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LUNG LESIONS IN ARTHRITIS
1208 blood
volume,
hsemo-concentration,
increased
blood
viscosity, hyperglycsemia, eosinopenia, and depletion of adrenocortical lipids and ascorbic acid. This widespread physiological upheaval is not seen when hypothermia is induced by cooling the exteriorised circulation,! nor has death or tissue injury followed in over 100 experiments in dogs. The method requires only the lightest anaesthesia, and premedication and muscle relaxants are unnecessary. Hmmodynamic disturbance does not result from the arteriovenous shunt due to a balanced resistance in the exteriorised circuit. Despite reports of successful application of surface cooling in relatively small numbers of cases, the accumulated experience in both clinical and laboratory trials has been that this procedure is hazardous and associated with a considerable mortality. A more complete understanding of what has been called " cold stress ’*-—a complex physiological derangement known to follow surface chilling-should be sought before the method is proposed for further clinical trial. In infants and children, the greater surface area relative to body mass and the poorly developed heat-regulating mechanism may, as suggested in your leading article of Nov. 14, make surface cooling in children a safe and effective procedure. Department of Surgery, University of Edinburgh.
E. J. DELORME.
INCISION FOR ACUTE APPENDICITIS
SiR,-Mr. Ewing and Mr. Monro (Oct. 24) severely use of the paramedian incision in acute appendicitis. Their criticism may or may not be valid, but they certainly do not make their point by quoting a solitary clinical history which could well be misinterpreted as suggesting that this particular patient had inadequate surgery or anaesthesia or both. Mr. Shemilt (Oct. 31) is similarly dogmatic about the absolute contra-indication to drainage following appendicectomy, but he does not attempt to justify his statement by arbitrarily selected case-records. Experience in emergency surgery has convinced me that the average " early " acute appendix can be removed with entirely satisfactory results by any competent senior house-surgeon through any standard incision, of which the muscle-splitting is one of the better ones. The case which most tests our judgment and skill is the advanced one with perforation or gangrene, in which fsecopurulent exudate is insecurely localised within a barrier of lightly adherent gut and omentum. Here the objective should be to approach the area directly through an adequate incision, guard its delicate margins with moist packs, and remove the appendix under direct vision and with careful suction control. Fortunatelv the majority of these cases show maximum tenderness and splinting laterally in the right iliac fossa, and in most of them a mass can be felt in this region when the patient is anaesthetised. In these circumstances, no surgeon in his right mind would employ an incision other than one in the right iliac fossa, and my own preference is for the ample exposure offered by the oblique muscle-cutting approach of Rutherford Morison. Other surgeons, more skilful or with many powerful assistants, may achieve similar access with MacBurney’s
criticise the
incision. But there remains a significant group in which the severely inflamed appendix hangs down into the midline cavity of the true pelvis, or in which it runs upwards and medially among the terminal loops of ileum. Here, if the appendix is long and is gangrenous at its tip, the pathological epicentre may lie far from MacBurney’s point. These cases can be recognised clinically, and the principles stated above dictate that the appendix should be exposed directly by a paramedian incision rather 1.
Delorme, E. J.
Lancet, 1952, ii, 914.
than
dragged out by the heels through a distant trapdoor. Drainage, if desired, can be achieved through a lateral stab incision near the anterior superior spine, and danger to the iliac vessels or any other structure from a strip of supple corrugated rubber so placed and soon removed .is non-existent. The right paramedian incision is advantageous also in certain cases of diagnostic doubt, including advanced general peritonitis of uncertain though prob. ably appendiceal origin. We should use it where it is indicated, and should not be discouraged because some operators find difficulty in coping with the bowels or in closing the wound securely. Finally, I envy Mr. Shemilt his faith in the invincibility of the peritoneum, but since there are so many variables, statistical proof is lacking. Where the appendix " bed .shows florid sloughs, severe inflammation, and heavy "
faecal contamination I shall continue-I believe rationally-to drain it. Baylor University College of Medicine,
E. G. HARDY.
Houston, Texas.
