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MEDIASTINOSCOPY
486
without consideration of its size and of the patient’s age and general condition. MEDIASTINOSCOPY
the lung roots or in the mediastinum can difficult diagnostic problem, notwithstanding information provided by radioscopy, tomography, bronchoscopy, and even arteriography. Still more difficult may be the decision whether thoracotomy is justifiable, either in diagnosis or with a view to resection. Carlens1 referred to Kirklin’s report that in 40% of all thoracotomies performed for lung cancer, after selection and in the absence of enlarged supraclavicular nodes, the tumour is found to be inoperable; these patients have been fruitlessly subjected to a distressing operation in the few months of activity left to them. Occasionally biopsy of a supraclavicular gland may provide decisive evidence. Where the supraclavicular glands are not involved, and the mass seems to be localised and to offer possibilities of total extirpation, mediastinoscopy can be helpful. This technique was devised by Carlens, of Stockholm, in 1959and has since been reported on by other workers.2-5 A
set
MASS near a
Full preparations are made for radical chest surgery; and the patient is anxsthetised and intubated. With his head tilted back, and turned to the left, the skin of the suprasternal notch and the deep fascia are incised. By blunt dissection, mainly with the fingertips, the trachea is stripped from the back of the sternum; any abnormal nodes can be immediately felt, as can tumours, up to the full reach of the fingertip. Any suspicious area is inspected through a rigid endoscope, preferably fitted with a telescope to yield a magnified image. From any discrete mass, apparently a node, an aspirationbiopsy specimen is taken; and when it is so proven not to be a blood-vessel, it is removed entire for section. Dissection with the beak of the endoscope, or with instruments passed through or alongside it, permits inspection and biopsy as far as the level of the distal border of the main bifurcation, and of the nodes that lie in and around that angulus. The patient leaves hospital after two or three days.
Palva6 finds
mediastinoscopy of greatest value in confirming suspected sarcoidosis in cases where the scalene glands are not evidently involved at biopsy. His technique has been taken up in other centres, and Palva4 has suggested that the procedure is suitable for widespread adoption. In a series of 132 cases 6 84 were of cancer; and 28 of these were proven only by mediastinoscopy, for the primary tumour was too peripheral to be examined by bronchoscopy, and cancer cells were not found in the sputum. There were no complications. In suitable cases this operation seems to be justified by the diagnostic information obtained: in particular, a decision whether a carcinoma is likely to be resectable can be the more readily reached if it is known whether the paratracheal or subcarinal glands are involved, and, if so, whether they are mobile or fixed. Sarcoidosis presents in the active phase as violaceous nodes, soft, bleeding readily on section (this bleeding is as readily controlled by light pressure); in the later stages as greyish hard nodes which may even be flecked black, thus mimicking anthracosis. Cysts and some tumours-e.g., thymoma-can be entirely removed by this suprasternal approach. On the evidence offered, it does seem that " it is time for the method to beexported ’ to thoracic clinics in other countries ".44 1. 2. 3. 4. 5. 6.
Carlens, E. Dis. Chest, 1959, 36, 343. Palva, T., Viikari, S. J. thorac. cardiovasc. Surg. 1961, 42, 206. Palva, T. Acta oto-laryng. 1961, 53, 405. Palva, T. Rev. med. int. Photo Ciné, 1962, 1, 84. Carlens, E. ibid. p. 86. Palva, T. ibid. p. 131.
