- Email: [email protected]
BILATERAL BRONCHIAL FOREIGN BODIES
769
(K. M.) has done part of this work with the a grant from the Geoffrey Duveen Trust. We are very grateful to Messrs. Pfizer Ltd. for providing the two sets of capsules and the nasal insufflators, and to Dr. M. J. H. Smith for help with the statistics. One of
pair felt that the hay-fever had benefited from the snuff. While this trial was in progress a, further 18 patients (8 male and 10 female, aged 13-50) with hay-fever were under observation in our clinics. They had all been treated by pollen desensitisatioii and were provided with anti-histamine tablets (chlorprophenpyridamine maleate 4 mg.) for relief of symptoms. Although they do not form a control group, we recorded the results of their treatment for comparison with our other patients. Desensitisation had continued until the end of May, 1956, and from May 18 to May 31 these 18 patients recorded 4 days of hay-fever (mean 0.22 days) and used only (i anti-histamine tablets (mean 0.33 tablets). From June 1 to June 30 they had 84 days of hay-fever and used 101 anti-histamine tablets (means 4-7 hay-fever days and 5-6 tablets). During the first week in July they had 21 days of hayfever (mean 1.2 days) and used 35 anti-histamine tablets (mean 1.9 tablets). 14 of these patients commented that they had been almost completely free from hay-fever, and 4 had experienced fairly good relief of symptoms. The results are summarised in the accompanying table.
only
1 of this
us
assistance of
REFERENCES
Anderson, J. R., Ogden, H. D. (1956) Ann. Allergy. 14, 44. Arbesman, C. E., Ehrenreich, It. J. (1956) J. Allergy, 27, 297. Brown. E. B., Seideman, T. (1956) Ibid, p. 305. Cotes. P. M., McLean, A., Sayer, J. B. (1956) Lancet, ii, 807. Feinberg, A. R., Feinberg, S. M. (1956) J. Amer. med. Ass. 160, 264. Friedlander, S. (1956) J. Allergy, 27, 282. Herxheimer, H., McAllen, M. (1956) Lancet. i, 537. Toogood, J. H. (1956) Canad. med. Ass. J. 74, 700.
BILATERAL
M.D.
BRONCHIAL BODIES
FOREIGN
T. SEMPLE Glasg., F.R.C.P.E., M.R.C.P.
CONSULTANT PHYSICIAN, VICTORIA
INFIRMARY,
GLASGOW
W. J. O. PAGE F.R.C.S.E., D.L.O.
Discussion CONSULTANT E.N.T.
Although we deliberately administered a small dose of prednisolone to avoid the possibility of undesirable sideeffects, our results suggest that the inhalation of prednisolone snuff is a promising method of controlling the symptoms of hay-fever. The 1956 hay-fever season was unusually mild, but this circumstance applied to both groups of patients, and pollen counts have shown that the peak of the season occurred during the period of nasal therapy from June 22 to June 28 (11. A. Hyde, personal communication). Both the symptoms of rhinitis and the itching and congestion of the conjunctive were relieved by the inhalation of prednisolone. A similar observation was made by Herxheimer and McAllen (1956) using hydrocortisone snuff for hay-fever. (’otes et al. (1956) have shown that the inhalation of 45 mg. of hydrocortisone powder through the month produces an increased urinary excretion of 17-hydroxycorticosteroids, suggesting that hydrocortisone is absorbed systemic ally when inhaled from a powder spray. It seems unlikely, in view of the small quantity of prednisolone used in our trial, that sufficient of the drug had been absorbed to exert a general effect ; but this point requires further investigation. The 5 patients treated with prednisolone who had bronchial asthma in addition to hay-fever are so few that it is impossible to draw any definite conclusion about the efficacy of prednisolone snuff in bronchial asthma. The relief of symptoms in the group treated by inhalation of prednisolone compares satisfactorily with the experience of the patients who had been desensitised to pollen. The latter therapy, though usually effective, is somewhat undesirable because of its potential danger and the necessity of weekly injections for three months before the start of the hay-fever season. We therefore consider that our results warrant a more extensive trial of prednisolone snuff, which may provide a simple, safe, and effective remedy for hay-fever.
