the treatment of tuberculous lung cavities by speleostomy

409

THE TREATMENT OF TUBERCULOUS LUNG CAVITIES BY SPELEOSTOMY.

By BRENDAN 0 'BRIEN.

F ~ROM the beginning of the " active " treatment of pulmonary tuberculosis attention has been directed to the closing of the cavity. I f no cavity existed, reliance was placed on the patient's own powers

of resistance, though this might be helped by such minor procedures as artificial pneumothorax, phrenic paralysis and, later, pneumoperitoneum. However, it has always been the cavity which has been the chief problem in treatment, as it is well known that an open cavity of tuberculous origin is a constant threat to the health of the patient and a possible source of bacilli for the spread of infection.

Artificial pneumothorax, phrenic paralysis with or without pneumoperitoneum, extrapleural pneumonolysis with artificial pneumothorax or plombage with various materials, thoracoplasty and lung resection are all directed to the same end. Even the advent of potent anti-tuberculous preparations such as streptomycin and P.A.S. has not solved the problem, because the tubercle bacillus lives in a relatively avascular medium in the wall of the cavity so that it is impossible to obtain a lethal concentration of the drug in the neighbourhood of the bacillus.

Artificial pneumothorax is the method of first choice in most cases of pulmonary tuberculosis with cavitation, particularly when the cavity is situated near the apex of the lung, but this form of treatment is often ineffective owing to the presence of pleural.obliteration or adhesions too broad to be divided. I t should not even be attempted when the cavity appears to be large, distended with air under pressure, or placed so close to the chest wall that the cavity appears to be fixed to it. A rash attempt to perform artificial pneumothorax in the presence of such a cavity will almost certainly lead to rupture of the cavity into the pleural space with the establishment of a broneho-pleural fistula and empyema.

Artificial pneumoperitoneum, usually combined with interruption of the phrenic nerve, is often more suitable than artificial pneumothorax, particularly when the disease appears in the lower lung field. But when the cavity is placed close to the chest wall in many cases the cavity wall is actually adherent to i t -- the diaphragm may be forced up so that the cavity is no longer visible, but it very rarely succeeds in closing it.

The above methods of attempting to close tuberculous cavities are nearly always tried before any others, apart from simple rest treatment, because if all goes well the lung can eventually re-expand and perform its functions nearly as efficiently as if it had never been the seat of disease.

I f rest, artificial pneumothorax and pneumoperitoneum fail to close the cavity, or if it is considered inadvisable to attempt either of the last two, it is often possible to close the cavity by surgical methods.

Extrapleural apicolysis maintained by air pressure as extrapleural pneumothorax, or by wax filling, or more recently by packing with poly- thene, after enjoying a period of great popularity is now comparatively rarely used.

410 IRISH JOURNAL OF MEDICAL SCIENCE

With the modern advances in chest surgery thoracoplasty has become an operation of so little immediate risk that it is often performed in preference to artificial pneumothorax. But though the immediate risk is slight, this operation does render permanently useless a very considerable proportion of the lung, and cannot be attempted when the opposite lung has a much reduced capacity or when the patient is a " poor operative risk " Moreover, thoracoplasty must collapse permanently all the lung situated above the cavity, so that if this method is used to close a cavity which is not in the apex of the lung a-considerable amount of useful tissue must be sacrificed in order to treat quite a small amount of diseased tissue.

Resection of the whole or part of a lung has increased rapidly in popularity of recent years, but this operation has most of the defects of thoracoplasty together with a very considerable operative mortality.

Surgical drainage of tuberculous lung cavities is by no means a modern form of treatment. E. J. O'Brien and his colleagues 1 in a paper dealing with this method have reviewed its history, and it is interesting to note that one of the earliest references is to a book by Dr. E. Barry 2 published in Dublin in 1726, in which he wrote of the beneficial effects from surgical puncture of tuberculous cavities in several patients. E. Sharpe (London, 1769) also referred to this procedure. Sir Henry Marsh may have drained tuberculous cavities in two patients about 1830. Hastings, with the help of Mr. Stokes, opened one tuberculous cavity in 1844, and later a second with some benefit to the patients, a~ was also noted in one on whom a Welsh surgeon, Mr. Thomas, operated.