LUNG LESIONS IN ARTHRITIS
SrR,-Your leading article of Nov. 21 raises the question of the aetiology of the nodular lesions described in rheumatoid arthritis by Caplan, who is quoted as identifying tubercle bacilli in the fibrous tissue of the lesions in three fatal cases. Reference to the original article, however, reveals that tubercle bacilli were isolated in only one of these cases. Furthermore, the reader is left in considerable doubt about the exact type of lesion from which the organisms weie obtained. The patient (case 38) is described as showing, on X-ray examination, " progressive massive fibrosis in both mid zones," and at necropsy " masses at the bases of both upper lobes " and microscopically " undifferentiated fibrous tissue in the masses." The tubercle bacilli were obtained " on culture of material from a massive lesion." It is also difficult to correlate the radiological with the morbid anatomical and histological appearances in the remaining two fatal cases. Caplan prefers the theory that the lesions he describes in the radiographs (" round opacities ") are basically tuberculous to the idea that they are " rheumatoid granulomata " resembling the subcutaneous nodules histologically. In this respect he has the support of most workers who have studied the lungs in fatal cases of rheumatoid arthritis. My own experience of 70 fatal cases of the disease is in agreement with the opinion that no specific lesion occurs. However, there is sufficient resemblance between the histological appearance of the rheumatoid subcutaneous nodule and that of some caseous tuberculous foci to suggest that, if one makes allowance for the different situations in which the two lesions are found, their differentiation might well be a difficult matter, should they both occur in the lungs. There is no question that Caplan’s patients presented an unusual radiological appearance, but the theory that the " rounded opacities " are tuberculous seems, at present, to rest upon the demonstration of -tubercle bacilli in a lesion whose exact nature is not clearly defined. That tuberculous lesions were present in the lungs of the other two cases does not help to establish the " round opacities " as tuberculous. If the true nature of these fascinating lesions is to be discovered, it is essential that the terminology used to describe their radiological, macroscopic, and histological appearances should be unequivocal. Histological examination should not be considered the final step, but each lesion so examined should be submitted also to
bacteriological investigation. Pathology Department, University of Edinburgh. 1.
Caplan, A.
BRUCE CRUICKSHANK, Thorax, 1953, 8, 29.
volume,
hsemo-concentration,
increased
blood
viscosity, hyperglycsemia, eosinopenia, and depletion of adrenocortical lipids and ascorbic acid. This widespread physiological upheaval is not seen when hypothermia is induced by cooling the exteriorised circulation,! nor has death or tissue injury followed in over 100 experiments in dogs. The method requires only the lightest anaesthesia, and premedication and muscle relaxants are unnecessary. Hmmodynamic disturbance does not result from the arteriovenous shunt due to a balanced resistance in the exteriorised circuit. Despite reports of successful application of surface cooling in relatively small numbers of cases, the accumulated experience in both clinical and laboratory trials has been that this procedure is hazardous and associated with a considerable mortality. A more complete understanding of what has been called " cold stress ’*-—a complex physiological derangement known to follow surface chilling-should be sought before the method is proposed for further clinical trial. In infants and children, the greater surface area relative to body mass and the poorly developed heat-regulating mechanism may, as suggested in your leading article of Nov. 14, make surface cooling in children a safe and effective procedure. Department of Surgery, University of Edinburgh.
