed, quite free of surface signs of disease. A radiogram showed this to be the case, and enabled me to score off the sanatorium physician; but the radiologist scored off us both, for his plato also
116
TUBERCLE
[December, 1919
demonstrated a small localized spontaneous pneumothorax already present. at the top of the worst side, and quite unsuspected by either of us stethoscopists ! A certain amount and activity of disease is allowable in the better lung, that is as shown by the radiogram, but only experience of cases can teach how much or how little this may be. I shall not attempt to describe it here or to lay down any rules or formulas for its determination, but some of the prints I shall show you later' will give you pictures of lungs which have been accepted as good enough for pneumothorax, and which have justified this opinion by their subsequent behaviour. It must be remembered that in exchange for the strain of increased functioning. pneumothorax . treatment has certain decided advantages to offer the remaining and functioning lung. Above all the removal of .autoinoculation with its resulting deleterious focal reactions; possibly, in addition, a condition of hyperremia which is considered by many an important item in the cure of tuberculous foci in the working lung. Provided auto-inoculation can be removed without much displacement. of the mediastinum and thus interference with the functioning of the opposite lung, it is astonishing with wha.t confidence one can predict improvement throughout this organ when disease is of a quiet type. Pneumonic Phthisis.
There is a type of one-sided case which occasionally comes to pneumothorax, but in which the prognosis is far from rosy; I refer to pneumonic phthisis. In such cases disease nearly always becomes active in the opposite lung, and this has happened in the two cases which have so far come under my care. One I was able to keep alive and in fair health for some three years; in the other, disease on the opposite side became active but eight months after the pneumothorax was started. In such cases I think the fillings should be small and frequent, and the opposite lung should be under most constant supervision if succes, is to be rendered permanent. In both my cases the flare up OCCurred when the patients were out of reach of control and observation. THE
OPERATION.
And now as to the operation itself, of which I have but little new to say; In this country, to its credit, no other than a needling operation has ever, so far as I know, been attempted for artificial pneumothorax. I have had two patients, however, in whom the initial operation was performed by Brauer's method of open incision down to the pleura, and both these were done in Swiss sanatoriums under German physicians. In my opinion there is nothing to justify the "open method" of pneumothorax operation at the present day. A needle, or a trocar and cannula (I myself always use the latter), serves all the purposes of the initial operation, providing the usual safeguards are adopted. The patient should be reassured beforehand that but little, if any, pain or discomfort will be felt, more than that of the prick of the hypodermic needle for injection of novocain, and in skilful hands this should be strictly the truth. I
Figs. I, 2 and 3.
December, 1919]
TUBERCLE
117
The Physician's Responsibility. In practice the initial operation if skilfully performed should seem, and is, to the patient, So very small and simple matter, such difficulties and risks as attach to it being a matter of anxiety for the operator and not, in my opinion, for the patient. If the doctor is quite clear in his mind (and in most suitable cases there is little doubt about the matter) that So pneumothorax is indicated, then he should himself shoulder the burden of responsibility for all such possible accidents as may be bound up in it. The patient should of course be told what it is hoped to achieve, and also warned that success may be barred by unforeseen difficulties such as adherent pleura, but to put before So patient or even his friends the hypothetical risks of pleural shock, gas embolism and the like as some authors appear to have advised, is both cruel and foolish. At most the friends should be told that certain risks attend all chest punctures, but that they are remote ones and not to be expected in the ordinary course of things. Pleural Adhesions. The success or otherwise of a pneumothorax in a suitable case is at the outset bound up in the question of adherent pleura. If only a partial pneumothorax can b~ achieve.d,.particularly if, as tends to happen, the more diseased and cavity-containing portion of the lung is densely a.dherent to the surface, then the treatment will probably fail. This latter accident is fortunately more apt to arise in "apical phthisis," where apical cav.itation is near. the ~urf~ce and the pleura readily implicated, than in hilus tuberculosis, which IS, par excellence, the recruitingground of artificial pneumothorax. In these latter cases, cavitation is generally deep, and even if disease spreads throughout the whole lung from apex to base, it is fortunately quite common for a complete. pneumothorax to be obtainable. As for the influence of a few adhesions, apart from adherence of a whole apex or large part of 0. lobe, I think the disabling effects of such have been on the whole exaggerated. Such adhesions will gradually stretch or separate, and it must be but very rarely that measures Cor separating them (such as have been suggested by a surgeon in this country, an~ more r~cently ~y Holmboe in the new journal TUBERCLE) will be needed in practice. It IS, however,.to strong adhesions in the neighbourhood of cavities tha~ we owe ~ne or the dangers or pneumothorax-therapy, namely, the. risk of .openmg such a cavity, by rupture, into the pleural space. It IS Cor this reason, among others, that X-ray examinations are indispensable during the course of induction oC a pneumothorax, and particularly where there is cavitation within ncar reach of the surface. Intrapleural Pressures. Having obtained our pneumothorax let us suppose that it is a moderately U complete" one and that we have thus attained our main aim. There still remain causes for anxiety, because at each stage failure is waiting on our footsteps in case we anywhere mistake the path. And now the whole secret of success will revolve around the question of finding and maintaining an "optimum" pressure. This optimum pressure varies greatly for different cases, and also in the same case at different stages of
118
TUBERCLE
(December, 1919
treatment, and it is very difficult, in some cases impossible, to find it or to maintain it without the use of the X-rays. The longer my experience of pneumothorax treatment becomes the more insistent I find myself on the necessity of direct visualisation of the collapsed lung and adjacent organs from time to time. Especially must this be resorted to whenever difficulties arise. The Optimunc Pressure.
Now the optimum pressure might be expected to be the least pressure which will ma intain efficient collapse of the lung, but this definition does not cover the whole ground, as I at least see it. As IL rule many opposing factors have to be reconciled , and a more or Jess satisfactory compromise is often all that can be expected. On the one side is the need for sufficient pressure to collapse the lung, on the other side the effect of this pressure on surrounding organs, A weak mediastinum may forbid anything but a very moderate pressure, sometimes only atmospheric or but little above, being employed, and this must be particularly the case where the integrity of the functioning lung is in any doubt. Where the other lung shows any evidence of active disease and is a source of anxiety in treatment, I am quite contented with a very moderate amount of collapse at first, with small fillings at rather frequent intervals. These two radiograms show such moderate collapse at an early stage. Both cases had signs of disease about the anterior base on the opposite side, in both cases this amount of collapse was sufficient to abolish all toxic symptoms and restore the physical health, and in both cases this restoration was accompanied by a gradual removal of evidence of activity in the functioning lung. Their after history is rather different and on this account I will return to them again later on in my lecture, One of these was having refills of 400-500 c.c. of air every five, later rising to seven days, with an end pressure of about + 2 + 4 ern. H 20 ; the other (fig . 1) 1 fillings of 400 c.c. or so, la.ter rising to as much as GOO, ai intervals of five rising gradually to eight or nine days with end pressure of + 1 + 5 em. H 20. These notes refer to the con~ ditions during the early months of treatment. Now both these cases had massive caseous disease with softening throughout practically the whole of one lung, and under these conditions you must not expect the lung to collapse well at first, though it will gradually undergo a reduction in size. In one of these cases you will notice there were several adhesions present. These somewhat impeded the collapse of the lung, but they did not prevent in the slightest· the disintoxication which was hoped for, and I considered them a positive help in supporting the mediastinum a.t Do time when the other lung was in a somewhat critical state. It will be seen from the print that there was, in fact, no small amount of disease, fortunately of only moderate a.ctivity, in this other functioning lung. My advice then is at the beginning go slowly, aim at disintoxication of the patient, loss of fever, tachycardia, anorexia, and general illness, . and make the pulmonary colla.pse, ·qua collapse, 0. secondary consideration. Keep your attention on the mediastinum and the other lung, rather than on the collapsing lung at the outset of treatment. But here I find I must digress to warn you of pitfalls which may surround the advice I have just given you. It might seem a desirable I
Fig. 1 illustra.tes one or the ra.diogra.ms shown; the other is not reproduced here.
