pulmonary tuberculosis

Surgical Procedures – Artificial Pneumothorax

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Pulmonary tuberculosis is by far the most common manifestation of TB witnessed throughout the Stannington records.  Prior to the development and use of any effective antibiotic treatments the most common form of intervention was the induction of an artificial pneumothorax.  Many of the different treatments employed to treat TB of all types at this time were based on the principles of resting and isolating the affected area, and the thinking behind artificial pneumothorax treatment was no different.

 

A needle would be inserted through the chest wall to allow for the insertion of air into the pleural cavity.  The amount of air inserted would depend on the size of the patient as well as how much the physician in charge though the patient could realistically manage in one go and how quickly they wished the lung to collapse.  Once inserted the pressure from the air would force the lung to collapse in on itself and to cease functioning properly.  The entire lung would not necessarily be collapsed at once, either because it wasn’t necessary for treatment or because fibrotic adhesions between the lung and the chest wall as a result of the disease prevented it from doing so.  Where only part of the lung was affected it would not be desirable to collapse the whole lung and in such instances just one lobe might be collapse.  Bilateral artificial pneumothorax was also a possibility, whereby part of both lungs would be collapsed at the same time.  A state of collapse could be maintained for a period of months or even years and required the patient to undergo regular refills of air in order to do so.

 

A great number of radiographic illustrations of the progression of a collapse are available in the Stannington collection.  One patient, 2/1946, has a large amount of radiographs taken over a period of two years which demonstrate the change in the lung from admission and through the progressive stages of lung collapse.

 

Patient 2/1946 was female an age15 when she was admitted to Stannington on 21 June 1945 with pulmonary TB stage 3, at which point her sputum tested positive for TB also.  A report on an x-ray taken pre-admission reads:

‘Right lung shows several active foci beginning to coalesce.  There is extensive infiltration in the upper zone & suspicious blotchy areas in the middle zone.  A small calcified opacity in the right lower zone.  The left lung shows infiltration in the middle zone.  The upper zone and apex are clear.  Early active foci are noticeable in both lungs in the affected areas.’

Figure 1 was the first x-ray taken after admission on 25 June 1945 being three weeks later than the one reported above.  Observations on this x-ray note:

‘Scattered foci in right upper zone.  One definite cavity.  Increased bronchial marking at both bases.’

HOSP/STAN/7/1/2/1057_22 25 June 1945
Figure 1 – HOSP/STAN/7/1/2/1057_22
25 June 1945
HOSP/STAN/7/1/2/1057_18 31 Aug 1945
Figure 2 – HOSP/STAN/7/1/2/1057_18
31 Aug 1945

 

 

 

 

 

 

 

 

 

 

 

 

 

It was quickly decided that and artificial pneumothorax should be induced on the right side and this took place on 16 Aug 1945. Figure 2 taken later on that month shows the initial results of the artificial pneumothorax.  The black area along the lateral side of the right lung is evidence of the air that has been inserted and the lung has begun to compress.

 

The collapse was maintained well into 1947 which involved her having refills of air every two weeks throughout this period.  For the first three months she received refills of 200-300ccs of air at a time, progressing to 400ccs the month after, and then eventually 500-600ccs at a time.  Figures 3-6 show the progression of the artificial pneumothorax as more air is inserted and the lung collapses further.  Over time we can see that the cavity in the right mid zone collapses and closes, one of the main aims of the treatment.  In early June 1946 a procedure was performed to divide adhesions between the lung and the chest wall which allowed the collapse to progress further.  She was discharged in June 1947 with her condition described as improved.

