548 TUBERCLE [September, 1933

[4] BONSDORFF, A.v. " Den vita blodkroppbildens betydelse vid lungtuberkulos fLr bodLmande av sjukdomens aktivite~ och prognos," Tuberkulose L~egemOde, Copenhagen, Transactions 1927, p. 12.

i5] GRIPENBERG, RITA. " UndersLkningar 5ver s/inkningsreaktionen, leuko- eytantalet och leukocytformeln hos lungtuberkulospatienter." Nordiska Tuberkulosliilca~fgreninqe~s Mdte, Helsingfors Transactions 1930, p. 44.

[6] BREDECK, J .F . " The Schilling Blood Differential Count in Tuberculosis," Amer. Rev. Tub., 1929, 20, 50,.

[7] WESTER(~REh ~, A. " Die Senkunsreaktion," Ergebnisse der inneren Medizin und Kinderheilkunde, 190,4, 26, 577.

[8] WEBB, G. B., GILBERT, G. B., and NEUMAN, J. A. " The Lymphocyte Index in Tuberculosis," A~zer. Rev. T~tb., 1923, 6, 1073.

[9] MoR]~ISS, W. H., and Tax, S. H. " The Differential Leucocyte Count in Pulmonary Tuberculosis. The Value of the Lymphocy~e-~fonoeyte Ratio in Determination of Activity," Ibid., 190.7, t6, 70.9.

[10] FINN, J. W., and FINN, R. S. "The Leucocytic Picture of the Blood as an Aid in the Prognosis and Treatment of Pulmonary Tuberculosis," 1bid., 1929, 20, 347.

[11] BROCK, B.L. " Leucocytes in Tuberculosis." Ibid., 1930, 2t, 745. [10.] REILLY, W. A. "The Behaviour of the i~{onocytes in Tuberculosis in

Children," Ibid., 1930,, 21~, 178. [13] BRISKMAN, A. L. " Red-cell Sedimentation and the Schilling Differential

Leucocyte Count," Ibid., 1930, 22, 560,. [14] HOUGHTON, L. E. "The Influence of Gold Salts on the Hmmogram in

Pulmonary Tuberculosis. A Method of Blood Assessment," Tubercle, 193o., 13, 385.

TWO REMARKABLE CASES OF LARGE PULMONARY CAVITIES CLOSED BY SUI~GICAL METHODS.

By BERNARD HUDSON, M.A., M.D.Cantab., M.R.C.P.Lond. Swiss Federal Diploma, Medical Snperintend~nt, " Victories" Brit ish Sanatori~lm,

Davos.

THE following cases are considered to be worth recording as showing how large pulmonary cavities may, sometimes, be closed by surgical methods.

Case l . - -Female , aged 35. Had tuberculosis of the lungs for over five years, the disease being situated in the right lung, the upper lobe of which was completely excavated. The temperature was never normal, and there was profuse expectoration containing large numbers of tubercle bacilli and elastic fibres. She was admitted to the Victoria British Sanatorium, Davos-Platz, in January, 1932. Artificial pneumothorax was at tempted in January, 1932, but proved to be a failure, owing to the presence of massive adhesions. Phrenic nerve avulsion was performed on February 28, 1932, a good rise of the diaphragm being obtained.

September, 1933] LARG~, PULMONARY CAVITIES CLOSED BY SURGERY 549

However, after nearly a year, the cavity showed no signs of closing, and had even increased in size. On January 10, 1933, a " plombage" was performed from the front, the space obtained being lightly packed with wax. The cavity was so large that the operation could not be completed in one sitting, as apicolysis could not be completed, the finger being unable to reach far enough. Therefore, on February 2, 1933, another operation was performed from the back, and apicolysis was then completed, the additional space obtained being again loosely packed with wax. Since the operation the patient has steadily improved, both as regards her local condition and her general health; the temperature is now steadily normal, the cough and sputum have practically ceased, and the sputum has become quite free from tubercle bacilli. The cavity, as shown by X-ray examination, is now completely closed.

Case 2.--Male, aged 38. Disease of some six years' duration, chiefly affecting the right lung, which was extensively affected and contained two very large cavities, and some smaller ones. The left lung was also slightly affected, but became quiescent. The patient was admitted to the Victoria British Sanatorium in October; 1932. After several months of rest, it was seen that the patient was going to do no good, and was slowly going down- hill. There was profuse expectoration containing numerous tubercle bacilli and elastic fibres, the temperature was never settled and there occurred frequent exacerbations of renewed activity, with high fever and increased sputum. Artificial pneumothorax was attempted on January 25, 1933, but with little hope of success, owing to the duration and type of the case. However, luckily, a good pocket was obtained. X-ray examination afterwards revealed that the upper lobe containing the two large cavities was adherent to the chest wall by a very large and broad adhesion. As a last resource it was decided to try and divide this adhesion. Three operations were necessary owing to the size of the adhesion. The first operation was performed on March 28, 1933, and a portion about 2} in. long and t in. thick was divided by a combination of the diathermic and galvano-cautery. The patient stood this very well, and on April 11, 1933, a second operation was performed, about the same amount of adhesion being dealt with. In spite of this severe interference the patient again showed surprising resisting power and stood the operation very well. On May 2, 1933, the third cauterisation was performed. This was a much smaller intervention. The division of the whole adhesion was thus completed, and the upper lobe containing the cavities was able to collapse. Shortly after this operation the patient had a very severe reaction indeed, the temperature rising to 104 ~ F. and fluid forming in the pleural cavity. However, he again stood up to it, and the reaction subsided in about ten days' time, the fluid disappearing. At the present moment the patient is making a really wonderful recovery. The temperature for the first time is steadily normal, the heart and pulse have settled down, the sputum has diminished from about 10 oz. per day to practically nothing, and also his general condition is vastly better. X-ray examination now shows that the cavities have almost closed, the collapse becoming complete.