December, 1919J
TUBERCLE
119
thing, in cases where the better lung is none too good, to go forward so tentatively as only to " damp down," as it were, the intoxication arising Crom the bad lung, or at most but partially to collapse it, with moderate fillings given at longish intervals. This attempt, theoretically so desirable, is unfortunately but seldom permissible in practice, for these fillings, forcing out toxins each time into the blood-stream , generally lead to reactions, both general and focal, which in cases of severe disease may reach an alarming intensity. To avoid these the lung may have to be further collapsed, though it need not be " compressed;" but sometimes a judicious shortening of the intervals between the refills, and thus of the amount of gas required, may suffice to abolish reactions where these are moderate, in cases where the lung is not, or cannot be, fully collapsed. Now the point to be ultimately aimed at is, as I have hinted, a compromise between the resistance of the lung to collapse and the stability of the mediastinum, both as a whole and also in its parts, for it may form a fairly strong partition, and yet possess weak spots as we shall see presently. The stability of the mediastinum varies very greatly in different individuals, and, where it is weak, an efficient pneumothorax may only be maintained with difficulty. Just as you cannot flatten out a fly, or even IJ, mosquito, against a yielding curtain, so you may not be able to collapse a lung against a soft and flaccid interpulmonary partition . Nearly always, however, with patience a useful compromise is obtainable. If not too much is expected at first, and pressures are very gradually and tentatively raised, the pneumothorax can usually be maintained with advantage. Strained Mediastinu ni,
'Vhat has happened all too frequently in my experience has been a serious overstretching, by pressures too high or carelessly applied, of a mediastinum that otherwise would have proved quite adequate. Once the mediastinum is overstretched it may be difficult to restore to it its former elasticity. Now the two cases I have referred to illustrate very well in their after history the different results which are to be expected according as the resistance of the mediastinum is adequately respected or otherwise. It was, indeed, for this reason that I introduced them to you at an earlier stage. In the one of them first quoted the pressures were kept at the same moderate + 2 + 4, and fillings given at weekly intervals; the lung has reached a condition of very satisfactory collapse without any encroachment on the other organs; the patient, who was very ill and whose friends expected her to die, is now in good health without symptoms, and enjoying life. The other case (figs. 1 and 2) was treated with pressures which gradually rose from + 1 + 5 without apparent need to + 4 + 10; he then got a pleural effusion, and end pressures of + 15 and + 18 were used. As a. result a considerable displacement of the mediastinum occurred, troublesome dyspncea and wheezineee came on, and he nearly died one day in a pseudo-asthmatic attack brought on by some extra exertion. When I saw him again the side was full of fluid and after drawing off 3,750 c.c. or 6! pints, replacing at the same time with air, the X-ray photo which is shown in fig. 2 was taken. It shows, you will see, the whole heart over in the left chest, the
120
[December, 1919
TUllERCLE
right lung completely disappeared, and about half the width of the vertebral column uncovered on the right side. There is some fluid at the right base (the photo was taken a week after the replacement), and as a consequence the apex of the heart is displaced out of proportion even to the rest of the organ. Now it has been my experience to see altogether four cases where overstretching of the mediastinum produced such encroachments on the functioning lung as to lead to a condition suggestive of asthma. In all these cases the patients, in addition to dyspncea, complained of an audible wheeze, and with the stethoscope there was heard a double stridor suggestive of obstruction in the larger bronchial tubes. It seems possible that in these cases the main bronchus stretched over· the mediastinal bulge may become partly flattened and obstructed, or in cases where, as described above, the lung entirely disappears from view, it may become" pocketed" in the posterior mediastinum between the spine and the heart and great vessels, and in this situation exert pressure on the opposite bronchus or its branches. In all but one of the cases I have seen, the pneumothorax was a right-sided one. This condition of affairs in which wheeziness and pseudo-asthma arise in the course of pneumothorax treatment is one which is worth knowing about, since its possible dependence on a stretched mediastinum must be kept in mind. In the first case coming to me I failed to recognize the condition of things, since the heart, generally a convenient guide to the movement of the mediastinum, did not show more than the usual displacement. There is no doubt tha.t the position of the heart is not sufficient evidence in these cases, perhaps because the. posterior mediastinum is the point of maximum weakness. The X-rays must be the ultimate appeal. And now as to the treatment of this overstretching of the mediastinum. In one of my cases the patient has been brought back to comfort by a gradual lowering of pressure, controlled by radiographic examinations, to the point where the apparent optimum" has been attained, I have no doubt that it .is a far less satisfactory optimum than. would have been possible if no overstretching had occurred. Another, more marked case, passed nearly five months without a refill before the collapsed lung- came into sight again. At the end of this time he had lost nearly all his discomfort, but there' was still slight stridor, presumably dependent on some mechanical narrowing of the bronchus, perhaps from fibrosing peribronchial disease. He was treated at a sanatorium 80 as to allow of continual X-ray examination, since pressures cannot be safely lowered or removed without such visualisation of the collapsed lung. In the case of pleurisy and displaced mediastinum, whose radiogram is here reproduced (see fig. 2), treatment is particularly difficult for two reasons: (1) all attempts to maintain a low or negative pressure are -defeated by a steadyaccumula.tion of fluid; (2) the elasticity of the pneumothorax cavity is so lowered as a.result of the pleurisy that a very few cubic centimetres more or less makes an enormous difference in the intrapleural pressure. 'Whenever, therefore, I lower it to or below atmospheric pressure, a few cubic centimetres of fluid poured out very qUickly raise it again to a plus figure and again embarrass the mediastinum. ·Constant release of gas seems the only, though somewhat unsatisCactory ' .expedient for the present. U
December, 1919J
TUBERCLE
121
Ballooning of the Pleura. In addition to displacement of the mediastinum as a whole, we may have pocketing or " ballooning" of the pleura at certain weak places.
