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THE NEW TREATMENT FOR TUBERCULOSIS
717
log,v, which would enable the nurse to teach patients the accepting illness. Anyone who has been warded knows that what the patient asks of the nurse is an indefinable quality of personality which makes her more than She should be able to make the patient feel a technician. that she is sharing the burden of his illness while remaining detached from it. Attention to this nurse-patient relationship is a first call on the education of nurses : the fact that those responsible for nurses’ training have turned themselves into shows how far
they
Worcester.
are
of facts to be memorised removed from the realities. C. F. J. CROPPER PAUL HOUGHTON.
AN UNUSUAL EPIDEMIC
SIR,—I have been interested in your annotation Feb. 9) and in the subsequent correspondence. Vertigo is not uncommon in this part of the country. The usual sequence in the cases I have seen is sudden severe headache, associated with vertigo and sometimes nausea and vomiting, usually coming on after waking in the morning. The symptoms are sometimes so severe that the patient is unable to lift his head from the pillow. Examination reveals no obvious disease of the ear, nor is there evidence of infection ; the temperature is usually normal or only slightly raised. Nystagmus is usually absent or doubtful. Two features are, however,, fairly constant-namely, the headache, which is usually liemicranial, and accompanying tender points in the suboccipital region. I have in many of these cases obtained immediate and lasting relief from an injection of procaine orMetycaine ’ into the tender point. The effect is dramatic. If care is taken to make the injection into the actual tender point, which is sought with the point of the needle and usually found on the surface of the aponeurosis, 2 iril. of ansesthetic is sufficient.
In my opinion these are casesof fibrositis. In many of these cases of headache hyperassthesia of the scalp is felt when the hair is combed ; this hypersesthesia was noted by me in 51% of 87 cases of fibrositic headache. It is analogous to the hyperaesthesia of the thighs met with in cases of lumbago and sciatica of filbrositic origin, and is an example of Lewis’s nocifensor manifestation.s There would seem no reason why this hyperaesthesia should not affect the vestibular system and
produce vertigo.
As regards the epidemic nature of the malady, I have had the impression for many years that fibrositic
disease—headaches, lumbago, pleurodynia-do
appear in waves of increased incidence ; and I have often wondered whether the Bornholrn syndrome is not merely
1. Shute, E. V., Shute, W. E. Amer. J. Surg. (in the press). Butturini, U. G. Clin. med. 1950, 31, 1. Mantero, O., Rindi,
2.
3.
be
Trozzi. Atti Congr. Cardiologia, 1949. M. Minerva med. 1950, 46, 694. Lewis, T., Kellgren, J. H. Clin. Sci. 1939,
Galeone, A., Minelli,
4, 47.
interesting this point.
on
’
R. M. S. MCCONAGHEY.
Dartmouth.
ABDOMINAL INJURY FROM A CRICKET-BALL
SIR,—In the U.S.A. Gonzales1 has lately described
a
in which the patient died from a non-penetrating abdominal wound by a cricket-ball. The following case had a happier ending. case
‘
crammers
PREVENTION OF CORONARY THROMBOSIS SIR,—I was aware of the studies by Tropeano and Prosperi, cited by Dr. Sbarigia (Feb. 2), on the influence1 We have warned of a-tocopherol on blood coagulation. that a fresh thrombosis may develop in a patient taking but we added that a large dosage of oc-tocopherol ; increasing the dose slightly will resolve that thrombus promptly. We have repeatedly seen this happen. The proper dosage is the dosage that is effective ; and, of course, it may not coincide with our first estimate. Dr. Sbarigia could have readily found reports by Italian workers2 who have pronounced oc-tocopherol very useful in coronary disease. Let Dr. Sbarigia try it for himself ; nothing is easier to settle than whether or not it can quickly resolve a fresh thrombosis. Then he and we may hunt for the explanation at our leisure. Quinine and a hundred other drugs were used by doctors long before their modus operandi was discovered. Shute Institute, W. E. SHUTE. London, Ontario.
manifestation of an epidemic of fibrositis. It would to hear the views of other practitioners
one
-art of
A man,
aged 33, was admitted to this hospital on Sept. 25, a history of having been hit in the abdomen by a cricket-ball 4½ hours previously. Since the injury he had experienced severe upper abdominal pain and had vomited once. On palpation of the abdomen there was generalised board-like rigidity with maximum tenderness apparently in the epigastrium and right iliac fossa. At operation on the evening of admission the abdomen contained free fluid, which was turbid ; there was a 3 4 in. 1948, with
tear of the antimesenteric border of the terminal
ileum, which in layers. There was also further evidence of contusion of the small gut just distal to the perforation. The abdomen was closed without drainage. The patient made an uninterrupted recovery, and was discharged on Oct. 8. was
repaired
It would be interesting to know how in this country.
common
such
cases are
Hackney Hospital,
R. F. READ.
London, E.9.
