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MASSIVE COLLAPSE OF THE LUNGS.
1570
Correspondence. " Audi alteram partem."
THE PLEA FOR IMMEDIATE OPERATION IN APPENDICITIS. To the Editor
of THE LANCET. SIR,-The point in connexion with the question
the only respiratory reserve, and hastens their massive collapse. That trouble might conceivably admit of some alleviation, if we could engineer for those cases a " respiratory bed," to rest the body upon three suitable air cushions : one along the spine, another across the upper thorax, and a third across the lower part of the trunk, thus relieving the posterior and lateral bases from all pressure. At bestthis would only be an instalment; but, to be of any use, it would brook no delay in its application. Whenever, in cases not absolutely hopeless, a determined attempt at any life-saving surgical or medical treatment is contemplated, the first essential for success is an immediate resort to respiratory treatment, to preserve as much of the advantage from a still normal basic condition as can possibly be saved. Any continuously acting substitute for the lost abdominal tone, such as the prone decubitus or a light elastic abdominal belt, being out of the question, the main rational indication is to supply the missing rhythmic expiratory force.
of immediate operation in acute appendicitis that neither Mr. Edmund Owen nor his followers will see is that it is the application of their principle to all cases, no matter what the stage of the disease, that is responsible for the unsatisfactory results that still exist in connexion with surgical interference in the acute phase of this affection. What the profession has to grasp and surgeons have to recognise, is that when acute appendicitis has existed for three or four days, and the possibly perforated and even gangrenous appendix is surrounded by inflammatory adhesions or even This leads to a second even more vital consideration. There seems to be no escape from the conclusion that, pus, but is shut off from the general peritoneal for any truly thorough treatment of that exclusive the has a better chance of then cavity, patient so long as it lasts, there recovery under local and palliative measures than diaphragmatic breathing can be no alternative to the application of adequate by immediate operation. These are the cases a manual " artificial rhythmic expiration," to be which when operated on give the fatal results, and and judiciously kept day night by a relay of up in acute are the cause of that heavy mortality in analogy with the hands, highly competent No fault can be all which we deplore. appendicitis found, as regards the results, with the doctrine that digital compression of arteries for haemorrhage or immediate operation should be practised within the aneurysm. These clinical remarks, limited to the extreme first few hours of an acute attack of appendicitis of the wide subject now under discussion in fringe instead of using medicinal and other measures; but it is the teaching that the principle holds equally the columns of THE LANCET, are as much as I can good in all cases, no matter what the stage of the dare ask space for; but they have some practical disease, that I take exception to, because I feel it is bearing upon the whole of it. The approved posture in the treatment of the local massive fraught with great dangers. thoracic and pulmonary collapse and the abdominal I am, Sir yours faithfully, atony of rickets, of the respiratory urgencies (due to GEORGE THOS. BEATSON. Glasgow, May 23rd, 1914. scattered lobular collapse) of broncho-pneumonia and of whooping-cough, and of many analogous MASSIVE COLLAPSE OF THE LUNGS. instances of disablement by collapse, including To the Editor, of THE LANCET. phthisis, is still exclusively dorsal. I need thereSIR,-Exclusive diaphragmatic breathing is the fore only renew the old plea for some revision of inevitable consequence of experimental, accidental, the therapeutical question, and for some wider clinical recognition of the practical uses of the or pathological absolute disablement of the spinal cord at a high level. It is sometimes temporary prone decubitus, and of its abdominal factors, in the and remediable, as in transverse compression, light of the anatomy and physiology of the respirahaemorrhage, or curable disease. When, however, tion and of the circulation. I am, Sir, yours faithfully, it results from permanently destructive causes it Brook-street, W., May 25th, 1914. WILLIAM EWART. is practically incompatible with a prolongation of Upper life. This is due to the fact that the diaphragm is purely inspiratory. That exclusive type cannot be RE-EDUCATION OF THE DEAF. imitated in health by our " voluntary diaphragmatic To the Editor of THE LANCET. breathing"; because in this the expiratory abdominal the both muscles paired with SIR,-I have read with interest Mr. Richard diaphragm preserve their tone, which ensures a rhythmic "passive" Lake’s paper in THE LANCET of May 23rd, but my expiration by their elastic recoil and that of the experience, so far as it goes, leads me to think abdominal gases, and also their rhythmic " active " that he has formed an unduly pessimistic view of contraction, if this should be required. So long as the value of auditory re-education. I have recently obtained oneof the instruments that disablement remains absolute, we have to deal with an unexampled crippling of the respiratory designed by M. Ziind Burguet. I did so for two mechanism-namely, an- active rhythmic inspiratory reasons : first, because I had read in French journals force-without any rhythmic expiratoryforce. There reports of cases which had been remarkably beneis still a steady "tensive " intra-abdominal pressure ; fited by the treatment: and secondly, because I had but this can only favour expiration at the cost of myself spoken to one or two patients who had been opposing the inspiratory efforts of the diaphragm and treated by this method and who felt themselves of gradually wearing them out. The added evil is greatly benefited. that the effective work of the diaphragm lies at the I have, of course, hitherto carefully refrained back ; and that, in the inevitably dorsal decubitus, from recommending or using the treatment in the the weight of the body steadily opposes the expan- case of any patient where the question of a fee sion of the bases, which are at the time absolutely entered until such time as I was convinced of its
Correspondence. " Audi alteram partem."
