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ARTIFICIAL RESPIRATION
266 reflects lymphadenoid changes surrounding the tumour, a known histological feature. One would expect to find a high level of circulating antibodies where cancer is associated with widespread thyroiditis, as in the cases reported by Dr. Stuart and Dr. Allan. In such cases, however, clinical features and other thyroid investigations often reveal the presence of a tumour. In many cases the character of the swelling or the presence of secondary glands make the diagnosis obvious, while topographical survey of the 1uptake over the thyroid shows deficient or absent pick-up over the majority of malignant
Fig. 2-Thyroid auto-antibodies in histologically proved Hashimoto’s disease. Tests done before or within 3 weeks of operation. Results are expressed as in fig. 1. The proportion of patients having positive precipitins is shown above the appropriate column.
nodules. Most Hashimoto goitres involve the entire gland, even when one lobe is larger than the other, and the iodine uptake is greater on the side of maximum swelling. The B.M.R. and serum-cholesterol may be of help since hypothyroidism is very uncommon in thyroid cancer and freThe rapid regression of quent in lymphadenoid goitre. Hashimoto goitres under thyroid medication is another feature of diagnostic value.
We agree with Dr. Stuart and Dr. Allan that serological should be interpreted only in conjunction with careful clinical assessment and other available investigations ; but only a more extensive study of goitre patients, especially those undergoing thyroidectomy, will show whether a differential diagnosis can be made with confidence on the basis of these combined criteria. DEBORAH DONIACH I. M. ROITT The Middlesex Hospital, R. VAUGHAN HUDSON. London, W.1. tests
ARTIFICIAL RESPIRATION your annotation on this subjectyou say: " Even with intubation Safar et al. did not succeed in moving more than 700-260 c.cm. of air with either the Holger-Nielsen This is far below the ventilation or the Silvester method. regularly attained in the investigation of Gordon et al., but the reason for this difference is not clear."
SIR,-In
When a tracheal tube was in place, we moved with the Holger-Nielsen method in 5 curarised subjects tidal volumes of 260-840 c.cm. (average 655 c.cm.)-the small tidal volumes in obese subjects, the large tidal volumes in lean subjects. Our subjects were lying on a hard table. Gordon moved approximately 1000 c.cm. per breath in tall, lean, and healthy volunteers, who were lying on the floor. Our small tidal volumes are easily explained by the reduced chest distensibility, since some of our subjects were heavy and short. Our large tidal volumes 1.
Lancet, 1958, i, 1322.
smaller than Gordon’s because our subjects were lying on a table. The small tidal volumes are not surprising in view of the findings of other investigatorsnamely Nims et al.,2 Waters and Bennett 3-who could move only 140-280 c.cm. per breath with these push-pull methods and with a tracheal tube in place; they studied apnoeic patients who were obese or whose lung-chest distensibility was reduced by disease. Without tracheal tube 11 of 15 subjects (lying on the floor) could not be ventilated with the Holger-Nielsen method, because of upper airway obstruction. This was confirmed recently by Gordon et al.,4 who were unable to ventilate 40-50% of the curarised subjects studied when they did not use a tracheal tube. We learned from a separate study of unconscious patients who were not curarised that pharyngeal obstruction by the tongue due to flexion of the neck and sagging of the mandible is at least as common in the prone as in the supine position, even when an artificial oropharyngeal airway is in place. The Esmarch-Heiberg manoeuvre (extension of the neck plus forward displacement of the mandible) seems to be the single most important point ,in respiratory resuscitation. You remark on successes known to have followed use of the Holger-Nielsen and Silvester methods. But who knows whether an asphyxia victim in the field survives in spite of or because of the method applied ? Many comatose asphyxiated patients have been awakened by external stimuli only. Airway obstruction is unpredictable. There is no doubt that occasionally the airway is are
during performance of the push-pull methods; but is unable to recognise movement of air while on the patient’s chest. working open
the
rescuer
You suggest that dizziness may affect the operator while performing mouth-to-mouth breathing. We confirmed Elam’s data.5 The rescuer could perform mouth-to-mouth breathing for 30 minutes or longer without becoming dizzy. Whenever he felt dizzy he automatically reduced the rate of inflations, and levelled off at an end-expiratory carbon-dioxide level of 3-4%, while that of the subject was z5%. The oxygen saturation and the end-expiratory carbon-dioxide level in the subject were maintained at, normal levels with tidal volumes at least twice as large as normal at a rate of 10 inflations per minute or more. The restricting factor in prolonged mouth-to-mouth breathing is not dizziness of the operator, but fatigue of his back and hands. A motion picture on Respiratory Resuscitation Techniques, which one of our experiments, shows the experimental and results better than a paper. The motion picture may be borrowed from Army Medical Institute of Research, MAVD, Walter Reed Hospital, Washington, D.C. (Attention: Sergeant H.
was
made
during
techniques Dixon).
Baltimore City
Hospitals, Baltimore, Maryland.
PETER SAFAR Chief, Department of Anesthesiology.
OOPHORECTOMY AND BREAST CANCER
SIR,-Your leader of July 12 refers in passing variable bilateral
to
the
persistence of oestrogen excretion following oophorectomy and adrenalectomy for breast
cancer.
I think it worth calling attention to a simple and practical may repay exploration, before some mysterious third source of cestrogens is postulated or sought-namely, the ovarian hilus cells. These (which resemble Leydig cells and
possibility that
2. Nims, R. G., Conner, E. H., Botelho, S. Y., Comroe, J. H., Jr. J. appl. Physiol. 1951, 4, 486. 3. Waters, R. M., Bennett, J. H. Anesth. Analg. 1936, 15, 151. 4. Gordon, A. S., Frye, C. W., Gittelson, L., Sadove, M. S., Beattie, E. J., Jr. J. Amer. med. Ass. 1958, 167, 320. 5. Elam, J. O., Brown, E. S., Elder, J. D., Jr. New Engl. J. Med. 1954, 250, 749.
