An Assessment of Antibacterial Treatment Used Alone or in Association with Surgical Operation in the Treatment of Pulmonary Tuberculosis

Abstract

The discovery of streptomycin by Schatz, Bugie, and Waksman (1944), followed by the introduction of para-amino salicylic acid (P.A.S.) (Lehmann, 1946) and of isoniazid (Robitzek and Selikoff, 1952), completely revolutionized the treatment of pulmonary tuberculosis. With preliminary antibacterial treatment using combinations of these agents, artificial pneumothorax and thoracoplasty became relatively safe procedures and shorter periods of bed rest were necessary. The results of surgical resection improved enormously, with a high proportion of successes and a low complication rate (Bickford, Edwards, Esplen, Gifford, and Thomas, 1952;Thompson, Savage, and Rosser, 1954), and operation came to be regarded as an essential part of treatment in most patients with extensive disease unsuitable for, or inadequately controlled by, other means. The persistence of cavitation was accepted as the strongest indication for operation, but resection or thoracoplasty continued to be widely employed as an " insurance " measure for the future in patients with lesions of the solid focus type, or in whom cavities had closed with preliminary treatment.As experience was gained with the prolonged administration of combinations of the antibacterial agents, their remarkable efficiency was more and more apparent. It became increasingly doubtful if " insurance " surgery was necessary, or if even the persistence of cavitation was a clear indication for operation. The present investigation was planned in an attempt to clarify these points.MATERIAL AND METHOD The material is drawn from a population of one million, and all patients coming under our care between January, 1954, and December, 1956, were reviewed for the present investigation.The principal purpose was to establish whether insurance " surgery was desirable for patients in whom cavities had already closed. We therefore included for study all patients with cavitary disease.and sputum containing tubercle bacilli, who had achieved sputum conversion and cavity closure during an arbitrary period of six months' antibacterial treatment; these were divided into two groups depending on whether or not surgery was carried out. At the onset we believed that surgery should normally be advised where cavitation persisted after six months' antibacterial treatment, and patients who had surgery for cavitated disease have not been studied. It became clear, however, that a large number of patients in whom cavities persisted after the sputum had become negative remained well in spite of not having surgery, and these have been studied as a third group. Thus there were three groups of patients: Group A, patients with cavity closure after six months' antibacterial treatment, followed by surgery; Group B, patients with cavity closure after six months, without surgery; Group C, patients with persisting cavity after six months, without surgery.All were treated with two or three of the standard antibacterial agents in the rdgimes now accepted in Great Britain, except a small number who had intermittent streptom...