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THE TECHNIQUE OF ARTIFICIAL PNEUMOTHORAX.
420
(Jan. 28th, 1913), held at the request
of
our
tuber-
culosis officer, who wished to explain the tuberculosis regulations to the members of the panel.
panel were invited out of courtesy. They were our guests in the offices of Information gained the Insurance Committee. The doctors not
on
the
I
the local medical practitioners, and that the pledge was dead when they took this step. I am, Sir, yours faithfully, HENRY BLAKE.
THE TECHNIQUE OF ARTIFICIAL PNEUMOTHORAX.
thus should not have been handed over to the press. With this violation of custom Dr. Shaw has combined gross inaccuracy. The minute to which he alludes runs thus :-
To the Editor
of THE LANCET.
SIR,-May I express regret for the tardy appearowing to my absence on holiday, of this reply to Dr. W. Parry Morgan’s letter. Dr. Morgan is generous enough to accept my assurance that I can Allocation was neither mentioned nor intended. pass a blunt needle through the parietal pleura We wanted people to exercise their own choice of so that its orifice rests in the pleural cavity without doctors before they were ill. As a matter of fact, injuring the visceral pleura," but, nevertheless, this minute does not appear to have been com- maintains that I cannot obtain ample manometer municated to the Insurance Committee at all. oscillations without causing the lung to leak and Nothing was done about allocation by us until thereby supply the necessary gas to communicate
A rough estimate of cards signed was taken, and it was resolved to point out to the Insurance Committee that steps should be taken to deal with those outstanding.
ance,
"
"
we had to answer a letter from the Insurance Committee two months later. Then we dealt with methods only and made no pressure. Dr. Shaw does not refer to another minute I read on Jan. 28th as follows :
Dr. is requested to write to Dr. suggesting that those medical men not on the panel should join the -
-
Statutory Committee, which showed that we still desired their presence and cooperation. When in March a general meeting of all the doctors was officially called to form a Local Medical Committee, the members of the panel combined to put a non-panel doctor in the
movements to the manometer." It is clear from what follows that Dr. Morgan accepts the oscillations of which I gave examples in my letter as " ample " ; this being so he must either hold that a leakage occurs from the unwounded lung, or else his polite acceptance of my ability to spare the visceral pleura was a mere figure of speech and represents in reality the exact opposite of what he thinks. I should have taken no offence if he had said what he meant more baldly and trust that none will be taken by him if my own criticisms are and have been less veiled under a cloak of
politeness. On purely theoretical grounds rejects the possibility that so small
Dr. Morgan kindly disposition. a quantity of With regard to the hospital, my speech comthe manometer as is contained in 6 cm. of plained of was made just after the receipt of a gas can be sufficient, after entering the pleural tubing letter from the secretary of the Great Yarmouth to supply a respiratory oscillation of 4 cm. Hospital by the Insurance Committee containing space, in one arm of the manometer. I confess I extent the following resolution :fail to see the difficulty in this, and would still At a meeting of the committee of the above institution oppose theory with fact and retort that it must be (Great Yarmouth Hospital) held on Monday afternoon last, sufficient, since in practice this fluctuation occurs the following resolution which had been passed by the under conditions where leakage from the lung can honorary medical staff was adopted by the committee : That while in no way going back on their previous resolu- really not be held to occur. If a positive pressure tions your honorary medical staff will continue to take in could be obtained on coughing, as Dr. Morgan selected cases amongst insured persons for operation which suspects, then I would certainly admit that the are not necessarily cases of urgent necessity until pleural cavity contained additional air; but I am March lst, in order that the Local Insurance Committee not aware that a true positive pressure is caused may have time to make the necessary arrangements by cough in these cases, and all that I obtain for providing that attention which the Act imposes myself is a mere momentary upward oscillation of upon them. the fluid produced by the sharp momentary impulse. I need not trouble you with comment. Wiser This swing suffices to give extra assurance of the counsels prevailed, of course, and no serious altera- whereabouts of the needle’s point, but is a much smaller phenomenon than that caused by cough in tions were made in local hospital management. In conclusion, I must allude to the account your cases where gas has been already introduced, and Special Commissioner gave of a special meeting of where, no doubt, a true positive pressure is pro-