E. J. DELORME.
INCISION FOR ACUTE APPENDICITIS
SiR,-Mr. Ewing and Mr. Monro (Oct. 24) severely use of the paramedian incision in acute appendicitis. Their criticism may or may not be valid, but they certainly do not make their point by quoting a solitary clinical history which could well be misinterpreted as suggesting that this particular patient had inadequate surgery or anaesthesia or both. Mr. Shemilt (Oct. 31) is similarly dogmatic about the absolute contra-indication to drainage following appendicectomy, but he does not attempt to justify his statement by arbitrarily selected case-records. Experience in emergency surgery has convinced me that the average " early " acute appendix can be removed with entirely satisfactory results by any competent senior house-surgeon through any standard incision, of which the muscle-splitting is one of the better ones. The case which most tests our judgment and skill is the advanced one with perforation or gangrene, in which fsecopurulent exudate is insecurely localised within a barrier of lightly adherent gut and omentum. Here the objective should be to approach the area directly through an adequate incision, guard its delicate margins with moist packs, and remove the appendix under direct vision and with careful suction control. Fortunatelv the majority of these cases show maximum tenderness and splinting laterally in the right iliac fossa, and in most of them a mass can be felt in this region when the patient is anaesthetised. In these circumstances, no surgeon in his right mind would employ an incision other than one in the right iliac fossa, and my own preference is for the ample exposure offered by the oblique muscle-cutting approach of Rutherford Morison. Other surgeons, more skilful or with many powerful assistants, may achieve similar access with MacBurney’s
criticise the
incision. But there remains a significant group in which the severely inflamed appendix hangs down into the midline cavity of the true pelvis, or in which it runs upwards and medially among the terminal loops of ileum. Here, if the appendix is long and is gangrenous at its tip, the pathological epicentre may lie far from MacBurney’s point. These cases can be recognised clinically, and the principles stated above dictate that the appendix should be exposed directly by a paramedian incision rather 1.
Delorme, E. J.
Lancet, 1952, ii, 914.
than
dragged out by the heels through a distant trapdoor. Drainage, if desired, can be achieved through a lateral stab incision near the anterior superior spine, and danger to the iliac vessels or any other structure from a strip of supple corrugated rubber so placed and soon removed .is non-existent. The right paramedian incision is advantageous also in certain cases of diagnostic doubt, including advanced general peritonitis of uncertain though prob. ably appendiceal origin. We should use it where it is indicated, and should not be discouraged because some operators find difficulty in coping with the bowels or in closing the wound securely. Finally, I envy Mr. Shemilt his faith in the invincibility of the peritoneum, but since there are so many variables, statistical proof is lacking. Where the appendix " bed .shows florid sloughs, severe inflammation, and heavy "
faecal contamination I shall continue-I believe rationally-to drain it. Baylor University College of Medicine,
E. G. HARDY.
Houston, Texas.
LUNG LESIONS IN ARTHRITIS
SrR,-Your leading article of Nov. 21 raises the question of the aetiology of the nodular lesions described in rheumatoid arthritis by Caplan, who is quoted as identifying tubercle bacilli in the fibrous tissue of the lesions in three fatal cases. Reference to the original article, however, reveals that tubercle bacilli were isolated in only one of these cases. Furthermore, the reader is left in considerable doubt about the exact type of lesion from which the organisms weie obtained. The patient (case 38) is described as showing, on X-ray examination, " progressive massive fibrosis in both mid zones," and at necropsy " masses at the bases of both upper lobes " and microscopically " undifferentiated fibrous tissue in the masses." The tubercle bacilli were obtained " on culture of material from a massive lesion." It is also difficult to correlate the radiological with the morbid anatomical and histological appearances in the remaining two fatal cases. Caplan prefers the theory that the lesions he describes in the radiographs (" round opacities ") are basically tuberculous to the idea that they are " rheumatoid granulomata " resembling the subcutaneous nodules histologically. In this respect he has the support of most workers who have studied the lungs in fatal cases of rheumatoid arthritis. My own experience of 70 fatal cases of the disease is in agreement with the opinion that no specific lesion occurs. However, there is sufficient resemblance between the histological appearance of the rheumatoid subcutaneous nodule and that of some caseous tuberculous foci to suggest that, if one makes allowance for the different situations in which the two lesions are found, their differentiation might well be a difficult matter, should they both occur in the lungs. There is no question that Caplan’s patients presented an unusual radiological appearance, but the theory that the " rounded opacities " are tuberculous seems, at present, to rest upon the demonstration of -tubercle bacilli in a lesion whose exact nature is not clearly defined. That tuberculous lesions were present in the lungs of the other two cases does not help to establish the " round opacities " as tuberculous. If the true nature of these fascinating lesions is to be discovered, it is essential that the terminology used to describe their radiological, macroscopic, and histological appearances should be unequivocal. Histological examination should not be considered the final step, but each lesion so examined should be submitted also to
bacteriological investigation. Pathology Department, University of Edinburgh. 1.
Caplan, A.
BRUCE CRUICKSHANK, Thorax, 1953, 8, 29.