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THE TREATMENT OF PULMONARY TUBERCULOSIS BY THE INDUCTION OF ARTIFICIAL PNEUMOTHORAX.
99 a
good
paper is not
necessarily
a
good reader, gifted
a
’,
I
!,
THE TREATMENT OF PULMONARY TUBERCULOSIS BY THE INDUCTION OF ARTIFICIAL PNEUMOTHORAX. ALTHOUGH the method of treatment of certain cases of tuberculosis by the induction of pneumothorax with a view to immobilisation of the lung has now been before the profession for many years, it is only recently that interest has been taken in the matter in this country,
pulmonary
largely owing to the interesting paper published in our columns by Dr. Claude Lillingston.l Reports upon the to various scientific continue periodicals, appear in subject few months. refer to the last We may notably during those in La Presse llfeelicale of June 12th, which contains two interesting communications on this subject. The first is a paper read to a Brussels medical society by M. Guvaerd, who bases his statements on a study of 16 cases subjected to treatment by injections of nitrogen into the pleura. Of these, ten have been under observation for six months, long enough to justify some conclusions as to results. In four of the ten the pleura was so widely adherent that it was impossible to induce pneumothorax; in one case there were adhesions which limited the pneumothorax, yet improvement followed and was maintained. A complete pneumothorax was achieved in five cases ; twice an apparently lasting cure was effected, in two others the outlook is rendered doubtful by the presence of the disease in the opposite lung, while in the fifth case, an acute one with intestinal lesions, the result was entirely negative. In order to avoid the danger of gas embolism, M. Guvaerd uses oxygen for_the first few injections, replacing this by nitrogen 1
THE LANCET,
July 15th, 1911, p. 145.
soon as the pleura has become moderately distended. The second contribution is a paper read in Marseilles by M. Billon and M. Eiglier, who have treated 16 patients. They exclude three of these from a consideration of the benefits received on the ground that in each case only one injection has as In yet been given. the others they have noted a remarkable diminution in the cough and expectoration, a reduction of fever, and an increase of weight. It is to be remembered, as these writers and also M. Guvaerd insist, that cases of bilateral pulmonary tuberculosis should be excluded, and also that it is futile to attempt the induction of pneumothorax in the presence of extensive pleural adhesions. So far, the cases to which this method has been applied have been in the second or third stage of the disease. Marked cachexia, or the presence of advanced tuberculosis of the bowel or other organs, is a contra-indication. On the other hand, success is claimed in cases of recurrent hoemoptysis. The various major and minor accidents which have been reported become far less likely, according to M. Guvaerd, as the operator’s technique improves with practice. It should be noted that M. Billon and M. Eiglier regard the injection of air as being equally efficacious with that of nitrogen. In the American Joitrnal of the j1[edical Seieatees for April Dr. Mary E. Lapham, physician to Highlands Camp Sanatorium, has published several encouraging results from the treatment. She has obtained striking results in the cases in which she employed the method. The indications for the operation were as follows : Inability to arrest the process, 15 cases ; inability to maintain a previous recovery, 3 cases ; impatience to return to work, 2 cases ; "theoretical grounds,"1case ; and "referred expressly for the treatment," 1 case. All of the 15 cases first mentioned were advanced and otherwise hopeless, yet among these there were only 3 deaths and 1 failure. One death was due to haemorrhage before the benefit of the method could be obtained. The second death was due to a violent exacerbation of intestinal tuberculosis, and in the case of the third the patient left the sanatorium too soon and was not properly cared for. Of the three patients unable previously to maintain a recovery, one has worked for a year without loss of a day and the other two are in an equally favourable condition. All the other patients are doing well, and in The none could recovery have otherwise been much expected. following is an example. A woman, aged 40 years, had a cough with abundant expectoration loaded with tubercle bacilli. Eighteen months’ rest in bed in the open air had failed to arrest the disease or to check persistent haemorrhages. Over the whole of the left lung there and at the were dulness and altered breath sounds, level of the second intercostal space there was a cavity. The right lung was normal. In November, 1910, injections of nitrogen into the pleural cavity were begun. In December tubercle bacilli had disappeared from the sputum. In May, 1911, the injections were discontinued and the lung was allowed to expand. At the time of the report there was no cough and no sputum. Over the left apex there was dulness with irregular expansion, but over the rest of the lung there was normal resonance with vesicular breath sounds. as
