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New Views on Bronchiectasis
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UNDER the Dentists Bill the new General Dental Council would be enabled to follow the New Zealand precedent and allow ancillary workers to perform simple dental operations, under professional supervision, in the public-health services. The British Dental Association has sought to prove that such a step is not only undesirable in the public interest but also unnecessary. The dental profession has always argued that it could treat satisfactorily the " priority classes " of the community, and that the reduced demand for treatment after the imposition of charges under the National Health Service would free enough dentists to restore the school dental service, which has virtually broken down since the health service began in 1948. Many more young dentists, it was contended, would wish to enter the local-authority - dental services, since they would find fewer openings as assistants in private practice ; while the reduced demand on practitioners would enable them to devote more time to the treatment, in their own surgeries, of school-children and expectant and nursing mothers. , The increase in the number of recruits to the localauthority health services has turned out to be much smaller than was expected by some prophets ; for it has made no significant impression on the staffing problem of the school dental service, and there are still very few parts of the country with a full complement of school dentists. The British Dental Association has accordingly sent a questionary to all practising dentists throughout the country asking them whether they are willing to treat children in their practices and, if so, how many hours each week they are prepared to set aside for this purpose. From the replies it appears that private practitioners are between them prepared to devote 10,000 hours a week to treating children ; which, according to the association, would suffice for the treatment of a million children per annum. It would be more to accurate, however, say that, working for fifty weeks in the year, these practitioners would set aside annually one million half-hour sessions for the children.. Thus each year one million children could each be seen once, for half an hour. But very few children can have all the dental- treatment they need in a single half-hour session each ye.ar. The average number of visits to the dentist by every child who needs dental care is at least four each year ; and little of permanent value can be done if each session is shorter than half an hour. Thus, on the most
optimistic estimate,
the returns
suggest
that
an
additional 250,000—300,000 children could be properly treated. Any scheme based on the willingness of dental practitioners to devote 10,000 hours weekly to their child patients can obviously reach only an insignificant fraction of the 6-7 million schoolchildren in the country, of whom at least 80% require continuous dental care. Far from supporting the case against the legalisation of dental ancillaries for simple routine dentistry, the results of the British Dental Association’s initiative seem to show that these ancillaries are essential if dental treatment for the vast majority of our children is to go beyond the emergency extraction of teeth for the relief of toothache.
surprising that of the 10,000 or dentists in the country, more than four-fifths have indicated their unwillingness to treat school-children. The work is mainly routine and holds little interest for the highly trained dental surgeon. For this reason, the proposal to train ancillaries specifically for simple operations, and to employ them in clinics under professional supervision, must seem to the unprejudiced observer of the neglect of our children’s dental health an unexceptionable development. The British Dental Association’s investigation demonstrates that without this step the neglect will continue. In the Parliamentary session that is now ending the Bill passed all but in the House of Lords 1; unfortunately, in stages the press of business, it did not come before the House of Commons. We hope that in the new session the Government will not forget it. It is
Dental Treatment of Children
perhaps practising
not
through
New Views on Bronchiectasis THE pathogenesis of bronchiectasis has long been a favourite subject of medical controversy : LAENNEC considered that the bronchi were dilated by their retained secretions ; STOKES, of Dublin, taught that the condition
arose when the bronchial walls were weakened by inflammation ; and others have since attributed the dilatation to fibrosis or to congenital
