(a) amounted to £143, 3s. 6d., and for services under (b) to £363, 7s. 6d.

The arrangement under which payments were made to certain local authorities for the services of health visitors in the visitation of tuberculous ex-service men was discontinued as from 31st December, 1926. In concurring with the Ministry of Pensions in the view that this special arrangement was no longer necessary, we had in mind the fact that the individual pensioners will now have been fully advised by the health visitors as to the manner in which they should order their lives on account of their disability. So far as the scheme of visitation of tuberculous persons adopted by local authorities is conceived in the interests of public health, it will as a matter of course include persons whose tuberculosis has arisen out of service in the Great War.

ARTIFICIAL PNEUMOTHORAX.

12. Introductory.-With a view to arriving at some conception of the extent to which artificial pneumothorax is practised in Scotland and of the results obtained, a number of Scottish medical officers were invited to give an account of their experiences of this form of treatment. The replies received were helpful and illuminating, and a summary of these is published as an appendix at the end of this chapter.

The operation of inducing artificial pneumothorax may be described in general terms as the introduction of air or other gas into the pleural cavity by puncture of the thoracic wall, so that the lung is allowed temporarily to collapse. The process is essentially one of resting the affected lung with the object of assisting the patient to combat the disease. The expectation is that in suitable cases the operation will result in the diminution of such distressing symptoms as severe cough and sputum, in a steadying of temperature, improvement of appetite, &c. As adhesions between the two pleural surfaces are not of infrequent occurrence in pulmonary tuberculosis, the induction of a pneumothorax may prove impossible, or at best may be only partially successful. It the initial operation is sufficiently successful to justify the continuance of treatment," refills of air will be administered to the patient from time to time.

The anatomical and other changes which take place when collapse of the lung is complete or almost complete are illustrated by the three reproductions of skiagrams facing this page. We are indebted to the Health Department of Glasgow Corporation for the use of the skiagrams.

Plate I shews the diseased and the less affected lung prior to induction of pneumothorax.

Plate II shews partial collapse of the diseased lung.
Plate III shews complete collapse of the lung.

13. Selection of Cases.-It will be readily appreciated that as a general rule the operation should be carried out only when the

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other lung is comparatively healthy and when the more normal methods of treatment have failed to effect any appreciable improvement in the patient's condition. Some of the observers who have given their experiences regard repeated hæmorrhage as justification for this form of treatment, especially when the side from which the hæmorrhage proceeds can be determined. The treatment has also been used occasionally for replacement of pleural effusion or in cases with recurrent dry pleurisy. On the other hand, extensive disease of both lungs, heart or kidney trouble, or abdominal tuberculosis are regarded as indications against this form of treatment. Some observers also consider that the presence of tuberculosis of the larynx rules out any attempt at inducing artificial pneumothorax. It will be recognised that the selection of suitable cases involves important issues, and that the selection must be left entirely to the expert. Only a small percentage of cases coming under observation are found to be suitable for treatment.

14. Complications attributable to the operation.-The technique of this form of treatment is now such that serious complications attributable directly to the operation are rarely met. One observer has seen mild pleural shock on a few occasions, while in one case rupture of the lung followed the initial operation. Another observer reports two cases of pyothorax from rupture of the lung. In one series of cases treated, pleural effusion occurred in 40 per cent. of the cases. Several of these went on to tuberculous empyema and have since died. The observer in these cases expresses the view that now that lower intra-pleural pressures are being used this complication is less common. In a second series of 18 cases no pleural effusion has so far been noted.

15. Conclusions.-It would appear that where pneumothorax is possible, considerable improvement may be expected in a large proportion of cases. In 374 of 492 cases in which the operation was attempted a complete or partial pneumothorax was induced. At least 176 of these 374 patients shewed improvement, the disease in many cases being evidently arrested. A number of the patients have returned to work. It must be kept in mind that in a large number of these cases the outlook of the patient before and at the time of the operation was far from hopeful. Those patients who, in spite of such improvement, ultimately succumbed, evidently experienced considerable amelioration of distressing symptoms. Even in unpromising cases, the operation may lead to appreciable improvement in the patient's condition.

But emphasis must be laid on the fact that the operation is not without its risks, immediate or remote. Nor must it be forgotten that, while the treatment may have to be continued for a period of months or years, active disease may develop in the interval either in the collapsed or the "healthy lung.

APPENDIX.

Summary of replies from Medical Officers regarding the practice of Artificial Pneumothorax.

(a) At Aberdeen City Hospital this treatment has been tried in eleven cases of pulmonary tuberculosis. The type of case selected has been that with advanced disease of one lung, with no progressive lesion in the other side and with tubercle bacilli in the sputum. A considerable period, usually a year or more, of previous sanatorium treatment had been given with no apparent lessening in the activity of the disease.

In seven cases the pneumothorax was complete, or almost so. Of these seven cases four improved and three shewed no improvement. In two cases the collapse was only partial, and of these one improved and the other shewed no improvement. In the remaining two cases the operation was unsuccessful. At present five patients are receiving this form of treatment.

(b) At Dundee the tuberculosis officer has tried this form of treatment in five cases during the past six months. In one case collapse was impossible owing to pleural adhesions. In the other four the pneumothorax was complete or almost complete. Two of the cases have improved, one is still under active treatment, and in the fourth case, where the operation was performed for recurring hæmorrhage, the bleeding was arrested, but otherwise the case has not so far improved. Three of these cases had undergone long periods of ordinary sanatorium treatment without benefit. By improvement Dr. Hunter implies general condition improving, increase in weight, temperature reduced and remaining normal, and cough and spit lessening.

