1059 I do not think it would impose an impossible burden the school doctors. To skin-test a batch of people is not a very formidable or lengthy business, and it need not actually be done by a doctor though perhaps The task of interhe or she should read the result. preting the films of the positive reactors would not fall on the school doctor. It may be argued that it would be better to X-ray school leavers " just to make sure " ; but this would be to belittle the value of the Mantoux test, and to .deflect attention from the need for X-ray examination when Mantoux-conversion takes place. Everyone working in tuberculosis must be sadly familiar with the false sense of security engendered by the single X ray, taken .six months or a year before, which was " all right," ,and therefore led to disastrous delay in seeking advice when symptoms arose. It is true that a misleading negative reading may be found while allergy is developing, or because the patient has measles or miliary tuberculosis ; but there are snags with any routine test. The formidable part of the business would be in keeping touch with and re-testing the negative reactors after they have left school, and have become so very elusive. Here we might take heart from the satisfactory change in the public mind towards diphtheria inoculation, and hope that this aspect of the campaign against tuberculosis will also be generally accepted. Skin-testing is less on
likely to create repeated " blind if
tuberculosis-phobia than resort to X-ray examinations. In any case, into its own in this country, extensive
will have to be done. RUTH DINGLEY.
Darvell Hall Sanatorium, Sussex.
AN IMPROVISED MECHANICAL RESPIRATOR
SiR,—The following account of an improvisation to assist protracted treatment and nursing in a box-type mechanical respirator may be of interest. A girl, aged 14, was admitted to the Coventry Isolation Hospital on June 18, 1949, with acute anterior poliomyelitis involving all the limbs and the back. Next morning the paralysis had spread to all the muscles except those supplied by the cranial nerves and the flexors of the fingers. Respiration, diaphragmatic and intercostal, was grossly impaired and rapidly became virtually non-existent. The patient was placed in a Both (Nuffield) box-type respirator and remains in it still. To date there is some return of power in hands and wrists and of a small but inadequate degree of intercostal The patient still cannot remain without the movement. assistance of the respirator for more than a minute, or at the outside two minutes, without grave distress.
After a few weeks the difficulty ofgiving physiotherapy to the limbs became an insistent and worrying problem. To provide oxygen through an Oxford inflater for longish periods seemed hardly the solution, though this apparatus had proved very useful, especially in the earlier weeks, in making more feasible brief nursing procedures-e.g., changing the bedpan-which had to be carried out with the utmost dispatch by an organised and practised team
of nurses and doctors. On the other hand, to transfer the patient wholly from her safe and life-saving Both respirator to some other type of respirator, which might leave the limbs accessible, was much too risky. Even if one could get such a respirator applied in time, which was very doubtful, it was uncertain whether the patient would tolerate it. With this problem in mind, and having read Dr. Ursula Blackwell’s article in The Lancet of July 16, 1949 (p. 99), the patient’s father, who is connected with the Coventry engineering industry, and one of us (J. F. G.) visited the Western Hospital,. Fulham, where they were kindly allowed to inspect the hospital’s comprehensive collection of mechanical respirators. In particular from their Stille respirator we acquired the basic idea of a rigid suction chamber sealing over the patient’s trunk, and we noted how the Stille shield had been adapted by the hospital staff with a Both motor and bellows unit. The father then set to work, with the help of a firm of patternmakers, to construct a wooden mechanical respirator that would (1) fit over the chest and upper half of the abdomen only ; (2) leave the limbs free ; (3) fit over the respirator mattress so that the patient, having been drawn out, could yet remain secure in the Both respirator attachments, and if anything went amiss, could be promptly sealed up again in the box respirator in a matter of seconds ; and (4) work off the box-respirator motor and bellows unit. A rubber valve and manometer similar to the Both were also planned to be fitted. The sealing of the respirator round the patient to make an adequately airtight junction was the greatest single difficulty. It was solved by two devices : (1) The new respirator was made to measure, both to the patient and to the Both respirator mattress. Malleable lead strips were quickly moulded round the upper part of the chest, the axillae, and the middle of the abdomen to obtain the relevant silhouettes. (2) A thick layer of ’Sorbo ’ rubber was fixed to those margins of the respirator which fit on to the patient. The sorbo was found to be appreciably porous to air, so, to overcome this, thin rubber aprons were fitted to the inside of the new respirator and carried round the sorbo. The free edge of this rubber sheeting, when tucked round the patient, assisted the sealing. This seal was completed by several pads of cotton-wool and (underneath) by the sorbo mattress supplied with the box respirator. The rubber bedpan, on which the patient lies, is removed when the patient is in the new respirator. To ensure that the respirator worked, and to make adjustments, experiments were made with a volunteer about the same size as the patient. The respirator (see figure) is used daily for about twenty minutes, during which period the patient has massage and passive movements. The longest time the new respirator has so far been in use is half an hour, but there seems to be no reason why it should not remain on for very much longer, given full psychological tolerance. Unfortunately, this is not yet forthcoming, partly because the patient feels safer in her box respirator, and partly because she associates the new respirator with a degree of pain and discomfort inseparable at present from her passive movements. There is also a sensation of pressure across the abdomen when the respirator is working efficiently, especially during the phase of greatest suction. The new respirator can be applied effectively in a few seconds by a minimum of four persons, but the patient must be lying squarely and centrally on her sorbo mattress, and the operators improve with practice. Of the four persons, two handle the respirator, one manages the arms, and the fourth attends to the hose and bellows. The respirator works well, but rather more suction is needed (18-20 cm. of water) to maintain the patient’s colour than in the box respirator (14 cm. of water), possibly because, owing to its shape and limited size.