 

Figure 3 - HOSP/STAN/7/1/2/1057_23 17 Jan 1946
Figure 3 – HOSP/STAN/7/1/2/1057_23
17 Jan 1946
Figure 4 - HOSP/STAN/7/1/2/1057_09 18 June 1946
Figure 4 – HOSP/STAN/7/1/2/1057_09
18 June 1946

 

 

 

 

 

 

 

 

 

 

 

 

Figure 5 - HOSP/STAN/7/1/2/1057_10 2 Sept 1946
Figure 5 – HOSP/STAN/7/1/2/1057_10
2 Sept 1946
Figure 6 - HOSP/STAN/7/1/2/1057_27 15 April 1947
Figure 6 – HOSP/STAN/7/1/2/1057_27
15 April 1947

 

 

 

Case Study – Pulmonary Tuberculosis

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In this post we’re going to explore the progression of pulmonary tuberculosis in one particular patient from Stannington Sanatorium in order to gain an insight into some of the common approaches to the treatment of the disease at this time.

 

Patient 95/1947 was admitted to Stannington Sanatorium on 4th September 1947 at the age of 12. After having begun to feel ill earlier in the year she was examined at the local clinic and sent for x-ray whereupon it was determined that she should be admitted to the sanatorium for treatment.  Prior to admission she had been living with her mother, step-father, two younger brothers and one younger sister in a 3 roomed house in Cockermouth which had no inside water or inside toilet.  The only family history of TB had been her father who had died from the disease when she was still a baby.  On admission she had no cough but a very poor appetite and was losing weight, weighing only 4st 0lbs 6oz.  There were no other physical symptoms or abnormalities reported.

 

The report on her first x-ray taken 4 days after admission reads:

“Tuberculous infiltration of both upper lobes with a large cavity in the mid-zone & a smaller one at the left apex.  There are several small calcified foci in the right upper lobe.”

Continuing reports over the next 4 months describe great improvement on the right side with the cavity in the right mid-zone no longer being visible.  However, the condition of the left side continues to deteriorate with a report 7 months after admission stating that the “cavity in the left upper lobe is now very much larger 1 ½” in diameter.”

 

NRO-3000-HOSP-STAN-07-01-02-1444-19

[HOSP/STAN/7/1/2/1444/19 – tomograph showing large cavity in left upper lobe, Dec 1948]

 

During her stay a series of different treatments were attempted to reduce the cavities.  Two months after admission in November 1947 her doctor initially observed that it was “doubtful if a satisfactory collapse could be obtained.  No treatment recommended.  Outlook very poor.”  Nevertheless, two months later in January an artificial pneumothorax was attempted but without success.

 

Artificial pneumothoraxes were performed on patients with the intention of resting the affected lung and hopefully collapsing the cavities at the same time whilst preventing any further spread as a collapsed lung was less likely to spread bacilli.  The procedure had been shown to effect a marked improvement in the size of tuberculous cavities for some patients but could at the same time be a dangerous procedure with a risk of air embolisms, pleural shock, sepsis, emphysema and effusion.

 

HOSP_STAN_9_1_1

 [HOSP/STAN/9/1/1, artificial pneumothorax treatment being performed in Stannington]

 

Three months later, after observing the growth of the cavity in the left upper lobe, a phrenic crush followed by a pneumoperitoneum was recommended and she was transferred to Shotley Bridge Hospital soon after for the procedures to be performed.  By crushing the left phrenic nerve, situated in the neck, they would be able to disable the left diaphragm thus forcing the muscle to relax and lift up, with the idea being that this would then rest the lower part of the lung.   A pneumoperitoneum was often performed in conjunction with the phrenic crush and involved inserting air into the abdominal peritoneal cavity forcing the diaphragm up.

 

Unfortunately after the patient was transferred to Shotley Bridge Hospital for the above procedures she never returned to Stannington and so we do not have any later case notes to follow up the result of her treatment.  However, some later correspondence does tell us that she was moved to Poole Sanatorium from where she was eventually discharged in May 1950.

 

The surgical procedures described here sound very drastic from a modern perspective but were a common approach in the pre-antibiotic era.  With no effective drug treatments surgical approaches such as these were at the forefront of tuberculosis treatment and looking through the files of Stannington Sanatorium it is clear that many of their young patients recovered, or at least showed significant improvements, and went on to live normal lives.