In this century, Sauerbruch (1922) performed open cavity drainage. Gekler and others (1924), Lilienthal (1927), and Nissen (1931) also did this. Coryllos and Ornstein attempted to close, cavities by endoscopic examination and cauterisation of the draining M'onchi, and later performed open drainage of cavities in a number of patients. Eloesser evolved a special method of open cavity drainage, and many others in recent years have performed variations of this operatiorl.

E. J. O'Brien and his colleagues reported a series of no less than 84- drainage operations on 74 patients with 30 deaths, of whom 15 were early and 15 late.

In 1936 Coryllos 3 pointed out the importance of the state of the draining bronchus in the maintenance of the cavity, and concluded that cavity closure could be produced by occlusion of the draining bronchi, which he attempted to bring about by endoscopy of the cavity and cauterisation of the bronchi.

In 1941 t t i lary Roche" described Monaldi's method of cavity drainage. In considering the basis of this method he wrote :

For many years phthisiologists have been dissatisfied with the old teaching that cavities represent a loss of lung tissue due entirely to caseation, liquefaction and elimination. I t is now generally recognised tha t the space occupied by a chronic lung cavity does not represent an equivalent amount of destroyed lung substance. More and more attention has been paid to mechanical influences, tha t is, pressure effects within and without the cavity . . . . Air enters the cavity during inspiration, but escapes more slowly during expiration . . . . This results in a positive endoeavitary pressure (i.e. a pressure greater than atmospheric) . . . Monaldi experimented with suction drainage primarily with the idea of overcoming these unfavourable extra-and endo-cavitary forces.

bIonaldi introduced a thin rubber catheter into the cavity by means

SPELEOSTOMY 411

of a trocar and cannula.and applied suction drainage to the interior, thus lowering the pressure inside and allowing the surrounding collapsed tissue" to re-expand, a t the same time removing the secretions, thus relieving the patient's cough, and eventually removing by aspiration the tuberculous tissue so that the cavity became lined with healthy non- tuberculous granulation tissue.

Roche quotes from Morelli (who was working with Monaldi in the Forlanini Institute) a series of 1"98 cases treated by Monaldi's method, of which 79 appeared cured. Of his own 30 cases treated in the Austin Hospital, Victoria (Australia), 5 he notes that most were unsuitable cases, but his results were not very satisfactory. Among unfavourable results " two patients died f rom the effects of bleeding as a direct result of the operation . . . . Ten improved temporarily, but the cavities re-expanded and positive sputum returned within a few weeks or months of the with- drawal of the catheter ".

Subsequent use of this method by others failed to reproduce the good results of Monaldi and Morelli. There were cases of gross infection of the chest wall (Maurer, personal communication) and h~emorrhage, with very frequent failure to close cavities (N. Browne, personal communication), the reason for which was failure to occlude the draining bronchi.

Surgical drainage was fairly often complicated by serious bleeding and occasionally by air embolism, as well as by occasional chest wall infections and empyema.

In 1947 G. MaureP conceived the brilliant idea of making an opening into a tuberculous cavity by introducing a laminaria tent into it with the help of a special stilette or trocar attachment, the swelling of the tent sealing off bloodvessels and air passages, so tha t neither serious h~emorrhage nor air embolism would be likely to occur. By stretching the fistula with a series of tents of increasing size, a wide opening could be made through which it should be possible to introduce instruments with which to attempt to close the draining bronchi (as demanded by Coryllos), or gauze packing (which was found effective by Gekler and his associates). In between .stretching operations he introduced rubber tubes of a suitable size to fit tightly into the track, through which secretions can be removed by continuous suctioa drainage. The gauze packing can be impregnated with potent antibiotics such as streptomycin or t'.A.S., which are thus brought into close contact with the home of the tubercle bacillus in the cavity wall in an infinitely higher concentration than can be achieved by systemic administration. So this method has the following advantages :

1. By free external 9pening the cavity is not subjected to the rising atmospheric pressure caused by a narrowed bronchus and can thus collapse freely round the packing;

2. The draining bronchus can be closed; 3. A potent drug can be brought into the closest contact with the

breeding ground of the bacillus; 4. There is no significant bleeding in the establishment of the fistula ; 5. The risk of air embolus is reduced to a minimum ;/ 6. The psychological effect on the patient who avoids a " c u t t i n g

operation " is very good.