powerful voice, and trained in all the arts of elocution. He too often mumbles incomprehensibly, and we should be much better informed and more edified if we could quietly read the paper at home when we felt so disposed. It is absurd to go to a congress to hear papers read-for the most part badly read-and to have no opportunity for discussion. Its adherents go to a great international congress to meet colleagues of all countries, to ’, make acquaintances they could not otherwise hope to see, and to interchange ideas. So far as the proceedings of the congress are concerned, the papers are often not of the highest importance. What is of real value and cannot possibly be obtained except at a congress is the discussion. This was well pointed out by proceedings at the recent Congress held at Rome on tuberculosis. Then without a discussion, and without translations of the important papers, many members of a congress find that it is not worth while voting on the great questions, and what business will the congress have done if it does not carry resolutions ? As hygiene is more especially a question of legislation the Governments are waiting for a pronounce- ’ ment from Washington so as to see how far opinion is’, ripening in the direction of the various sanitary measures that need a legal sanction. In the Military Hygiene Section a good many speeches are limited to 15 minutes in the ’, English programme, but though the same papers are announced in the French and German programmes no mention is made of the limitation to 15 minutes. In the Bacteriological Section the 20-minute limit is mentioned in the French programme, only no one has had the courage to translate it into French and the words appear in English. In these circumstances, if the French- and German-speaking delegates read longer papers they cannot be blamed. Again, if a paper is really important it ought not to be too short. We must have fewer papers at these meetings. with
SCHOOL INSPECTION IN CANADA. IN No. 4 of the official publications issued by the Medical Faculty of the Queen’s University, Ontario, Canada, appears an interesting article by Dr. A. P. Knight on the organisation of the medical inspection of schools. This procedure has been adopted in but a few cities in Ontario, and only during the past year or two. The statistics for Montreal for 1910 show that of the children examined 53 per cent. were ill with some form of disease," 2 per cent.
good
paper is not
necessarily
a
good reader, gifted
a
’,
I
!,
THE TREATMENT OF PULMONARY TUBERCULOSIS BY THE INDUCTION OF ARTIFICIAL PNEUMOTHORAX. ALTHOUGH the method of treatment of certain cases of tuberculosis by the induction of pneumothorax with a view to immobilisation of the lung has now been before the profession for many years, it is only recently that interest has been taken in the matter in this country,
pulmonary
largely owing to the interesting paper published in our columns by Dr. Claude Lillingston.l Reports upon the to various scientific continue periodicals, appear in subject few months. refer to the last We may notably during those in La Presse llfeelicale of June 12th, which contains two interesting communications on this subject. The first is a paper read to a Brussels medical society by M. Guvaerd, who bases his statements on a study of 16 cases subjected to treatment by injections of nitrogen into the pleura. Of these, ten have been under observation for six months, long enough to justify some conclusions as to results. In four of the ten the pleura was so widely adherent that it was impossible to induce pneumothorax; in one case there were adhesions which limited the pneumothorax, yet improvement followed and was maintained. A complete pneumothorax was achieved in five cases ; twice an apparently lasting cure was effected, in two others the outlook is rendered doubtful by the presence of the disease in the opposite lung, while in the fifth case, an acute one with intestinal lesions, the result was entirely negative. In order to avoid the danger of gas embolism, M. Guvaerd uses oxygen for_the first few injections, replacing this by nitrogen 1
THE LANCET,
July 15th, 1911, p. 145.