defects in the bronchi. In the last twenty years, largely as a result of the work of LEE LANDER and DAVIDSON,2the importance of peripheral collapse of the lung has received a great deal of attention. It is argued that mucus is aspirated into the peripheral bronchi, leading to collapse of the affected area of lung, and that this collapse increases the negative pressure in the pleural space and causes dilatation of the bronchi proximal to the obstruction. This explanation has been widely accepted, but it was challenged by ROBERTS and BLAIR3 on the grounds of their work on pulmonary collapse in primary tuberculosis ; among 77 children with collapse they found 31 in whom there was no suggestion of bronchiectasis and no increase in the pleural negative pressure, though this was not measured in all cases. They considered that in the children who did have bronchiectasis the imporwere retention of secretion and in.flammation of the bronchial wall. The wheel has thus come full circle. The latest contribution to the discussion comes from WHITWELL.4 He has examined 200 bronchiectatic lungs removed at operation, and he has explored the bronchial tree by serial histological sections, by direct dissection, and by the preparation of neoprene casts. Believing that bronchiectasis is not one disease but several, he has tried to correlate the pathological findings with the clinical picture, and to some extent he has succeeded. He distinguishes three types of the bronchiectasis, atelectatic, the saccular, and the so he was unable to classify a but even follicular, of his material. The atelectatic type large proportion was the least common, accounting for only IQ% of his specimens, and it was the only type iri which all the bronchi to a lobe were involved ; in the other types bronchial involvement was patchy. Here the
tant factors
’
1. Lancet, 1952, i, 363. 2. Lee Lander, F. P., Davidson, M. Brit. J. Radiol. 3. Roberts, J. C., Blair, L. G. Lancet, 1950, i, 386. 4. Whitwell, F. Thorax, 1952, 7, 213.
1938, 11, 65.
815 whole lobe was collapsed and airless, and the right middle and lower lobes were the ones most commonly a,9ected. This type was usually found in children, but it also occurred in adults. On section, obvious alveolar collapse was seen throughout the affected lobe, and fibrosis and haemorrhage into the alveoli were common, but, on the other hand, active inflammation was comparatively rare. WHITWELL attributes these changes to compression of the lobar bronchus by lymphatic glands which have been enlarged either by tuberculosis or by the adenitis that sometimes develops in measles or whooping-cough. The obstruction was proximal rather than peripheral, and the peculiar vulnerability of the middle-lobe bronchus to this kind of blockage has been stressed by BROCK.5 The term " saccular bronchiectasis " covers the pathological appearances in another and slightly larger group described by WHITWELL. Bronchography had usually shown saccular changes, but he is careful to point out that X-ray signs do not correspond closely to pathological findings, and are not a satisfactory basis for classification. On this point he confirms the opinion of OGILVIE, 6 but differs from that of REID. Saccular bronchiectasis often developed later in life than the other two types, usually after the age of 15, and, in sharp distinction to the atelectatic group, the disease was found in the left lower lobe in three-quarters of the lungs examined. The distribution of the lesions was patchy, segments rather than entire lobes being affected. The saccules showed considerable squamous metaplasia, and chronic inflammatory changes were an outstanding feature, but there was no lymphadenopathy. The saccules did not arise at the periphery of the bronchial tree, but between the first and third branches of the segmental bronchi. They ended blindly and the branches beyond them were obliterated. The pathogenesis of this type is uncertain : there is no direct association with measles or whoopingcough, but about half the cases followed bronchopneumonia ; and most of the others began insidiously, though it is impossible to rule out a mild aspiration pneumonitis as the start of the trouble. WHITWELL himself suggests that they began as a chronic inflammation in the walls of the medium-sized bronchi. The third and largest group is the most interesting. This WHITWELL calls " follicular bronchiectasis "-a name chosen because the most prominent histological feature is an excess of lymphoid tissue in the follicles and nodes in the walls of the affected bronchi and This type follows among the surrounding alveoli. acute viral infection of the lungs in early childhood, usually after measles, whooping-cough, or bronchopneumonia. Again the disease is spread in patches, and affects mainly the left lower lobe. The dilated bronchi commonly, but not invariably, appear cylindrical on bronchography. In both the follicular and the saccular types, the affected lung is usually well aerated, in spite of the fact (noted by REID7 in Australia and DUPREZ 3 in Belgium) -that the affected bronchi end blindly because their distal ends have been destroyed. It has been observed both experimentally and during operations that occlusion of a main lobar bronchus produces collapse of the lobe, which, as the air is absorbed, fills up with its own 5. Brock, R. C. Ibid, 1950, 5, 5. 6. Ogilvie, A. G. Arch. intern. Med. 1941, 68, 395. 7. Reid, L. M. Thorax, 1950, 5, 233. 8. Duprez, A. J. franç. Méd. Chir. thor. 1951, 5, 442.