chair, again showing
a
the Medical Benefit Subcommittee of the Insurance Committee which all the medical practitioners in Great Yarmouth were invited to attend in January, 1913. The chairman opened by expressly stating that whatever was then said should necessarily be regarded as said in committee or in camera. We now have a version of an important particular in the public press and a copy of THE LANCET’S article sent to one of the local papers. Who has been the informant ? I cannot criticise this version, but I can say that from inquiries made since there is no doubt that if a panel had not been formed promptly we should have had an influx of an efficient medical staff for attending all insured persons and others besides. Those who joined to form the panel at the last moment contend that they saved the livelihoods of nearly all
duced. The valve action of the lung, which Dr. Morgan accuses me of overlooking, is not a phenomenon which concerns those who use a side opening as well as a terminal one to their needle. That in the absence of this side opening it can occur and cause symptoms of blockage of the needle I should be perfectly ready to admit, and also that some of Dr. Morgan’s cases were very probably of this nature if he uses a needle with a single terminal
opening. That the presence of pleural adhesions necessarily implies the absence of a potential pleural space, as Dr. Morgan asserts, I should certainly be inclined to deny from the results of personal experience. I have treated a case where small quantities of gas could be put in, at negative pressures at first, over
421
parts of the lung, but where no efficient form of treatment. In the case which I quoted I do blame the Insurance Committee. If they had pleural space could be opened out. Dr. Morgan remarks that experience with his not instructed my patient to attend at a certain apparatus would cause me to remove the objections dispensary she would never have been treated with I have expressed, and I do not deny that some tuberculin. Official interference between doctor apparent difficulties would probably disappear after and patient was the initial step towards tuberculin prolonged use of the method. But, unfortunately, treatment. With regard to the treatment itself and the I am still in the hopeless condition of considering the single manometer an extremely satisfactory method of administration in this case, I prefer not instrument, and of differing entirely with Dr. to express my opinion, as I do not think it Morgan’s condemnation of it. My attitude towards ’, necessary to do so.-I am, Sir, yours faithfully, CHARLES MILLER. his two manometers reminds Dr. Morgan of the z, one-time rejection of the single manometer by the pioneer of pneumothorax therapy, but I think a THE USE OF LIQUID PARAFFIN IN little consideration will soon show him how very ENTERIC FEVER. superficial is the resemblance between the two many
To tAe Editor of THE LANCET.
cases.
With regard to my fear that the oscillations would be damped down by inertia of the fluid in the reservoirs of his manometer, I am glad to have his assurance that this is groundless, for there seem to me great points of convenience in this arrangement of movable reservoirs. He then remarks : "Curiously enough, the only advantage which Dr. Riviere sees-that is the advantage regarding the range of working pressure-really does not exist." I should like to ask how he reconciles this with his statement in the original paper that " we may record a pressure of 35 cm. by raising, -35 cm. by lowering, the manometer reservoirs." The arrangement of the apparatus certainly seems to bear out the correctness of this, his original assertion. Finally, Dr. Morgan’s preference for oxygen because if it passes into the tissues it is more quickly absorbed and produces less surgical emphysema serves to illustrate very well the objection, if not the danger, of the continuous flow of gas which Dr. Morgan favours. With the established method no such leakage of gas need occur, and I cannot help feeling that its avoidance is a gain on the side of safety and convenience alike. With apologies for the length of this communicaI am, Sir, yours faithfully, tion, CLIVE RIVIERE.
TUBERCULIN "ENTHUSIASTS." To the Editor of THE LANCET.
SIR,-I think the letter in
your issue of July 25th a Dr. Charles Miller most important one. As he by writes the time for discussing this subject is passed. This so-called remedy has received a long and careful trial, and the consensus of opinion formed by unbiassed observers is that no benefit arises from the injection of tuberculin and that even when used with the greatest care harmful results are liable to ensue.