122
[D(cember,1919
TU13EnCLl!.:
I refer to pleural effusion. In the .first place there is a tendency of the lung to creep out and become attached under the fluid in all cases where this is great in amount. For this reason, among others, I am loth to leave effusions of large size untapped over long periods. In the second place, there are conditions of "cold abscess" of the pleura (to borrow a near equivalent in terms) which lead to great inflammatory thickening, and after a. time to fibrous contraction of the cavity and expansion of the lung. Fortunately they are rare. These conditions bring me rather conveniently to the subject of pleurisy, about which I have one or two things to say. Pleuritis. Pleurisy will occur at some time in the course of quite 50 per cent. of properly selected pneumothorax cases. I say "properly selected" cases. because if early and slight cases of phthisis are so treated the incidence of pleurisy will be much smaller; but these are not the cases for which a. pneumothorax should be done! Pleurisy shows itself in a great variety of ways, and differs so much in its effects that it is often difficult to compare one case with another. There is, however, one very common" benign form which leads to the effusion of a moderate amount of fluid, and there stops, with little or no detriment-sometimes advantage-to the patient. Very troublesome are cases where fluid continues to be poured out over a long period of time. sometimes years, leading to the need for periodic replacements with gas, and constant difficulty in the regulation of pressures. The difficulty of maintaining a. satisfactory intrapleural pressure, so as to ensure a steady collapse of the lung, is a very real one in all cases of more than fleeting pleurisy. The elasticity of the pneumothorax walls becomes EO greatly impaired that the pressures rise and fall very abruptly, and a 'Very few cubic centimetres of gas suffice to change the pressure from a low minus to a high plus. It thus happens that only very small fillings of gas can be given, and two opposite accidents have to be constantly in mind: (1) that absorbing fluid will quickly produce a considerable negative pressure, and may expand the collapsed lung; (2) that a growing effusion may cause an undesirably high pressure and displace the mediastinum. These tendencies must be carefully watched, and each case made a law unto itself with regard to the pressures and fillings which are most suitable. So far as the gas itself goes, this is but little absorbed by an inflamed pleura, and even after the pleurisy has abated, the former absorption rate is nearly always lowered. An effusion reaching half way up the chest, and stationary, is best, in my opinion, removed. Thereby, the dangers of lung expansion and attachment, and also those of excessive pleural thickening, are removed or lessened. A growing effusion may be left to become bigger than this before removal and replacement by air or N 2 ; but the effect or its weight on the lower mediastinum, and the chance of undesirable intra.thoracic pressures being reached, must be borne in mind and carefully watched for. When it is aspirated, its removal should be as complete as possible--air or N 2 being allowed to flow in from the pneumothorax npparutus all the time the fluid is flowing out, and not, as is sometimes done, only when n. decided negative pressure has been reached. This II
December, 1919]
TUBERCLE
123
latter plan may lead to very decided auto-inoculations from its pumping effects on the collapsed lung and inflamed pleura, and if it is adopted, it should be done deliberately, and with these ends clearly in view in cases where such effects appear desirable. These persistent effusions generally become thicker and thicker with time till they are decidedly purulent, and often contain numerous tubercle bacilli. Purely tuberculous effusions may also be purulent from the beginning. An interesting and rather rare form of pleurisy occurring in the course of pneumothorax is that which shows evidence of iii general pleural inflammation but without the occurrence of exudation. A lady whose pneumothorax was just a year old had her pressure inadvertently raised a little above the usual at a refill (an accident by the way which it is most important to avoid I), and some gas was immediately released to bring it down. During the following three weeks she complained of a "creaking" at the base on the pneumothorax side, but was otherwise well; at the next and at subsequent fillings over a period of two months evidence of general pleurisy showed itself, but no signs of fluid (" splash" or dullness) ever appeared. The evidences of pleurisy in this case were diminution of gas absorptlOn-only some 250 to 300 c.c, were needed in place of the usual 700 to 800 c.c ; and loss of elasticity-negative pressures abnormally great for her case developed, and were raised to adequate positive pressures by these quite small fillings . The patient felt perfectly well during this time, was entirely without symptoms, and put on weight; she lived her usual fairly active life. There may, of course, have been fluid of too small amount to cause a. .. splas~:" the .ea~liest sign of fluid. in. these cases. With regard to the" splash of fluid III pneumothorax It IS necessary to warn against certain deceptive imitations. Firstly, there is the splash of an atonic stomach, which condition is very commonly present before the patient has arrived at vigorous health-or in cases which never achieve this. In this case the metallic qualities of a hydro-pneumothorax splash fail. Another sound which will simulate a splash somewhat, including metallic resonance, is when cough is excited each time the patient is shaken, and is heard over the chest just at the moment of the expected splash. This may, though perhaps it should not, deceive .. As for the symptoms of onset of pleurisy with pneumothorax these vary in a most curious manner. There may be no pain or other symptoms at all, and the patient may announce that a "splash" comes when he moves. As Ilo rule some fever ushers in the attack. In one case rapidity of pulse was the first symptom, the patient appearing otherwise quite well and the temperature normal; next day a refill showed reduced a.bsorption of gas. On the third day appeared pain, fever, and a slight splash, On the fifth day there was a decided splash and after this the evidences of pleurisy abated, and the splash had gone a week later. At times pleurisy is ushered in with violent vomiting, and it may be difficult to decide at first whether we have only a gastric attack or something further. Pleurisy may also be double in pneumothorax cases, and forms a puzzling condition for those who are not prepared for this possibility. They may find pain and friction over the base of the functioning lung, and will be duly astonished when a splash appears at the pneumothorax base. Truth to tell. pleurisy is often no isolated phenomenon, for, if they
124
TUBERCLE
[December,
Hnn
are carefully looked for, evidences of accompanying disturbance in lung foci can often also be found. These may show themselves as a .. congestion," or consolidation of attached portions of lung on the pneumothorax side, or as an increase of signs at some suspicious spot over the functioning lung. The pleurisy and the lung congestion in these cases are often so closely concurrent that it is difficult to regard them as other than the expressions of some common influence, a general exacerbation of disease, a It congestive attack" (to adopt a continental expression). or some accidental catarrhal complication . Certain it is that catarrhal affections of the upper air passages and bronchi may form the starting point of a pleurisy in some cases. Doubtless the mere separation of the pleural surfaces by gas leads to a lowering of their normal health, and renders them prone to inflammatory reactions. In addition there are pleurisies of purely local, or even mechanical causation, due to perforation of the pleural layer by surface foci, or to a rupture of adhesions. RESULTS OF PNEUMOTHORAX TREATMENT.
And now at the end a few words as to the results of pneumothorax: treatment, and in estimating these it must be borne in mind that We are dealing with cases of comparatively advanced and progressive disease, in which no hopeful outlook would otherwise have been possible. I have never yet myself recommended or performed a pneumothorax on a. case which I considered recoverable by any other method of treatment. In addition, I have often successfully discouraged or postponed a proposed pneumothorax in cases where recovery seemed likely without it. In many of my most successful cases the patient has been bedridden and going downhill, and the bad lung has been the seat of extensive softening, often with gross signs of cavitation at some spot and moist crepitations over most or the whole of a side. In not a few the patient's condition has been too bad to permit of a radiogram being taken. When after two or three months' treatment such a. patient is feeling well with a. vigorous appetite, and no cough, and is walking out without fever' one cannot but look upon the results with wonder and delight. As one of these patients, returned to life after much suffering and misery. used to remark to me, II I did not know before that Medicine could perform miracles," and miracles these cases certainly seem. Not all, of course. can receive such rapid and striking benefit from pneumothorax-therapy; but if the bad lung is extensively diseased and will still collapse efficiently and if the other lung is a moderately good one, you may expect Such ~ resurrection 'with some confidence.
The Ultimate Prognosis.