THE NEW
TREATMENT FOR TUBERCULOSIS
SIR,—One has seen many messiahs come to the tuberculous and fade away-garlic, creosote, and cacodylate and gold. But none has had such good credentials as isonicotinic acid hydrazide, with its respectable background of laboratory and animal experiment, with its record of improvement in 90 cases of advanced tuberculosis, all of whom put on weight and became afebrile, some of whom ceased to have tubercle bacilli in the sputum, and some of whom displayed that clinical rarity-the large dry cavity. As you said on March 15, it has made an excellent debut. The point of this letter is to ask what is being done in this country for large-scale production and extensive trials. It would be nice to suppose that when the Minister of Health’s attention was drawn to the half-column on the important page in the Times of Feb. 23, headed " New Drugs for Tuberculosis," he said to his staft: "
this concerns me very much. I am responsible hundred thousand patients with tuberculosis. We’ll send Dr. Hook and Dr. Crook over by air tomorrow ; they can cable back their report, then ive can have a conference with tuberculosis officers and manufacturers next week, and arrange for extensive trials." for
By Jove,
a
That is the degree of urgency that, to anyone not habituated to the thought of thousands of men and women
coughing away life,
the situation
would
seem
to
demand. Remembering, however, the paralysing fairness of the official medical mind, so often indistinguishable from inertia, I do not think this sense of urgency can be taken for granted in the circles where it is most needed. Perhaps our medical M.P.S will stimulate it with shrewd questioning. They must not be put off with The matter is still very much in the experimental stage and the Ministry is keeping a close watch on the whole question." We are not interested in what they are watching but in what they are doing. "
It may be suggested that the drug is
not without its but the six months of the American trials do not seem to have disclosed anything more than trivial drawbacks. Because a drug has a remarkable action in a disease it does not necessarily mean it is potent in other directions-e.g., that fraction of vitamin B which does the miracle in beriberi. Secondlv, it mav be suggested
dangers ;
1. Gonzales, T. A.
J. Amer. med. Ass.
1951, 146, 1506.
718 that there is no hurry. But that statement would not appeal to the army of people who are being excavated by the tubercle bacillus. Besides, it would show a of the urgencies of humanity without complete absence which the " scientific, detached mind " can become an
evil. C. G. LEAROYD. LBAROYD.
Beckley, Rye.
TENSION PNEUMOTHORAX FOLLOWING TRACHEOTOMY SIR,—I was interested in Mr. Bauer’s helpful letter (March 15). The sole point of my article, however, was to draw attention once again to this very dramatic, lethal, tension pneumothorax coinciding with the dislodgement of the tracheotomy tube from within the lumen of the trachea ; and to bring out the fact that mere replacement of the tube is not sufficient to save life. The only way of preve-nting this calamity is-to make the tracheotomy as high as possible, and not to fix the tube with the neck extended. If it is fixed with the neck extended there is a considerable risk that when the child fleges his neck and the trachea sinks into the chest, the tube will be left behind, as it were, and will slip out of the hole in the trachea. The fatal sequence of events will then be set in motion. Park Hospital, JJARK. JOHN DARK. Davyhulme, Manchester. CAT-BITE FEVER
described as " cat-scratch fever " by SIR,—The Dr. Garai (March 29) was caused by the bite of a kitten, and therefore appears to be one of cat-bite fever." Dr. Garai says that it seems to be the first recorded case in England. In 1935 I described with Dr. Morton Gill a case of cat-bite fever which responded in a remarkable way to intravenous injections of N.A.B.1 G. E. BEAUMONT. London. W.I. case
"
PANCREATICOGASTROSTOMY would like to support the contentions
of SIR,—I Professor Wells and his colleagues and of Mr. DillRussell (March 22) concerning the implantation of the pancreatic stump into the stomach. I .came across this procedure quite accidentally when performing an excision for carcinoma of the head of the pancreas in October, 1950. It struck me that the parts seemed to fall together easily, and the substance of the stomach wall lent itself to suture more easilv than the of age, jejunum. Although the patient was 71 he made an uneventful recovery ; and he died nine months later from metastases. The stump of the pancreas was simply inserted into a small incision on the posterior wall of the stomach, using a treble layer of no. 40 cotton sutures. I have lately had cause to regret not using this procedure in another case, where the patient died from a fistulous leak three weeks after I had implanted the pancreatic stump into the jejunum. I would like to make a plea for bringing up the jejunum and the common duct end-to-end, rather than using a loop of the jejunum with an end-to-side anastomosis. It is quite simple to divide the jejunum " just distal to the duodenojejunal flexure and to dislocate " it from underneath the superior mesenteric vessels. The cut end of the jejunum seems to have considerable mobility and can easily be brought up to the end of the common duct. The anastomosis of the common duct, I believe, is easier ; and there is less risk of stenosis, which to my mind is the chief cause - of ascending cholangitis. In addition, it saves time by dispensing with intestinal- clasure. The pyloric end of the stomach can then be implanted into the jejunum 3-4 in. more distally.. C. PATRICK SAMES. Ba,th.