The insurance authorities would do a great public service if they officially condemned this drug, for such action would go far to banish its use from all paths of practice. Surely it is time the true position of tuberculin in the treatment of pulmonary tuberculosis should become a matter of common
knowledge. I am,
Sir,
yours
faithfully,
THOS. GLOVER LYON. To the Editor of THE LANCET.
glad to find in THE LANCET of that Dr. J. E. Squire is in agreement with my remarks. Dr. Squire, however, does not see how any blame can be put upon the Insurance Committee, as they do not direct the
SIR,-I August lst
was
SiR,—Professor Ll. P. Phillips’s advocacy in LANCET of THE paraffin in typhoid fever raises a larger question than whether we should administer it for constipation in one massive daily dose or in repeated divided doses for the sake of its lubricant and protective action-namely, what it can do for the septic diarrhoea in the worse type ofThe " local treatment of the bowel," which cases. must remain our first consideration until the vaccine. treatment may have completely suppressed the disease, was not thought of, at any rate not practically attempted, before Sir William Jenner’s indictment of milk as a factor in the septic intestinal fermentation of typhoid fever. We owe the clinical proof of the correctness of that view to Prideaux Selby’s historical paperl on the successful substitution of whey for milk in the dietary. That paper deserves full credit for having led to the wider practical conclusion, subsequently identified under the name of the " empty bowel treatment" or " traitement a videsthat from the beginning to the end of our treatment the all-essential indication is the constant sanitation or sanitary toilet of the bowel. " For the evacuant" purpose in that treatment paraffin was used as an adjuvant in frequent frac. tional doses; and subsequently it was found that, as an additional security, a small daily dose of castor oil was useful and well borne. That treat-" disinfection"" by the free ment also aimed at administration of animal charcoal (originally used in France by Bouchard in typhoid) for the sake of its remarkable absorptive and neutralising powerover alkaloids, as, for instance, after massive lethal doses of strychnine or morphine. But the first and indispensable indication was to systematically and completely remove the septic culture from the lower ileum; leaving the upper bowel and the stomach in a much better condition for their all-essential alimentary function of absorbing abundant supplies of varied and nourishing foods (either purely crystalloid, such as sugar and salts ; subcrystalloid and diffusible, such as the maltine group, yolk of egg, and whey itself; or leaving practically no residue, such as cream, predigested foods, meat and fruit jellies, &c., and particularly white of egg added in high dilutions to the whey to replace its coagulable casein). That proposition ha, I believe, never been fully discussed. It still faces us, on the foundation, which presumably is not disputed, that the multiple spread of the ulcerations (accounting for the clinical " relapses "), up the ileum and down into. the colon, is secondary, and most probably due to 1
2
THE LANCET, Nov. 2nd, 1901, p. 1182. Brit. Med. Jour., vol. ii., p. 1507, 1905.
(Jan. 28th, 1913), held at the request
of
our
tuber-
culosis officer, who wished to explain the tuberculosis regulations to the members of the panel.
panel were invited out of courtesy. They were our guests in the offices of Information gained the Insurance Committee. The doctors not
on
the
I
the local medical practitioners, and that the pledge was dead when they took this step. I am, Sir, yours faithfully, HENRY BLAKE.
THE TECHNIQUE OF ARTIFICIAL PNEUMOTHORAX.
thus should not have been handed over to the press. With this violation of custom Dr. Shaw has combined gross inaccuracy. The minute to which he alludes runs thus :-
To the Editor
of THE LANCET.
SIR,-May I express regret for the tardy appearowing to my absence on holiday, of this reply to Dr. W. Parry Morgan’s letter. Dr. Morgan is generous enough to accept my assurance that I can Allocation was neither mentioned nor intended. pass a blunt needle through the parietal pleura We wanted people to exercise their own choice of so that its orifice rests in the pleural cavity without doctors before they were ill. As a matter of fact, injuring the visceral pleura," but, nevertheless, this minute does not appear to have been com- maintains that I cannot obtain ample manometer municated to the Insurance Committee at all. oscillations without causing the lung to leak and Nothing was done about allocation by us until thereby supply the necessary gas to communicate
A rough estimate of cards signed was taken, and it was resolved to point out to the Insurance Committee that steps should be taken to deal with those outstanding.
