- Email: [email protected]
The value of artificial pneumothorax
June, 1020]
TUDEnCLE
411
SHORTER COMMUNICATIONS, TIlE VALUE
OF
AHTIFICIAL PNEUMO'rnOHAX:
hlPRESSIONS AFTER EIGIIT YEARS AND FIFTY-FOUn CASES.
By ESTHER CARLING, M.D. Medical Superintendent, Berk« and Bucks Sanatorium, rr'IIIS treatment has only been attempted in casea that were doing no ~ood on ordinary lines and for whom, therefore, the outlook was thoroughly
lind: 0.11 have been either advanced or acute, and 0.11 presented moro or less unilateral disease. In 12 of the 54 cases it was not possible to establish tho treatment (in 10 instances because lree pleural space could not be found and in ~ because oC the nervous apprehension of tho patients). In 42 cases a pneumothorax was more or less completely established and tho treatment was con tinned. In 2~ of these 0. marked and definite improvement was observed, but what oC their subsequent histories? At the end of eight years, reviewing all the cases, it is Iound : of the 12 in whom the treatment was not established 10 are dead; of the ·12 in whom ~ho treatment was established 21 are dead; of the 22 who showed 0. marked improvement, 8 are dead; 13 have returned to their old occnpation or to 0. moderately active and useful lile : 1 is going downhill. 'I'hese !.!2 cases represent the Lest results of 0. treatment undertaken when all else seemed hopeless, and though eight of them have died and another will soon follow, all of them have experienced ll. period oC betterment, which was unexpected and extraordinarily encouraging. S01l10 of these patients became ternporurily not merely better but pmctically well; two Ilt least were dramatic in that they arrived here helpleas and nlmost dying, and to the amazement of everyone and of themselves they became norm III individua.ls, with all trace of invalidism put away, One took a post 011 the &taff and held it Cor a year; tho other was making arrangements to resuuio work when the downfall came. Doth died eventually, but each had a ~oou )'ear of health nud haJ?piness, which they certainly owed to their collapsed lung. or tho remaining 20 cases, 12 nro still undergoing treatment or have finished it too recently to classify (i.o., less thau ono year); H were uno.ffected, i.e., tho disease went on without nPl:?3.l'enl check. In two oC theso cases it is possible that the inevitable end was hnstcncd father than hindered by the compression treatment. In ono tho II ~ood lung" gave way and an acute process set in which quickly ended l\ patient worn with many years of chronic disease. In this case tho treatment was deliberately cbosen, though the risk to the more sound or tho two lungs had Leen pointed out. 'l' he other case is the only one or tho whole series which I wish had been left alone. It was unpromising certainly, but LciD~ of Iairly recent origin was not recognized as serious Ly tho patient or her friends. A good start was made, but domestic reasons made it necc8sary for the patient to leave tho sanatorium after only three months from statting tho compression. A week after returning bome I heard sho was o.cutely ill. lIer doctor asked me to sec her, and I round signs or an effusion in tho pleural cll.vit, in addition to the abdominal symptoms which he had queried as appendicitis, Death followed quickly, both chest.
412
TUDEnCLE
[June.