So much for the immediate effects of a successful pneumothorax in a suitable case; what of the ultimate results? Now these, of course, mUst greatly vary according to the later course of the case. Thus the other lung may show itself unequal to the burden, and disease in it may becOtne active and necessitate the cessation of treatment. This happens, on the whole, 'far less readily than might at first sight be expected, considerinO' b
December; 1919J
TUBERCLE
125
how constantly disease of some amount is present in this organ. There is no doubt that, given a wise administration, such disease tends to improve rather than deteriorate under pneumothorax treatment. Then pleuritic accidents may supervene with results which are but rarely fatal, but which may prejudice the chances of complete recovery. In many such cases the collapsed lung can expand but moderately on cessation of treatment, and refills at long intervals may be necessary for the patient's comfort. In one way or another, it must be admitted, a goodly proportion of cases fail to obtain permanent benefit, and die after a longer or shorter interval; but not without having obtained in most cases a renewed lease of" life, and nearly always a marked increase of comfort. But besides these cases there are many who, in spite of the serious nature of their disease, yet proceed to complete restoration of health. Among such cases who have practically weathered the storm, I may cite for illustration the following exam ples :A young man whom 1 saw in 1912 with disease of the whole left lung, and sent to a sanatorium for pneumothorax treatment, was passed into the Army category A in 1915 and is now well, at work, and about to get married. A somewhat similar case, but with extensive laryngeal ulceration also, who began treatment in 1911, is well and at work, but still for his own comfort has refills at long intervals. since expansion of the lung is a good deal hampered. In many cases, however, the collapsed lung will expand as fully, or nearly so, as that of the sound side. In a. lady who had a. left-sided pneumothorax from November, 1914, to August, 1917, the lung is not only completely expanded but also non-adherent, judging from the presence of a free tidal movement at its base. Movement is a little less ample on that side, and the heart's apex is outside the nipple line, but otherwise the lung appears capable of functioning fully and the patient is completely restored to. health. In a young man whose pneumothorax, alert-sided one,:was continued from December, 1914, to March, 1919, and who Buffered two slight pleuritic attacks. the lung has expanded fairly adequately-the side measuring 17~ inches as against 19 inches on the right side, and the heart's apex being 2! inches outside the nipple line. He is in excellent health and at work, as, indeed, he has been throughout the greater period of his treatment. Occasionally, it appears, disease will become active again, either in the bad or in the opposite lung, some years after pneumothorax treatment is suspended. Such a case, which had been treated many years before by the late Dr. Forlanini, of Pavia, came to me a while back with suspicion of recrudescence in the bad lung, and was sent back to Italy by me for the winter. I have failed unfortunately to find my notes on this case. At the beginning of this year a patient who had a pneumothorax initiated in September, 1915, and the last filling in June, un 7. and had completely regained his health, came to me with a. recrudescence of disease in the upper part of the other lung, and was condemned by me to a course of sanatorium treatment. In this case disease had been mainly basal. in ·the left side and the lung had expanded only moderately, the breath sounds being very feeble over the side, the percussion note greatly impaired, and the heart's apex in the anterior axillary line. He is still, I hear, in a sanatorium, and is only slowly overcoming the fresh exacerba-
126
[December, Hl1n
TUBERCLE
tion of disease in his right lung. Obviously a patient who has qualified for pneumothorax treatment has shown a notable lack of resistance to tubercle, and may show the same again at some later period. For this reason I feel that such people should be put under conditions the best possible for health after the treatment is suspended, though I confess that some of my own patients are working in towns without any very obvious detriment. At the conclusion, I would again remind you that collapse therapy is no panacea for pulmonary tuberculosis, but a treatment with decided indications and contra-indications, and hence somewhat severely limited in its application. At the same time it must be remarked that many fatal cases go through a period when this treatment might have been possible and beneficent, and it behoves the doctor to be on the look-out for this favourable moment so that the chance of this remedy be not postponed till it is too late.
SHORTER COMMUNICATIONS.
A NOTE ON THE TREATMENT OF LARYNGEAL TUBERCULOSIS \VITH INTRAVENOUS GOLD. E. G.
GLOVER,
M.D.
Birmingham Municifal Sanatorium, Cheltenham. ALTHOUGH it is six years since the introduction of Spiess's gold solution (ethylcne-diamin-cantharidin-auricyanide) for use in treating mucosnj tuberculosis, intervening events have prevented any detailed investigation of the drug's action in this country at any rate. For this reason . no apology is offered for the following brief note. It may be remembered that according to the original investigations of Spiess [1J, and later of Spiess and Feldt [2J, cantharidin salts given subcutaneously produce an inflammatory reaction in tuberculous lesions, and advantage was taken of this selective action to link these salts with gold cyanide, the action of which on the growth of tubercle bacilli had already been noted in vitro. The introduction of ethylene-diamin in the ortho position reduced the toxicity of the cantharidin constituent 680 times without any corresponding reduction in the salt's properties. The final salt was tested on the rabbit with satisfactory results, and intravenous administration was recommended in preference to the subcutaneous method, gold resistant strains being easily produced.
The Patient's Past. History. In 1014 Dr.. J. A. D. Radcliffe, Pathologist at King Edward VII Sanatorium, kindly supplied me with about enough of the salt to try in one case arid an endeavour was made to give this as se!ere a trial as possible. The case chosen was that of a man with laryngeal tuberculosis of a chronic
TUBERCLE
[December. 1919
.. Valeur semeilogique de Ill. Tuberculose fibreuse dans Ill. recherche de la Syphilis," Proqres Medical, April 26, 1913. .. Formes scrofuloides de Ill. Syphilis." Bulletin medical, May 28, 1913. See also.. Syphilis de l'appareil respiratoire sous-larynge " in the "Precis de Syphiligraphie du Professeur Gaucher" (Doin}, 1909.
THE P~EUMOTHORAX TREATMENT OF TUBERCULOSIS.l
PULMONARY
By CLIVE RIVIERE, M.D., F.RC.P. Physician, City of London Hospital for Diseases of the Chest. THE treatment of pulmonary tuberculosis by artificial pneumothorax has now achieved a fair hold in this country, and there can be few dealing with tuberculous cases who have not by now acquired some knowledge of its theory and practice. Since the subject is too wide to be covered in a single lecture, I shall presume at least a. nodding acquaintance with it on your part, and devote my time to such points as suggest themselves to me on account of their special interest or importance. Having published a small text-book on the subject some two years since. I am, perhaps, especially -desirous of laying stress on points which I then too lightly emphasised, but also of bringing forward certain matters which have forced themselves on my notice recently. I will not remind you here of the history of collapse of the lung in the treatment of tuberculosis, nOL' go into theories of its effects. I am anxious to stick to practical points! I will, therefore, wander over the headlines of the subject, anti pick out such points as may suit my present purpose.
INDICATIONS AND CONTRA-INDICATIONS.
Artificial pneumothorax stands apart from other methods of treating pulmonary tuberculosis especially in one particular namely, in the possession of more definite and clear - cut indications and contraindications. One of the unsatisfactory features about tuberculosi~ treatment in general is the very imperfect knowledge we have acquirel1 of the applicability of individual methods and remedies to individual cases. In spite of the variety that exists among cases in type, actiVit)". amount and location of disease, and other elements in the response of the individual's tissues, but very little is definitely known of the therapeutic indications which should be based upon them. True, the experienced physician acquires in process of time a certain intuition as to the therapeutic requirements of particular cases, but the grOunds on which it rests seldom become sufficiently clear and defined to enable him to hand on the results of his experience to others. No doubt our knowledge of the disease, and Qf the various actions of the remedies I
A lecture delivered at the Royal Institute of Public Health on November 13, 1919,
FIG. 2 -From same case as Fig. I, showing strained mediastinum. There is some fluid in right pleural cavi~y. right lung has disappeared from view, and half the width of the spine is uncovered on the right side.
FIG. a.-Arrow points to elliptical shadow of pleural pocket encroaching on the right lung. Collapsed left lung is adherent in many places.
