the treatment of tuberculous cavities

748

THE T R E A T M E N T OF T U B E R C U L O U S CAVITIES. ~

By BRENDAN O'BRIEN.

T HE treatment to be considered in this paper is largely surgical, but may, I think, properly be brought before the Section of Medicine, as it is particularly in dealing with

pulmonary tuberculosis that physician and surgeon must work in the closest co-operation. The disease is, after all, treated in the first place by the physician, and must again come under his care during the long period of after-treatment which inevitably follows even the most successful operations. I do not intend in this paper to go into great detail of surgical technique, nor to make any exhaustive survey of the work that has been done, but to present some of the possibilities of treatment with their indications, by giving an account of the methods I have seen used in Davos by Dr. Maurer, and in Heidelberg by Dr. Schmidt.

A point to be considered at the outset is why one should be justified in exposing a patient to the risk entailed by a major operation in order to close a cavity which may be giving him very little trouble. First, there is the danger to the patient himself : A patent cavity is always a source of danger however quiescent it may seem, as it may, at any moment, when stimulated by other illness, especially influenza or pneumonia, or by the strain of exertion or pregnancy, again become active and produce a dissemination through the lungs of such an extent that any form of treatment is useless. Second is the danger to contacts : Patients quite often have cavities which cause them very little inconvenience, but they are hardly ever completely sputum-free, and such sputum as there is nearly always contains tubercle bacilli, so that they are dangerous carriers of the disease. When the cavity is not quiescent the need to close it and the justification for the operative risk are obvious.

As one has to be very largely guided by x-ray findings in planning any form of active intervention, I am considering three types of cavity as distinguished by this and clinical means : (a) the early thin- walled cavity; (b) the progressive thick-walled cavity, in which the central clear space is surrounded by a zone of infiltration whose inner surface is continually dissolving to enlarge the cavity and whose outer surface spreads ever further into the lung; (c) the regressive cavity, surrounded by a zone of fibrous tissue, which tends to shrink and close the space, as soon as it is released from the pressure of the air or the traction of adhesions.

Treatment falls into two main divisions, passive and active. Passive or rest treatment should in nearly all eases be tried first, especially when there is much toxemia, or when the cavities belong to the early or the progressive types, as the active forms of treatment are most successful and least dangerous when there is already a tendency to healing. Early thin-walled cavities will sometimes

*Communication to the Section of Medicine, October 28th, 1938.

THE TREATMENT OF TUBERCULOUS CAVITIES 749

close spontaneously with passive treatment alone, as may be seen from Figs I and II. In this case the patient was a man of 35 when he fell ill. Artificial pneumothorax had failed and he was sent to Davos for active treatment. However rest, without further intervention, allowed the cavities to heal of their own accord in one and a half years. I t is quite exceptional for cavities of this size, or any but the smallest, to heal without collapse therapy of some kind, and even if they do, it is probably wise to institute some kind of artificial immobilisation after they have closed, in order to keep them in that state. In this case temporary phrenic paralysis was the method Chosen.

Active treatment entails releasing the lung from the forces which keep it expanded and allowing its natural elasticity to collapse it, so that the walls of the cavity are approximated and allowed to heah The means to be considered are artificial pneumothorax, phrenic paralysis, intra- and extra-pleural pneumolysis and thoracoplasty.

Artificial pneumothorax has become so familiar to everyone, that I only touch on it briefly; when successful it has the merit of being easy to induce, giving very little shock or discomfort to the patient, collapsing the whole lung, and therefore a cavity in any part of the lung, and of being a temporary measure which can be relinquished when it is considered that the cavity is finally healed. The only complication to be feared in a successful pneumothorax is the development of pleural effusion. This may be slight and disappear without needing more than rest, but it may lead to a progressive obliterative pleurisy and the loss of the plcural space and consequently of the collapse. Or the effusion may become large and, while maintaining the collapse of the lung, cause so much thickening of the visceral pleura that the lung will not re-expand when it is wished to relinquish the pneumothorax. Finally, the effusion may become purulent, which is however very rare in cases of complete pneumothorax.

Pneumothorax can be used bilaterally also, and owing to the tendency of diseased lung to collapse more than healthy, the patient stands it well, provided that on one side the lesion is not more than apical.