ID20
and abdominal symptoms remaining acute to the end. Whatever it wns that caused death, tbe treatment was blamed, This, however, is the only case oC the tJ4 in which nny feeling of regret remained that the treatment was undertaken. Even in the two cases in which the attempt to establieh this trentmont had to be given up owing to the nervous dread of the punctures, the vatients both expressed regret that tbey could not continus. . A great hope IS established and it gocs hardly with people when this has to be given up • hence it is desimble fully to advise patients that it IDny 110t be possibl~ to get the compression established beforo beginning the treatment, The -choicc on their parts should be deliberate, and though one cannot 301\\'11)'8 emphasise possible Iailure the friends at least should be clearly told. Sometimes this means 0. refusal to allow the treatment to be tried, but that is 0. lesser evil than recrimination. The first three CMCS of this series were started at St. Mary's Hospital .by Dr. Leonard Colebrook, who kindly allows me to include them, as their -subsequent treatment was continued hero. Most of the rest were undertaken in co-operation with Dr. Claude Lillingston, who introduced tho treatment to this country after successfully undergoing it himself in Norway. Many diflicult corners were turned by his steady confidence and Borne oC the best results would have been lost but for his encourn""cment to persist. The treatment requires some facing', and patients nr: much more helped by seeing good results" in the flesh" than by any explanation -ol tho theory. For this reason probably the treatment has its best chance in 0. sanatorium where it can be kept going and where encouraging object lcssona 301'0 ulways on hand. In spite of the disappointments, which were the more keenly felt because of the bright hopes raised nt an earlier stage, it still remains that no other procedure offers as good a hope of improving the dreary lot or ~n advancing case oC phthisis as docs the successful induction of an artificial Vllcull1othoro.x.
IN n. recent number of the New i'ork Medical Journal (1019, 109.187), Dr. D. Btivelmun makes 11 careful assessment of tho dnngers arising from tho induction of artiflcial pneumothorax. lIe notes that not one C3.S0 of gas em bolism was experienced among 8G7 cases treated by nineteen American workers. lIo thinks, since chest wounds during the war hlL\'o not led to gas em holism, that air escaping from ruptured alveoli cannot be no potent Iactor. Under injury to the heart he describes a case ot pre. Burned heart puncture recorded by Minor. Spontnneous pneumothorax he makes out to be less common in artiflcial pneumothornx (1 per ccut.) than in serious cases of tubercle otherw.iso (4 to Q per ~ent. of fatnl cases). lIe thinks them duo to ruptured adhesions or to tearing of unsupported lung tissue during cough (Bcgga). Pleural shock, II one of tho lllost frequent accidents," occurred twenty-two times among 1,122 CllSCS trcatcll 1Jy twenty-Iour American workers. The common symptoms are given in detail. 'I.'he writer remarks that it occurs as often alter nn~sthetisa. Lion of tho pleura us when no anrosthctic is used.
TUDEnCLE
411
SHORTER COMMUNICATIONS, TIlE VALUE
OF
AHTIFICIAL PNEUMO'rnOHAX:
hlPRESSIONS AFTER EIGIIT YEARS AND FIFTY-FOUn CASES.
By ESTHER CARLING, M.D. Medical Superintendent, Berk« and Bucks Sanatorium, rr'IIIS treatment has only been attempted in casea that were doing no ~ood on ordinary lines and for whom, therefore, the outlook was thoroughly
lind: 0.11 have been either advanced or acute, and 0.11 presented moro or less unilateral disease. In 12 of the 54 cases it was not possible to establish tho treatment (in 10 instances because lree pleural space could not be found and in ~ because oC the nervous apprehension of tho patients). In 42 cases a pneumothorax was more or less completely established and tho treatment was con tinned. In 2~ of these 0. marked and definite improvement was observed, but what oC their subsequent histories? At the end of eight years, reviewing all the cases, it is Iound : of the 12 in whom the treatment was not established 10 are dead; of the ·12 in whom ~ho treatment was established 21 are dead; of the 22 who showed 0. marked improvement, 8 are dead; 13 have returned to their old occnpation or to 0. moderately active and useful lile : 1 is going downhill. 'I'hese !.!2 cases represent the Lest results of 0. treatment undertaken when all else seemed hopeless, and though eight of them have died and another will soon follow, all of them have experienced ll. period oC betterment, which was unexpected and extraordinarily encouraging. S01l10 of these patients became ternporurily not merely better but pmctically well; two Ilt least were dramatic in that they arrived here helpleas and nlmost dying, and to the amazement of everyone and of themselves they became norm III individua.ls, with all trace of invalidism put away, One took a post 011 the &taff and held it Cor a year; tho other was making arrangements to resuuio work when the downfall came. Doth died eventually, but each had a ~oou )'ear of health nud haJ?piness, which they certainly owed to their collapsed lung. or tho remaining 20 cases, 12 nro still undergoing treatment or have finished it too recently to classify (i.o., less thau ono year); H were uno.ffected, i.e., tho disease went on without nPl:?3.l'enl check. In two oC theso cases it is possible that the inevitable end was hnstcncd father than hindered by the compression treatment. In ono tho II ~ood lung" gave way and an acute process set in which quickly ended l\ patient worn with many years of chronic disease. In this case tho treatment was deliberately cbosen, though the risk to the more sound or tho two lungs had Leen pointed out. 'l' he other case is the only one or tho whole series which I wish had been left alone. It was unpromising certainly, but LciD~ of Iairly recent origin was not recognized as serious Ly tho patient or her friends. A good start was made, but domestic reasons made it necc8sary for the patient to leave tho sanatorium after only three months from statting tho compression. A week after returning bome I heard sho was o.cutely ill. lIer doctor asked me to sec her, and I round signs or an effusion in tho pleural cll.vit, in addition to the abdominal symptoms which he had queried as appendicitis, Death followed quickly, both chest.
