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DISPLACEMENT OF THE TRACHEA IN PULMONARY FIBROSIS.
THE NORMAL INFANT’S CHEST.
example to anyone who happens peutic procedure of value. T am Ri1"-
VOll1"!’:
across a
I
novel thera-
faithful Hv
A. E. BOYCOTT.
Medical School, University College W.C., Nov. 18th, 1922.
Hospital,
** * The statement of the Medical Research Council should, we think, have made the position clear. The Council accepted the gift of the University of Toronto with the
patent provision already
made.
So far from
without which progress preventing free research work, is of this
remedy impossible, towards the establishment the Council are using every effort to initiate and assist I it. As the results emerge they are certain to be published
II
freely, placing individual workers, as well as great manufacturing firms, in a more advantageous position to assist. We feel that our distinguished correspondent is
a
little
previous
in his
apprehensions.-ED.
London, W., Nov. 20tb,
1H?.
vnnT*s
L.
Tuberculosis Department, St. Thomas’s Nov. 17th, 1922.
To the Editor of THE LANCET. SiR,—I live so far away that my criticism of Mr. R. P. Rowlands’s interesting note in your issue of August 5th must, of necessity, lose much of its point. But as I am engaged in building new operating theatres in the British hospital in this city you can easily understand that I am more than passingly interested. I am one of those who believe in the hot operating room. I cannot conceive of anything more injurious to a patient than to expose, not only the skin of his abdomen, but also his intestines, to a,
fa,ithfnl1v.
STANLEY MELVILLE.
Editor of THE LANCET. SIR,-Observations during the last few months have convinced me that displacement of the trachea in the neck is one of the most helpful signs in cases of chronic pulmonary disease, but I can find no mention of it in any of the leading text-books on diseases of the chest
or
the
manuals devoted to clinical examination.
G. T. HEBERT. Hospital,
THE HOT OPERATING THEATRE.
DISPLACEMENT OF THE TRACHEA IN PULMONARY FIBROSIS. To
degree of the first are self-evident; the second it is difficult to recognise, especially on the right side of the chest, and more difficult still to measure, by means of the displacement of the trachea except in the neck. If the trachea is displaced in the neck and the heart is displaced little or not at all, the fibrosis is apical. If the fibrosis is purely basal (and therefore probably not tuberculous in origin) the heart and the trachea are both displaced. I would claim, therefore, that displacement of the trachea in the neck (1) is a readily recognisable sign ; and, in the absence of a good radiogram, (2) is the most important sign of displacement of the upper mediastinum ; and (3) an essential sign for the estimation of the degree and position of pulmonary fibrosis. I Sir yours faithfully more
am
THE NORMAL INFANT’S CHEST. To the Editor of THE LANCET. SiR,-Nothing was further from my mind than to criticise unfairly the excellent work that Dr. Paton and Dr. Rowand have set out to do. The basis of their work being, however, founded upon the radiological aspect, to this they must adhere, and my one desire in writing was to emphasise the vital importance of great precision in radiography of the chest. I may say that I have read very carefully their description of the method adopted by them, and I think all radiologists will agree with me that to place the patient upon his back with the tube overhead is to make precise centering almost impossible ; at the very least the mediastinum and cardiac shadows must be to some extent distorted. The writers do not say how precisely they centre the overhead tube, and this is a difficult matter under the most advantageous conditions. I am sorry to learn that the Scottish mother is so much less easy a person than is her southron sister. In London at any rate’I had no difficulty with the mothers ; they gave me every assistance and themselves bandaged their babies with flannel to the padded board and were greatly interested in seeing how much happier the babies were than previously when it required at least two people to hold them down. Anything issued under the aegis of the Medical Research Council ought to be as perfect in detail as it is possible, and I can only regret if Dr. Paton and Dr. Rowand mistake my motive in writing ; at all events I, for one, shall look forward with great interest to further articles from their pen on a subject of such vital imrtDT’a-nno-——T am- Sir*
1145
i