years
implanting
1. Brit. med. J. 1935, i, 582.
PSYCHOSES IN CHILDHOOD SIR,—In your annotation of March 22 on a meeting at the Royal Society of Medicine at which I spoke, on; sentence suggests that sphincter control and motor sUl may be lost, coupling this together, and going on to say that the child becomes clumsy. This gives a distorted picture of what I said. The striking thing about thescases is the extent to which motor skill is retained. It would often appear that the inability to do things is due to a lack of interest, even perhaps to a lack of willingness to conform. My actual words were : " A child unable to feed himself or dress himself will balance on a narrow or twiddle a tin lid with and this curious combination is features of these cases.
wall
fascinating dexterity", of the distinguishing
one
E. M. London, W.I. ARTIFICIAL RESPIRATION
CREAK. CREAE.
Schafer’s method is efficient, easily carried out ; but there is little doubt that of the better-known methods of artificial respiration it produces the smallest respiratory excursion. This in inevitable as it is only a " push " method, and so. although’expiration is full, inspiration is passive following the release of pressure, and thus essentially limited. A " method, where both inspiration and push-pull are actively assisted, is obviously more sound expiration physiologically and likely to be more effective in practice. For these reasons, in America a modified form of the Holger-Nielsen method has been officially recommended for general adoption, and this method should be considered for official recommendation in this country. To condemn this suggestion, as does Dr. Burnet (March 22.), because first-aiders have been using Schafer’s method efficiently for many years is not really progressive. Further, the first-aider does not need to be blinded with science in order to appreciate the superiority of the Holger-Nielsen method-one demonstration in which all members took the parts of both patient and operator convinced all the members of my division of the St. John Ambulance Brigade. In addition to its physiological superiority the HolgerNielsen method is easily taught, is very little more tiring to carry out than Schafer’s method, and can be carried out by one operator. I feel certain that when it is more widely known its value will be generally appreciated; and, if only prejudices can be overcome, it will be universally adopted as the method of choice. A. R. H. HICKS. HICKS. Harrow, Middlesex.
SIR,—Certainly taught, and easily
"
ANÆSTHESIA FOR TUBERCULOUS PATIENTS SIR,—I would agree with Dr. Mushin’s plea (March 22)’ for a more rational approach to the problem of anmsthesia for patients who incidentally have pulmonary tuberculosis. Since lung resections have been introduced for the treatment of tuberculosis, necessitating the use of general anaesthesia, the traditional arguments for regional anaesthesia for thoracoplastiea have been breached. It is this latter group, where control series between local and general anaesthetic techniques tan be contrasted easily, that can produce the moat relevant evidence. I am at present compiling figures from my own experience for a more detailed examination with regard to thoracoplasties, but it is already evident that the particular dangers under general anaesthesia, are : (1) new foci of disease arising by bronchogenic spread of " sputum ; and (2) light-up of quiescent -foci, possibly by excessive stretching of lung tissue. It. is essential, therefore, that the patient should be breathing quietly, and that bronchospasm and other respiratory disturbances should be avoided. The anaesthetic, agent per se is irrelevant as long as it, is capable of producing the above conditions. "
-
log,v, which would enable the nurse to teach patients the accepting illness. Anyone who has been warded knows that what the patient asks of the nurse is an indefinable quality of personality which makes her more than She should be able to make the patient feel a technician. that she is sharing the burden of his illness while remaining detached from it. Attention to this nurse-patient relationship is a first call on the education of nurses : the fact that those responsible for nurses’ training have turned themselves into shows how far
they
Worcester.
are
of facts to be memorised removed from the realities. C. F. J. CROPPER PAUL HOUGHTON.
