66 T U B E R C L E January - February 1956

The survivors became a diminishing band of heroic fibrotics who look back proudly to the old days of good fellowship and even happiness in adversity. Later came the even more heroic group, bereft of man)" ribs, of phrenic nerves and transverse processes padding out their vests to hide their scoliotic figures.

Let us be grateful to all these human guinea-pigs by whose sufferings and fortitude hope was kept alive which enabled our surgeons and biochemists to step up a ladder runged with blood and sweat and tears. Now in fast diminishing numbers they remember the bad old days with a grati tude which is all the more touching when we look at the almost invisible scars and the s)wnmetry of the modern patient.

We recall those grim statistical tables , which would now be a statistician's nightmare but which showed how sometimes the multiple holed '.lungers' lived while the 'early ' cases beat our vain optimism by passing on into the next year 's obituary column.

The great names of Tudor Edwards, Roberts and Nelson are not yet forgotten but let us give a thought to those whose fortitude on the opera t ing table and after- wards under sandbags in pain and fearfulness kept such men and their physicians from despair. The victor 5, in 1918 over Germany was won not only during that autumn but by the great and bloody battles of the years before when the days were dark and the guns all too few, but 'Old Bill' was sticking it, with oaths and grouses.

Yours faithfully, WILLIAM C. FOWLER.

Postura l R e c u m b e n c y in P u l m o n a r y Tuberculos is

To the E d i t o r - 'Tubercle ' . S IR , - Drs Breathnach and Quinn (I955) have done a useful service in drawing attention to the value of postural rest in the t reatment of cavitation in pulmonary tuberculosis.

They do not, however, consider the important effect of posture during the hours of sleep in preventing spread of disease to a new area, and this is possibly the reason that two of their cases showed spread of disease to the mid-zone on the opposite side. I t should be more widely realized that posture, with or without raising the foot of the bed, is a simple way of preventing infection of new areas of lung in patients with unilateral cavitated disease.

I do not agree with their objection to the use of the lateral position based on the possible larger movement of the lower diaphragm. Herxheimer (1949) has related diaphragmatic movement to reserve air, and in g patient on complete rest in bed, movement of reserve air is unlikely to be called for: In the lateral position the dia- ph ragm on the lower side rises in the thorax, sometimes to a surprising extent, and this rise is accentuated when the patient is inclined head down.

On the remainder of the respiratory apparatus there is evidence of diminished movement. The mediastinum, if mobile, moves to the lower side. Double exposure chest x-rays in inspiration and expiration, show that rib movement is much less extensive on the lower as compared with the upper side. The bronchi are narrower on the lower side. Wade and Gilson (I95X) quoted unpublished work suggesting by bronchospirometric results that air movement was less on the lower side.

I suggest that such findings give fair evidence in favour of the use of the lateral position in posture.

Finally, Breathnaeh and Q uinn consider the open closure of cavities by slow reduc- tion in cavity size mainly by extraeavitary factors is the main mechanism of cavity closure. My experience is that while a minority close by retention of secretion and formation of a solid focus, more close leaving a linear or radiating type of scar.

J a c ~ r y - February 1956 T U B E R G L E 67

The rapid disappearance of a cavity and its frequent recurrence suggest that the mechanism of cavity closure in posture, is more frequently related to bronchial blockage, probably associated with the restricted movement of the postured side of the chest.

Yours faithfully, J . B. CLARK.

R e f e r e n c e s

Breathnach, C. H., and Q.uinn, E.J. (1955) Tubercle, xxxvL 362. Herxheimer, H. 0949) Thorax, iv, 65. ~Vadc, O. L., and Gilson, J. C. (195 Q Thorax, v L m 3.

Canterbury Retold To the Editor - 'Tubercle . ' SIR, - While surveying the contemporary scene I have been impressed that people still have their characteristics and oddities and I have felt impelled to add the following three to my sketches in the original tales.

At night there came into my hostel~. Some half a dozen in a company O f sundry doctors, happening then to fall In fellowship; they were post-graduates all. For as I gathered from their intercourse They came to London Town upon a course. While does their learned talk our table grace I write withal, while I have time and space, O f each of them as it appeared to me According to profession and degree.

A Practitioner there was from the south-west A merry fellow he with many a jest. Divers sly digs made he at politicians, At those that sat on boards, and statisticians. As sharp as sword his wit and observation. Muchknowledge did he cull from conversation: Thus druggists' travellers might enrich his learning,. Or colleagues discourse that he heard while journeying. To join his fellows on a course or conference Than reading books or journals was his preference. Prescription had he for esteem he won: Tha t justice must appear as well be done; Thus all his patients had full explanation Anent each treatment or investigation. Thereby he h a d a s I would dare to bet The finest practice in all Somerset.

A disillusioned wight did grouse and flown The Chest Physician he of a north town. He spoke of days when he prestige did know As one of worth - to wit the town T .O. No tribute owed he then to Regional Board, Unchallenged then his clinic's ovei'lord, With right to screen his patients or x - r a y - No radiologist to say him nay. And pneumothoraces he oft induced And refilled same till healing was produced.