temperature 30’or more below anything they have ever experienced before ; it may be 40° below should the patient have fever, or the room be cold, as it is so often in emergency operations. I sympathise with Mr. Rowlands in having to, operate in a hot, stuffy, ill-ventilated atmosphereNothing could be worse for him or for his patients, and the effects, as he has pointed out, are likely to be disastrous. But that does not prove anything against having a hot theatre ; it only shows that the arrangements supplied to Mr. Rowlands are anti-hygienic and antiquated. The reason hot theatres are usually oppressive is that it is almost impossible to convincearchitects of the necessity of supplying an apparently excessive heating installation. The result is, that,. in order to get the proper temperature, it is necessary to have every opening hermetically sealed, when the complete absence of air currents produces an intolerable atmosphere, apart from the vitiation produced by the vapour of anaesthetics and the exhalations of’ human beings. Now for the remedy. In the first place infection by air, no matter how important it may appear to. the theorist, may be neglected in practice. There need be no fear of frequently changing the air in the theatre, the best way of doing it being to have plenty of windows, and to open them wide between, not during, operations. No surgeon need be afraid of fresh air, but- every surgeon who understands evapora-tion and latent heat will dread a draught. To enablefrequent change of air to be carried out the following arrangement, which is what we are putting up here, will be found efficient. Two operating rooms have been built, separated by a sterilising room. There is’ nothing in the operating room except the table. The patient is placed on the table and anaesthetised, the instruments are wheeled in from the sterilising room,
Displacement of the trachea in the neck means displacement of the upper part of the mediastinum, and vice versa ; and, unless definite thyroid enlargement where the surgeon and his assistants have made theiris present, inspection and palpation in Burns’s space preparations, and the operation begins. At a conwill reveal any displacement that is worth con- venient time patient No. 2 is brought into the othersidering. I have tested these facts by means of X ray room and operated on. As soon as patient No. I controls. The estimation of the amount of fibrosis present is Perhaps the most important piece of information to he derived from the clinical examination of cases of chronic pulmonary tuberculosis. Apical fibrosis always causes either falling in of the chest wall or displacement of the upper mediastinum, or both conditions in varying degree. The presence and
has been removed, room No. 1 is opened up for a fewminutes, and the air completely changed by a through draught. Now the excess heating plant, in this case steam radiators, is turned on, and by the time the surgeon is ready for patient No. 3, room No. 1 is up to standard heat (75° to 85° F.), when the excess plant is turned off. There is no moisture, there is no stuffiness, and the surgeon is not bathed in sweat,
example to anyone who happens peutic procedure of value. T am Ri1"-
VOll1"!’:
across a
I
novel thera-
faithful Hv
A. E. BOYCOTT.
Medical School, University College W.C., Nov. 18th, 1922.
Hospital,
** * The statement of the Medical Research Council should, we think, have made the position clear. The Council accepted the gift of the University of Toronto with the
patent provision already
made.
So far from
without which progress preventing free research work, is of this
remedy impossible, towards the establishment the Council are using every effort to initiate and assist I it. As the results emerge they are certain to be published
II
freely, placing individual workers, as well as great manufacturing firms, in a more advantageous position to assist. We feel that our distinguished correspondent is
a
little
previous
in his
apprehensions.-ED.
London, W., Nov. 20tb,
1H?.
vnnT*s
L.
Tuberculosis Department, St. Thomas’s Nov. 17th, 1922.
To the Editor of THE LANCET. SiR,—I live so far away that my criticism of Mr. R. P. Rowlands’s interesting note in your issue of August 5th must, of necessity, lose much of its point. But as I am engaged in building new operating theatres in the British hospital in this city you can easily understand that I am more than passingly interested. I am one of those who believe in the hot operating room. I cannot conceive of anything more injurious to a patient than to expose, not only the skin of his abdomen, but also his intestines, to a,
fa,ithfnl1v.
STANLEY MELVILLE.
Editor of THE LANCET. SIR,-Observations during the last few months have convinced me that displacement of the trachea in the neck is one of the most helpful signs in cases of chronic pulmonary disease, but I can find no mention of it in any of the leading text-books on diseases of the chest
or
the
manuals devoted to clinical examination.
G. T. HEBERT. Hospital,
THE HOT OPERATING THEATRE.