SURGEON,
CUMBERLAND
INFIRMARY,
CARLISLE
THE rarity of such an occurrence, with the unusual and misleading bronchoscopic appearance produced, prompts
report this case of simultaneous inhalation into the and left lower-lobe bronchi respectively of a metallic right radio-opaque and a plastic radiotranslucent foreign body. The latter remained in situ unrecognised for ten months despite several bronchoscopic inspections. us
to
Case-report A farmer, aged 35, was dancing at a Christmas Eve party when he inhaled part of a blow-out " whistle (see figure). ‘‘
Forceful exhalation produced a slight whistling sound from the right side of his chest. On arrival at hospital about two hours later, radiography revealed the presence of a metallic reed in the lower lobe of his right lung. At bronchoscopy the reed was easily found and removed without difficulty. The left bronchus was not inspected. The patient’s statement that he had inhaled a plastic whistle was discounted because of his somewhat convivial state on admission and the absence of any abnormal clinical or radiological signs at the time of discharge from hospital three days later. About two months later he developed a wheeze and later a cough with occasional bloodstained sputum and slight leftsided chest pain. Further radiography during the ensuing months did not reveal any abnormality. Nine months after the incident a chest physician reported excellent general health, a recurrent dry cough, and rhonchi on auscultation, chiefly on the left side, with good air entry to the left lung. The result of bronchoscopy by the chest physician at this time was reported as follows : " Marked foetor. In the left stem bronchus, below the left upper lobe orifice, there is gangrene. The whole bronchus from this level down appears It is avascular and completely covered by to be involved. white slough. There is a sharp line of demarcation between this and the proximal part of the main bronchus, which is entirely healthy. Basal orifices can just be seen, and there is no
foreign body."
Summary The effect of the inhalation of prednisolone snuff was compared with that of placebo snuff in patients with
hay-fever. 38 patients were
studied : 18 in the prednisolone group and 20 in the control group. Treat rnent was given from June 1 to June 30, 1956. The results suggest that the daily inhalation of 2 mg. of prednisolone snuff is of considerable value in the control of symptoms due to hay-fever. No side-effects were observed after the inhalation of prednisolone, and this treatment is considered to be worthy of more extensive clinical trial.
-
Type
of
whistle
responsible for inharation of
two
foreign bodies shown.
770
Accordingly
the
unit, where he
patient
was
was
described
transferred to a chest surgery as being in excellent general
condition and apyrexial, with a wheeze present over both lungs but loudest at the left base. Nothing abnormal was found on radiography. Bronchoscopy was repeated, and a similar report was given of the appearances in the left lowerlobe bronchus. Coliform organisms were grown from the bronchus, and the patient was given a course of chloramphenicol. Once more he was submitted to bronchoscopy palpation (by a fourth bronchoscopist) and on this occasion " with forceps revealed the " gangrenous slough to be a tubular piece of yellow plastic, the original mouth-piece of the whistle. This was removed with some difficulty. It had fitted the left lower-lobe bronchus snugly between the apical and distal segmental bronchial orifices, thus producing no obstruction and allowing a clear view of all segmental orifices. The patient’s symptoms were relieved immediately, and the wheeze
disappeared
at once.