412
TUDEnCLE
[June.
ID20
and abdominal symptoms remaining acute to the end. Whatever it wns that caused death, tbe treatment was blamed, This, however, is the only case oC the tJ4 in which nny feeling of regret remained that the treatment was undertaken. Even in the two cases in which the attempt to establieh this trentmont had to be given up owing to the nervous dread of the punctures, the vatients both expressed regret that tbey could not continus. . A great hope IS established and it gocs hardly with people when this has to be given up • hence it is desimble fully to advise patients that it IDny 110t be possibl~ to get the compression established beforo beginning the treatment, The -choicc on their parts should be deliberate, and though one cannot 301\\'11)'8 emphasise possible Iailure the friends at least should be clearly told. Sometimes this means 0. refusal to allow the treatment to be tried, but that is 0. lesser evil than recrimination. The first three CMCS of this series were started at St. Mary's Hospital .by Dr. Leonard Colebrook, who kindly allows me to include them, as their -subsequent treatment was continued hero. Most of the rest were undertaken in co-operation with Dr. Claude Lillingston, who introduced tho treatment to this country after successfully undergoing it himself in Norway. Many diflicult corners were turned by his steady confidence and Borne oC the best results would have been lost but for his encourn""cment to persist. The treatment requires some facing', and patients nr: much more helped by seeing good results" in the flesh" than by any explanation -ol tho theory. For this reason probably the treatment has its best chance in 0. sanatorium where it can be kept going and where encouraging object lcssona 301'0 ulways on hand. In spite of the disappointments, which were the more keenly felt because of the bright hopes raised nt an earlier stage, it still remains that no other procedure offers as good a hope of improving the dreary lot or ~n advancing case oC phthisis as docs the successful induction of an artificial Vllcull1othoro.x.
IN n. recent number of the New i'ork Medical Journal (1019, 109.187), Dr. D. Btivelmun makes 11 careful assessment of tho dnngers arising from tho induction of artiflcial pneumothorax. lIe notes that not one C3.S0 of gas em bolism was experienced among 8G7 cases treated by nineteen American workers. lIo thinks, since chest wounds during the war hlL\'o not led to gas em holism, that air escaping from ruptured alveoli cannot be no potent Iactor. Under injury to the heart he describes a case ot pre. Burned heart puncture recorded by Minor. Spontnneous pneumothorax he makes out to be less common in artiflcial pneumothornx (1 per ccut.) than in serious cases of tubercle otherw.iso (4 to Q per ~ent. of fatnl cases). lIe thinks them duo to ruptured adhesions or to tearing of unsupported lung tissue during cough (Bcgga). Pleural shock, II one of tho lllost frequent accidents," occurred twenty-two times among 1,122 CllSCS trcatcll 1Jy twenty-Iour American workers. The common symptoms are given in detail. 'I.'he writer remarks that it occurs as often alter nn~sthetisa. Lion of tho pleura us when no anrosthctic is used.