CHRYSOTHERAPY IN TUBERCULOSIS: BANERJEA
April, 1937] SOME
OBSERVATIONS ON iHERAPY IN PULMONARY
CULOSIS %
J. C.
CHRYSOTUBER-*
I
BANERJEA,
(Lond.) onorary Junior Visiting Physician, Medical College m.b.
Hospitals,
(Cal.),
m.r.c.p.
Calcutta
of Copenjust a decade since Mollgaard hagen discovered the gold treatment o Pulmonary tuberculosis in 1924. Greatandenthut ic siasm swept over the medical world taken was ?anocrysin treatment of Mollgaard llP by the specialists in tuberculosis of neai y every country with high hopes of success, but, o as time passed on, the enthusiasm gave place in treated depression. Follow-up of the cases the earlier years revealed unfavourable results so the at the hands of nearly all the experts and The time being. the treatment was given up for French school, however, headed by Leon Bernard and Dumarest, persisted in this method treatment, using gold salts of lower toxicity than sanocrysin and in smaller doses. They have reported favourable results in 50 to 60 of other Per cent of cases, but the experiences workers on this method of treatment differ Widely and in spite of so much work the value gold treatment remains still unproven.* In America it is much less thought of and less utilized. But in India we find that gold treatis being tried with great zeal both by It is practitioners and by specialists. time that we should be using this method ?t treatment with caution and discretion and l0uld pause to take stock of our experiences lr?ni time to time. With these thoughts in ^uid I took which is based up the present study ?u personal observations in a series of sixty esses. It is
^
ment general
Jgh
~
205
discretion the treatment may be extended
cases
^ is essential to remember that the whole or failure of chrysotherapy depends on 1 le selection of cases. It is unanimously agreed lat (1) cases with recent exudative lesions are few a m?st suitable for gold therapy. Only eases, however, are seen by us at this stage, this anu, if We ^jie ygg of gold salts to H?UP, we shall find that about 10 to 20 per cent
Recess
eases
will
receive
this
treatment.
ltli
C on tra -indica tions
headings
:? ..
13
..
6
Recent exudative cases 4 Unilateral 9 Bilateral (2) Cases suitable for artificial pneumothorax which however could not be induced because of pleural adhesions 4 Unilateral 2 Bilateral (3) Advanced cases unsuitable for artificial pneumothorax artificial pneumo(4) Cases where thorax was carried out on one side and gold treatment resorted to for checking the progress of recent lesions on the other side or to promote healing of uncollapsed diseased areas (5) Phrenic evulsion cases Mode of action of gold salts
(1)
.
..
.
..
..
..
..
..
..
* rri
theraDv
based chiefly
on cases
B. injections of solganalgold cases without f?r 00rnParative figures Many as controls. Ve ,n?t been included those at the Madanapalle
?leoSUn, Workers
are
. ?
?a' Particularly author's statenot subscribe to the still remains ^e value of gold treatment particularly Unprov; success of gold therapy, not with in^n of sanocrysin, depends Ejections on careful also only on +Lenous selection of cases but of the urine, on observ r repeated examinations on other tests, the hi 10? set,irnentati?n index, and BeCaut; " squires great care in the selection of cases should not and n^G gold therapy 58 be con l agement of treatment, per cent series, author's the in mnedEven of flip improvement.?Editoh, definite I. \f j-j casQs showed
?aHator'm ment
,
'
?
.
.
.
.
.
19
17 5
The mode of action of gold salts in pulmonary obscure. Mollgaard's original idea that gold salts have a direct bactericidal action in vivo has not been confirmed by experiFeldt believes that gold mental observations. accelerates the complex defensive mechanisms of the host by an activation of the cells of the reticulo-endothelial system which is chiefly concerned in the production of immunity. Apart from these theories, there are certain demonstrable effects on the blood, such as (1) decrease of the sedimentation rate of the erythrocytes, (2) increase of total leucocytes with lymphocytosis and decrease or slight increase of monocytes. These blood changes
tuberculosis is
conclusions treated a*.lth?r.'s intramuscular ,W
(2)
It must be emphasized that cases showing markedly toxic symptoms with high fever, gastro-intestinal lesions and renal lesions, as well as cases with marked emaciation, are not suitable for chrysotherapy. I would like to point out that cases with recurrent attacks of haemoptysis are unsuitable for gold treatment, though many workers do not think haemoptysis to be a contra-indication. Involvement of the larynx by itself does not contra-indicate the use of gold salts and I have had one such case where the pulmonary and the laryngeal lesions showed considerable improvement under chrysotherapy and the improvement has been maintained till now, a period of one year. In my series the cases selected for chrysotherapy may be grouped as follows under five
.
Selection of
to
second group where it is desirable to collapse one lung by artificial pneumothorax or phrenic evulsion and to check the progress of recent lesions in the other lung. There is yet a third group (3) where the use of gold salts has been advocated to check the acute exacerbations of a chronic fibrotic type of case. a
THE INDIAN MEDICAL GAZETTE
200
favourable. There are other changes which unfavourable and in such cases gold salts should be stopped. These are (a) rise of the polymorphonuclear count and eosinophilia, and (b) diminution of the blood platelets. are
are
of administration There are various preparations of gold salts on the market and any of the following may be used provided the dosage is carefully regulated :? Sanocrysin (double thiosulphate of gold and sodium). Preparations
and mode
Crisalbine.