December. UH9]
'l'UnnnCL£
115
we use, is still too imperfect to allow of our dovetailing them one into the other with any great accuracy, but still one cannot but feel that some clear thinking on the subject might enable us to " make the punishment fit the crime" more accurately. At present the treatment sheets over the beds of the average tuberculosis ward are, to say the least, a most uninspiring spectacle! Now the choice of pneumothorax treatment implies at the outset the fulfilment of two necessary conditions: (1) That one lung is so much diseased that its recovery under any known treatment while in an expanded and functioning state is despaired of. (2) That the other lung is a fairly good organ and not the seat of active tuberculosis. Outside these indications there still lies one class of case which calls for pneumothorax treatment on its own account, namely, hmmoptysis of a recurrent or dangerous type. Evidence of Hiius Tuberculosis.
Now the application of these axioms reduces the treatment in practice very largely to a particular class of case, namely to that with evidence of disease over the greater part of one lung. the other lung being comparatively free and generally appearing to be quite clear on the surface. These are undoubtedly cases of "central lung" or "hilus" tuberculosis in which disease has not been recognised as serious till it has reached the surface and rapidly spread over it. That they are not cases of " apical phthisis" will generally be borne in on you, when you have had a good deal of pneumothorax experience, by the beha.viour of the opposite lung. For .you ~ill fin~ that the area~ giving ~nxiety (and perhaps definite physical SIgns) WIll generally be 10 the neIghbourhood of the nipple in front, not at the apex, and it is just at this point that hilus disease so commonly comes within reach of the stethoscope. Now in these cases of apparent one-sided tuberculosis you must always be prepared to find extensive deep disease in the opposite (and apparently healthy) lung. I know no certain mea~s of ~eciding about this except the use of the X-rays, but ther~ .a re certain po~nts that may be of assistance. Thus the general condition of the patient may be too good to allow of more disease than is already obvious to the stethoscope. In particular his colour and breathing may be too good to be compatible with active disease on both sides of the che~t. Dyspnooa may be of a kind which is removable by collapse of the diseased lung (probably through the closing of its useless capillary channel~, ~nd the diversion ?f their blo~d into the functioning lung whereby anoxremia IS reduced); but If dyspncea IS marked, and particularly if it is accompanied by cyanosis, the probability is great that the" good .. lung is the seat of serious deep disease. I remember a patient with this condition being sent to me by a sanatorium physician for my opinion as to the advisability of a pneumothorax. The dyspncoa was marked, and was attributed by the physician to his cardiac condition, but I felt convinced there was extensive deep disease in what was called the" good lung," this being, indeed, quite free of surface signs of disease. A radiogram showed this to be the case, and enabled me to score off the sanatorium physician; but the radiologist scored off us both, for his plato also
116
TUBERCLE
[December, 1919
demonstrated a small localized spontaneous pneumothorax already present. at the top of the worst side, and quite unsuspected by either of us stethoscopists ! A certain amount and activity of disease is allowable in the better lung, that is as shown by the radiogram, but only experience of cases can teach how much or how little this may be. I shall not attempt to describe it here or to lay down any rules or formulas for its determination, but some of the prints I shall show you later' will give you pictures of lungs which have been accepted as good enough for pneumothorax, and which have justified this opinion by their subsequent behaviour. It must be remembered that in exchange for the strain of increased functioning. pneumothorax . treatment has certain decided advantages to offer the remaining and functioning lung. Above all the removal of .autoinoculation with its resulting deleterious focal reactions; possibly, in addition, a condition of hyperremia which is considered by many an important item in the cure of tuberculous foci in the working lung. Provided auto-inoculation can be removed without much displacement. of the mediastinum and thus interference with the functioning of the opposite lung, it is astonishing with wha.t confidence one can predict improvement throughout this organ when disease is of a quiet type. Pneumonic Phthisis.
There is a type of one-sided case which occasionally comes to pneumothorax, but in which the prognosis is far from rosy; I refer to pneumonic phthisis. In such cases disease nearly always becomes active in the opposite lung, and this has happened in the two cases which have so far come under my care. One I was able to keep alive and in fair health for some three years; in the other, disease on the opposite side became active but eight months after the pneumothorax was started. In such cases I think the fillings should be small and frequent, and the opposite lung should be under most constant supervision if succes, is to be rendered permanent. In both my cases the flare up OCCurred when the patients were out of reach of control and observation. THE
OPERATION.
And now as to the operation itself, of which I have but little new to say; In this country, to its credit, no other than a needling operation has ever, so far as I know, been attempted for artificial pneumothorax. I have had two patients, however, in whom the initial operation was performed by Brauer's method of open incision down to the pleura, and both these were done in Swiss sanatoriums under German physicians. In my opinion there is nothing to justify the "open method" of pneumothorax operation at the present day. A needle, or a trocar and cannula (I myself always use the latter), serves all the purposes of the initial operation, providing the usual safeguards are adopted. The patient should be reassured beforehand that but little, if any, pain or discomfort will be felt, more than that of the prick of the hypodermic needle for injection of novocain, and in skilful hands this should be strictly the truth. I
Figs. I, 2 and 3.
December, 1919]
TUBERCLE
117
The Physician's Responsibility. In practice the initial operation if skilfully performed should seem, and is, to the patient, So very small and simple matter, such difficulties and risks as attach to it being a matter of anxiety for the operator and not, in my opinion, for the patient. If the doctor is quite clear in his mind (and in most suitable cases there is little doubt about the matter) that So pneumothorax is indicated, then he should himself shoulder the burden of responsibility for all such possible accidents as may be bound up in it. The patient should of course be told what it is hoped to achieve, and also warned that success may be barred by unforeseen difficulties such as adherent pleura, but to put before So patient or even his friends the hypothetical risks of pleural shock, gas embolism and the like as some authors appear to have advised, is both cruel and foolish. At most the friends should be told that certain risks attend all chest punctures, but that they are remote ones and not to be expected in the ordinary course of things. Pleural Adhesions. The success or otherwise of a pneumothorax in a suitable case is at the outset bound up in the question of adherent pleura. If only a partial pneumothorax can b~ achieve.d,.particularly if, as tends to happen, the more diseased and cavity-containing portion of the lung is densely a.dherent to the surface, then the treatment will probably fail. This latter accident is fortunately more apt to arise in "apical phthisis," where apical cav.itation is near. the ~urf~ce and the pleura readily implicated, than in hilus tuberculosis, which IS, par excellence, the recruitingground of artificial pneumothorax. In these latter cases, cavitation is generally deep, and even if disease spreads throughout the whole lung from apex to base, it is fortunately quite common for a complete. pneumothorax to be obtainable. As for the influence of a few adhesions, apart from adherence of a whole apex or large part of 0. lobe, I think the disabling effects of such have been on the whole exaggerated. Such adhesions will gradually stretch or separate, and it must be but very rarely that measures Cor separating them (such as have been suggested by a surgeon in this country, an~ more r~cently ~y Holmboe in the new journal TUBERCLE) will be needed in practice. It IS, however,.to strong adhesions in the neighbourhood of cavities tha~ we owe ~ne or the dangers or pneumothorax-therapy, namely, the. risk of .openmg such a cavity, by rupture, into the pleural space. It IS Cor this reason, among others, that X-ray examinations are indispensable during the course of induction oC a pneumothorax, and particularly where there is cavitation within ncar reach of the surface. Intrapleural Pressures. Having obtained our pneumothorax let us suppose that it is a moderately U complete" one and that we have thus attained our main aim. There still remain causes for anxiety, because at each stage failure is waiting on our footsteps in case we anywhere mistake the path. And now the whole secret of success will revolve around the question of finding and maintaining an "optimum" pressure. This optimum pressure varies greatly for different cases, and also in the same case at different stages of
118
TUBERCLE
(December, 1919
treatment, and it is very difficult, in some cases impossible, to find it or to maintain it without the use of the X-rays. The longer my experience of pneumothorax treatment becomes the more insistent I find myself on the necessity of direct visualisation of the collapsed lung and adjacent organs from time to time. Especially must this be resorted to whenever difficulties arise. The Optimunc Pressure.
