How Long Should Collapse Therapy be Delayed

By GEOFFREY MARSHALL, M.D., F.R.C.P.

PtIYSICIAN, GuY's HOSPITAL ; ASSISTANT PHYSICIAN, BROMPTON HOSPITAL

A paper read at the Provincial Meeting of the Tuberculosis Association held at Manchester on June I o, 1 i , and x 2, 1937.

This is an eminently debatable subject, and I have more than once regretted my own temerity in undertaking its introduction. My first duty is to suggest the main points on which our limited time may be expended. Let us consider collapse therapy only in its application to the treatment of tuberculous disease of the lungs. This is not the occasion for a detailed consideration of the indications for this type of treatment, so I propose that we direct our attention to the object for which it is most commonly employed--its use in facilitating the healing of cavities in the lungs.

Tuberculous cavities of recent origin may heal without the aid of collapse therapy, provided the patient is kept at rest in bed for sufficient time. The very small cavity responsible for the initial haemoptysis, often invisible in X-ray photographs, will generally heal after two or three months rest in bed, with efficient nursing, hygiene and diet. Larger cavities, exceeding 2 or 3 cm. in diameter, may heal with much more prolonged rgst in bed, but one or two years may be needed. Even then success is far from certain, and the psychological effect of such long confinement is apt to be both serious and Iasting. We are often asked why we attach such overwhelming importance to the closure of cavities ; our answer is that the patient in whom a pulmonary cavity can be demonstrated radiographically, has a poor chance of surviving five years [I]. However well he may become, he is ahvays liable to a fresh extension of the disease and he may at any time have a severe haemorrhage. There are a minority who survive in very fair health for many years, despite unhealed cavities; but if they themselves escape death, they are infectious to others, for cavities are the main source of infected sputum, and tubercle bacilli are almost certain to be discharged from time to time.

Each patient must be considered individually, and from several aspects, psychological as well as physical. I f there be a cavity of recent origin and of less than 3 cm. in diameter, it is surely justifiable to trcat such a case by the method which has been appropriately entitled ' expcctant '. Absolute rest in bed is enforced, and the chest is skiagraphcd once a week. Jaquerod (E935) has urgcd the advantages in natural healing unaided by collapse therapy; but even he would not defer active measures in the face of severe toxaemia or haemoptysis, or ifserial skiagrams showed no improvement in the first few weeks of treatment by rest alone. Jaquerod pleads the case for natural healing only for the cavity of recent origin. With the chronic cavity, natural healing is liable to produce as much distortion ofsurrounding lung tissue as does collapse therapy, while the latter is nmre likely to achieve a

O_O TUBERCLE October I937

successful result. And Davies (x935) has pointed out the danger of delaying active measures when a cavity, developes near the outer surface of the lung or near the interlobar septum, because of the rapidity with which pleural adhesions are formed in such cases, with consequent addition to the difficulty of obtaining selective relaxation by artificial pneumothorax.

ARTIFICIAL PNEUMOTHORAX

While there are some cases of tuberculous cavitation in which it is justifiable to wait, because the cavity is small and single and remote from the surface of the lung, my own practice is to attempt tim induction of an artificial pneumothorax in every case where a tuberculous cavity is demonstrated by X-ray examination, unless there is some definite contra-indication. Absolute contra-indication would be deficient total lung capacity associated with widespread fibrosis or with generalized emphysema or old age. Another is the very large superficial cavity, the wall ofwhich is likely to be adherent and to tear open into an artificial pneumothorax. Extensive infiltration of the opposite hmg might be a good reason for delay, and in several such cases I have seen good results follow the induction of a pneumothorax after preliminary treatment by rest and the injection of gold salts, which brought about arrest o f inflammation in the unexcavated lung. Extra-pulmonary complications, such as tuberculous ulceration of the larynx or of the intestines, are not an indication for delaying pneumothorax treatment, but rather for its expedition.