ance,
"
"
we had to answer a letter from the Insurance Committee two months later. Then we dealt with methods only and made no pressure. Dr. Shaw does not refer to another minute I read on Jan. 28th as follows :
Dr. is requested to write to Dr. suggesting that those medical men not on the panel should join the -
-
Statutory Committee, which showed that we still desired their presence and cooperation. When in March a general meeting of all the doctors was officially called to form a Local Medical Committee, the members of the panel combined to put a non-panel doctor in the
movements to the manometer." It is clear from what follows that Dr. Morgan accepts the oscillations of which I gave examples in my letter as " ample " ; this being so he must either hold that a leakage occurs from the unwounded lung, or else his polite acceptance of my ability to spare the visceral pleura was a mere figure of speech and represents in reality the exact opposite of what he thinks. I should have taken no offence if he had said what he meant more baldly and trust that none will be taken by him if my own criticisms are and have been less veiled under a cloak of
politeness. On purely theoretical grounds rejects the possibility that so small
Dr. Morgan kindly disposition. a quantity of With regard to the hospital, my speech comthe manometer as is contained in 6 cm. of plained of was made just after the receipt of a gas can be sufficient, after entering the pleural tubing letter from the secretary of the Great Yarmouth to supply a respiratory oscillation of 4 cm. Hospital by the Insurance Committee containing space, in one arm of the manometer. I confess I extent the following resolution :fail to see the difficulty in this, and would still At a meeting of the committee of the above institution oppose theory with fact and retort that it must be (Great Yarmouth Hospital) held on Monday afternoon last, sufficient, since in practice this fluctuation occurs the following resolution which had been passed by the under conditions where leakage from the lung can honorary medical staff was adopted by the committee : That while in no way going back on their previous resolu- really not be held to occur. If a positive pressure tions your honorary medical staff will continue to take in could be obtained on coughing, as Dr. Morgan selected cases amongst insured persons for operation which suspects, then I would certainly admit that the are not necessarily cases of urgent necessity until pleural cavity contained additional air; but I am March lst, in order that the Local Insurance Committee not aware that a true positive pressure is caused may have time to make the necessary arrangements by cough in these cases, and all that I obtain for providing that attention which the Act imposes myself is a mere momentary upward oscillation of upon them. the fluid produced by the sharp momentary impulse. I need not trouble you with comment. Wiser This swing suffices to give extra assurance of the counsels prevailed, of course, and no serious altera- whereabouts of the needle’s point, but is a much smaller phenomenon than that caused by cough in tions were made in local hospital management. In conclusion, I must allude to the account your cases where gas has been already introduced, and Special Commissioner gave of a special meeting of where, no doubt, a true positive pressure is pro-
chair, again showing
a
the Medical Benefit Subcommittee of the Insurance Committee which all the medical practitioners in Great Yarmouth were invited to attend in January, 1913. The chairman opened by expressly stating that whatever was then said should necessarily be regarded as said in committee or in camera. We now have a version of an important particular in the public press and a copy of THE LANCET’S article sent to one of the local papers. Who has been the informant ? I cannot criticise this version, but I can say that from inquiries made since there is no doubt that if a panel had not been formed promptly we should have had an influx of an efficient medical staff for attending all insured persons and others besides. Those who joined to form the panel at the last moment contend that they saved the livelihoods of nearly all
duced. The valve action of the lung, which Dr. Morgan accuses me of overlooking, is not a phenomenon which concerns those who use a side opening as well as a terminal one to their needle. That in the absence of this side opening it can occur and cause symptoms of blockage of the needle I should be perfectly ready to admit, and also that some of Dr. Morgan’s cases were very probably of this nature if he uses a needle with a single terminal
opening. That the presence of pleural adhesions necessarily implies the absence of a potential pleural space, as Dr. Morgan asserts, I should certainly be inclined to deny from the results of personal experience. I have treated a case where small quantities of gas could be put in, at negative pressures at first, over
421
parts of the lung, but where no efficient form of treatment. In the case which I quoted I do blame the Insurance Committee. If they had pleural space could be opened out. Dr. Morgan remarks that experience with his not instructed my patient to attend at a certain apparatus would cause me to remove the objections dispensary she would never have been treated with I have expressed, and I do not deny that some tuberculin. Official interference between doctor apparent difficulties would probably disappear after and patient was the initial step towards tuberculin prolonged use of the method. But, unfortunately, treatment. With regard to the treatment itself and the I am still in the hopeless condition of considering the single manometer an extremely satisfactory method of administration in this case, I prefer not instrument, and of differing entirely with Dr. to express my opinion, as I do not think it Morgan’s condemnation of it. My attitude towards ’, necessary to do so.-I am, Sir, yours faithfully, CHARLES MILLER. his two manometers reminds Dr. Morgan of the z, one-time rejection of the single manometer by the pioneer of pneumothorax therapy, but I think a THE USE OF LIQUID PARAFFIN IN little consideration will soon show him how very ENTERIC FEVER. superficial is the resemblance between the two many
To tAe Editor of THE LANCET.
cases.