secretions. On the other hand, when a segmental bronchus is occluded, collapse does not usually follow, though the segment may retain its own secretions just the same, giving the radiological appearances of segmental collapse. If, for any reason, the secretions do not accumulate or are absorbed, the segment will become re-aerated by the collateral circulation of air from neighbouring segments, even though the bronchus is still occluded. This phenomenon was first demonstrated twenty years ago by VAN ALLEN and his colleagues, s-11 but its importance has only lately been realised, by CHURCHILL 12 13 in America and by BAARSMA, DIRKEN, and HUIZINGA 14 15 in Holland. Incidentally, this collateral circulation of air provides strong evidence of the existence of KOHN’S alveolar pores, which have provoked such controversy in the past. CHURCHILL argues that the collateral air drift cannot serve any respiratory function except that of filling space, because the air that enters the obstructed segment will already be in equilibrium with the blood. A further point to which he draws attention is that the bronchial arterial supply to a segment seems to be increased when the segmental bronchus is occluded. This, he thinks, may establish a pressure gradient great enough to prevent the shunting of pulmonary arterial blood into an area of lung where it would be physiologically useless. WHITWELL’S conception of these three types of bronchiectasis as separate clinical and pathological entities of different aetiology may represent a real advance in this difficult subject. Clinically, however, the distinction between his saccular and follicular groups seems to involve little that could not be accounted for by the different age at which the events leading to the bronchiectasis take place. The clinicianr who would welcome an explanation which takes greater account of the bronchographic changes, may, for this reason, be attracted by REID’S suggestion that the difference between saccular and other types- of bronchiectasis lies in the level at which the dilatation begins and in the degree of peripheral bronchial obliteration.
The Patient’s Favour IN his Harveian Oration to the Royal College of on Oct. 17 Lord MORAN recalled that when was founded in 1518 its primary purpose was to suppress unlicensed practitioners. It had shown more aptitude for repression than for getting to the root of the trouble-which was that people go to the quack because they think he is better than the doctor. One remedy was to educate the public as to what a good doctor could do, and another was to purge medicine of its elements of humbug. But the real remedy, he thought, was to make it unnecessary to win the patient’s favour, and he welcomed the evolutionary process by which, in hospital practice, the fortunes and advancement of the doctor now depend less and less on the patient’s likes and dislikes, and more and more on theverdict of his colleagues. The danger in this, Lord: MORAN said, is that in the cultivation of -his science the physician may neglect his art. In the address which we publish on p. 820 Sir HENEAGE OGILVIE draws attention yet more forcibly to the danger that science may come to be preferred to the patient.
Physicians the college
9. Van Allen, C. M., Jung, T. S. J. thorac. Surg. 1931, 1, 3. 10. Van Allen, C. M., Lindskog, G. E. Surg. Gynec. Obstet, 1931, 53, 16. 11. Van Allen, C. M., Lindskog, G. E., Richter, H. G. J. clin. Invest, 1931, 10, 559. 12. Churchill, E. D. J. thorac. Surg. 1949, 18, 279. 13. Churchill, E. D. Obliterative Bronchitis and Bronchiectasis. Alex Simpson-Smith lecture delivered at the Institute of Child Health, University of London, on Oct. 19, 1951. London, 1952. 14. Baarsma, P. R., Dirken, M. N. J. J. thorac. Surg. 1948, 17, 238, 15. Baarsma, P. R., Dirken, M. N. J., Huizinga, E. Ibid, p. 252.