Indications: 1. Tension cavities. 2. Residual cavities under thoracoplasty operations. 3. Peripheral cavities in the lower lung field. 4. Cavities in patients whose respiratory reserve has been so

diminished by age, disease of or treatment of the opposite lung as to make thoracoplasty impossible.

In these cases the advantages of speleostomy* over thoracoplasty are : in type 1, that the latter must be extensive and is often unsuccessful ; in type 2, that the latter is extremely difficult owing to the irregularity of new,one formation and is accompanied by a great deal of surgical shock; in type 3, thoracoplasty, in order to close a small cavity, may have to collapse permanently a large amount of healthy and use fu l lung; in type 4 thoracoplasty is impossible.

The above may be considered absolute indications. In addition there are many cavities which might be equally well

treated by either thoracoplasty or speleostomy, but in which the latter is the more desirable as it entails less operative interference.

Limitations. Speleostomy cannot be performed on small or multiple cavities, and is probably not successful on very high apical cavities with fibrosis.

Instruments and Technique (Fig. 6). 1. Laminaria tents, centrally drilled and with tapered points in sizes

from 7 to 12 ram. and 12 cm. long. 2. Introducing stilette with trocar point and fixing wing nut. 3. Graduated pneumothorax needle with free falling stilette and

sliding stop marker. "4. Graduated stout rubber tubes from 8 ram. to 18 ram. 5. A strong trocar about 4 ram. diameter.

The instruments are made by Schaerer, of Berne, who has devised a means of extracting some of the salt from the laminaria tents without reducing their efficacy, the high concentration of salt in natural laminaria having proved too irritant for the lung and chest wall.

The cavity is carefully located by means of tomograms. The pleural space is explored to make certain that both layers are completely adherent; if they are not, the procedure must be postponed until they can be made to adhere by the injection of some irritating substance.

The patient is laid prone or supine, according to the position of the cavity, on an x-ray table so that the cavity may be seen by fluoroscopy at intervals during the induction.

After skin preparation the chest wall is an~esthetised with procaine solution (1 or 2 per cent.) for its full thickness.

The graduated pneumothorax needle is pushed through the chest wall in the direction of the cavity with the stilette in position. This being longer than the needle, the head projects about 3 cm. above the tap while the needle is traversing solid tissue, but drops down immediately the point enters the cavity. The needle is then pushed about 1 cm.

*(Jr. sp~laion, grot~to, cave , c a v e r n .

SPELEOSTOMY 413

further and the sliding stop allowed to fall to the chest wall where it is then fixed by its locking screw. The exact angle of the needle to the vertical is carefully observed by two assistants looking at right angles to each other.

The p, neumothorax needle is withdrawn, an incision 2 cm. long is made in the skin and the steel trocar is pushed through the chest wall ia the track of the exploring needle. This is done to facilitate the passage of the 7 ram. tent, which, armed with its stilette, is driven along the track made for it by the trocax and following the line observed from the exploring needle until it has reached the depth shown by the stop on the graduated needle to be correct. In practice the wall of the cavity and the moment of penetrgting it can generally be £elt quite distinctly.

The patient is then photographed in antero-posterior and lateral posi- tions to make sure that the tent is in position; if it is not, the tent is withdrawn and its angle or depth of entry corrected. Dressings are applied and the patient returned to bed.

Twenty-four hours later, traction is applied to the tent ; if this causes pain procaine is injected round it and the tent is then pulled out with strong forceps. Occasionally it is necessary to slide the point of a fine straight tenotome down along the side of the tent to divide constricting rings of tough fibrous tissue before it is possible to extract it.

A graduated rubber tube lubricated with sterile liquid paraffin is passed into the fistula left by the tent, 9 mm. being usually the largest which can be introduced. To this a pump is attached and continuous suction applied for the next seven to ten days.

