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TRAVELLING FELLOWSHIPS IN MEDICINE
22 because it enabled their dogs to withstand a much higher pressure. Otherwise,, since it is chiefly concerned with penetrating wounds, it is unlikely to add much to our knowledge of cardiac trauma as seen in civil life. In accident hospitals and centres, however, there should be ample opportunity to amplify the observations of Barber and others. And the elderly workman recovering from an accident involving the chest should be an excellent subject for reablement, be any question of permanent damage, should there or even of a cardiac neurosis.
intrapericardial
RESECTION
IN the
OF THE
ŒSOPHAGUS
surgery
with the retention of an efficient circulation. The colour of the viscera remained good, and there was no postoperative necrosis. The blood-supply to the upper end of the oesophagus depends on the descending oesophageal branches of the inferior thyroid vessels, and the surgeon must remember and preserve these vessels during dissection of the oesophagus. The transthoracic approach in resection of the aesophagus and stomach for carcinoma is now well enough established in the United States to encourage Sweet4 of the Massachusetts General Hospital, Boston, to analyse the methods and late results in 127 ases. Of 85 cases of carcinoma of the stomach or lower oesophagus invading the cardia, 24 were found to be inoperable. Of the 42 middle oesophageal cases resection was possible and was done in 25 ; but high intrathoracic oesophagogastric anastomosis was not adopted in the hospital until the past year (1944), so only 11 of the 25 cases had this anastomosis done. For the remainder the Thorek operation was used. Of these 11 patients, 7 were still alive and apparently well at the end of 1944. Sweet reports encouraging results for resection of the cardia and immediate low anastomosis. Of 43 patients, 35 survived the operation and 19 were well a few months to 5 years afterwards. Whatever their technique, all writers on oesophageal resection emphasise’ the great importance of the preoperative and postoperative periods, and the greatly increased chance of success that has been provided by modern advances in anaesthesia and in the prevention and treatment of surgical shock. We are witnessing the evolution of a very severe and difficult surgical procedure, but one in which Grey Turner’s optimism seems likely to be justified. Since deep X-ray therapy and radium have failed us in this field, there is every justification for strenuous efforts to perfect operative cure. ’
of oesophageal cancer two major difficulties have to be faced-the approach to the posterior mediastinum, and the restoration of swallowing. The recent strides made in anaesthesia and the technique of chest surgery have combined to make exploration of the oesophagus much safer. Excision of the oesophagus is still a very major operation, but one which, in the desperate circumstances, certainly justifies the risk. Successful reconstruction of the oesophagus continues to tax all the ingenuity of the surgeon. Grey Turner1 in his George Haliburton Hume memorial lectures, briefly reviewed the evolution of cesophagoplasty, and concluded that the last word has not yet been said. He believes it to be much sounder surgery to restore the functional capacity of the original cesophagus than to supplant it by some new tube, however ingeniously it may be made. He advises the younger surgeons to pay most attention to those methods which make use of any healthy oesophagus which may remain after the resection; and maintains that the intrathoracic anastomosis between the fundus of the stomach and the cut end of the oesophagus will, in future, hold the field against the It’ is therefore interesting extrathoracic operations. to note which methods have recently been chosen by TRAVELLING FELLOWSHIPS IN MEDICINE other surgeons. THE Medical Research Council announce that preFrom Chicago, Clark2 describes a successful resection of the middle third of the oesophagus for a most extensive liminary arrangements have been made for the resunpgrowth. He completed the operation by anastomosing tion of Rockefeller medical fellowships, to be provided the stomach and oesophagus above the archof the aorta. from a fund entrusted to the Council bv the Rockefeller The free mobilisation of the stomach required for Foundation of New York. These fellowships are insuch a high junction involves considerable danger to its tended for graduates living in this country who have had viability. Clark suggests a technique for preserving the some training in research in clinical medicine or surgery, gastro-epiploic arteries which would allow complete or in some other branch of medical science, and who removal of the left gastric artery and the lymph-nodes are likely to profit by working at a centre in the United along the lesser curvature of the stomach without fear States, or elsewhere abroad, before taking up positions of impairing gastric circulation. He also recommends for higher teaching or research in this country. It is excision of a long segment of the phrenic nerve to ensure hoped that a limited number of awards can be made permanent paralysis of the left. side of the diaphragm. during the academic year 1945-46, depending on the In his own case he crushed the phrenic nerve just above availability of candidates and facilities for travelling. the diaphragm, and he noticed clinical and roentgeno4. Sweet, R. H. Ann. Surg. 1945, 121, 272. logical evidence of obstruction to the stomach where it passed through the diaphragm. The excursion of the THE AIR AMBULANCE SERVICE FiLMED.