Fig. 2-Thyroid auto-antibodies in histologically proved Hashimoto’s disease. Tests done before or within 3 weeks of operation. Results are expressed as in fig. 1. The proportion of patients having positive precipitins is shown above the appropriate column.
nodules. Most Hashimoto goitres involve the entire gland, even when one lobe is larger than the other, and the iodine uptake is greater on the side of maximum swelling. The B.M.R. and serum-cholesterol may be of help since hypothyroidism is very uncommon in thyroid cancer and freThe rapid regression of quent in lymphadenoid goitre. Hashimoto goitres under thyroid medication is another feature of diagnostic value.
We agree with Dr. Stuart and Dr. Allan that serological should be interpreted only in conjunction with careful clinical assessment and other available investigations ; but only a more extensive study of goitre patients, especially those undergoing thyroidectomy, will show whether a differential diagnosis can be made with confidence on the basis of these combined criteria. DEBORAH DONIACH I. M. ROITT The Middlesex Hospital, R. VAUGHAN HUDSON. London, W.1. tests
ARTIFICIAL RESPIRATION your annotation on this subjectyou say: " Even with intubation Safar et al. did not succeed in moving more than 700-260 c.cm. of air with either the Holger-Nielsen This is far below the ventilation or the Silvester method. regularly attained in the investigation of Gordon et al., but the reason for this difference is not clear."
SIR,-In
When a tracheal tube was in place, we moved with the Holger-Nielsen method in 5 curarised subjects tidal volumes of 260-840 c.cm. (average 655 c.cm.)-the small tidal volumes in obese subjects, the large tidal volumes in lean subjects. Our subjects were lying on a hard table. Gordon moved approximately 1000 c.cm. per breath in tall, lean, and healthy volunteers, who were lying on the floor. Our small tidal volumes are easily explained by the reduced chest distensibility, since some of our subjects were heavy and short. Our large tidal volumes 1.
Lancet, 1958, i, 1322.
smaller than Gordon’s because our subjects were lying on a table. The small tidal volumes are not surprising in view of the findings of other investigatorsnamely Nims et al.,2 Waters and Bennett 3-who could move only 140-280 c.cm. per breath with these push-pull methods and with a tracheal tube in place; they studied apnoeic patients who were obese or whose lung-chest distensibility was reduced by disease. Without tracheal tube 11 of 15 subjects (lying on the floor) could not be ventilated with the Holger-Nielsen method, because of upper airway obstruction. This was confirmed recently by Gordon et al.,4 who were unable to ventilate 40-50% of the curarised subjects studied when they did not use a tracheal tube. We learned from a separate study of unconscious patients who were not curarised that pharyngeal obstruction by the tongue due to flexion of the neck and sagging of the mandible is at least as common in the prone as in the supine position, even when an artificial oropharyngeal airway is in place. The Esmarch-Heiberg manoeuvre (extension of the neck plus forward displacement of the mandible) seems to be the single most important point ,in respiratory resuscitation. You remark on successes known to have followed use of the Holger-Nielsen and Silvester methods. But who knows whether an asphyxia victim in the field survives in spite of or because of the method applied ? Many comatose asphyxiated patients have been awakened by external stimuli only. Airway obstruction is unpredictable. There is no doubt that occasionally the airway is are
during performance of the push-pull methods; but is unable to recognise movement of air while on the patient’s chest. working open
the
rescuer
You suggest that dizziness may affect the operator while performing mouth-to-mouth breathing. We confirmed Elam’s data.5 The rescuer could perform mouth-to-mouth breathing for 30 minutes or longer without becoming dizzy. Whenever he felt dizzy he automatically reduced the rate of inflations, and levelled off at an end-expiratory carbon-dioxide level of 3-4%, while that of the subject was z5%. The oxygen saturation and the end-expiratory carbon-dioxide level in the subject were maintained at, normal levels with tidal volumes at least twice as large as normal at a rate of 10 inflations per minute or more. The restricting factor in prolonged mouth-to-mouth breathing is not dizziness of the operator, but fatigue of his back and hands. A motion picture on Respiratory Resuscitation Techniques, which one of our experiments, shows the experimental and results better than a paper. The motion picture may be borrowed from Army Medical Institute of Research, MAVD, Walter Reed Hospital, Washington, D.C. (Attention: Sergeant H.
was
made
during
techniques Dixon).
Baltimore City
Hospitals, Baltimore, Maryland.
PETER SAFAR Chief, Department of Anesthesiology.
OOPHORECTOMY AND BREAST CANCER
SIR,-Your leader of July 12 refers in passing variable bilateral
to
the
persistence of oestrogen excretion following oophorectomy and adrenalectomy for breast
cancer.
I think it worth calling attention to a simple and practical may repay exploration, before some mysterious third source of cestrogens is postulated or sought-namely, the ovarian hilus cells. These (which resemble Leydig cells and
possibility that
2. Nims, R. G., Conner, E. H., Botelho, S. Y., Comroe, J. H., Jr. J. appl. Physiol. 1951, 4, 486. 3. Waters, R. M., Bennett, J. H. Anesth. Analg. 1936, 15, 151. 4. Gordon, A. S., Frye, C. W., Gittelson, L., Sadove, M. S., Beattie, E. J., Jr. J. Amer. med. Ass. 1958, 167, 320. 5. Elam, J. O., Brown, E. S., Elder, J. D., Jr. New Engl. J. Med. 1954, 250, 749.