AN UNUSUAL EPIDEMIC
SIR,—I have been interested in your annotation Feb. 9) and in the subsequent correspondence. Vertigo is not uncommon in this part of the country. The usual sequence in the cases I have seen is sudden severe headache, associated with vertigo and sometimes nausea and vomiting, usually coming on after waking in the morning. The symptoms are sometimes so severe that the patient is unable to lift his head from the pillow. Examination reveals no obvious disease of the ear, nor is there evidence of infection ; the temperature is usually normal or only slightly raised. Nystagmus is usually absent or doubtful. Two features are, however,, fairly constant-namely, the headache, which is usually liemicranial, and accompanying tender points in the suboccipital region. I have in many of these cases obtained immediate and lasting relief from an injection of procaine orMetycaine ’ into the tender point. The effect is dramatic. If care is taken to make the injection into the actual tender point, which is sought with the point of the needle and usually found on the surface of the aponeurosis, 2 iril. of ansesthetic is sufficient.
In my opinion these are casesof fibrositis. In many of these cases of headache hyperassthesia of the scalp is felt when the hair is combed ; this hypersesthesia was noted by me in 51% of 87 cases of fibrositic headache. It is analogous to the hyperaesthesia of the thighs met with in cases of lumbago and sciatica of filbrositic origin, and is an example of Lewis’s nocifensor manifestation.s There would seem no reason why this hyperaesthesia should not affect the vestibular system and
produce vertigo.
As regards the epidemic nature of the malady, I have had the impression for many years that fibrositic
disease—headaches, lumbago, pleurodynia-do
appear in waves of increased incidence ; and I have often wondered whether the Bornholrn syndrome is not merely
1. Shute, E. V., Shute, W. E. Amer. J. Surg. (in the press). Butturini, U. G. Clin. med. 1950, 31, 1. Mantero, O., Rindi,
2.
3.
be
Trozzi. Atti Congr. Cardiologia, 1949. M. Minerva med. 1950, 46, 694. Lewis, T., Kellgren, J. H. Clin. Sci. 1939,
Galeone, A., Minelli,
4, 47.
interesting this point.
on
’
R. M. S. MCCONAGHEY.
Dartmouth.
ABDOMINAL INJURY FROM A CRICKET-BALL
SIR,—In the U.S.A. Gonzales1 has lately described
a
in which the patient died from a non-penetrating abdominal wound by a cricket-ball. The following case had a happier ending. case
‘
crammers
PREVENTION OF CORONARY THROMBOSIS SIR,—I was aware of the studies by Tropeano and Prosperi, cited by Dr. Sbarigia (Feb. 2), on the influence1 We have warned of a-tocopherol on blood coagulation. that a fresh thrombosis may develop in a patient taking but we added that a large dosage of oc-tocopherol ; increasing the dose slightly will resolve that thrombus promptly. We have repeatedly seen this happen. The proper dosage is the dosage that is effective ; and, of course, it may not coincide with our first estimate. Dr. Sbarigia could have readily found reports by Italian workers2 who have pronounced oc-tocopherol very useful in coronary disease. Let Dr. Sbarigia try it for himself ; nothing is easier to settle than whether or not it can quickly resolve a fresh thrombosis. Then he and we may hunt for the explanation at our leisure. Quinine and a hundred other drugs were used by doctors long before their modus operandi was discovered. Shute Institute, W. E. SHUTE. London, Ontario.
manifestation of an epidemic of fibrositis. It would to hear the views of other practitioners
one
-art of
A man,
aged 33, was admitted to this hospital on Sept. 25, a history of having been hit in the abdomen by a cricket-ball 4½ hours previously. Since the injury he had experienced severe upper abdominal pain and had vomited once. On palpation of the abdomen there was generalised board-like rigidity with maximum tenderness apparently in the epigastrium and right iliac fossa. At operation on the evening of admission the abdomen contained free fluid, which was turbid ; there was a 3 4 in. 1948, with
tear of the antimesenteric border of the terminal
ileum, which in layers. There was also further evidence of contusion of the small gut just distal to the perforation. The abdomen was closed without drainage. The patient made an uninterrupted recovery, and was discharged on Oct. 8. was
repaired
It would be interesting to know how in this country.
common
such
cases are
Hackney Hospital,
R. F. READ.
London, E.9.
