€.T CufoSX?) Return this book on or before the Latest Date stamped below. University of Illinois Library L161—H41 Reprinted from the Transactions of the Eighth Annual Meeting of The National Association for the Study and Prevention of Tuberculosis ADVANCED TUBERCULOSIS CONEINED TO ONE LUNG; A COMPARATIVE ANALYSIS OF 150 CASES By F. C. Smith, M.D. Fort Stanton, N. M. The present study comprises 1705 moderately advanced and far-advanced cases, so classified on admission to the Marine-Hospital Sanatorium, and particularly 150 of those in which no sign of disease was detected in one lung, either at the first examination or at the second, two months later. In 95 of these the right lung was involved, in 55 the left. It is possible that the opposite apex had been previously involved, the left seven times and the right eleven, as slight variations from normal, but no signs of active disease w^re detected in these instances. TABULATION OF CASES OF ADVANCED DISEASE CONFINED TO ONE LUNG ON ADMISSION U. S. Marine-Hospital Sanatorium Moderately Advanced Apparently Cured Arrested Improved Unimproved Dead Whole number, 693 .... III 119 302 66 95 Confined to one lung, 87 26 22 21 13 5 * Right lung involved, 59 . 18 19 12 7 3 Left lung involved, 28. . . 8 3 9 6 2 Far-Advanced Apparently Cured Arrested Improved Unimproved Dead Whole number, 1012 . . . 26 125 234 IIS 512 Confined to one lung, 63 5 20 12 7 19* Right lung involved, 36. 3 12 7 5 9 Left lung involved, 27 . . 2 8 5 2 10 * Two of the 24 cases were not autopsied. 2 ADVANCED TUBERCULOSIS CONFINED TO ONE LUNG Advanced one-sided disease is thus seen to be nearly twice as frequent on the right side as on the left, which supports in a measure the idea that the right side is most frequently attacked. The comparatively small number of cases, however, would indicate that disease past incipiency is not long confined to one lung. While under treatment the sound left lung became involved 22 times out of 95, and the sound right lung 15 times out of 55, the disease showing very little difference in its relative tendency to extend from one lung to the other. This fresh involvement of the sound lung was evanescent^ subacute, and never serious in 19, and was not detected before autopsy in 5, while in 12 instances an acute involvement of the sound lung was serious enough to have caused death soon, although 3 of these patients died of hemorrhage. Of the 12 last mentioned, 7 were right-sided cases which ex¬ tended to the left lung, and 5 were cases of left-sided disease extending to the right. Only one normal lung was found in the 22 autopsies in this series, i. e., the right lung in the patient dying from ruptured aortic aneurysm. When the better lung became involved, the apex was the part usually first affected, but the antero-external portion of the base of the left upper lobe was attacked twice and the antero-external border of the left lower lobe once, the latter being found only at autopsy, a very small patch of subpleural infiltration. Comparing the results in advanced one-sided cases with advanced dis¬ ease in both lungs, the one-sided cases show, as might be expected, a much higher percentage of recoveries. Thus, while the one-sided cases furnish only 8.8 per cent, of the whole number, they show 22.6 per cent, of the appar¬ ent cures, 17 per cent, of the arrests, and only 4 per cent, of the deaths. There were 24 deaths in this series: i caused by ruptured aortic aneurysm, I by tabes dorsalis and tuberculosis of the kidneys, i by pneumothorax, I by tuberculosis of the larynx, i by empyema, i by nephritic coma, i by hemorrhage from the bowel, 7 by hemorrhage from the lung, 2 by acute invasion of the better lung following hemorrhage, 4 by acute invasion of the better lung without known cause, and the remaining 4 by sepsis, invasion of the better lung, and advanced terminal changes. An unusually large number of deaths in this series was due to accident or complication pecu¬ liar to tuberculosis. I believe that advanced cases with disease confined to one lung enjoy a greater degree of chronicity than the usual type of advanced case, and that chronicity affords greater opportunity for accident or complication. This has been previously investigated with regard to death 4 '^, 5-^2 6 CL F. C. SMITH, M.D. 3 from hemorrhage at the Fort Stanton Sanatorium.