As an adjunct to double pneumothorax or bilateral active treat~ ment of any kind where one side is being treated with pneumothorax, one must mention the use of artificial pleural effusions for causing a healthy lower lobe to adhere to the chest wall, while the diseased upper lobe is collapsed; in order to get the maximum amount of respiratory surface into action. This object may be attained when there is a natural effusion present, by allowing the lung to re-expand just enough for the base to adhere. When there is no natural effusion Maurer t uses 50 per cent. glucose solution as a sterile irritant. This is not always successful in producing adhesion, and sometimes the adhesion when produced proves to be progressive, so that the pneumothorax is lost, but in some cases it has proved of great value in taking the load off the other lung.

750 IRISH JOURNAL OF MEDICAL SCIENCE

Incomplete pneumothorax, due to adhesions between the pleural layers, is unfortunately all too common, and varies greatly in degree from case to case. In some, thin fibrous strings or membranes extend from lung to chest wall preventing collapse; in others, a small area of lung tissue adheres with the pleura to the chest wall and is drawn out into a long cone by the collapsing lung; in yet others wide areas of lung adhere to the wall and the collapse can be seen to be ineffective. This may not be of great importance if the cavity can close without complete collapse of the lung, but when a cavity is held open by adhesions, not only can it not heal, but it pours its contents into the rest of the lung and spreads the disease, and enlarges itself by the traction of the collapsing lung on it. The effect of relieving the tension on a hanging cavity is illustrated by the case of a young man who was sent to Dr. Maurer with an incomplete pneumothorax for division of adhesions. On thoracoseopic examination, this was found to be impossible, so the pneumothorax was diminished in order to release the tension on the cavity wall. The result was that the cavity disappeared from the picture. Later, progressive pleurisy set in, and a temporary phrenie paralysis was performed in order to reduce ~ e size of the lung as much as possible before complete adhesion took place.

Intra-pleural pneumolysis means the division of adhesions within the pleural space; this is usually performed by means of the thoracoscope and cautery. The instrument devised ~nd used by Maurer ~ supplies coagulation diathermy for h~emostasis and simple galvano- eautery for .cutting, through the same electrode, which is introduced through a canula of the same bore as that for the thoracoscope, thereby giving a double line of access to any adhesion. The coagulating current is so efficient that there is never any bleeding from the site of his work, though the passage of the troear through the chest walt may cause a little oozing occasionally. The plain fibrous adhesions are comparatively easy and safe to divide, but the lung cones present much greater difficulty, as they have to be enucleated from the chest wall in order to avoid perforation of the lung. The chief difficulty is to decide which adhesions can safely be divided and how best to do it. Many cases of incomplete pneumothorax can be made complete or can be improved sufficiently to avoid more drastic treatment. The interwention is well tolerated, and it is not uncommon to see Dr. Maurer's .eases up and about again three or four days after the operation. Possible complications are: pleural effusion, which occurs often, though rarely to a serious extent; perforation of the lung, which is as serious as it is in skilled hands rare; surgical emphysema, which is principally the result of careless after-treatment; and bleeding, which is very rare when diathermy is used. Internal pneumolysis can also be performed by open operation, and under direct vision, but this is a much more drastic procedure and is no more efficient than the closed method in the hands of one who knows how to use it.

The two forms of artificial paralysis of the diaphragm which I wish to consider are : permanent, by evulsion of the nerve, and tern-

FIo. I. Large cavity right, small cavity left.

FIs. If. Same ease, 18 months later, rest only.

FxG. I I I . Wax plombage i~v s~u.

FIc~. IV. Same case after the removaI of t, he wax~ showing how the plombage bed has been filled.


porary, by crushing the nerve and cutting the nerve to the sub- clavius. The former is nearly always successful in paralysing the diaphragm, the latter does not always do this; and when it does, the nerve does not invariably regenerate, but when all goes well the paralysis is perfect and lasts for twelve months or more, and eventually the diaphragm works as well as before. The chief indication for phrenic evulsion is the presence of a cavity in the base of the lung, with a considerable amount of destruction of tissue. Otherwise phrenic paralysis should be temporary only, as a patient with a healthy base and diseased apex cannot afford the loss of respiratory surface involved in permanent phrenic paralysis. In any case phrenic paralysis is only moderately successful in closing apical cavities, which also tend to recur later above the paraiysed diaphragm, in which case the loss of the base is a serious handicap to the treatment of the relapse. The time when temporary phrenie paralysis is of the greatest value is in combination with pneumothorax in the common case in which the latter leaves the lung adherent at the apex, the lobes adherent to one another, and the lower adherent to the diaphragm, so that at each excursion of the diaphragm the lung is stretched between its adherent points and the cavity is given no chance to heal. The effectiveness Of this c0m- bined operation is shown in the case of a man of 40 who had a large right apical cavity which an incomplete pneumothorax had failed to close, in spite of the division of a number of adhesions. After the phrenic nerve had been crushed, there was an immediate improvement in the clinical condition, ,sputum diminished and the Mood sedimentation rate became nominal, and in a radiogram taken five months later the cavity was no longer visible.