When the tube is found to be loose and easily removable, the surrounding tissues are again carefully anmsthetised and a 10 to 11 mm. tent is substituted for it. This does not need the introducing stilette, for the tent is simply pushed along the track. After 24 hours this in its turn is removed and replaced by the largest size of tube which can be introduced; this process is repeated until it is possible to introduce a tube of 18 mm. diameter; this can often be done after the second stretching', but may need a third.

With the rubber tube in position, Maurer used to apply suction, but he found that the pressure was sometimes too high and caused bleeding or obstruction of the tube, so that more recently he has merely tied a waterproof bag over the end of the tube and allowed the secretions to escape into i t / Monaldi found that it was important that the suction force should not be too high, and Roche has illustrated a simple device advocated by Jeanneret and Joyet to ensure this. A modification of this device is used in the Meath Hospital, where suction drainage has been found to be of considerable value in certain cases.

After the 18 mm. tube has been in position for about eight to ten days it is removed and the cavity is packed with 2" ribbon gauze soaked in 5 per cent. solution of sodium-para-aminosalicylate. The packing is replaced twice weekly, and in the intervals ] c.c. of sodium P.A.S. solution i~ dripped on to it twice daily.

Penicillin is administered for three or more days after the induction in a dosage of 250,000 units twice daily to counter any pulmonary infection attributable to the trauma.

The fistula gradually shrinks in diameter and when it is reduced so


much that repacking is difficult (which usually means that it has shrunk to about 12 ram.) it is re-stretched as in ttfc initial stages. The time between stretchings varies greatly from case to case, and may be as short as two weeks or as long as six.

A modification introduced by the author is to inject proctocaine (an oily solution of procaine) into the chest wall in addition to the procaine anaesthetic, as the effect of the procaine wears off in one or two hours and the stretching pressure of the tent produces severe pain, while the proctocaine, while not producing complete anaesthesia, does very appre- ciably reduce the amount of pain felt.

Duration of the Treatment. So far it is not quite clear how long this should be continued. If the bronchus is successfully closed (which can be judged clinically by making the patient t ry to :force air out through his fistula, or radiologically by introducing lipiodol into it), the external track may be allowed to close when the cavity has diminished to a simple sinus no greater in diameter than the external opening, and the packings have" been free of tubercle bacilli on culture for about three months.

Maurer has described the method fully and reported his results in his monograph, Die chemotherapeutische Tamponade der I_,ungenkavernen. In it he states that he now injects the appropriate intercostal nerve with alcohol to produce that lasting anaesthesia which has been achieved by the author by means of proctocaine.

Results. Maurer 8 reports 52 cases, 49 effective. One died, and in two it was impossible to find the cavity, while 41 were untreatable by other means. In all 49 patients the cavity secretions became negative and remained so; sputum became negative except when there were other loci of infection. For ty patients became sputum negative; the remaining 9 could possibly be cured by further treatment, and even in these ca~es tox~emia was much reduced. Late results cannot yet be assessed, but more than half the patients have returned to their homes and are leading a normal life and working. In the remainder, treatment is not yet completed.

Present Series.

Speleostomy has been attempted in 17 cases. Failed in one (cavity could not be located with needle). Stopped in one, owing to the patient's pulling out the tube and causing

bleeding with loss of the track. Patients discharged from hospital, 3 Apparently cured, 1. Quiescent, but with small fistula, 1. Not completed, but much improved, 1. Still undergoing treatment, 12. Making satisfactory progress with marked diminution of size of

cavity, 6. Fatalities, 2: One directly attributable to treatment,

One not directly" attributable to treatment. Progress not satisfactory, as the cavities do not appear likely to close, 3. Developed bronchial stenosis and bronchiectasis~ probably due to

treatment, 1.