DISPLACEMENT OF THE TRACHEA IN PULMONARY FIBROSIS. To
degree of the first are self-evident; the second it is difficult to recognise, especially on the right side of the chest, and more difficult still to measure, by means of the displacement of the trachea except in the neck. If the trachea is displaced in the neck and the heart is displaced little or not at all, the fibrosis is apical. If the fibrosis is purely basal (and therefore probably not tuberculous in origin) the heart and the trachea are both displaced. I would claim, therefore, that displacement of the trachea in the neck (1) is a readily recognisable sign ; and, in the absence of a good radiogram, (2) is the most important sign of displacement of the upper mediastinum ; and (3) an essential sign for the estimation of the degree and position of pulmonary fibrosis. I Sir yours faithfully more
am
THE NORMAL INFANT’S CHEST. To the Editor of THE LANCET. SiR,-Nothing was further from my mind than to criticise unfairly the excellent work that Dr. Paton and Dr. Rowand have set out to do. The basis of their work being, however, founded upon the radiological aspect, to this they must adhere, and my one desire in writing was to emphasise the vital importance of great precision in radiography of the chest. I may say that I have read very carefully their description of the method adopted by them, and I think all radiologists will agree with me that to place the patient upon his back with the tube overhead is to make precise centering almost impossible ; at the very least the mediastinum and cardiac shadows must be to some extent distorted. The writers do not say how precisely they centre the overhead tube, and this is a difficult matter under the most advantageous conditions. I am sorry to learn that the Scottish mother is so much less easy a person than is her southron sister. In London at any rate’I had no difficulty with the mothers ; they gave me every assistance and themselves bandaged their babies with flannel to the padded board and were greatly interested in seeing how much happier the babies were than previously when it required at least two people to hold them down. Anything issued under the aegis of the Medical Research Council ought to be as perfect in detail as it is possible, and I can only regret if Dr. Paton and Dr. Rowand mistake my motive in writing ; at all events I, for one, shall look forward with great interest to further articles from their pen on a subject of such vital imrtDT’a-nno-——T am- Sir*
1145
i
temperature 30’or more below anything they have ever experienced before ; it may be 40° below should the patient have fever, or the room be cold, as it is so often in emergency operations. I sympathise with Mr. Rowlands in having to, operate in a hot, stuffy, ill-ventilated atmosphereNothing could be worse for him or for his patients, and the effects, as he has pointed out, are likely to be disastrous. But that does not prove anything against having a hot theatre ; it only shows that the arrangements supplied to Mr. Rowlands are anti-hygienic and antiquated. The reason hot theatres are usually oppressive is that it is almost impossible to convincearchitects of the necessity of supplying an apparently excessive heating installation. The result is, that,. in order to get the proper temperature, it is necessary to have every opening hermetically sealed, when the complete absence of air currents produces an intolerable atmosphere, apart from the vitiation produced by the vapour of anaesthetics and the exhalations of’ human beings. Now for the remedy. In the first place infection by air, no matter how important it may appear to. the theorist, may be neglected in practice. There need be no fear of frequently changing the air in the theatre, the best way of doing it being to have plenty of windows, and to open them wide between, not during, operations. No surgeon need be afraid of fresh air, but- every surgeon who understands evapora-tion and latent heat will dread a draught. To enablefrequent change of air to be carried out the following arrangement, which is what we are putting up here, will be found efficient. Two operating rooms have been built, separated by a sterilising room. There is’ nothing in the operating room except the table. The patient is placed on the table and anaesthetised, the instruments are wheeled in from the sterilising room,
Displacement of the trachea in the neck means displacement of the upper part of the mediastinum, and vice versa ; and, unless definite thyroid enlargement where the surgeon and his assistants have made theiris present, inspection and palpation in Burns’s space preparations, and the operation begins. At a conwill reveal any displacement that is worth con- venient time patient No. 2 is brought into the othersidering. I have tested these facts by means of X ray room and operated on. As soon as patient No. I controls. The estimation of the amount of fibrosis present is Perhaps the most important piece of information to he derived from the clinical examination of cases of chronic pulmonary tuberculosis. Apical fibrosis always causes either falling in of the chest wall or displacement of the upper mediastinum, or both conditions in varying degree. The presence and
has been removed, room No. 1 is opened up for a fewminutes, and the air completely changed by a through draught. Now the excess heating plant, in this case steam radiators, is turned on, and by the time the surgeon is ready for patient No. 3, room No. 1 is up to standard heat (75° to 85° F.), when the excess plant is turned off. There is no moisture, there is no stuffiness, and the surgeon is not bathed in sweat,