Solganal B. Oleo-sanocrysin. Solganal B. oleosum. In the present series of cases I used solganal B. oleosum in 55 cases, oleo-sanocrysin in 3 and lopion in 2. One cannot definitely lay down a scheme of dosage which will suit all cases. The dosage and interval have to be modified according to (a) the general condition of the patient, (6) weight of the patient, (c) extent and type of disease and (d) reactions of the patient. In a febrile case it is desirable to begin with a small dose 0.002 gm. by the intramuscular route and increase it by 0.002 gm. at intervals of four to six days, provided no reactions supervene. In an afebrile case we may start with 0.01 gm. and use double the dose every week till 0.4 gm. is reached and this last dose is repeated at weekly intervals until a total dosage of 5 to 6 gm. is administered. Then, after an interval of two months, a second course of 5 gm. is given, if Unfortunately it has been found necessary. that many cases cannot tolerate gold injections, In others, 20 per even in very low dosages. cent in my series, treatment had to be abandoned in the middle of a course because of unfavourable reactions, such as rise of temperature of more than two degrees above the previous level and continued for more than a week, haemoptysis, stomatitis and dermatitis. In the early years when dosage was high, severe reactions were frequent. Now, we generally K. Secher (1931) use a low or moderate dosage. however believes that many poor results of gold treatment are due to the low dosage and therefore he advocates larger dosages which cause some reaction. The complications that might arise during chrysotherapy have been stated to be numerous,
viz:?
(a) (b)
Febrile reactions. Gastro-intestinal?ulcers of mouth and lips, loss of appetite, nausea, vomiting, and diarrhoea.
(c) Circulatory?collapse. (d) Renal?albuminuria, red casts in urine.
(e) Hepatic?jaundice. (/) Joint complications.
blood cells and
[April,
1937
(f/) Skin?rashes?morbilliform, erythematous, or purpuric [22 cases recorded recently in literature (Hudson, 1935) ]! herpes, pruritus or pigmentation. In the past, when larger dosages were used, the complications were frequent, but with the use of smaller dosages and of oily preparations they are few and mild. The commonest that
I have come across have been febrile reactions and mild gastro-intestinal symptoms. In one case, I saw an erythematous rash all over the body, more marked on the extremities, on the third day after injection. In another, I have seen slate-grey pigmentations of the skin of the back and the abdomen appearing after the seventeenth injection and persisting for over three years. In a third I have seen severe stomatitis and gingivitis. Apart from the occasional appearance of albumin in the urine I have not seen any marked renal complication. Results of chrysotherapy difficult to assess the value of any anti-tuberculous remedy unless we adopt the same criteria of clinical improvement or cure. A patient is clinically considered t'o be cured when there is anatomical healing with disappearance of toxaemia and return to normal living and working conditions. Results of any method of treatment should be assessed at the end of five years, if not at the end of ten years. Hence a follow-up of the treated and untreated cases is essential for the evaluation of chrysotherapy. From this point of view my observations are not likely to yield much valuable information inasmuch as they have been made during the last five years. Still the results oi gold treatment in my series of 60 cases are presented for the consideration of my medical It is
extremely
colleagues.
It will be seen from the table (p. 207) that about 58 per cent of cases showed definite These improvement under chrysotherapy. results agree closely with those of Mayer (1934) who reports improvement in 66 per cent of his 404 cases and with those of Bernard (1932) who reports favourable results in 50 per cent of his series. Even if we leave out of our consideration the cases of temporary improvement we find marked improvement in 25 pei' cent of the present series. Peters and Short (1935) however have recently published a controlled statistical study on the results of chrysotherapy in the age group 16 to 26 during the last five years and they conclude that gold treatment is of no appreciable value. Regarding the effects of chrysotherapy on the sputum it may be interesting to point out that bacilli disappeared only temporarily and they were present some time or other in about 40 per cent of the cases who received a fairly adequate dose of gold salts.
Reports of
a
few
illustrative
cases
Case 1.?C. P., girl, aged 14 years. Fever and cough for two mouths; physical examination showed impaired
Plate IV
.
*
CI FigFig.
1. 1. Case 1?Before Case 1.?Before
gold gold
treatment. treatment.
treatment. 1.?After gold Fig. gold treatment. Case 1.?After Fig. 2.2. Case
tm
figFig.
3.
Case 2?Before gold treatment. treatment.
Fig. Fig. 4.4.
Case 2.?After gold Case 2.?Atter treatment. gold treatment.
Plate V *&..
j8g
''M.
.....
Fig.
5.
Case 3.?Before phrenicectomy.
Fig.
7.
Case 3.?After five
Fig. Fig.
years of
6. 6.
Case Case 3.?Four after phrenicectomy 3.?Four months months after phrenicectomy and and before treatment. before gold gold treatment.
gold treatment.
April, 1937]
CHRYSOTHERAPY IN TUBERCULOSIS: BANERJEA Results
207
of chrysotherapy Results
?lypes
Tr
ITT IV y
?
?
of
exudative ^ecentwhere
cases
A p faiIed where A P cona -^^ered unsuitable. A P cases with gold treat-
r