GAS REPLACI'MENT OF PLEURAL I~FFUSIONS

In mentioning tiffs subject I am exceeding the limits which I had suggested for this discussion. There are physicians whose routine treatment for a simple pleural effusion is to aspirate the fluid and replace it with air. They argue that even though 11o pulmonary !esion may be visible when the effusion occurs, disease of the lung frequently follows. Such disease may go on to excavation and render pneumothorax treatment desirable ; but that if they wait for the cavity to form, the opportunity for pneumothorax treatment will be lost as a result of the widespread pleural adhesion which follows an effusion. This argument is persuasive, but I would urge objections to it. The treatment of a simple effusion by gas replacement, instead of by ordinary aspiration, tends to prolong the presence of fluid in the pleural sac. Under the hydropneumothorax, the visceral pleura becomes thickened and un- yielding, so that tim lung can never re-expand to its full size. There is therefore some permanent loss of function and although this is a minor handicap compared with tuberculous excavation ofthe lung, this treatment does not guarantee the patient against excavation. When pulmonary tuberculosis follows an effusion, it sometimes makes its appearance in the contralateral lung and in such a case the loss of function brought about by the gas replacement will be a serious handicap to further treat- ment. I believe that gas replacement should bc reserved for cases in which there is X-i'ay evidence of disease in the lung underlying the effusion.

SELECTIVE PNEUMOTHORAX

It goes without saying that in treating cavities by artificial pneumothorax, selective relaxation must be obtained. With cavities in the upper zone, such

October r937 TUBERCLE 2I

relaxation is commonly prevented by adhesions. How long should we defer an at tempt to divide these adhesions ? Jn one of my cases they were dealt with success- fully three weeks ;trier the first introduction of air into the pleural cavity. A contraselective pneumothorax is apt to be not only useless but actually harmfid, and may expedite the spread of disease to the opposite lung. It is usually wise to cease refilling an artificial pneumothorax if it cannot be rendered truly selective within a few months.

Adhcsions to the excavated lobe should therefore be divided as soon as the skiagraphic appearances and inspection through the thoracocsope indicate that the operation may be undertaken without undue risk. The presence of tubercles on the pleura does not necessarily rendcr adhesicctomy unsafe.

SURGICAl. COLI.APSI';

In many cases of tuberculous cavitation, selective pneumothorax is rendered unattainable by adhesions so widespread that their dMsion is impossible. Alternative methods have then to be considered. These are, in order of severity, phrenic interruption, apicolysis with plombage, and thoracoplasty in its wmous forms.

There are relatively few contra-indications to the induction of an artificial pneumothorax during the treatment of a case of tuberculous cavitation. Unless we are singularly unfortunate, our interference will not cause any severe constitutional disturbance in the patient ; his resistance to the disease will not be lowered, and if we find that selective collapse is unattainable by this method, refills can be discontinued and conditions quickly return to the status ante quo. When the lesions are confined to one lung, the appearance of new areas of inflammation should cause us to hasten and not to delay the induction of a pneumothorax. It is only in some cases of bilateral disease that active extensions of disease in tim better hmg make delay advisable. These remarks are not equally applicable to the more strictly surgical methods used in collapse therapy.

PHRENIC INTEI~.RUI'TION

Paralysis of the appropriate half of the diaphragm, by crushing or evulsion of the phrenic nerve, seldom provokes a serious reaction. This operation may therefore be undertaken while the disease is still in the inflammatory stage, and it is applicable in conjunction with an artificial pneumothorax, or as soon as it is found that induction of a pneumothorax is impossible. A disadvantage of phrenic paralysis is that the status quo cannot be promptly restored if it is found to be doing no good. Even the temporary paralysis produced by a crush may persist for three months or more, and the effects of the operation on cavities in any part of a hmg are impossible to foretell. Some surgeons are umvilling to cruise a phrenic nerve where cavitation is confined to the upper zone of a lung, because they hold that it will render the patient unfit for selective thoracoplasty. Does disaster befall a patient with a paralysed diaphragm if he is submitted to an upper thoracoplasty ? I have seen

�9 good results from such a sequence, but my experience is limited, and I hol m Mr Morriston Davies will deal with this point.