SPELEOSTOMY 415

Types of case for which used: 1. Tension cavities 1 2. Residual cavities under thoracoplasty Nil 3. Peripheral cavities in lower lung field 1 4. Cavities in patients whose respiratory reserve has been

so diminished by age, disease of or treatment of the opposite lung as to make thoracoplasty impossible 12

5. Cavity equally suitable for thoracoplasty

Complications and difficulties: Pyrexia sufficient to cause anxiety, in two cases. Fcetid pus on packing occurred in a few cases, but responded well

to penicillin therapy or suction drainage. Acute pulmonary inflammation with copious sputum and asthmatic

dyspncea occurred in three cases, of whom two responded well to ephedrin and atropin; the third developed bronchial stenosis and bronchiectasis.

Pleura not adherent: In one case adhesion was finally secured by injection of the patient's own blood after injection (i) of glucose 50 per cent., and (ii) of silver nitrate, had failed to produce it. In the other, adhesion was secured after injection of 0.5 per cent. silver nitrate when injection of blood had failed.

In the present series endoscopy of the cavity was performed in seven eases. In one case the draining bronchus was clearly seen, and an attempt made to close it by diathermy coagulation, but this was unsuccessful in that the bronchus was not closed. In the remaining cases the bronchus could not be clearly visualised and therefore could not be cauterised.

The instrument used (a straight cystoscope) did not give a very satisfactory field of vision and the diathermy point could not be used alternatively for galvano-cautery so that the coagulum tended to lift out on the point of the wire. Dr. Maurer, in demonstrating the procedure used a Graf single puncture combined thoracoscope and cantery; this was a much more satisfactory instrument, but is at present unobtainable.

Cases left with an open bronchus tend to discharge from the fistula for a long period ~fter treatment has stopped. Two of Dr./V[aurer's cases seen here in Ireland have shown this, and in the present series two cases have also re-opened the fistula after it had apparently closed.

I L L U S T R A T I V E CASE REPO RT S. CASE 1WO. 1. Miss L: N. Aged 29 years. 1929. Tuberculosis diagnosed. Left artificial pneumothorax obliterated with gross

pleural thickening. 1942. Developed cavity in right lung, t reated by artificial pneumothorax for two

years with apparent success. 1946. Relapse, given sanatorium treatment. Sputum remained positive. Tomo-

grams showed a dorsal cavity on the right side. t948. Jun~ : Speleostomy induced by Dr. Maurer in the Meath Hospital, by dorsal

approach in the seventh space. July : By July 3rd, fistula had been distended to 16 ram. On 5th August, gauze

packing was commenced with streptomycin and one-eighth gram of streptomycin dissolved in four c.c. of normal saline were instilled four times daily. Gauze packing was renewed every fifth day.

October : A ten ram. rubber drainage tube was substituted,for the gauze packing, a gauze wick being placed in the tube. Four instillations of streptomycin per day were continued. Tubercle bacilli were found in the sputum up to 23rd June, 1948 ; thereafter it remained negative until 28th September. On 26th October, tubercle bacilli were found, and again on 2rid and 10th November.


November : On 20th November, blood count l ib . , 65 per cent. Red cell count, 4,000,000. White cell count, 13,400. Van don Bergh, negative. As the sputum had become positive in spite of streptomycin t reatment , the cavity was t reated with a preparation known as B.53, which has been found a valuable topical application in other conditions, especially in genito-urinary tuberculosis. On Nov. 24th there was breathlessness and tachycardia with evidence of pulmonary oedema on the right. The patient continued to be dyspnoeie in spite of symptomatic t rea tment and died on 1st December. Autopsy showed tha t death was duo to pneumonia of the right lung, almost certainly caused by the B.53.

CASE No. 2. Miss B. K. Aged 26 years. (See Fig. 1.) 1942. Pulmonary tuberculosis with cavity or~ the left diagnosed. 1943. Left thoracoplasty. Relapse 1947 with disease in the right lung and cavity;

Rest t reatment until March, 1948, when she first came under my care. She then had a left-sided thoracoplasty and a cavity in the right lung about five cm. in diameter.