UNDER the Dentists Bill the new General Dental Council would be enabled to follow the New Zealand precedent and allow ancillary workers to perform simple dental operations, under professional supervision, in the public-health services. The British Dental Association has sought to prove that such a step is not only undesirable in the public interest but also unnecessary. The dental profession has always argued that it could treat satisfactorily the " priority classes " of the community, and that the reduced demand for treatment after the imposition of charges under the National Health Service would free enough dentists to restore the school dental service, which has virtually broken down since the health service began in 1948. Many more young dentists, it was contended, would wish to enter the local-authority - dental services, since they would find fewer openings as assistants in private practice ; while the reduced demand on practitioners would enable them to devote more time to the treatment, in their own surgeries, of school-children and expectant and nursing mothers. , The increase in the number of recruits to the localauthority health services has turned out to be much smaller than was expected by some prophets ; for it has made no significant impression on the staffing problem of the school dental service, and there are still very few parts of the country with a full complement of school dentists. The British Dental Association has accordingly sent a questionary to all practising dentists throughout the country asking them whether they are willing to treat children in their practices and, if so, how many hours each week they are prepared to set aside for this purpose. From the replies it appears that private practitioners are between them prepared to devote 10,000 hours a week to treating children ; which, according to the association, would suffice for the treatment of a million children per annum. It would be more to accurate, however, say that, working for fifty weeks in the year, these practitioners would set aside annually one million half-hour sessions for the children.. Thus each year one million children could each be seen once, for half an hour. But very few children can have all the dental- treatment they need in a single half-hour session each ye.ar. The average number of visits to the dentist by every child who needs dental care is at least four each year ; and little of permanent value can be done if each session is shorter than half an hour. Thus, on the most
optimistic estimate,
the returns
suggest
that
an
additional 250,000—300,000 children could be properly treated. Any scheme based on the willingness of dental practitioners to devote 10,000 hours weekly to their child patients can obviously reach only an insignificant fraction of the 6-7 million schoolchildren in the country, of whom at least 80% require continuous dental care. Far from supporting the case against the legalisation of dental ancillaries for simple routine dentistry, the results of the British Dental Association’s initiative seem to show that these ancillaries are essential if dental treatment for the vast majority of our children is to go beyond the emergency extraction of teeth for the relief of toothache.
surprising that of the 10,000 or dentists in the country, more than four-fifths have indicated their unwillingness to treat school-children. The work is mainly routine and holds little interest for the highly trained dental surgeon. For this reason, the proposal to train ancillaries specifically for simple operations, and to employ them in clinics under professional supervision, must seem to the unprejudiced observer of the neglect of our children’s dental health an unexceptionable development. The British Dental Association’s investigation demonstrates that without this step the neglect will continue. In the Parliamentary session that is now ending the Bill passed all but in the House of Lords 1; unfortunately, in stages the press of business, it did not come before the House of Commons. We hope that in the new session the Government will not forget it. It is
Dental Treatment of Children
perhaps practising
not
through
New Views on Bronchiectasis THE pathogenesis of bronchiectasis has long been a favourite subject of medical controversy : LAENNEC considered that the bronchi were dilated by their retained secretions ; STOKES, of Dublin, taught that the condition
arose when the bronchial walls were weakened by inflammation ; and others have since attributed the dilatation to fibrosis or to congenital