THE QUAKER PAMPHLET IT is now a commonplace that Western civilisation is almost destitute of generally accepted " values ". The march of the sciences (occupied exclusively with the objective and demonstrable kinds of truth, doubtful of the existence of other kinds, and largely unconcerned with the consequences of their own discoveries), the shock of two devastating wars, and perhaps the passage of time have exploded or shaken down the accepted and established values of what could, at the turn of the century, still be called Christendom. The young must somehow find their way in a desert strewn with ruined shrines. In no province of life is their dilemma more obvious than in sexual relations and behaviour. The conventions and rules of conduct which did partly govern and determine sexual behaviour fifty years ago have crumbled with special thoroughness, because they were, in fact, little more than conventions floating in air without logical foundation in reason or belief. To set them up again is neither possible nor desirable. Yet anarchy will not do; and condemnations, taboos, and legal punishments arising from ignorance, unreason, and lack of sympathy and of understanding have been and are responsible for a vast amount of suffering and missed happiness. There is urgent need for enlightenment and reform both of public opinion and the law. All who are concerned about these things will welcome an informative and stimulating pamphlet 1 by a group of Quakers who have been working on the subject individually and together for the past five years. The group’s eleven members include men and women with experience in teaching, penology, marriage guidance, psychiatry, biology, psychology, and the law; three are medically qualified, and six are Elders in the Society of Friends. Their starting-point was the problem of helping and " advising young Quaker students faced with homosexual difficulties ", but they soon found themselves compelled to explore and consider the whole subject of sexual relations and practices, homosexual and heterosexual, within marriage and without, in both sexes and among animals. The contents of the pamphlet correspond with its title, Towards a Quaker View of Sex. The many intricate problems raised are fairly stated, and when, as often, there are two sides, they are both presented. Conclusions are seldom dogmatic and often tentative, but on some fundamental points the group feels sure of its collective opinion. " We shall have reason to say that sexuality, looked at dispassionately, is neither good nor evil-it is a fact of nature. But looking at it as Christians we have felt impelled to state without" reservation that it is a glorious gift of God." They reject almost completely the traditional approach of the organised Christian church to morality with its supposition that it knows precisely what is right and what is wrong ". They make it clear that in their view the words " natural " and " unnatural" have no-or next to no-meaning when applied to sexual performances. Masturbation, homosexual practices, and even a kind of transvestism occur among animals as among men. They are emphatic that public opinion-and laws reflecting it-concern themselves too much with acts, too little with circumstances and motivation. They cannot condemn homosexuality or the acts springing from it as such. " Homosexual affection can be as selfless as heterosexual affection and therefore we cannot see that it is in some way morally worse." " At the same time a Quaker View of Sex. Edited by Alastair Heron. London; Friends Home Service Committee. 1963. Pp. 75. 3s. 6d.
1. Towards
without consideration of its size and of the patient’s age and general condition. MEDIASTINOSCOPY
the lung roots or in the mediastinum can difficult diagnostic problem, notwithstanding information provided by radioscopy, tomography, bronchoscopy, and even arteriography. Still more difficult may be the decision whether thoracotomy is justifiable, either in diagnosis or with a view to resection. Carlens1 referred to Kirklin’s report that in 40% of all thoracotomies performed for lung cancer, after selection and in the absence of enlarged supraclavicular nodes, the tumour is found to be inoperable; these patients have been fruitlessly subjected to a distressing operation in the few months of activity left to them. Occasionally biopsy of a supraclavicular gland may provide decisive evidence. Where the supraclavicular glands are not involved, and the mass seems to be localised and to offer possibilities of total extirpation, mediastinoscopy can be helpful. This technique was devised by Carlens, of Stockholm, in 1959and has since been reported on by other workers.2-5 A
set
MASS near a
Full preparations are made for radical chest surgery; and the patient is anxsthetised and intubated. With his head tilted back, and turned to the left, the skin of the suprasternal notch and the deep fascia are incised. By blunt dissection, mainly with the fingertips, the trachea is stripped from the back of the sternum; any abnormal nodes can be immediately felt, as can tumours, up to the full reach of the fingertip. Any suspicious area is inspected through a rigid endoscope, preferably fitted with a telescope to yield a magnified image. From any discrete mass, apparently a node, an aspirationbiopsy specimen is taken; and when it is so proven not to be a blood-vessel, it is removed entire for section. Dissection with the beak of the endoscope, or with instruments passed through or alongside it, permits inspection and biopsy as far as the level of the distal border of the main bifurcation, and of the nodes that lie in and around that angulus. The patient leaves hospital after two or three days.