Comment The only previous report that we have been able to discover of bilateral bronchial foreign bodies is that of Orton (1924), who removed half a peanut from the right stem bronchus of a child and the other half two days later from the left side. Here also the left bronchial tree was not inspected at the original bronchoscopy. Orton states that Chevalier Jackson at that time had seen three cases in which peanuts acted as bilateral bronchial foreign bodies. Examining our patient’s X-ray films in retrospect we could just make out the faint outline of the plastic tube. It was very faintly radio-opaque, whereas the metal reed was, of course, distinctly so. It was unsuspected because of the raritv of simultaneous inhalation of dual foreign bodies and the very faint radio-opacity ; it was undiscovered at the first examination because the examination was incomplete, the left bronchus not being inspected. The appearances at two subsequent broncho-
Preliminary
Communication
NON-TUBERCULOUS JUVENILE BRONCHIECTASIS : A VIRUS DISEASE ? NoN-TUBERCULOUS bronchiectasis in the child is usually ascribed to some ill-defined episode of pyogenic bronchitis, perhaps complicating a specific fever. We suggest that, in a substantial number of such cases, the lesion is due to chronic infection of the bronchi with the adenovirus (A.P.C. virus), and that some of the characteristics of the lesion are due to the persistent presence of virus. This suggestion arose from the demonstration to us by Dr. W. F. H. Jarrett, of the veterinary pathology department of Glasgow University, of the lesions of the common respiratory disease of cattle which he has described1 under the name of "cuffing pneumonia" and has suggested might well be of virus ætiology. Since this work was begun, the description by Junes et a1.2 of similar lung changes in the rat, which they ascribe to infection by the Nelson rat-lung pneumonia virus, adds further support. Jarretthas shown that the cattle disease begins in the calf in an acute form with mild peribronchial lymphocytic infiltration, passes through a chronic stage in which lymphoid hyperplasia is the main feature, and ultimately develops into bronchiectasis with fibrosis. From early 1956 our morphological investigation of lobectomy specimens from patients with bronchiectasis indicated strongly the presence of a similar process in human lungs. In brief, the dominant feature present in about three-quarters of the cases was lymphoid hyperplasia affecting the hilar nodes and irregularly narrowing the lumen throughout the whole length of the bronchial 1. Jarrett, W. F. H. J. Path. Bact. 1954, 67, 441. 2. Innes, J. R. M., McAdams, A. J., Yevich, P. 1956, 32, 141.
Amer. J. Path.
scopic examinations, some months after the original one, did not arouse suspicion of this second foreign body because of apparent disease within the left bronchus, the preservation of a. clear lumen, and possibly because the bronchoscopists were lens familiar with the details of the original incident and examination. The immediate disappearance of the generalised bronchospasm on the removal of the offending foreign body was very striking. It brought to mind the reflex bronchospasm not infrequently found in patients with localised disease in the bronchus or in the lung. In such patients, perhaps also having chronic tuberculosis, bullous emphysema., or bronchial adenoma, operation may be long delayed because of associated " generalised bronchitis," only to find that the rhonchi, which have failed to respond even partly to medical measures, have disappeared immediately after resection. It is worth remembering that generalised, as distinct from local, bronchospasm may have a reflex aetiology from
a
focal
source
of irritation.
Summary A man inhaled the proximal end of a toy whistle. The metallic radio-opaque reed was removed from the right lower-lobe bronchus about four hours after the incident, but the plastic mouth-piece remained in the left lower-lobe bronchus for ten months and was recognised and removed at a, fourth bronchoscopy. No localising radiological signs were produced by this tubular plastic foreign body, but reflex bronchospasm was relieved immediately by its removal.
grateful to Mr. Bruce Dick, of the thoracic unit, for his encouragement and to nublish. We
are
Hospital
Hairmyres permission
REFERENCE Orton. H. B. (1924) Laryngoscope, 34, 811.
ramifications ill the affected segments or lobes (see figure). In 1948 Cruickshank3 investigated bronchiectasis in rats and suggested that lymphoid hyperplasia might 3.
Cruickshank, A. H. J. Path. Bact. 1948, 60, 520.
Characteristic hyperplastic lymphoid tissue ensheaths medium and small bronchi and extends almost to pleural surface. Lung parenchyma is not severely diseased. (Haematoxyjin and eosin. x
10.)
(K. M.) has done part of this work with the a grant from the Geoffrey Duveen Trust. We are very grateful to Messrs. Pfizer Ltd. for providing the two sets of capsules and the nasal insufflators, and to Dr. M. J. H. Smith for help with the statistics. One of
pair felt that the hay-fever had benefited from the snuff. While this trial was in progress a, further 18 patients (8 male and 10 female, aged 13-50) with hay-fever were under observation in our clinics. They had all been treated by pollen desensitisatioii and were provided with anti-histamine tablets (chlorprophenpyridamine maleate 4 mg.) for relief of symptoms. Although they do not form a control group, we recorded the results of their treatment for comparison with our other patients. Desensitisation had continued until the end of May, 1956, and from May 18 to May 31 these 18 patients recorded 4 days of hay-fever (mean 0.22 days) and used only (i anti-histamine tablets (mean 0.33 tablets). From June 1 to June 30 they had 84 days of hay-fever and used 101 anti-histamine tablets (means 4-7 hay-fever days and 5-6 tablets). During the first week in July they had 21 days of hayfever (mean 1.2 days) and used 35 anti-histamine tablets (mean 1.9 tablets). 14 of these patients commented that they had been almost completely free from hay-fever, and 4 had experienced fairly good relief of symptoms. The results are summarised in the accompanying table.