(c) At East Fortune Sanatorium treatment by artificial pneumothorax has been reserved for those patients whose disease is largely on one side, and who after a fair trial of routine. sanatorium treatment are still failing. So far five patients have been treated by this method. In three of these the operation was unsuccessful. The treatment was undertaken in one case with a fair amount of disease and large repeated hemorrhages. The collapse was complete, the hæmoptysis ceased; as Dr. Cameron, the Medical Superintendent, puts it "The operation saved her life from repeated hæmoptyses." However, for months the case was complicated with tuberculous empyema, and for many months the pneumothorax cavity secreted tuberculous pus. The empyema has disappeared and the patient has improved, though still requiring refills-after twenty-five months' treatment. The fifth case, one in which the pneumothorax was partial, was not improved and ultimately died.

(d) During the past three years Dr. John Guy, Chief Tuberculosis Officer for the City of Edinburgh, has attempted this form of treatment in eighty-three cases. In sixteen of these the operation was unsuccessful. In thirty-one collapse of the lung

was complete or almost complete. Improvement took place in twenty-one of these and ten shewed no improvement. Partial collapse occurred in thirty-six patients, of whom eleven are returned as improved and twenty-five as not improved.

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Dr. Guy states :-" A fair number of these cases were undertaken just to give the patient a chance; not that I expected very much out of it. The immediate results are as a rule excellent. I have not yet begun to deal with the late results. They will be a good deal poorer than one might expect. This is in great part due to the fact that the cases that we dealt with were of a very hopeless character."

(e) At Ruchill Hospital, Glasgow, during the past year, the attempt to induce an artificial pneumothorax was made in eleven cases. In this series the indications for treatment resolved themselves into (1) replacement of a pleural effusion; (2) very extensive disease of one lung with early involvement of the other; chronic type of case with little febrile disturbance, some toxæmia and troublesome cough and spit; (3) extensive and rather active disease of one lung with a marked degree of toxæmia, a fluctuating temperature, troublesome cough and spit. In three cases. the collapse of the lung was complete or almost complete, and all these cases shewed improvement. In other three cases it was partial, improvement being recorded. In five cases the operation was unsuccessful.

In those cases shewing improvement this can be observed after the fourth or fifth injection, and is demonstrated generally by a feeling of increased vigour and well-being and disappearance of a tendency to night sweats. The face assumes a more healthy look, and there is an absence of any tendency to cyanosis, a disappearance of hectic flushing and signs of toxæmia, and an outstanding amelioration in cough and diminution in spit.

Dr. M'Gowan sums up :-"In my opinion this form of treatment has had very satisfactory results in the more acute cases when unilateral active disease caused a profound toxæmia. In two of my cases I venture to suggest that it was the means of saving their lives. In the more chronic cases I suggest that it gave an impetus in the right direction when otherwise they were in a stationary condition or on a slow downward trend. I cannot foretell what is to be the ultimate prognosis of my cases, but at present it appears to be quite fair."

(f) At Robroyston Hospital, Glasgow, artificial pneumothorax has been attempted in five cases of pulmonary tuberculosis and in two of bronchiectasis. In two cases of the former series a pneumothorax could not be induced. In two the collapse was complete or almost complete, and of these one improved and one did not. The fifth case had a partial collapse and improvement resulted.

This form of treatment was adopted for unilateral disease or where there was slight disease in the less affected lung. The two patients recorded as being improved shewed disappearance of

pyrexia, increase of weight, diminution in pathological physical signs and marked general improvement, with diminution in quantity of sputum and the number of tubercle bacilli therein.

Neither of the bronchiectatic cases (one successful, one unsuccessful) shewed any improvement which could be directly attributed to the operation.

(g) At Glenlomond Sanatorium this form of treatment has been tried in twenty-two cases. The operation was confined to those cases where active disease was limited to one lung or where repeated haemoptysis was a feature of the case. Of the twentytwo cases four left the sanatorium or were dismissed for various reasons, while in five cases the operation was impossible owing to pleural adhesions.

Of seven cases in which the pneumothorax induction was complete, one is working, four are likely to make good recoveries, one is working but returns to the sanatorium for refills, and one has improved.

Of six cases in which the collapse of the lung was only partial, one is working; two are much improved; in one partial pneumothorax is being carried out on both sides, the case being much improved; in one there has been no improvement. The sixth case died.

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Dr. Munro, the Medical Superintendent, defines improvement as a general feeling of well-being." He instances patients with toxic breathlessness who are much less breathless with one lung collapsed and shew a diminution of physical signs, fewer tubercle bacilli or none, and a fall in pulse-rate. regards this form of treatment as a very useful one.

He

(h) At the Grampian Sanatorium fourteen patients were treated by artificial pneumothorax. All these cases were advanced and were deteriorating more or less rapidly. With two exceptions they had received prolonged periods of sanatorium treatment without benefit. In all of them tubercle bacilli had been detected in the sputum.

of five cases where the pneumothorax was complete or almost complete, four were improved (three arrested) and one was not improved. Of nine where the operation resulted in a partial pneumothorax, the patient's condition was improved in five (two arrested) while the other four shewed no improvement. In four additional cases in which the operation was attempted a pneumothorax was impossible owing to the very dense adhesions.

Dr. Savy, the Medical Superintendent, states that "of the cases classified as improved' with complete pneumothorax three can be classified as arrested with all symptoms in abeyance and no sputum or tubercle bacilli in the sputum. When a complete pneumothorax can be obtained the treatment is undoubtedly very successful and life can be prolonged for years with refills, but there is always the possibility of fresh activity somewhere else."

(i) Dr. Stewart, late of Nordrach-on-Dee Sanatorium, has