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A LOW-RESISTANCE RESPIRATORY VALVE
745
Whereas, in the case of this drug, the unpleasant sideeffects provide an adequate reason, we believe that the issue may be much wider. A similar picture might well be revealed in the medication for diseases other than
tuberculosis. our general disapproval of W. was responsible for the modification of the standard ferric-chloride test, so to call it " Dixon’s test " would be doubly wrong. W. M. DIXON PETER STRADLING Hammersmith Chest Clinic, I. D. P. WOOTTON. London, W.12.
Finally, may we express eponyms ? In fact 1. D. P.
A LOW-RESISTANCE RESPIRATORY VALVE
SiR,ŅImust take exception to the comments of Dr. Theron and his colleagues (Feb. 22) upon the lowresistance respiratory valve described by my former colleagues.1 It seems that Dr. Theron and his colleagues have never seen such a valve, and so their comments on its suitability, however valid, are out of place. Furthermore, it is not true to say: " The only valve of com"; had parable (sic) resistance is that described they plotted the published resistance of Bannister and Cormack’s larger valve in their fig. 1, they would have found that it falls between the curves (5a and b) for their own doubtless excellent valve. D. J. C. CUNNINGHAM. ...
LUNG RESECTION FOR BRONCHIECTASIS
SIR,—Your annotation of March 22 is a gross misrepresentation of the present position of surgery in bronchiectasis. One has come to regard pulmonary resection for localised bronchiectasis as a most rewarding adjunct to treatment in a substantial proportion of cases, rude shock to see you dismiss it as desirable ". rarely You base your opinion on the grounds of (1) high
and it
"
comes as a
in the
of pneu-
operative mortality, prohibitive monectomy, (2) high incidence of morbidity, in particular postoperative collapse, (3) loss of pulmonary function, and (4) extension of bronchiectasis in the residual lung. case
You further state that the results of conservative ment are favourable.
treat-
series of 109 cases, including 17 bilateral pneumonectomies, there were no operative or postoperative deaths. One patient died a year after extensive bilateral surgery from pneumonia and respiratory failure. About half of the patients were under 20, and all were operated In
a
personal
and 6
cases
because of failure of medical treatment. There was no of persistent postoperative atelectasis. Only patients who were not symptom-free for a year after surgery were followed up for longer periods; the great majority of patients have been discharged. Of the remainder, in no case has further bronchiectasis been shown to develop. Gross localised bronchiectasis (which may include as much as both lower lobes, middle lobe, and lingula) is surely accompanied by loss of function in the diseased areas, and its removal results in little or no further loss of function. Pulmonary efficiency may be improved. Finally, you state that no modern advance in technique is likely to affect the most important factor in the alleged failure of surgery-namely, the inevitable distortion of the bronchial tree and interference with the drainage of the remaining bronchi. I am aware of no evidence to show that bronchial distortion, if it occurs, is a cause either of bronchiectasis or of impaired bronchial drainage. on
case
1.
Bannister,
R.
G., Cormack,
R. S.
J. Physiol. 1954, 124, 4
P.