With regard to the regeneration of a successfully paralysed diaphragm I should like to mention the case of a patient who had his left phrenic nerve crushed in April, 1937. He had no gastric disturbance, though the diaphragm rose to a considerable height and there were paradoxical movements on respiration. By April, 1938, tone had returned to the muscle though it was still high and was not moving. In October, 1938, the diaphragm could be seen on the fluoroscopic screen to be moving well on respiration, though the film showed it still to be rather higher than the right half.

When artificial pneumothorax has proved impossible, we consider the possibilities of extra-pleural pneumolysis, of which there are two types, both of which take us definitely from minor into major surgery. In both the thick pleura formed by the fusion of the parietal with the visceral layers is released from the chest walI by manual means, but in plombage the space so made is maintained by a plug of paraffin wax, and in extra-pleural pneumothorax by the pressure of air.

Plombage is, within the limits of its indications, an excellent operation; the indications for its performance are:

(a) that the closing of a cavity is the sole object of the operation;


(b) that the cavity is of the regressive type; (c) that it is situated above the level of the upper border of the

second rib in front; (d) that the lower part of the lung is free from progressive

disease.

The operation is performed through a four-inch paravertebral incision, a piece of the third or fourth rib is resected, and the extra- pleural plane is found, then the pleura is stripped from the chest wall in such a way as to leave a bed as nearly horizontal as possible. When the space so made is quite dry it is filled with lumps of a special paraffin wax mixture about the size of walnuts, which are gently moulded together so as to fill the space without exerting any real pressure on the lung. The function of the wax is to maintain the collapse produced by the release of the lung, and not to attempt to obliterate a cavity by pressure, as this would probably produce necrosis and perforation of the wax into the lung. 3

The operation produces very little shock at the time. There is a good deal of pain for the first few days after, but the patient is usually feeling quite well in two weeks. The effect is a strictly selective collapse of the apex of the lung. Bilateral plombage is well tolerated, or the plombage on one side may be combined with other collapse methods on the opposite side. Another merit of the operation is that should it fail to close the cavity or should the disease progress after the operation the way is still left open for a thoracoplasty, whereas the regenerated bone after an apical thoracoplasty makes any further intervention difficult and dangerous. Possible complications are: (a) early perforation when the wax finds its way into the lung and is expectorated by the patient. This is only likely to happen when the operation has been performed over a progressive focus, or when there has been some fault in operative [echnique. The result may be suppuration in the plombage bed, or there may be no worse result than the need to remove the wax and perform a small thoracoplasty; (b) late perforation due to the presence of a foreign body, which is avoided by making the intervention, like pneumothorax a temporary one, by removing the wax after about two years when the cavity should be healed. The space left after the wax has been removed is filled partly by the lung re-expanding and partly by cutting small pieces out of the first four ribs at the time of the removal of the wax and so allowing them to fall in towards the lung; (c) large effusion of blood or serum into the plombage bed, which may require aspiration, or cause the dis- placement downwards of the wax filling, but this shotild be avoided by really careful hsemostasis at the time of operation. Fig. I I I shows the wax filling in situ in a case of plombage performed after a phrenic evulsion had failed to close an apical cavity. Fig. IV shows the same case after the wax had been removed and small pieces had been cut from the fi~st four ribs.

Another case is of interest for the number of means used in the ~,reatment and its final success : the patient, a woman born in 1911,


came under treatment in 1934 with bilateral apical cavitation and recent spread in the left lung. Pneumothorax was induced on the right side and was attempted on the left, but failed. Then the left phrenic nerve was cruised after which the left cavity became larger. At this stage the patient came under the care of Dr. Maurer who introduced an artificial effusion of glucose into the right pneumothorax cavity. This was only partly successful in producing adhesion, but the left cavity began to close after this intervention and finally almost disappeared so that it was possible to close it easily by means of a plombage in 1936. In 1937, the patient went home in very good condition and with scanty sputum in which no tubercle bacilli could be found.