1948. Had bed rest until November, when she was admitted to the Meath Hospital. At that time, was constantly pyrexial, had a very troublesome cough and was very toxic in appearance. The cavity had enlarged until it occupied the whole of the upper third of the right lung field. Speleostomy was started without difficulty and she was given systemic streptomycin to a total of 64 grams. There was one day's fever after the induction. Since then temperature has remained normal except for occasional short episodes of pyrexia. The cavity was at first packed with gauze soaked in strep- temycin, but later with P.A.S. Her general condition has improved considerably, her cough is not troublesome, though there is still some. The cavity has been reduced in size to a small oval about 2.5 x 2 era. Sputum is much reduced in amount, but is still positive, and there is another cavity below the original one. During the course of treatment there have been attacks of coughing with asthmatic wheezing, relieved by adrenalin and ephedrine.

C o m m e n t s : The disease had progressed in this patient too far to give hope of complete cure, but the patient, who appeared likely to die within one or two months in November, 1948, is still (July, 1950) alive and feels comparatively well. I f t reatment could have been started in March when she was first seen, it might have been possible to effect a cure, but the necessary instruments could not be obtained from Switzerland unti l Novem- ber. Still, the reduction in the size of the cavity is very striking (Fig. 2).

CASE NO. 3. Miss E. B. Aged 29 years. 1943. ~ilateral tuberculosis diagnosed January. 1944. Right artificial pneumothorax. 1945. Left phrenlc crush and pneumoperitoneum. Sanatorium, January, 1944,

to July, 1945. 1946. Right artificial pneumothorax abandoned on account of effusion. August,

left artificial pneumothorax at tempted and failed. November, returned to sanatorium. 1947. Left sanatorium and was treated by rest alone. 1948. ~,~ovember : Admitted to the Meath Hospital. General condition very good,

was found to have mild diabetes. Sputum contained tubercle bacilli. Right lung appeared healed ; left showed irregular cavity over the posterior par t of the left seventh rib (Fig. 3). Speleostomy performed (December) by dorsal approach with great difficulty as the patient was very fat. Temperature rose to 100°F. on the day after the induction, and showed another rise two weeks later to 100°F. The stoma was dilated to take an 18 mm. tube, and gauze packing was started. After the second packing the sinus closed where it traversed the chest wall, and packing could" not bo continued. I t was found tha t the cavity had disappeared, as it was presumably of the tension variety. The wound was allowed to granulate, which it did without trouble and the cavity, as anticipated, gradually re-expanded. Sputum contained T.B. throughout.

1949. J u n e : The cavity having re-expanded to its previous size, three cm. of the sixth rib was resected by Mr. Montgomery, a tent was inserted into the cavity and the wound sutured loosely around it. The fistula was once again dilated up to 18 ram. ; packing with gauze soaked in P.A.S. has been maintained ever since. An a t tempt was made in December to eauteriso the draining bronchus which had remained open, but the opening could not be clearly seen and the effort was not successful.

Presen t condi t ion: There is a bronchial fistula to the back lined with healthy granula tion tissue. Since early JuIy it was impossible to find tubercle bacilli in the spu tum or on the gauze on removal from the fistula, but a guinea pig innoeulatedin January- showed one or two small lesions at autopsy.

C o m m e n t : This patient had a cavity situated peripherally and low down in the left lung, the remainder of which appeared healthy. I t had proved impossible to close by artificial pneumothorax or pnoumoperitoneum. To have closed it by thoracoplasty would have required the removal of at .least nine ribs and the disabling of the whole left lung. The only reasonable methods of t rea tment were lung resection or speloo-

l"m.

('¢~*. 3:o. 2,

I. l,~trge , '¢wity oecupyin~ lun~ tield from third rib to a p e x ,

Mfss I]. [~.

Fl~;. 2.- -L~wge vnvity has lilh'd up. Seeoiul rib eroded by listula. Small new cavity

,ju~l helow l i p ¢~[' t h i rd r ib .

I:H:. :L

('a~(' A'o. 3. -Mrs~ lq. IL

Tomo~a'ram 3 era. from Jmek showm~ c.avity i . the left lun~ m'o~sed hy the s,,venth rib.

('a,~'¢; N~,. 5 . - Mts.~ T . S.

Fi(~'. 4 . - - l ,a rge cavity left apex with FIu. 5 . - Cavity has disappeared. pneumothorax out linin~ it, There is some increased str iat ion in

the left apex.