soon as the pleura has become moderately distended. The second contribution is a paper read in Marseilles by M. Billon and M. Eiglier, who have treated 16 patients. They exclude three of these from a consideration of the benefits received on the ground that in each case only one injection has as In yet been given. the others they have noted a remarkable diminution in the cough and expectoration, a reduction of fever, and an increase of weight. It is to be remembered, as these writers and also M. Guvaerd insist, that cases of bilateral pulmonary tuberculosis should be excluded, and also that it is futile to attempt the induction of pneumothorax in the presence of extensive pleural adhesions. So far, the cases to which this method has been applied have been in the second or third stage of the disease. Marked cachexia, or the presence of advanced tuberculosis of the bowel or other organs, is a contra-indication. On the other hand, success is claimed in cases of recurrent hoemoptysis. The various major and minor accidents which have been reported become far less likely, according to M. Guvaerd, as the operator’s technique improves with practice. It should be noted that M. Billon and M. Eiglier regard the injection of air as being equally efficacious with that of nitrogen. In the American Joitrnal of the j1[edical Seieatees for April Dr. Mary E. Lapham, physician to Highlands Camp Sanatorium, has published several encouraging results from the treatment. She has obtained striking results in the cases in which she employed the method. The indications for the operation were as follows : Inability to arrest the process, 15 cases ; inability to maintain a previous recovery, 3 cases ; impatience to return to work, 2 cases ; "theoretical grounds,"1case ; and "referred expressly for the treatment," 1 case. All of the 15 cases first mentioned were advanced and otherwise hopeless, yet among these there were only 3 deaths and 1 failure. One death was due to haemorrhage before the benefit of the method could be obtained. The second death was due to a violent exacerbation of intestinal tuberculosis, and in the case of the third the patient left the sanatorium too soon and was not properly cared for. Of the three patients unable previously to maintain a recovery, one has worked for a year without loss of a day and the other two are in an equally favourable condition. All the other patients are doing well, and in The none could recovery have otherwise been much expected. following is an example. A woman, aged 40 years, had a cough with abundant expectoration loaded with tubercle bacilli. Eighteen months’ rest in bed in the open air had failed to arrest the disease or to check persistent haemorrhages. Over the whole of the left lung there and at the were dulness and altered breath sounds, level of the second intercostal space there was a cavity. The right lung was normal. In November, 1910, injections of nitrogen into the pleural cavity were begun. In December tubercle bacilli had disappeared from the sputum. In May, 1911, the injections were discontinued and the lung was allowed to expand. At the time of the report there was no cough and no sputum. Over the left apex there was dulness with irregular expansion, but over the rest of the lung there was normal resonance with vesicular breath sounds. as
powerful voice, and trained in all the arts of elocution. He too often mumbles incomprehensibly, and we should be much better informed and more edified if we could quietly read the paper at home when we felt so disposed. It is absurd to go to a congress to hear papers read-for the most part badly read-and to have no opportunity for discussion. Its adherents go to a great international congress to meet colleagues of all countries, to ’, make acquaintances they could not otherwise hope to see, and to interchange ideas. So far as the proceedings of the congress are concerned, the papers are often not of the highest importance. What is of real value and cannot possibly be obtained except at a congress is the discussion. This was well pointed out by proceedings at the recent Congress held at Rome on tuberculosis. Then without a discussion, and without translations of the important papers, many members of a congress find that it is not worth while voting on the great questions, and what business will the congress have done if it does not carry resolutions ? As hygiene is more especially a question of legislation the Governments are waiting for a pronounce- ’ ment from Washington so as to see how far opinion is’, ripening in the direction of the various sanitary measures that need a legal sanction. In the Military Hygiene Section a good many speeches are limited to 15 minutes in the ’, English programme, but though the same papers are announced in the French and German programmes no mention is made of the limitation to 15 minutes. In the Bacteriological Section the 20-minute limit is mentioned in the French programme, only no one has had the courage to translate it into French and the words appear in English. In these circumstances, if the French- and German-speaking delegates read longer papers they cannot be blamed. Again, if a paper is really important it ought not to be too short. We must have fewer papers at these meetings. with
SCHOOL INSPECTION IN CANADA. IN No. 4 of the official publications issued by the Medical Faculty of the Queen’s University, Ontario, Canada, appears an interesting article by Dr. A. P. Knight on the organisation of the medical inspection of schools. This procedure has been adopted in but a few cities in Ontario, and only during the past year or two. The statistics for Montreal for 1910 show that of the children examined 53 per cent. were ill with some form of disease," 2 per cent.