Extra-pleural pneumothorax is a very similar operation to p~ombage, the only difference being that the wound is closed leaving the space left by the operation empty. Dr. Schmidt, 4 of Heidelberg, who is one of the chief exponents of this form of treatment, divides h~s indications into absolute and relative. Absolute indications are practically identical with those for plombage, which he never per- forms, except that the intervention can be rather more extensive, a~ plombage is limited to the size of 250 gms. of wax, any greater amount being too heavy. The relative indications are the need to collapse a lung as much as possible when the contralateral lung is too bad to allow a thoracoptasty. Dr. Maurer regards the latter as the only valid indication.

The advantages of the operation as against plombage are that it. can be more extensive, and that there is no foreign body left in the tissues; as against thoraeoplasty, that it gives a good deal less shock during the operation and can be used when the opposite lung is too much affected to allow a thoracoplasty. Its disadvantages are: (a) the need for daily refills after the operation; the refills being difficult to do and painful for the patient; (b) the risk of effusion of blood or serum into the space, which is increased by the absence of the tampon effect of the wax; (c) the risk of infection of the space by organisms released from the extra-pleural lymphatics during the operation, or introduced during the refills; (d) the risk of progressive obliteration of the space, which needs an extra-pleural oleothorax. A ILual difficulty is the problem of the space when the tuberculous process has healed, the alternatives being refills for life, a permanent oleothorax to avoid them, or some kind of thoracoplasty. In a few of Dr. Schmidt's cases the space has closed spontaneously after refills had been stopped, but these were only small extra- pleural spaces which might have been treated by plombage; others have been given oleothorax, but thoracoplasty has been performea only when the extra-pleural operation had failed. The operation has not been sufficiently long in regular use to say what the final result is going to be.

Both forms of extra-pleural pneumolysis are able to collapse only those cavities which are in the upper part of the lung. The value of the operation is shown in the case of a man of 50 on whom an extra-pleural pneumothorax was performed on Dr. Maurer's advice,


as a desperate remedy, the condition being very bad, with left apical cavitation and bilateral infiltration. The condition did not improve on plain rest treatment, as pyrexia persisted mud the patient was obviously losing ground. The operation was well tolerated and progress was uninterrupted after it.

When the cavity to be closed is not strictly apical or when its wall is so thin and so close to the chest wall that it seems unlikely to be possible to strip it off without tearing into it, thoracoplasty is the operation to which one must resort. This is a serious operation which gives a great deal of shock, so the patient's condition should be as good as possible beforehand, and the opposite lung should not show active or recently healed lesions. There are a great many different methods of performing the operation, but details of these are chiefly of interest to the surgeon who has to perform them. What the physician requires is that his patient's cavity should be closed with the minimum of risk and the maximum prospect of final cure. Of the five or six methods I have seen used, that used by Dr. Schmidt seemed to me the best. He uses the technique of Graf, of Dresden, in which the upper ribs are first removed through an anterior incision and the operation is completed through a dorsal ene. This gave much the best collapse of the apex that I have seen, and seemed to be very well tolerated by the patient. I do not know Schmidt's mortality figures, but I gathered that they were at least as low as those procured by any other method, and his results seemed to be better than most.

The results of thoracoplasty that I have seen fully justified the risks of the operation, and patients were able to work again sur- prisingly soon after the operation. The deformity, while sufficient to prevent a woman's wearing a low dress, is scarcely noticeable when the patient is wearing ordinary clothes, and the strength of the arm is only very slightly affected.

My thanks are most particularly due to Dr. Gustav Maurer of Schatzalp Sanatorium, Davos, for allowing me to see a very large number and wide variety of forms of active intervention, for explaining his views and methods, and for permission to use copies of his radiograms for this paper. My thanks are also due to Dr. Walther Schmidt of Krankenhaus Rohrbach~ Heidelberg, for allowing me to be present at many operations for extra-pleural pneumothorax and thoracoplasty, and for showing me a large number of his cases after operation.

~e]e~fe~ces.

1. Maurer, G. : " The Therapeutic Possibilities of Artificial P |eural Effusions." Bri~. Jo. Tuberc, Apr., 1937.

2. " Thorakoskopie und Kaustik, IV Mit tei lung." Bei~. z. Kliu. d. Tub., Vol. 76, No. 1.

3. H~berlin: Bvi~. Jo. Tuberc., Vol. 29, No. 2, Apr. , 1935. 4. Schmidt, W. : " Die Pneumolyse mi~ nachfolgendem extrapleuralen

Pneumothorax oder Oleothorax, I I Mit~eilung." B e l l z. Kli~. d. Tub., Vol. 91, No. 2, 1938.

the treatment of tuberculous cavities

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