A

P

~z:3i

d~

c

F

A. Stiletto. B. Tent. ('. Wing Nut. D. Ten¢ and Stilette assembled. E. Graduated Saugmaa needle. F- Graduated Rubbe r tube.

SPELEOSTOMY 417

stomy. I t would appear tha t the tuberculous infection is at present under control and it is to be hoped that the fistula will eventually granulate from the base and leave the lung healed.

The patient was discharged from hospital in March, 1950, getting P.A.S. orally and into a tube which is in the fistula.

CASE :NO. 5. l~Iiss T. S. Aged 20. 1946. Suspected of pulmonary tubercolos;s, had been t reated with rest and

injections of gold salts. 1948. May : Found to have a large cavity in the left lung (Fig. 4). September : Artificial pneumothorax at tempted to determine whether pleura was

adherent or not. A free pleural space was found except over the cavity. An a t tempt was made to produce an ohliterative pleuritis by injecting 50 e.e. of 50 per cent glucose solution ; this was not successful. On 12th November, 4 c.c. of 0.5 per cent. silver nitrate solution was injected into the pleural cavity. Thi s produced a well-marked pleurisy with pyrexia to 103"F., which settled in one week. There was a sharp rise of temperature on 26th November, .which again subsided in one week, and was followed by another rise when the temperature reached 103.6"F. ; this coincided with the develop- ment of disease on the right side. Streptomycin was started on 7th December, 0.5 gr. twice daily and continued to 29thJanuary, 1949. Patient afebrile from 17th December.

1949. On 31st January the pleura was found not to be adherent and on 5th February, 4 c.c. of blood were injected into the pleural space. On 5th March two a t tempts to find the pleural space failed, and on 8th March speleostomy was induced in the second left interspace. On replacing the laminaria tent with a rubber tube, this was found not to be in the cavity and on 12th March a fresh laminaria was introduced this t ime successfully into the cavity and t reatment continued without further difficulties. On 24th April the cavity was packed with gauze soaked in sodium P.A.S. (5 per cent solution). The track was stretched on 10th May and 1st June, 1st July, 27th July, 23rd August and 26th September.

S]~utum constantly contained tubercle bacilli until 8th February, 1949, after which they were never found either in the sputum or in the secretions from the fistula.

Progress was uninterruptedly good apart from a brief pyrexial episode lasting four days at the beginning of June, 1949. The pat ient was discharged on the 19th October and when last seen in January, 1950, her general condition was e~cellent with neither cough nor sputum. No sign of the cavity was apparen~ on x-ray film (Fig. 5).

Commen~ : This was a case of giant tension cavity, for which the only possible t reatment was speleostomy or lung resection.

Conclusions.

Speleostomy provides a means of treating cavities which are untreatable by other methods, and in certain cases provides an alternative to more drastic intervention.

It is technically a difficult procedure, and the patient must remain in an institution over a long period---six months or more but on the whole the operative risks would appear to be slight and worth incurring in view of the hopeless nature of the disease in most of those patients for whom it is advocated.

Of the present series of cases, only three might equally well have been treated by radical surgery. The remainder had no choice except chronic invalidism with the prospect of an early death, or speleostomy.

(1) O'Brien, E. J. et al. (1947). J. Thee. Surg., 16, 6. (2) Barry, F. (1926). A Treatise of a Consumption of the Lung~, Dublin. (3) Coryllos (1936). Am. Rev. Tuberc., 33, 639. (4) Roche, H. (1941). Tubercle, xxii, 1. (5) Roche, H. (1945). Med. J . Australia, 307, Sept. (6) Maurer, G. (1948). Hchwei~ Merl. Wchechr., 78, 15, 345. (7) Maurer, G. (1949). Diseases o] the Chest, Chicago, xvl, 676, Dec. (8) Maurer, G. (1950). Dis Chv/mothexapeuti~he Tampanade dov L~s@emJaaveenan.

Thiemo Verlag, Stuttgart.

the treatment of tuberculous lung cavities by speleostomy

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