—The achieveleft diaphragm was full, pointing to an early and complete ments of the Casualty Air Evacuation Service during the nerve. of Hermon the London 3 of Taylor regeneration fighting in Europe were described in THE LANCET of Hospital argues that the shortest route between the Aug. 26, 1944, p. 278. The Medical Service of the Royal cricoid and the duodenum, with the patient, propped up Air Force has now completed a film, which, although in bed and his trunk flexed, is in the plane of the sternum. designed for training air orderlies engaged in this work, also He therefore designed his operation to include a preshows more clearly than words the tremendous organisation sternal anastomosis between the stomach and the stump which enabled the scheme to work so efficiently. Evacuation of the oesophagus. He has done this operation three of Castialties by Ail’ shows the Dakota transport adapted for times, with one death from accidental pneumothorax stretcher-carrying, and the medical equipment it carries for the orderly to use. Patients are loaded, and when the of the contralateral side of the chest. The mobilised plane is airborne the orderly’s duties are explained and stomach comes to lie directly under the skin in front described in detail, always with the emphasis that reassuring of the sternum, and there seems to be a risk of external the man is as important as tending his wounds. When the fistul2e forming through the anastomosis breaking down. plane lands we see the arrangements for reception and Taylor points out, however, that an external fistula is disposal, still with as much emphasis paid to comfort as to better than one within the thorax. The reduction of - medicine. Besides giving instruction on various points of blood-supply involved in transposing the viscera into routine and handling of equipment the film integrates the the
presternal position
is
apparently
not
incompatible
Grey Turner, G. Newcastle med. J. 1945, 22, 21. 2. Clark, D. E. Ann. Surg. 1945. 121, 65. Taylor, H. Brit. J. Surg. 1945, 32, 394.
1. 3.
of the orderly to the evacuation scheme as a whole and will have a wide appeal on that account. The director was A. C. Hammond, and the running time is 31 minutes.
relationship
--
intrapericardial
RESECTION
IN the
OF THE
ŒSOPHAGUS
surgery
with the retention of an efficient circulation. The colour of the viscera remained good, and there was no postoperative necrosis. The blood-supply to the upper end of the oesophagus depends on the descending oesophageal branches of the inferior thyroid vessels, and the surgeon must remember and preserve these vessels during dissection of the oesophagus. The transthoracic approach in resection of the aesophagus and stomach for carcinoma is now well enough established in the United States to encourage Sweet4 of the Massachusetts General Hospital, Boston, to analyse the methods and late results in 127 ases. Of 85 cases of carcinoma of the stomach or lower oesophagus invading the cardia, 24 were found to be inoperable. Of the 42 middle oesophageal cases resection was possible and was done in 25 ; but high intrathoracic oesophagogastric anastomosis was not adopted in the hospital until the past year (1944), so only 11 of the 25 cases had this anastomosis done. For the remainder the Thorek operation was used. Of these 11 patients, 7 were still alive and apparently well at the end of 1944. Sweet reports encouraging results for resection of the cardia and immediate low anastomosis. Of 43 patients, 35 survived the operation and 19 were well a few months to 5 years afterwards. Whatever their technique, all writers on oesophageal resection emphasise’ the great importance of the preoperative and postoperative periods, and the greatly increased chance of success that has been provided by modern advances in anaesthesia and in the prevention and treatment of surgical shock. We are witnessing the evolution of a very severe and difficult surgical procedure, but one in which Grey Turner’s optimism seems likely to be justified. Since deep X-ray therapy and radium have failed us in this field, there is every justification for strenuous efforts to perfect operative cure. ’