THE NEW
TREATMENT FOR TUBERCULOSIS
SIR,—One has seen many messiahs come to the tuberculous and fade away-garlic, creosote, and cacodylate and gold. But none has had such good credentials as isonicotinic acid hydrazide, with its respectable background of laboratory and animal experiment, with its record of improvement in 90 cases of advanced tuberculosis, all of whom put on weight and became afebrile, some of whom ceased to have tubercle bacilli in the sputum, and some of whom displayed that clinical rarity-the large dry cavity. As you said on March 15, it has made an excellent debut. The point of this letter is to ask what is being done in this country for large-scale production and extensive trials. It would be nice to suppose that when the Minister of Health’s attention was drawn to the half-column on the important page in the Times of Feb. 23, headed " New Drugs for Tuberculosis," he said to his staft: "
this concerns me very much. I am responsible hundred thousand patients with tuberculosis. We’ll send Dr. Hook and Dr. Crook over by air tomorrow ; they can cable back their report, then ive can have a conference with tuberculosis officers and manufacturers next week, and arrange for extensive trials." for
By Jove,
a
That is the degree of urgency that, to anyone not habituated to the thought of thousands of men and women
coughing away life,
the situation
would
seem
to
demand. Remembering, however, the paralysing fairness of the official medical mind, so often indistinguishable from inertia, I do not think this sense of urgency can be taken for granted in the circles where it is most needed. Perhaps our medical M.P.S will stimulate it with shrewd questioning. They must not be put off with The matter is still very much in the experimental stage and the Ministry is keeping a close watch on the whole question." We are not interested in what they are watching but in what they are doing. "
It may be suggested that the drug is
not without its but the six months of the American trials do not seem to have disclosed anything more than trivial drawbacks. Because a drug has a remarkable action in a disease it does not necessarily mean it is potent in other directions-e.g., that fraction of vitamin B which does the miracle in beriberi. Secondlv, it mav be suggested
dangers ;
1. Gonzales, T. A.
J. Amer. med. Ass.
1951, 146, 1506.
718 that there is no hurry. But that statement would not appeal to the army of people who are being excavated by the tubercle bacillus. Besides, it would show a of the urgencies of humanity without complete absence which the " scientific, detached mind " can become an
evil. C. G. LEAROYD. LBAROYD.
Beckley, Rye.
TENSION PNEUMOTHORAX FOLLOWING TRACHEOTOMY SIR,—I was interested in Mr. Bauer’s helpful letter (March 15). The sole point of my article, however, was to draw attention once again to this very dramatic, lethal, tension pneumothorax coinciding with the dislodgement of the tracheotomy tube from within the lumen of the trachea ; and to bring out the fact that mere replacement of the tube is not sufficient to save life. The only way of preve-nting this calamity is-to make the tracheotomy as high as possible, and not to fix the tube with the neck extended. If it is fixed with the neck extended there is a considerable risk that when the child fleges his neck and the trachea sinks into the chest, the tube will be left behind, as it were, and will slip out of the hole in the trachea. The fatal sequence of events will then be set in motion. Park Hospital, JJARK. JOHN DARK. Davyhulme, Manchester. CAT-BITE FEVER
described as " cat-scratch fever " by SIR,—The Dr. Garai (March 29) was caused by the bite of a kitten, and therefore appears to be one of cat-bite fever." Dr. Garai says that it seems to be the first recorded case in England. In 1935 I described with Dr. Morton Gill a case of cat-bite fever which responded in a remarkable way to intravenous injections of N.A.B.1 G. E. BEAUMONT. London. W.I. case
"
PANCREATICOGASTROSTOMY would like to support the contentions
of SIR,—I Professor Wells and his colleagues and of Mr. DillRussell (March 22) concerning the implantation of the pancreatic stump into the stomach. I .came across this procedure quite accidentally when performing an excision for carcinoma of the head of the pancreas in October, 1950. It struck me that the parts seemed to fall together easily, and the substance of the stomach wall lent itself to suture more easilv than the of age, jejunum. Although the patient was 71 he made an uneventful recovery ; and he died nine months later from metastases. The stump of the pancreas was simply inserted into a small incision on the posterior wall of the stomach, using a treble layer of no. 40 cotton sutures. I have lately had cause to regret not using this procedure in another case, where the patient died from a fistulous leak three weeks after I had implanted the pancreatic stump into the jejunum. I would like to make a plea for bringing up the jejunum and the common duct end-to-end, rather than using a loop of the jejunum with an end-to-side anastomosis. It is quite simple to divide the jejunum " just distal to the duodenojejunal flexure and to dislocate " it from underneath the superior mesenteric vessels. The cut end of the jejunum seems to have considerable mobility and can easily be brought up to the end of the common duct. The anastomosis of the common duct, I believe, is easier ; and there is less risk of stenosis, which to my mind is the chief cause - of ascending cholangitis. In addition, it saves time by dispensing with intestinal- clasure. The pyloric end of the stomach can then be implanted into the jejunum 3-4 in. more distally.. C. PATRICK SAMES. Ba,th.
