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Abstract
In the treatment of pulmonary tuberculosis three combinations of antituberculosis
drugs, SM-PAS, SM-INH and INH-PAS, appear equally effective. Differences between them,
however, may be evident upon completion of studies now in progress. If these regimens
were equally effective, the selection of SM-PAS for initial therapy would leave INH,
the more versatile of the two major drugs, in reserve for retreatment if it should
become necessary. Drug resistance is effectively delayed by all three combinations
of drugs, but the particular advantages, if any, of one combination over another in
this respect have not yet been clarified. Toxicity of drugs is now a relatively unimportant
consideration either in the selection of a regimen or in the duration of chemotherapy.
Whatever regimen is employed, there is now general agreement that uninterrupted drug
therapy should be continued for at least one year, or six to twelve months after a
target point of (1) closure of all cavities, (2) persistently negative sputum cultures
and (3) maximal resolution of lesions, has been achieved. However, the optimum duration
of chemotherapy is not known.
The changes in the morphology of tuberculous lesions following the use of drugs do
not differ qualitatively from those occurring with other forms of therapy. However,
resolution is prompt and predictable. Solid necrotic lesions are affected relatively
little. Cavity closure is usually a process of their filling in with necrotic material,
and potential bronchial communications can often be demonstrated between the filled-in
cavity and the bronchial tree. Filled-in cavities are not healed in a morphologic
sense and thus there may be a rationale for resecting them. Yet bacilli are non-viable
in closed necrotic lesions in 85 to 95 per cent of resections. There is no general
agreement, however, that such bacilli are in fact dead. In the meantime the interpretation
of these bacteriologic data is bound to influence the indications for resection of
closed necrotic lesions. The relationships between surgery and chemotherapy not only
involve the interpretation of the morphology and bacteriology of closed necrotic lesions,
but depend also upon whether the primary role in the treatment of pulmonary tuberculosis
is given to chemotherapy or to surgery.
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© 1955 Published by Elsevier Inc.