of oesophageal cancer two major difficulties have to be faced-the approach to the posterior mediastinum, and the restoration of swallowing. The recent strides made in anaesthesia and the technique of chest surgery have combined to make exploration of the oesophagus much safer. Excision of the oesophagus is still a very major operation, but one which, in the desperate circumstances, certainly justifies the risk. Successful reconstruction of the oesophagus continues to tax all the ingenuity of the surgeon. Grey Turner1 in his George Haliburton Hume memorial lectures, briefly reviewed the evolution of cesophagoplasty, and concluded that the last word has not yet been said. He believes it to be much sounder surgery to restore the functional capacity of the original cesophagus than to supplant it by some new tube, however ingeniously it may be made. He advises the younger surgeons to pay most attention to those methods which make use of any healthy oesophagus which may remain after the resection; and maintains that the intrathoracic anastomosis between the fundus of the stomach and the cut end of the oesophagus will, in future, hold the field against the It’ is therefore interesting extrathoracic operations. to note which methods have recently been chosen by TRAVELLING FELLOWSHIPS IN MEDICINE other surgeons. THE Medical Research Council announce that preFrom Chicago, Clark2 describes a successful resection of the middle third of the oesophagus for a most extensive liminary arrangements have been made for the resunpgrowth. He completed the operation by anastomosing tion of Rockefeller medical fellowships, to be provided the stomach and oesophagus above the archof the aorta. from a fund entrusted to the Council bv the Rockefeller The free mobilisation of the stomach required for Foundation of New York. These fellowships are insuch a high junction involves considerable danger to its tended for graduates living in this country who have had viability. Clark suggests a technique for preserving the some training in research in clinical medicine or surgery, gastro-epiploic arteries which would allow complete or in some other branch of medical science, and who removal of the left gastric artery and the lymph-nodes are likely to profit by working at a centre in the United along the lesser curvature of the stomach without fear States, or elsewhere abroad, before taking up positions of impairing gastric circulation. He also recommends for higher teaching or research in this country. It is excision of a long segment of the phrenic nerve to ensure hoped that a limited number of awards can be made permanent paralysis of the left. side of the diaphragm. during the academic year 1945-46, depending on the In his own case he crushed the phrenic nerve just above availability of candidates and facilities for travelling. the diaphragm, and he noticed clinical and roentgeno4. Sweet, R. H. Ann. Surg. 1945, 121, 272. logical evidence of obstruction to the stomach where it passed through the diaphragm. The excursion of the THE AIR AMBULANCE SERVICE FiLMED.—The achieveleft diaphragm was full, pointing to an early and complete ments of the Casualty Air Evacuation Service during the nerve. of Hermon the London 3 of Taylor regeneration fighting in Europe were described in THE LANCET of Hospital argues that the shortest route between the Aug. 26, 1944, p. 278. The Medical Service of the Royal cricoid and the duodenum, with the patient, propped up Air Force has now completed a film, which, although in bed and his trunk flexed, is in the plane of the sternum. designed for training air orderlies engaged in this work, also He therefore designed his operation to include a preshows more clearly than words the tremendous organisation sternal anastomosis between the stomach and the stump which enabled the scheme to work so efficiently. Evacuation of the oesophagus. He has done this operation three of Castialties by Ail’ shows the Dakota transport adapted for times, with one death from accidental pneumothorax stretcher-carrying, and the medical equipment it carries for the orderly to use. Patients are loaded, and when the of the contralateral side of the chest. The mobilised plane is airborne the orderly’s duties are explained and stomach comes to lie directly under the skin in front described in detail, always with the emphasis that reassuring of the sternum, and there seems to be a risk of external the man is as important as tending his wounds. When the fistul2e forming through the anastomosis breaking down. plane lands we see the arrangements for reception and Taylor points out, however, that an external fistula is disposal, still with as much emphasis paid to comfort as to better than one within the thorax. The reduction of - medicine. Besides giving instruction on various points of blood-supply involved in transposing the viscera into routine and handling of equipment the film integrates the the
presternal position
is
apparently
not
incompatible
Grey Turner, G. Newcastle med. J. 1945, 22, 21. 2. Clark, D. E. Ann. Surg. 1945. 121, 65. Taylor, H. Brit. J. Surg. 1945, 32, 394.
1. 3.
of the orderly to the evacuation scheme as a whole and will have a wide appeal on that account. The director was A. C. Hammond, and the running time is 31 minutes.
relationship
--