My present practice is to advise phrenie evulsion when there is a single cavity of moderate size near tim apex of the lung, as soon as I find selective relaxation by pneumothorax to be impossible, and provided there be no gross disease in the

22 T U B E R G L E O c t o b e r I937

other lung. I have seen no bad results in such cases, while in several, complete healing has followed.

APICOLYSIS AND PLOMBAGE

I intend no pun when I say that this operation has waxed and waned, in the approval of chest surgeons, in alternate years over a long period. Theoretically it is a humane method of encompassing the obliteration of a single cavity near the apex of a lung, and the X-ray appearance is highly encouraging during the period of convalescence. In the cases which I have had under personal observation the end results have been lamentable. In some there have been disastrous complications, and in all the others there has been a recurrence of positive sputum, which has been associated with persistence of the cavity, obscured but not closed by the plombage. How long should we delay this form of collapse therapy ? My answer is sine die.

THORACOPLASTY

Thoracoplasty remains the most effective method of dealing with cavities which cannot be treated successfully by pneumothorax, reinforced if necessary by adhesiectomy and/or phrenic evulsion. Patients feel a natural repugnance to a severe plastic operation on the thorax and it must entail a considerable psychological effect if the victim be a young and attractive woman. There is therefore a tendency to postpone thoracoplasty until less drastic methods have proved unsuccessfid. The patient will face the ordeal only after many disappointments, when he finds that periods of improvement are followed by a return of toxaemia or of haemoptysis, and that persistent positive sputum makes him uneasy in mixing with his fellows. The patient looks upon thoracoplasty as the last line of defence in the fight against his disease : and, to a large extent, the patient's view is correct.

We have probably all seen cases in which thoracoplasty has been performed with such skill and judgement that the diseased portions of the hmg were thoroughly relaxed and yet the result has been a prompt extension of the disease to other parts of the lungs, with the formation of new Cavities outside the area for which the operation was performed. Surgeons with their customary magnanimity are apt to shoulder the blame for such untoward results, and to accuse themselves of having planned their operations on too restricted a scale. I believe that in many of these cases the fault lies with the physician who has called upon his colleague to operate too soon. Even in skilled hands, thoracoplasty is a severe operation and it must cause temporary lowering of the patient's resistance to infection. Unless there is a margin of resistance, the operation cannot be undertaken with a reasonable hope of success. Dr Graveson dealt ~vith this point in his address at Oxford last year, when he urged that thoracoplasty should not be performed while there was active or spreading tuberculous inflammation in the lungs, and that such activity must never be looked upon as a vital indication for expediting thoracoplasty ; indeed there were no vital indications for expediting this operation. The object of thoracoplasty is to relax the tension on pulmonary cavities, and allow their hea l ing by the natural processes of repair. Operations do not cure a general disease such as tuberculosis, and thoracoplasty should not be undertaken until the patient's resistance has reached a point at which the infection will be held in check, and the disease will be in process of arrest. Prolonged medical treatment is usually necessary

October i937 TUBERCLE 23

to fit a patient for thoracoplasty, and the most careful observation is necessary before deciding whether resistance to infection has reached all adequate level.

I f my argument implies a wish to limit the indications for thoracoplasty and to cmphasise the need for careful observation of each individnal patient before advising operation, it comes from no lack of appreciation of the successes which are so often achieved. Thanks to these operations many of my patients have regained health and happiness, because the well-timed intervention of a surgeon has made it possible for nature to complete the process of healing, in cases where tile damage would otherwise have been irreparable.

CnARKE, B. R. DAVIES, II. M. JAQUEROD, ~L

REFERENCI'S

Tubercle, I93 , xv. 5'2,9. Brit. Journ. Tub., 1935, x..XlX. 86. ibid., p. 9 I.