* It should be noted that we have had 71 deaths from hemorrhage out of a total of 658 fatalities at this station, a mortality of 10.8 per cent, from hemoptysis. In this series, however, of 24 deaths 7, or over 29 per cent., were due to hemor¬ rhage from the lungs. Comparing the results of treatment of the cases of right-sided involve¬ ment with those of left-sided, there is no great difference. Reduced to percentages and tabulated it is seen that the cases of right lung involvement show slightly better results. COMPARISON OF RESULTS OF TREATMENT; RIGHT-SIDED AND LEFT¬ SIDED INVOLVEMENT Moderately advanced Far-advanced Right Lung Involved Left Lung Involved Right Lung Involved Left Lung Involved Apparently cured. 31 per cent. 28.5 per cent. 8 per cent. 7 per cent. Arrested . 32 per cent. II per cent. 33 per cent. 30 per cent. Improved. 20 per cent. 32 per cent. 20 per cent. 19 per cent. Unimproved and dead. 17 per cent. 28.5 per cent. 39 per cent. 44 per cent. Symptoms .—Dyspnea and pulse-rate were compared in this series, with the following results: Seventeen per cent, of cases with right lung involve¬ ment suffered considerable dyspnea, 12 per cent, of cases with left lung involvement were so affected. Sixty-one per cent, of right lung involve¬ ment had an average pulse-rate above 84, 69 per cent, of left lung involve¬ ment showed pulse-rate above this number. There would seem to be no great difference in the amount of respiratory or circulatory embarrassment caused by involvement of either lung. As a matter of casual interest I investigated all the phenomenal recov¬ eries from very far-advanced disease at the Fort Stanton Sanatorium. By this is meant those cases where patients with complete involvement of at least one lung and extensive excavation have sufficiently recovered to work and otherwise lead an active life for several years. The average stay of these individuals at the Sanatorium was a little over three years, all being employed as attendants at different times. There have been 19 such * “Pulmonary Hemorrhage in the Tuberculous at High Altitude,” Public Health Reports, vol. xxv. No. 4, October 17, 1910. 4 ADVANCED TUBERCULOSIS CONFINED TO ONE LUNG phenomenal cases, ii being instances where the right lung was the one chiefly involved, and 8 where the left was more affected. SUMMARY 1. Advanced pulmonary tuberculosis is not often (8.8 per cent, in this series) confined to one lung. 2. In advanced disease confined to one lung the right is affected most frequently. 3. Extension of disease from either lung to the opposite seems about equally frequent, and serious in about the same proportion. 4- The sound lung when freshly involved seemed to show' a fair degree of resistance. The apex was usually first affected. 5. The prognosis in advanced disease confined to one lung is more favorable than wTen both are actively affected. 6. Deaths from accident (hemorrhage) or complications w'ere unusually frequent; unusual chronicity is suggested as a possible explanation. 7. Cases w'here the right lung only w’as involved show'ed slightly better results than w'here the left onl}^ w'as affected. 8. Dyspnea and rapid pulse w'ere experienced in about the same degree, d}-spnea being slightly more noticeable in the cases of right-lung involve¬ ment and tachycardia in left-sided disease. 9. Of 19 recoveries from very far-advanced disease with restoration to working capacity, ii were cases of right-lung involvement and 8 of left. ■ ■ . :-p}'^^mi4 . ■■ ' ' ' • - , ‘ ^ ■r'^' ■'■ . .... . - <. ■ -'•: ’ ■ ' ' V --'■■■■ •:'« &■, r "-i • .^• ■' ' ’ - '. ■^' ■* ^ -’" ^ ’•■•'-'-l ; ■ ■^■-C’ r y, ’ "■■:'L ^ V:-. ,- : < / ' . K »•••.* ■. 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