I submit, Sir, that the figures I have outlined are more in keeping with the experience of a modern chest service than those you quote, and which you admit are unusual in the very high average age of the patients reviewed. It would be a disservice to patients suitable for surgery if they were instead to be condemned to a life of recurrent exacerbations and increasins respiratory disabilitv. K. M. SHAW. CLINICAL GERIATRICS
SIR,-Dr. Pappworth (March 22) asks in effect whether the clinical signs of any disease differ in elderly as compared with younger patients. The answer is, oddly enough, that very often they do, though the differences are greater in those in their 70s and above. To mention but a few: elderly people with pneumonia seldom exhibit any pyrexia, cardiac infarction is common yet frequently silent ", and many disorders come to notice only because of mental symptoms which are, however, not evidence of senile dementia. It is important both that the many differences should be recognised, and that the limits of normality at various ages should be better understood. But geriatrics is also concerned with the many ways in which elderly and partially disabled old people can be rehabilitated and helped afterwards to live an independent existence outside hospital. Those who have not seen it taking place can scarcely believe that nearly half of those admitted to an active geriatric department can be made well enough to leave hospital. This is achieved not by administration, but by hard work in the clinical field. Should not geriatrics therefore be taught as a branch of medicine by those who practise it, so that we may at last be rid of the attitude of mind which classes patients over 70 as "senile" and thus unworthy of our clinical attentions ?7 JOHN AGATE. "
SIR,-Dr. Pappworth does not seem to have read your annotation of March 1, which mentions several ways in which the symptoms and signs of disease may be altered by age. If he consults the current issue of The Practitioner he can read a short paper describing a series of gastric ulcers, proved at necropsy, but not presenting normal clinical features in old people. The same journalalso records a group of patients with new growths whose signs and symptoms were cloaked by mental symptoms. The special effects of haemorrhage in the elderly have been described by Bedford 2;the organic basis of confusional states in the elderly by Flint 3 ; hypoglycxmia and confusion by Helps 4 ; and Vines5 has written on clinical pitfalls in the elderly and so have others elsewhere. Dr. Pappworth mentions an age of 68 for a hypothetical patient. This is rather on the young side for a typical geriatric case. A survey at Queen’s Hospital, Croydon, showed that 34% of the patients were between 80 and 89, while 9% were over 90. The administrative problems, which Dr. Pappworth says he can understand, arise because the clinical aspects of disease change as the patient grows older. For necropsy proof of this I would refer him to a series of papers in Geriatrz"cs.6 Clinical instruction in geriatrics is also desirable because the limits of normality change with age. My own book on Old Age was one of the first to give detailed examples of this. Hobson 1. Practitioner, 1957, 178, 233. 2. Lancet, 1956, ii, 750. 3. Brit. med. J. 1956, ii, 1537. 4. Lancet, 1957, i, 138. 5. ibid. 1955, ii, 103. 6. Geriatrics, 1949, 4, 281 ; ibid.
1950, 5, 90 ; ibid. 1951, 6, 85 ; ibid. 1952, 7, 137 ; ibid. 1953, 8, 215, 267.
Whereas, in the case of this drug, the unpleasant sideeffects provide an adequate reason, we believe that the issue may be much wider. A similar picture might well be revealed in the medication for diseases other than
tuberculosis. our general disapproval of W. was responsible for the modification of the standard ferric-chloride test, so to call it " Dixon’s test " would be doubly wrong. W. M. DIXON PETER STRADLING Hammersmith Chest Clinic, I. D. P. WOOTTON. London, W.12.
Finally, may we express eponyms ? In fact 1. D. P.
A LOW-RESISTANCE RESPIRATORY VALVE
SiR,ŅImust take exception to the comments of Dr. Theron and his colleagues (Feb. 22) upon the lowresistance respiratory valve described by my former colleagues.1 It seems that Dr. Theron and his colleagues have never seen such a valve, and so their comments on its suitability, however valid, are out of place. Furthermore, it is not true to say: " The only valve of com"; had parable (sic) resistance is that described they plotted the published resistance of Bannister and Cormack’s larger valve in their fig. 1, they would have found that it falls between the curves (5a and b) for their own doubtless excellent valve. D. J. C. CUNNINGHAM. ...
LUNG RESECTION FOR BRONCHIECTASIS
SIR,—Your annotation of March 22 is a gross misrepresentation of the present position of surgery in bronchiectasis. One has come to regard pulmonary resection for localised bronchiectasis as a most rewarding adjunct to treatment in a substantial proportion of cases, rude shock to see you dismiss it as desirable ". rarely You base your opinion on the grounds of (1) high
and it
"
comes as a
in the
of pneu-
operative mortality, prohibitive monectomy, (2) high incidence of morbidity, in particular postoperative collapse, (3) loss of pulmonary function, and (4) extension of bronchiectasis in the residual lung. case
You further state that the results of conservative ment are favourable.