years
implanting
1. Brit. med. J. 1935, i, 582.
PSYCHOSES IN CHILDHOOD SIR,—In your annotation of March 22 on a meeting at the Royal Society of Medicine at which I spoke, on; sentence suggests that sphincter control and motor sUl may be lost, coupling this together, and going on to say that the child becomes clumsy. This gives a distorted picture of what I said. The striking thing about thescases is the extent to which motor skill is retained. It would often appear that the inability to do things is due to a lack of interest, even perhaps to a lack of willingness to conform. My actual words were : " A child unable to feed himself or dress himself will balance on a narrow or twiddle a tin lid with and this curious combination is features of these cases.
wall
fascinating dexterity", of the distinguishing
one
E. M. London, W.I. ARTIFICIAL RESPIRATION
CREAK. CREAE.
Schafer’s method is efficient, easily carried out ; but there is little doubt that of the better-known methods of artificial respiration it produces the smallest respiratory excursion. This in inevitable as it is only a " push " method, and so. although’expiration is full, inspiration is passive following the release of pressure, and thus essentially limited. A " method, where both inspiration and push-pull are actively assisted, is obviously more sound expiration physiologically and likely to be more effective in practice. For these reasons, in America a modified form of the Holger-Nielsen method has been officially recommended for general adoption, and this method should be considered for official recommendation in this country. To condemn this suggestion, as does Dr. Burnet (March 22.), because first-aiders have been using Schafer’s method efficiently for many years is not really progressive. Further, the first-aider does not need to be blinded with science in order to appreciate the superiority of the Holger-Nielsen method-one demonstration in which all members took the parts of both patient and operator convinced all the members of my division of the St. John Ambulance Brigade. In addition to its physiological superiority the HolgerNielsen method is easily taught, is very little more tiring to carry out than Schafer’s method, and can be carried out by one operator. I feel certain that when it is more widely known its value will be generally appreciated; and, if only prejudices can be overcome, it will be universally adopted as the method of choice. A. R. H. HICKS. HICKS. Harrow, Middlesex.
SIR,—Certainly taught, and easily
"
ANÆSTHESIA FOR TUBERCULOUS PATIENTS SIR,—I would agree with Dr. Mushin’s plea (March 22)’ for a more rational approach to the problem of anmsthesia for patients who incidentally have pulmonary tuberculosis. Since lung resections have been introduced for the treatment of tuberculosis, necessitating the use of general anaesthesia, the traditional arguments for regional anaesthesia for thoracoplastiea have been breached. It is this latter group, where control series between local and general anaesthetic techniques tan be contrasted easily, that can produce the moat relevant evidence. I am at present compiling figures from my own experience for a more detailed examination with regard to thoracoplasties, but it is already evident that the particular dangers under general anaesthesia, are : (1) new foci of disease arising by bronchogenic spread of " sputum ; and (2) light-up of quiescent -foci, possibly by excessive stretching of lung tissue. It. is essential, therefore, that the patient should be breathing quietly, and that bronchospasm and other respiratory disturbances should be avoided. The anaesthetic, agent per se is irrelevant as long as it, is capable of producing the above conditions. "
-