THE PLEA FOR IMMEDIATE OPERATION IN APPENDICITIS. To the Editor
of THE LANCET. SIR,-The point in connexion with the question
the only respiratory reserve, and hastens their massive collapse. That trouble might conceivably admit of some alleviation, if we could engineer for those cases a " respiratory bed," to rest the body upon three suitable air cushions : one along the spine, another across the upper thorax, and a third across the lower part of the trunk, thus relieving the posterior and lateral bases from all pressure. At bestthis would only be an instalment; but, to be of any use, it would brook no delay in its application. Whenever, in cases not absolutely hopeless, a determined attempt at any life-saving surgical or medical treatment is contemplated, the first essential for success is an immediate resort to respiratory treatment, to preserve as much of the advantage from a still normal basic condition as can possibly be saved. Any continuously acting substitute for the lost abdominal tone, such as the prone decubitus or a light elastic abdominal belt, being out of the question, the main rational indication is to supply the missing rhythmic expiratory force.
of immediate operation in acute appendicitis that neither Mr. Edmund Owen nor his followers will see is that it is the application of their principle to all cases, no matter what the stage of the disease, that is responsible for the unsatisfactory results that still exist in connexion with surgical interference in the acute phase of this affection. What the profession has to grasp and surgeons have to recognise, is that when acute appendicitis has existed for three or four days, and the possibly perforated and even gangrenous appendix is surrounded by inflammatory adhesions or even This leads to a second even more vital consideration. There seems to be no escape from the conclusion that, pus, but is shut off from the general peritoneal for any truly thorough treatment of that exclusive the has a better chance of then cavity, patient so long as it lasts, there recovery under local and palliative measures than diaphragmatic breathing can be no alternative to the application of adequate by immediate operation. These are the cases a manual " artificial rhythmic expiration," to be which when operated on give the fatal results, and and judiciously kept day night by a relay of up in acute are the cause of that heavy mortality in analogy with the hands, highly competent No fault can be all which we deplore. appendicitis found, as regards the results, with the doctrine that digital compression of arteries for haemorrhage or immediate operation should be practised within the aneurysm. These clinical remarks, limited to the extreme first few hours of an acute attack of appendicitis of the wide subject now under discussion in fringe instead of using medicinal and other measures; but it is the teaching that the principle holds equally the columns of THE LANCET, are as much as I can good in all cases, no matter what the stage of the dare ask space for; but they have some practical disease, that I take exception to, because I feel it is bearing upon the whole of it. The approved posture in the treatment of the local massive fraught with great dangers. thoracic and pulmonary collapse and the abdominal I am, Sir yours faithfully, atony of rickets, of the respiratory urgencies (due to GEORGE THOS. BEATSON. Glasgow, May 23rd, 1914. scattered lobular collapse) of broncho-pneumonia and of whooping-cough, and of many analogous MASSIVE COLLAPSE OF THE LUNGS. instances of disablement by collapse, including To the Editor, of THE LANCET. phthisis, is still exclusively dorsal. I need thereSIR,-Exclusive diaphragmatic breathing is the fore only renew the old plea for some revision of inevitable consequence of experimental, accidental, the therapeutical question, and for some wider clinical recognition of the practical uses of the or pathological absolute disablement of the spinal cord at a high level. It is sometimes temporary prone decubitus, and of its abdominal factors, in the and remediable, as in transverse compression, light of the anatomy and physiology of the respirahaemorrhage, or curable disease. When, however, tion and of the circulation. I am, Sir, yours faithfully, it results from permanently destructive causes it Brook-street, W., May 25th, 1914. WILLIAM EWART. is practically incompatible with a prolongation of Upper life. This is due to the fact that the diaphragm is purely inspiratory. That exclusive type cannot be RE-EDUCATION OF THE DEAF. imitated in health by our " voluntary diaphragmatic To the Editor of THE LANCET. breathing"; because in this the expiratory abdominal the both muscles paired with SIR,-I have read with interest Mr. Richard diaphragm preserve their tone, which ensures a rhythmic "passive" Lake’s paper in THE LANCET of May 23rd, but my expiration by their elastic recoil and that of the experience, so far as it goes, leads me to think abdominal gases, and also their rhythmic " active " that he has formed an unduly pessimistic view of contraction, if this should be required. So long as the value of auditory re-education. I have recently obtained oneof the instruments that disablement remains absolute, we have to deal with an unexampled crippling of the respiratory designed by M. Ziind Burguet. I did so for two mechanism-namely, an- active rhythmic inspiratory reasons : first, because I had read in French journals force-without any rhythmic expiratoryforce. There reports of cases which had been remarkably beneis still a steady "tensive " intra-abdominal pressure ; fited by the treatment: and secondly, because I had but this can only favour expiration at the cost of myself spoken to one or two patients who had been opposing the inspiratory efforts of the diaphragm and treated by this method and who felt themselves of gradually wearing them out. The added evil is greatly benefited. that the effective work of the diaphragm lies at the I have, of course, hitherto carefully refrained back ; and that, in the inevitably dorsal decubitus, from recommending or using the treatment in the the weight of the body steadily opposes the expan- case of any patient where the question of a fee sion of the bases, which are at the time absolutely entered until such time as I was convinced of its