With regard to my fear that the oscillations would be damped down by inertia of the fluid in the reservoirs of his manometer, I am glad to have his assurance that this is groundless, for there seem to me great points of convenience in this arrangement of movable reservoirs. He then remarks : "Curiously enough, the only advantage which Dr. Riviere sees-that is the advantage regarding the range of working pressure-really does not exist." I should like to ask how he reconciles this with his statement in the original paper that " we may record a pressure of 35 cm. by raising, -35 cm. by lowering, the manometer reservoirs." The arrangement of the apparatus certainly seems to bear out the correctness of this, his original assertion. Finally, Dr. Morgan’s preference for oxygen because if it passes into the tissues it is more quickly absorbed and produces less surgical emphysema serves to illustrate very well the objection, if not the danger, of the continuous flow of gas which Dr. Morgan favours. With the established method no such leakage of gas need occur, and I cannot help feeling that its avoidance is a gain on the side of safety and convenience alike. With apologies for the length of this communicaI am, Sir, yours faithfully, tion, CLIVE RIVIERE.
TUBERCULIN "ENTHUSIASTS." To the Editor of THE LANCET.
SIR,-I think the letter in
your issue of July 25th a Dr. Charles Miller most important one. As he by writes the time for discussing this subject is passed. This so-called remedy has received a long and careful trial, and the consensus of opinion formed by unbiassed observers is that no benefit arises from the injection of tuberculin and that even when used with the greatest care harmful results are liable to ensue.
The insurance authorities would do a great public service if they officially condemned this drug, for such action would go far to banish its use from all paths of practice. Surely it is time the true position of tuberculin in the treatment of pulmonary tuberculosis should become a matter of common
knowledge. I am,
Sir,
yours
faithfully,
THOS. GLOVER LYON. To the Editor of THE LANCET.
glad to find in THE LANCET of that Dr. J. E. Squire is in agreement with my remarks. Dr. Squire, however, does not see how any blame can be put upon the Insurance Committee, as they do not direct the
SIR,-I August lst
was
SiR,—Professor Ll. P. Phillips’s advocacy in LANCET of THE paraffin in typhoid fever raises a larger question than whether we should administer it for constipation in one massive daily dose or in repeated divided doses for the sake of its lubricant and protective action-namely, what it can do for the septic diarrhoea in the worse type ofThe " local treatment of the bowel," which cases. must remain our first consideration until the vaccine. treatment may have completely suppressed the disease, was not thought of, at any rate not practically attempted, before Sir William Jenner’s indictment of milk as a factor in the septic intestinal fermentation of typhoid fever. We owe the clinical proof of the correctness of that view to Prideaux Selby’s historical paperl on the successful substitution of whey for milk in the dietary. That paper deserves full credit for having led to the wider practical conclusion, subsequently identified under the name of the " empty bowel treatment" or " traitement a videsthat from the beginning to the end of our treatment the all-essential indication is the constant sanitation or sanitary toilet of the bowel. " For the evacuant" purpose in that treatment paraffin was used as an adjuvant in frequent frac. tional doses; and subsequently it was found that, as an additional security, a small daily dose of castor oil was useful and well borne. That treat-" disinfection"" by the free ment also aimed at administration of animal charcoal (originally used in France by Bouchard in typhoid) for the sake of its remarkable absorptive and neutralising powerover alkaloids, as, for instance, after massive lethal doses of strychnine or morphine. But the first and indispensable indication was to systematically and completely remove the septic culture from the lower ileum; leaving the upper bowel and the stomach in a much better condition for their all-essential alimentary function of absorbing abundant supplies of varied and nourishing foods (either purely crystalloid, such as sugar and salts ; subcrystalloid and diffusible, such as the maltine group, yolk of egg, and whey itself; or leaving practically no residue, such as cream, predigested foods, meat and fruit jellies, &c., and particularly white of egg added in high dilutions to the whey to replace its coagulable casein). That proposition ha, I believe, never been fully discussed. It still faces us, on the foundation, which presumably is not disputed, that the multiple spread of the ulcerations (accounting for the clinical " relapses "), up the ileum and down into. the colon, is secondary, and most probably due to 1
2
THE LANCET, Nov. 2nd, 1901, p. 1182. Brit. Med. Jour., vol. ii., p. 1507, 1905.