defects in the bronchi. In the last twenty years, largely as a result of the work of LEE LANDER and DAVIDSON,2the importance of peripheral collapse of the lung has received a great deal of attention. It is argued that mucus is aspirated into the peripheral bronchi, leading to collapse of the affected area of lung, and that this collapse increases the negative pressure in the pleural space and causes dilatation of the bronchi proximal to the obstruction. This explanation has been widely accepted, but it was challenged by ROBERTS and BLAIR3 on the grounds of their work on pulmonary collapse in primary tuberculosis ; among 77 children with collapse they found 31 in whom there was no suggestion of bronchiectasis and no increase in the pleural negative pressure, though this was not measured in all cases. They considered that in the children who did have bronchiectasis the imporwere retention of secretion and in.flammation of the bronchial wall. The wheel has thus come full circle. The latest contribution to the discussion comes from WHITWELL.4 He has examined 200 bronchiectatic lungs removed at operation, and he has explored the bronchial tree by serial histological sections, by direct dissection, and by the preparation of neoprene casts. Believing that bronchiectasis is not one disease but several, he has tried to correlate the pathological findings with the clinical picture, and to some extent he has succeeded. He distinguishes three types of the bronchiectasis, atelectatic, the saccular, and the so he was unable to classify a but even follicular, of his material. The atelectatic type large proportion was the least common, accounting for only IQ% of his specimens, and it was the only type iri which all the bronchi to a lobe were involved ; in the other types bronchial involvement was patchy. Here the
tant factors
’
1. Lancet, 1952, i, 363. 2. Lee Lander, F. P., Davidson, M. Brit. J. Radiol. 3. Roberts, J. C., Blair, L. G. Lancet, 1950, i, 386. 4. Whitwell, F. Thorax, 1952, 7, 213.
1938, 11, 65.
815 whole lobe was collapsed and airless, and the right middle and lower lobes were the ones most commonly a,9ected. This type was usually found in children, but it also occurred in adults. On section, obvious alveolar collapse was seen throughout the affected lobe, and fibrosis and haemorrhage into the alveoli were common, but, on the other hand, active inflammation was comparatively rare. WHITWELL attributes these changes to compression of the lobar bronchus by lymphatic glands which have been enlarged either by tuberculosis or by the adenitis that sometimes develops in measles or whooping-cough. The obstruction was proximal rather than peripheral, and the peculiar vulnerability of the middle-lobe bronchus to this kind of blockage has been stressed by BROCK.5 The term " saccular bronchiectasis " covers the pathological appearances in another and slightly larger group described by WHITWELL. Bronchography had usually shown saccular changes, but he is careful to point out that X-ray signs do not correspond closely to pathological findings, and are not a satisfactory basis for classification. On this point he confirms the opinion of OGILVIE, 6 but differs from that of REID. Saccular bronchiectasis often developed later in life than the other two types, usually after the age of 15, and, in sharp distinction to the atelectatic group, the disease was found in the left lower lobe in three-quarters of the lungs examined. The distribution of the lesions was patchy, segments rather than entire lobes being affected. The saccules showed considerable squamous metaplasia, and chronic inflammatory changes were an outstanding feature, but there was no lymphadenopathy. The saccules did not arise at the periphery of the bronchial tree, but between the first and third branches of the segmental bronchi. They ended blindly and the branches beyond them were obliterated. The pathogenesis of this type is uncertain : there is no direct association with measles or whoopingcough, but about half the cases followed bronchopneumonia ; and most of the others began insidiously, though it is impossible to rule out a mild aspiration pneumonitis as the start of the trouble. WHITWELL himself suggests that they began as a chronic inflammation in the walls of the medium-sized bronchi. The third and largest group is the most interesting. This WHITWELL calls " follicular bronchiectasis "-a name chosen because the most prominent histological feature is an excess of lymphoid tissue in the follicles and nodes in the walls of the affected bronchi and This type follows among the surrounding alveoli. acute viral infection of the lungs in early childhood, usually after measles, whooping-cough, or bronchopneumonia. Again the disease is spread in patches, and affects mainly the left lower lobe. The dilated bronchi commonly, but not invariably, appear cylindrical on bronchography. In both the follicular and the saccular types, the affected lung is usually well aerated, in spite of the fact (noted by REID7 in Australia and DUPREZ 3 in Belgium) -that the affected bronchi end blindly because their distal ends have been destroyed. It has been observed both experimentally and during operations that occlusion of a main lobar bronchus produces collapse of the lobe, which, as the air is absorbed, fills up with its own 5. Brock, R. C. Ibid, 1950, 5, 5. 6. Ogilvie, A. G. Arch. intern. Med. 1941, 68, 395. 7. Reid, L. M. Thorax, 1950, 5, 233. 8. Duprez, A. J. franç. Méd. Chir. thor. 1951, 5, 442.