treat-
series of 109 cases, including 17 bilateral pneumonectomies, there were no operative or postoperative deaths. One patient died a year after extensive bilateral surgery from pneumonia and respiratory failure. About half of the patients were under 20, and all were operated In
a
personal
and 6
cases
because of failure of medical treatment. There was no of persistent postoperative atelectasis. Only patients who were not symptom-free for a year after surgery were followed up for longer periods; the great majority of patients have been discharged. Of the remainder, in no case has further bronchiectasis been shown to develop. Gross localised bronchiectasis (which may include as much as both lower lobes, middle lobe, and lingula) is surely accompanied by loss of function in the diseased areas, and its removal results in little or no further loss of function. Pulmonary efficiency may be improved. Finally, you state that no modern advance in technique is likely to affect the most important factor in the alleged failure of surgery-namely, the inevitable distortion of the bronchial tree and interference with the drainage of the remaining bronchi. I am aware of no evidence to show that bronchial distortion, if it occurs, is a cause either of bronchiectasis or of impaired bronchial drainage. on
case
1.
Bannister,
R.
G., Cormack,
R. S.
J. Physiol. 1954, 124, 4
P.
I submit, Sir, that the figures I have outlined are more in keeping with the experience of a modern chest service than those you quote, and which you admit are unusual in the very high average age of the patients reviewed. It would be a disservice to patients suitable for surgery if they were instead to be condemned to a life of recurrent exacerbations and increasins respiratory disabilitv. K. M. SHAW. CLINICAL GERIATRICS
SIR,-Dr. Pappworth (March 22) asks in effect whether the clinical signs of any disease differ in elderly as compared with younger patients. The answer is, oddly enough, that very often they do, though the differences are greater in those in their 70s and above. To mention but a few: elderly people with pneumonia seldom exhibit any pyrexia, cardiac infarction is common yet frequently silent ", and many disorders come to notice only because of mental symptoms which are, however, not evidence of senile dementia. It is important both that the many differences should be recognised, and that the limits of normality at various ages should be better understood. But geriatrics is also concerned with the many ways in which elderly and partially disabled old people can be rehabilitated and helped afterwards to live an independent existence outside hospital. Those who have not seen it taking place can scarcely believe that nearly half of those admitted to an active geriatric department can be made well enough to leave hospital. This is achieved not by administration, but by hard work in the clinical field. Should not geriatrics therefore be taught as a branch of medicine by those who practise it, so that we may at last be rid of the attitude of mind which classes patients over 70 as "senile" and thus unworthy of our clinical attentions ?7 JOHN AGATE. "
SIR,-Dr. Pappworth does not seem to have read your annotation of March 1, which mentions several ways in which the symptoms and signs of disease may be altered by age. If he consults the current issue of The Practitioner he can read a short paper describing a series of gastric ulcers, proved at necropsy, but not presenting normal clinical features in old people. The same journalalso records a group of patients with new growths whose signs and symptoms were cloaked by mental symptoms. The special effects of haemorrhage in the elderly have been described by Bedford 2;the organic basis of confusional states in the elderly by Flint 3 ; hypoglycxmia and confusion by Helps 4 ; and Vines5 has written on clinical pitfalls in the elderly and so have others elsewhere. Dr. Pappworth mentions an age of 68 for a hypothetical patient. This is rather on the young side for a typical geriatric case. A survey at Queen’s Hospital, Croydon, showed that 34% of the patients were between 80 and 89, while 9% were over 90. The administrative problems, which Dr. Pappworth says he can understand, arise because the clinical aspects of disease change as the patient grows older. For necropsy proof of this I would refer him to a series of papers in Geriatrz"cs.6 Clinical instruction in geriatrics is also desirable because the limits of normality change with age. My own book on Old Age was one of the first to give detailed examples of this. Hobson 1. Practitioner, 1957, 178, 233. 2. Lancet, 1956, ii, 750. 3. Brit. med. J. 1956, ii, 1537. 4. Lancet, 1957, i, 138. 5. ibid. 1955, ii, 103. 6. Geriatrics, 1949, 4, 281 ; ibid.
1950, 5, 90 ; ibid. 1951, 6, 85 ; ibid. 1952, 7, 137 ; ibid. 1953, 8, 215, 267.