Now the optimum pressure might be expected to be the least pressure which will ma intain efficient collapse of the lung, but this definition does not cover the whole ground, as I at least see it. As IL rule many opposing factors have to be reconciled , and a more or Jess satisfactory compromise is often all that can be expected. On the one side is the need for sufficient pressure to collapse the lung, on the other side the effect of this pressure on surrounding organs, A weak mediastinum may forbid anything but a very moderate pressure, sometimes only atmospheric or but little above, being employed, and this must be particularly the case where the integrity of the functioning lung is in any doubt. Where the other lung shows any evidence of active disease and is a source of anxiety in treatment, I am quite contented with a very moderate amount of collapse at first, with small fillings at rather frequent intervals. These two radiograms show such moderate collapse at an early stage. Both cases had signs of disease about the anterior base on the opposite side, in both cases this amount of collapse was sufficient to abolish all toxic symptoms and restore the physical health, and in both cases this restoration was accompanied by a gradual removal of evidence of activity in the functioning lung. Their after history is rather different and on this account I will return to them again later on in my lecture, One of these was having refills of 400-500 c.c. of air every five, later rising to seven days, with an end pressure of about + 2 + 4 ern. H 20 ; the other (fig . 1) 1 fillings of 400 c.c. or so, la.ter rising to as much as GOO, ai intervals of five rising gradually to eight or nine days with end pressure of + 1 + 5 em. H 20. These notes refer to the con~ ditions during the early months of treatment. Now both these cases had massive caseous disease with softening throughout practically the whole of one lung, and under these conditions you must not expect the lung to collapse well at first, though it will gradually undergo a reduction in size. In one of these cases you will notice there were several adhesions present. These somewhat impeded the collapse of the lung, but they did not prevent in the slightest· the disintoxication which was hoped for, and I considered them a positive help in supporting the mediastinum a.t Do time when the other lung was in a somewhat critical state. It will be seen from the print that there was, in fact, no small amount of disease, fortunately of only moderate a.ctivity, in this other functioning lung. My advice then is at the beginning go slowly, aim at disintoxication of the patient, loss of fever, tachycardia, anorexia, and general illness, . and make the pulmonary colla.pse, ·qua collapse, 0. secondary consideration. Keep your attention on the mediastinum and the other lung, rather than on the collapsing lung at the outset of treatment. But here I find I must digress to warn you of pitfalls which may surround the advice I have just given you. It might seem a desirable I
Fig. 1 illustra.tes one or the ra.diogra.ms shown; the other is not reproduced here.
December, 1919J
TUBERCLE
119
thing, in cases where the better lung is none too good, to go forward so tentatively as only to " damp down," as it were, the intoxication arising Crom the bad lung, or at most but partially to collapse it, with moderate fillings given at longish intervals. This attempt, theoretically so desirable, is unfortunately but seldom permissible in practice, for these fillings, forcing out toxins each time into the blood-stream , generally lead to reactions, both general and focal, which in cases of severe disease may reach an alarming intensity. To avoid these the lung may have to be further collapsed, though it need not be " compressed;" but sometimes a judicious shortening of the intervals between the refills, and thus of the amount of gas required, may suffice to abolish reactions where these are moderate, in cases where the lung is not, or cannot be, fully collapsed. Now the point to be ultimately aimed at is, as I have hinted, a compromise between the resistance of the lung to collapse and the stability of the mediastinum, both as a whole and also in its parts, for it may form a fairly strong partition, and yet possess weak spots as we shall see presently. The stability of the mediastinum varies very greatly in different individuals, and, where it is weak, an efficient pneumothorax may only be maintained with difficulty. Just as you cannot flatten out a fly, or even IJ, mosquito, against a yielding curtain, so you may not be able to collapse a lung against a soft and flaccid interpulmonary partition . Nearly always, however, with patience a useful compromise is obtainable. If not too much is expected at first, and pressures are very gradually and tentatively raised, the pneumothorax can usually be maintained with advantage. Strained Mediastinu ni,
'Vhat has happened all too frequently in my experience has been a serious overstretching, by pressures too high or carelessly applied, of a mediastinum that otherwise would have proved quite adequate. Once the mediastinum is overstretched it may be difficult to restore to it its former elasticity. Now the two cases I have referred to illustrate very well in their after history the different results which are to be expected according as the resistance of the mediastinum is adequately respected or otherwise. It was, indeed, for this reason that I introduced them to you at an earlier stage. In the one of them first quoted the pressures were kept at the same moderate + 2 + 4, and fillings given at weekly intervals; the lung has reached a condition of very satisfactory collapse without any encroachment on the other organs; the patient, who was very ill and whose friends expected her to die, is now in good health without symptoms, and enjoying life. The other case (figs. 1 and 2) was treated with pressures which gradually rose from + 1 + 5 without apparent need to + 4 + 10; he then got a pleural effusion, and end pressures of + 15 and + 18 were used. As a. result a considerable displacement of the mediastinum occurred, troublesome dyspncea and wheezineee came on, and he nearly died one day in a pseudo-asthmatic attack brought on by some extra exertion. When I saw him again the side was full of fluid and after drawing off 3,750 c.c. or 6! pints, replacing at the same time with air, the X-ray photo which is shown in fig. 2 was taken. It shows, you will see, the whole heart over in the left chest, the
120
[December, 1919
TUllERCLE
right lung completely disappeared, and about half the width of the vertebral column uncovered on the right side. There is some fluid at the right base (the photo was taken a week after the replacement), and as a consequence the apex of the heart is displaced out of proportion even to the rest of the organ. Now it has been my experience to see altogether four cases where overstretching of the mediastinum produced such encroachments on the functioning lung as to lead to a condition suggestive of asthma. In all these cases the patients, in addition to dyspncea, complained of an audible wheeze, and with the stethoscope there was heard a double stridor suggestive of obstruction in the larger bronchial tubes. It seems possible that in these cases the main bronchus stretched over· the mediastinal bulge may become partly flattened and obstructed, or in cases where, as described above, the lung entirely disappears from view, it may become" pocketed" in the posterior mediastinum between the spine and the heart and great vessels, and in this situation exert pressure on the opposite bronchus or its branches. In all but one of the cases I have seen, the pneumothorax was a right-sided one. This condition of affairs in which wheeziness and pseudo-asthma arise in the course of pneumothorax treatment is one which is worth knowing about, since its possible dependence on a stretched mediastinum must be kept in mind. In the first case coming to me I failed to recognize the condition of things, since the heart, generally a convenient guide to the movement of the mediastinum, did not show more than the usual displacement. There is no doubt tha.t the position of the heart is not sufficient evidence in these cases, perhaps because the. posterior mediastinum is the point of maximum weakness. The X-rays must be the ultimate appeal. And now as to the treatment of this overstretching of the mediastinum. In one of my cases the patient has been brought back to comfort by a gradual lowering of pressure, controlled by radiographic examinations, to the point where the apparent optimum" has been attained, I have no doubt that it .is a far less satisfactory optimum than. would have been possible if no overstretching had occurred. Another, more marked case, passed nearly five months without a refill before the collapsed lung- came into sight again. At the end of this time he had lost nearly all his discomfort, but there' was still slight stridor, presumably dependent on some mechanical narrowing of the bronchus, perhaps from fibrosing peribronchial disease. He was treated at a sanatorium 80 as to allow of continual X-ray examination, since pressures cannot be safely lowered or removed without such visualisation of the collapsed lung. In the case of pleurisy and displaced mediastinum, whose radiogram is here reproduced (see fig. 2), treatment is particularly difficult for two reasons: (1) all attempts to maintain a low or negative pressure are -defeated by a steadyaccumula.tion of fluid; (2) the elasticity of the pneumothorax cavity is so lowered as a.result of the pleurisy that a very few cubic centimetres more or less makes an enormous difference in the intrapleural pressure. 'Whenever, therefore, I lower it to or below atmospheric pressure, a few cubic centimetres of fluid poured out very qUickly raise it again to a plus figure and again embarrass the mediastinum. ·Constant release of gas seems the only, though somewhat unsatisCactory ' .expedient for the present. U
December, 1919J
TUBERCLE
121
Ballooning of the Pleura. In addition to displacement of the mediastinum as a whole, we may have pocketing or " ballooning" of the pleura at certain weak places.