1060 chest and abdominal movements are less comprehensive in the new respirator. It is important for the patient not to have a full stomach when the new respirator is applied ; omission to take this precaution seems to lead to cyanosis and nausea. Presumably in the patient’s prone position the stomach lies high and is forced upwards against the diaphragm by the closely fitting respirator. Unless enough spontaneous respiration returns in the near future to make mechanical aid unnecessary, our ultimate aim is to wean the patient from the box respira,tor into the new respirator. Once this stage was reached she could be transferred to a bed suitably adapted, and this would be a great encouragement to her. It remains to praise the parents’ resource and perfect cooperation, and to say that nothing could have been achieved without the constant assistance of Miss H. O’Sullivan, the sister in charge of the ward, the night sister, and all the other nurses who have handled the
patient. Coventry Isolation Hospital.
J. F. GALPINE J. W. BROWN.
SiR,-In your annotation of Nov. 19 Dr. Bodley Scott is quoted as saying that aspiration biopsy of lymphnodes " will avoid the full operative panoply which surgeons deem necessary for excision of the smallest and most superficial lymph-node." The reader must assume that you have quoted correctly, and I am afraid that the tone of Dr. Bodley Scott’s statement, coupled with his eminence as a physician, may lead some of the younger surgeons-or even a rash young physician, if such a contradiction exists-to proceed to the removal of a lymph-node without appreciating the possible danger to the patient. Surgeons are only too apt to remove nodes before hsematological and serological examinations have been completed, but speaking as a pathologist who has seen what can happen, I would commend wholeheartedly the surgeon who approaches this operation seriously and with every precaution taken. It is no doubt Dr. Bodley Scott’s misfortune to have a jesting remark, probably made with a smile at some surgical friend, quoted as if it were a considered opinion. Indeed, his interest in needle biopsy is certainly due to his full appreciation of the seriousness of this sometimes too lightly undertaken operation. A. C. LENDRUM. Dundee. IRON POISONING
SiR,—May I offer a footnote to your leading article of Nov. 12 about iron poisoning ? To avoid further tragedies, it is necessary that not only the patient who handles the tablets, but also the doctor who prescribes them, should be aware of the danger. The manufacturers of the proprietary ferrous sulphate tablets (’ Fersolate’) taken in the New Malden case print a warning on the container, but there is no such warning on the container in which the pharmacist issues the tablets on prescription. In this case the practitioner was consulted within five minutes and again after an hour and a half, and said that there was no danger and that the infant would be all right. Replying to questions at the inquest about the need for more attention, he said " If, as I thought, the tablets had contained no more than ferrous sulphate, it would not have been necessary." The pathologist said that previous fatalities had occurred from ferrous sulphate, but this was " perhaps not generally known." The coroner summed up, naturally, that " iron and iron sulphate were not generally regarded as poisons ; it was not generally known, even perhaps among doctors, that fatal poisoning could occur." If this is so, more inquests seem probable. HENRY PORTER. West W’imbledon.
SiR,-]E)r. Sheldon’s article of Nov. 12 is of especial I know of two sisters who developed me. lipodystrophia progressiva after strenuous efforts at weight-reduction. The younger, in whom the signs were first noticed about the age of 23, became pregnant when she was 34 and this brought about a redeposition of fat
in the affected areas. I have been unable to trace any reference to the effect of pregnancy on lipodystrophy. R. N. HERSON. Grays, Essex. THE DOCTOR’S CREED
SiR,-May I, as theological student and doctor, point out the weakness of Professor Platt’s position He cannot accept the Christian creed, because God tolerates evil. Is this not analogous to the situation of a surgeon presented with signs and symptoms suggesting appendicitisAccording to how these add up, he will operate or he will not. If he operates he sees for himself ; if he does not, the death of the patient may also tell him. He could escape the issue by saying As I do not know why this patient has appendicitis, I will not operate but he would still be unable to escape the effects of his "
decision. Either God exists or He does not. He claims to have revealed Himself in Nature, in the Old and New Testament, and in the person of Jesus Christ. A study of these three leads us to believe that God and Christ do exist. As in the case of appendicitis we can never be absolutely sure, but there is sufficient evidence to lead us to believe, just as the evidence before the surgeon is sufficient to lead him to operate. lives must change, and by shall influence others. It may not be too late to build a world in which Love, Justice, If we do not and Brotherly Kindness predominate. believe, what check is there, or need there be, on our putting ourselves first and striving to further our ends by fair means or foul ? " Life is short and we are a long time dead." Since 1918 there has been a gradual putting into’practice of the latter formula-we see the results If
our words and
SiR,—Professor Platt is wrong when he writes : " We must either believe that (God) is powerless to intervene against the evils of Satan and of man, or that they are of His own creation," unless he is restricting the use of the word " power " to miraculous intervention with the Laws of Nature. It is this meaning of the Power of God that the scientist is led by his training and experience to reject, but there is another kind of power. If God has created man with free will (the possession of which Professor Platt appears to admit) to choose between responding to His will or to that of Satan, we are engaged in a momentous struggle of the will or spirit and our highest fulfilment is to be found in obedience to the will of God. If God is true to His stake in man, and will only give help in the sphere of the spirit to those who freely choose to seek it, we need not be surprised at evils on the material plane which may stem directly or indirectly from our ignorance or choice of evil. We can seek to fight these evils, drawing strength to our spirits from God, without expecting miraculous intervention, except for " miracles" of the spirit, such as doctors are so often privileged to see when suffering is cheerfully accepted and overcome. In this way, the power of God may be seen to be more powerful than that of evil in a very real way. If, on the other hand, God has retained the power to intervene miraculously on the material plane where