secretions. On the other hand, when a segmental bronchus is occluded, collapse does not usually follow, though the segment may retain its own secretions just the same, giving the radiological appearances of segmental collapse. If, for any reason, the secretions do not accumulate or are absorbed, the segment will become re-aerated by the collateral circulation of air from neighbouring segments, even though the bronchus is still occluded. This phenomenon was first demonstrated twenty years ago by VAN ALLEN and his colleagues, s-11 but its importance has only lately been realised, by CHURCHILL 12 13 in America and by BAARSMA, DIRKEN, and HUIZINGA 14 15 in Holland. Incidentally, this collateral circulation of air provides strong evidence of the existence of KOHN’S alveolar pores, which have provoked such controversy in the past. CHURCHILL argues that the collateral air drift cannot serve any respiratory function except that of filling space, because the air that enters the obstructed segment will already be in equilibrium with the blood. A further point to which he draws attention is that the bronchial arterial supply to a segment seems to be increased when the segmental bronchus is occluded. This, he thinks, may establish a pressure gradient great enough to prevent the shunting of pulmonary arterial blood into an area of lung where it would be physiologically useless. WHITWELL’S conception of these three types of bronchiectasis as separate clinical and pathological entities of different aetiology may represent a real advance in this difficult subject. Clinically, however, the distinction between his saccular and follicular groups seems to involve little that could not be accounted for by the different age at which the events leading to the bronchiectasis take place. The clinicianr who would welcome an explanation which takes greater account of the bronchographic changes, may, for this reason, be attracted by REID’S suggestion that the difference between saccular and other types- of bronchiectasis lies in the level at which the dilatation begins and in the degree of peripheral bronchial obliteration.
The Patient’s Favour IN his Harveian Oration to the Royal College of on Oct. 17 Lord MORAN recalled that when was founded in 1518 its primary purpose was to suppress unlicensed practitioners. It had shown more aptitude for repression than for getting to the root of the trouble-which was that people go to the quack because they think he is better than the doctor. One remedy was to educate the public as to what a good doctor could do, and another was to purge medicine of its elements of humbug. But the real remedy, he thought, was to make it unnecessary to win the patient’s favour, and he welcomed the evolutionary process by which, in hospital practice, the fortunes and advancement of the doctor now depend less and less on the patient’s likes and dislikes, and more and more on theverdict of his colleagues. The danger in this, Lord: MORAN said, is that in the cultivation of -his science the physician may neglect his art. In the address which we publish on p. 820 Sir HENEAGE OGILVIE draws attention yet more forcibly to the danger that science may come to be preferred to the patient.
Physicians the college
9. Van Allen, C. M., Jung, T. S. J. thorac. Surg. 1931, 1, 3. 10. Van Allen, C. M., Lindskog, G. E. Surg. Gynec. Obstet, 1931, 53, 16. 11. Van Allen, C. M., Lindskog, G. E., Richter, H. G. J. clin. Invest, 1931, 10, 559. 12. Churchill, E. D. J. thorac. Surg. 1949, 18, 279. 13. Churchill, E. D. Obliterative Bronchitis and Bronchiectasis. Alex Simpson-Smith lecture delivered at the Institute of Child Health, University of London, on Oct. 19, 1951. London, 1952. 14. Baarsma, P. R., Dirken, M. N. J. J. thorac. Surg. 1948, 17, 238, 15. Baarsma, P. R., Dirken, M. N. J., Huizinga, E. Ibid, p. 252.