122
[D(cember,1919
TU13EnCLl!.:
I refer to pleural effusion. In the .first place there is a tendency of the lung to creep out and become attached under the fluid in all cases where this is great in amount. For this reason, among others, I am loth to leave effusions of large size untapped over long periods. In the second place, there are conditions of "cold abscess" of the pleura (to borrow a near equivalent in terms) which lead to great inflammatory thickening, and after a. time to fibrous contraction of the cavity and expansion of the lung. Fortunately they are rare. These conditions bring me rather conveniently to the subject of pleurisy, about which I have one or two things to say. Pleuritis. Pleurisy will occur at some time in the course of quite 50 per cent. of properly selected pneumothorax cases. I say "properly selected" cases. because if early and slight cases of phthisis are so treated the incidence of pleurisy will be much smaller; but these are not the cases for which a. pneumothorax should be done! Pleurisy shows itself in a great variety of ways, and differs so much in its effects that it is often difficult to compare one case with another. There is, however, one very common" benign form which leads to the effusion of a moderate amount of fluid, and there stops, with little or no detriment-sometimes advantage-to the patient. Very troublesome are cases where fluid continues to be poured out over a long period of time. sometimes years, leading to the need for periodic replacements with gas, and constant difficulty in the regulation of pressures. The difficulty of maintaining a. satisfactory intrapleural pressure, so as to ensure a steady collapse of the lung, is a very real one in all cases of more than fleeting pleurisy. The elasticity of the pneumothorax walls becomes EO greatly impaired that the pressures rise and fall very abruptly, and a 'Very few cubic centimetres of gas suffice to change the pressure from a low minus to a high plus. It thus happens that only very small fillings of gas can be given, and two opposite accidents have to be constantly in mind: (1) that absorbing fluid will quickly produce a considerable negative pressure, and may expand the collapsed lung; (2) that a growing effusion may cause an undesirably high pressure and displace the mediastinum. These tendencies must be carefully watched, and each case made a law unto itself with regard to the pressures and fillings which are most suitable. So far as the gas itself goes, this is but little absorbed by an inflamed pleura, and even after the pleurisy has abated, the former absorption rate is nearly always lowered. An effusion reaching half way up the chest, and stationary, is best, in my opinion, removed. Thereby, the dangers of lung expansion and attachment, and also those of excessive pleural thickening, are removed or lessened. A growing effusion may be left to become bigger than this before removal and replacement by air or N 2 ; but the effect or its weight on the lower mediastinum, and the chance of undesirable intra.thoracic pressures being reached, must be borne in mind and carefully watched for. When it is aspirated, its removal should be as complete as possible--air or N 2 being allowed to flow in from the pneumothorax npparutus all the time the fluid is flowing out, and not, as is sometimes done, only when n. decided negative pressure has been reached. This II
December, 1919]
TUBERCLE
123
latter plan may lead to very decided auto-inoculations from its pumping effects on the collapsed lung and inflamed pleura, and if it is adopted, it should be done deliberately, and with these ends clearly in view in cases where such effects appear desirable. These persistent effusions generally become thicker and thicker with time till they are decidedly purulent, and often contain numerous tubercle bacilli. Purely tuberculous effusions may also be purulent from the beginning. An interesting and rather rare form of pleurisy occurring in the course of pneumothorax is that which shows evidence of iii general pleural inflammation but without the occurrence of exudation. A lady whose pneumothorax was just a year old had her pressure inadvertently raised a little above the usual at a refill (an accident by the way which it is most important to avoid I), and some gas was immediately released to bring it down. During the following three weeks she complained of a "creaking" at the base on the pneumothorax side, but was otherwise well; at the next and at subsequent fillings over a period of two months evidence of general pleurisy showed itself, but no signs of fluid (" splash" or dullness) ever appeared. The evidences of pleurisy in this case were diminution of gas absorptlOn-only some 250 to 300 c.c, were needed in place of the usual 700 to 800 c.c ; and loss of elasticity-negative pressures abnormally great for her case developed, and were raised to adequate positive pressures by these quite small fillings . The patient felt perfectly well during this time, was entirely without symptoms, and put on weight; she lived her usual fairly active life. There may, of course, have been fluid of too small amount to cause a. .. splas~:" the .ea~liest sign of fluid. in. these cases. With regard to the" splash of fluid III pneumothorax It IS necessary to warn against certain deceptive imitations. Firstly, there is the splash of an atonic stomach, which condition is very commonly present before the patient has arrived at vigorous health-or in cases which never achieve this. In this case the metallic qualities of a hydro-pneumothorax splash fail. Another sound which will simulate a splash somewhat, including metallic resonance, is when cough is excited each time the patient is shaken, and is heard over the chest just at the moment of the expected splash. This may, though perhaps it should not, deceive .. As for the symptoms of onset of pleurisy with pneumothorax these vary in a most curious manner. There may be no pain or other symptoms at all, and the patient may announce that a "splash" comes when he moves. As Ilo rule some fever ushers in the attack. In one case rapidity of pulse was the first symptom, the patient appearing otherwise quite well and the temperature normal; next day a refill showed reduced a.bsorption of gas. On the third day appeared pain, fever, and a slight splash, On the fifth day there was a decided splash and after this the evidences of pleurisy abated, and the splash had gone a week later. At times pleurisy is ushered in with violent vomiting, and it may be difficult to decide at first whether we have only a gastric attack or something further. Pleurisy may also be double in pneumothorax cases, and forms a puzzling condition for those who are not prepared for this possibility. They may find pain and friction over the base of the functioning lung, and will be duly astonished when a splash appears at the pneumothorax base. Truth to tell. pleurisy is often no isolated phenomenon, for, if they
124
TUBERCLE
[December,
Hnn
are carefully looked for, evidences of accompanying disturbance in lung foci can often also be found. These may show themselves as a .. congestion," or consolidation of attached portions of lung on the pneumothorax side, or as an increase of signs at some suspicious spot over the functioning lung. The pleurisy and the lung congestion in these cases are often so closely concurrent that it is difficult to regard them as other than the expressions of some common influence, a general exacerbation of disease, a It congestive attack" (to adopt a continental expression). or some accidental catarrhal complication . Certain it is that catarrhal affections of the upper air passages and bronchi may form the starting point of a pleurisy in some cases. Doubtless the mere separation of the pleural surfaces by gas leads to a lowering of their normal health, and renders them prone to inflammatory reactions. In addition there are pleurisies of purely local, or even mechanical causation, due to perforation of the pleural layer by surface foci, or to a rupture of adhesions. RESULTS OF PNEUMOTHORAX TREATMENT.