Palva6 finds
mediastinoscopy of greatest value in confirming suspected sarcoidosis in cases where the scalene glands are not evidently involved at biopsy. His technique has been taken up in other centres, and Palva4 has suggested that the procedure is suitable for widespread adoption. In a series of 132 cases 6 84 were of cancer; and 28 of these were proven only by mediastinoscopy, for the primary tumour was too peripheral to be examined by bronchoscopy, and cancer cells were not found in the sputum. There were no complications. In suitable cases this operation seems to be justified by the diagnostic information obtained: in particular, a decision whether a carcinoma is likely to be resectable can be the more readily reached if it is known whether the paratracheal or subcarinal glands are involved, and, if so, whether they are mobile or fixed. Sarcoidosis presents in the active phase as violaceous nodes, soft, bleeding readily on section (this bleeding is as readily controlled by light pressure); in the later stages as greyish hard nodes which may even be flecked black, thus mimicking anthracosis. Cysts and some tumours-e.g., thymoma-can be entirely removed by this suprasternal approach. On the evidence offered, it does seem that " it is time for the method to beexported ’ to thoracic clinics in other countries ".44 1. 2. 3. 4. 5. 6.
Carlens, E. Dis. Chest, 1959, 36, 343. Palva, T., Viikari, S. J. thorac. cardiovasc. Surg. 1961, 42, 206. Palva, T. Acta oto-laryng. 1961, 53, 405. Palva, T. Rev. med. int. Photo Ciné, 1962, 1, 84. Carlens, E. ibid. p. 86. Palva, T. ibid. p. 131.
THE QUAKER PAMPHLET IT is now a commonplace that Western civilisation is almost destitute of generally accepted " values ". The march of the sciences (occupied exclusively with the objective and demonstrable kinds of truth, doubtful of the existence of other kinds, and largely unconcerned with the consequences of their own discoveries), the shock of two devastating wars, and perhaps the passage of time have exploded or shaken down the accepted and established values of what could, at the turn of the century, still be called Christendom. The young must somehow find their way in a desert strewn with ruined shrines. In no province of life is their dilemma more obvious than in sexual relations and behaviour. The conventions and rules of conduct which did partly govern and determine sexual behaviour fifty years ago have crumbled with special thoroughness, because they were, in fact, little more than conventions floating in air without logical foundation in reason or belief. To set them up again is neither possible nor desirable. Yet anarchy will not do; and condemnations, taboos, and legal punishments arising from ignorance, unreason, and lack of sympathy and of understanding have been and are responsible for a vast amount of suffering and missed happiness. There is urgent need for enlightenment and reform both of public opinion and the law. All who are concerned about these things will welcome an informative and stimulating pamphlet 1 by a group of Quakers who have been working on the subject individually and together for the past five years. The group’s eleven members include men and women with experience in teaching, penology, marriage guidance, psychiatry, biology, psychology, and the law; three are medically qualified, and six are Elders in the Society of Friends. Their starting-point was the problem of helping and " advising young Quaker students faced with homosexual difficulties ", but they soon found themselves compelled to explore and consider the whole subject of sexual relations and practices, homosexual and heterosexual, within marriage and without, in both sexes and among animals. The contents of the pamphlet correspond with its title, Towards a Quaker View of Sex. The many intricate problems raised are fairly stated, and when, as often, there are two sides, they are both presented. Conclusions are seldom dogmatic and often tentative, but on some fundamental points the group feels sure of its collective opinion. " We shall have reason to say that sexuality, looked at dispassionately, is neither good nor evil-it is a fact of nature. But looking at it as Christians we have felt impelled to state without" reservation that it is a glorious gift of God." They reject almost completely the traditional approach of the organised Christian church to morality with its supposition that it knows precisely what is right and what is wrong ". They make it clear that in their view the words " natural " and " unnatural" have no-or next to no-meaning when applied to sexual performances. Masturbation, homosexual practices, and even a kind of transvestism occur among animals as among men. They are emphatic that public opinion-and laws reflecting it-concern themselves too much with acts, too little with circumstances and motivation. They cannot condemn homosexuality or the acts springing from it as such. " Homosexual affection can be as selfless as heterosexual affection and therefore we cannot see that it is in some way morally worse." " At the same time a Quaker View of Sex. Edited by Alastair Heron. London; Friends Home Service Committee. 1963. Pp. 75. 3s. 6d.
1. Towards