And now at the end a few words as to the results of pneumothorax: treatment, and in estimating these it must be borne in mind that We are dealing with cases of comparatively advanced and progressive disease, in which no hopeful outlook would otherwise have been possible. I have never yet myself recommended or performed a pneumothorax on a. case which I considered recoverable by any other method of treatment. In addition, I have often successfully discouraged or postponed a proposed pneumothorax in cases where recovery seemed likely without it. In many of my most successful cases the patient has been bedridden and going downhill, and the bad lung has been the seat of extensive softening, often with gross signs of cavitation at some spot and moist crepitations over most or the whole of a side. In not a few the patient's condition has been too bad to permit of a radiogram being taken. When after two or three months' treatment such a. patient is feeling well with a. vigorous appetite, and no cough, and is walking out without fever' one cannot but look upon the results with wonder and delight. As one of these patients, returned to life after much suffering and misery. used to remark to me, II I did not know before that Medicine could perform miracles," and miracles these cases certainly seem. Not all, of course. can receive such rapid and striking benefit from pneumothorax-therapy; but if the bad lung is extensively diseased and will still collapse efficiently and if the other lung is a moderately good one, you may expect Such ~ resurrection 'with some confidence.
The Ultimate Prognosis.
So much for the immediate effects of a successful pneumothorax in a suitable case; what of the ultimate results? Now these, of course, mUst greatly vary according to the later course of the case. Thus the other lung may show itself unequal to the burden, and disease in it may becOtne active and necessitate the cessation of treatment. This happens, on the whole, 'far less readily than might at first sight be expected, considerinO' b
December; 1919J
TUBERCLE
125
how constantly disease of some amount is present in this organ. There is no doubt that, given a wise administration, such disease tends to improve rather than deteriorate under pneumothorax treatment. Then pleuritic accidents may supervene with results which are but rarely fatal, but which may prejudice the chances of complete recovery. In many such cases the collapsed lung can expand but moderately on cessation of treatment, and refills at long intervals may be necessary for the patient's comfort. In one way or another, it must be admitted, a goodly proportion of cases fail to obtain permanent benefit, and die after a longer or shorter interval; but not without having obtained in most cases a renewed lease of" life, and nearly always a marked increase of comfort. But besides these cases there are many who, in spite of the serious nature of their disease, yet proceed to complete restoration of health. Among such cases who have practically weathered the storm, I may cite for illustration the following exam ples :A young man whom 1 saw in 1912 with disease of the whole left lung, and sent to a sanatorium for pneumothorax treatment, was passed into the Army category A in 1915 and is now well, at work, and about to get married. A somewhat similar case, but with extensive laryngeal ulceration also, who began treatment in 1911, is well and at work, but still for his own comfort has refills at long intervals. since expansion of the lung is a good deal hampered. In many cases, however, the collapsed lung will expand as fully, or nearly so, as that of the sound side. In a. lady who had a. left-sided pneumothorax from November, 1914, to August, 1917, the lung is not only completely expanded but also non-adherent, judging from the presence of a free tidal movement at its base. Movement is a little less ample on that side, and the heart's apex is outside the nipple line, but otherwise the lung appears capable of functioning fully and the patient is completely restored to. health. In a young man whose pneumothorax, alert-sided one,:was continued from December, 1914, to March, 1919, and who Buffered two slight pleuritic attacks. the lung has expanded fairly adequately-the side measuring 17~ inches as against 19 inches on the right side, and the heart's apex being 2! inches outside the nipple line. He is in excellent health and at work, as, indeed, he has been throughout the greater period of his treatment. Occasionally, it appears, disease will become active again, either in the bad or in the opposite lung, some years after pneumothorax treatment is suspended. Such a case, which had been treated many years before by the late Dr. Forlanini, of Pavia, came to me a while back with suspicion of recrudescence in the bad lung, and was sent back to Italy by me for the winter. I have failed unfortunately to find my notes on this case. At the beginning of this year a patient who had a pneumothorax initiated in September, 1915, and the last filling in June, un 7. and had completely regained his health, came to me with a. recrudescence of disease in the upper part of the other lung, and was condemned by me to a course of sanatorium treatment. In this case disease had been mainly basal. in ·the left side and the lung had expanded only moderately, the breath sounds being very feeble over the side, the percussion note greatly impaired, and the heart's apex in the anterior axillary line. He is still, I hear, in a sanatorium, and is only slowly overcoming the fresh exacerba-
126
[December, Hl1n
TUBERCLE
tion of disease in his right lung. Obviously a patient who has qualified for pneumothorax treatment has shown a notable lack of resistance to tubercle, and may show the same again at some later period. For this reason I feel that such people should be put under conditions the best possible for health after the treatment is suspended, though I confess that some of my own patients are working in towns without any very obvious detriment. At the conclusion, I would again remind you that collapse therapy is no panacea for pulmonary tuberculosis, but a treatment with decided indications and contra-indications, and hence somewhat severely limited in its application. At the same time it must be remarked that many fatal cases go through a period when this treatment might have been possible and beneficent, and it behoves the doctor to be on the look-out for this favourable moment so that the chance of this remedy be not postponed till it is too late.
SHORTER COMMUNICATIONS.
A NOTE ON THE TREATMENT OF LARYNGEAL TUBERCULOSIS \VITH INTRAVENOUS GOLD. E. G.
GLOVER,
M.D.
Birmingham Municifal Sanatorium, Cheltenham. ALTHOUGH it is six years since the introduction of Spiess's gold solution (ethylcne-diamin-cantharidin-auricyanide) for use in treating mucosnj tuberculosis, intervening events have prevented any detailed investigation of the drug's action in this country at any rate. For this reason . no apology is offered for the following brief note. It may be remembered that according to the original investigations of Spiess [1J, and later of Spiess and Feldt [2J, cantharidin salts given subcutaneously produce an inflammatory reaction in tuberculous lesions, and advantage was taken of this selective action to link these salts with gold cyanide, the action of which on the growth of tubercle bacilli had already been noted in vitro. The introduction of ethylene-diamin in the ortho position reduced the toxicity of the cantharidin constituent 680 times without any corresponding reduction in the salt's properties. The final salt was tested on the rabbit with satisfactory results, and intravenous administration was recommended in preference to the subcutaneous method, gold resistant strains being easily produced.
The Patient's Past. History. In 1014 Dr.. J. A. D. Radcliffe, Pathologist at King Edward VII Sanatorium, kindly supplied me with about enough of the salt to try in one case arid an endeavour was made to give this as se!ere a trial as possible. The case chosen was that of a man with laryngeal tuberculosis of a chronic