only
1 of this
us
assistance of
REFERENCES
Anderson, J. R., Ogden, H. D. (1956) Ann. Allergy. 14, 44. Arbesman, C. E., Ehrenreich, It. J. (1956) J. Allergy, 27, 297. Brown. E. B., Seideman, T. (1956) Ibid, p. 305. Cotes. P. M., McLean, A., Sayer, J. B. (1956) Lancet, ii, 807. Feinberg, A. R., Feinberg, S. M. (1956) J. Amer. med. Ass. 160, 264. Friedlander, S. (1956) J. Allergy, 27, 282. Herxheimer, H., McAllen, M. (1956) Lancet. i, 537. Toogood, J. H. (1956) Canad. med. Ass. J. 74, 700.
BILATERAL
M.D.
BRONCHIAL BODIES
FOREIGN
T. SEMPLE Glasg., F.R.C.P.E., M.R.C.P.
CONSULTANT PHYSICIAN, VICTORIA
INFIRMARY,
GLASGOW
W. J. O. PAGE F.R.C.S.E., D.L.O.
Discussion CONSULTANT E.N.T.
Although we deliberately administered a small dose of prednisolone to avoid the possibility of undesirable sideeffects, our results suggest that the inhalation of prednisolone snuff is a promising method of controlling the symptoms of hay-fever. The 1956 hay-fever season was unusually mild, but this circumstance applied to both groups of patients, and pollen counts have shown that the peak of the season occurred during the period of nasal therapy from June 22 to June 28 (11. A. Hyde, personal communication). Both the symptoms of rhinitis and the itching and congestion of the conjunctive were relieved by the inhalation of prednisolone. A similar observation was made by Herxheimer and McAllen (1956) using hydrocortisone snuff for hay-fever. (’otes et al. (1956) have shown that the inhalation of 45 mg. of hydrocortisone powder through the month produces an increased urinary excretion of 17-hydroxycorticosteroids, suggesting that hydrocortisone is absorbed systemic ally when inhaled from a powder spray. It seems unlikely, in view of the small quantity of prednisolone used in our trial, that sufficient of the drug had been absorbed to exert a general effect ; but this point requires further investigation. The 5 patients treated with prednisolone who had bronchial asthma in addition to hay-fever are so few that it is impossible to draw any definite conclusion about the efficacy of prednisolone snuff in bronchial asthma. The relief of symptoms in the group treated by inhalation of prednisolone compares satisfactorily with the experience of the patients who had been desensitised to pollen. The latter therapy, though usually effective, is somewhat undesirable because of its potential danger and the necessity of weekly injections for three months before the start of the hay-fever season. We therefore consider that our results warrant a more extensive trial of prednisolone snuff, which may provide a simple, safe, and effective remedy for hay-fever.
SURGEON,
CUMBERLAND
INFIRMARY,
CARLISLE
THE rarity of such an occurrence, with the unusual and misleading bronchoscopic appearance produced, prompts
report this case of simultaneous inhalation into the and left lower-lobe bronchi respectively of a metallic right radio-opaque and a plastic radiotranslucent foreign body. The latter remained in situ unrecognised for ten months despite several bronchoscopic inspections. us
to
Case-report A farmer, aged 35, was dancing at a Christmas Eve party when he inhaled part of a blow-out " whistle (see figure). ‘‘
Forceful exhalation produced a slight whistling sound from the right side of his chest. On arrival at hospital about two hours later, radiography revealed the presence of a metallic reed in the lower lobe of his right lung. At bronchoscopy the reed was easily found and removed without difficulty. The left bronchus was not inspected. The patient’s statement that he had inhaled a plastic whistle was discounted because of his somewhat convivial state on admission and the absence of any abnormal clinical or radiological signs at the time of discharge from hospital three days later. About two months later he developed a wheeze and later a cough with occasional bloodstained sputum and slight leftsided chest pain. Further radiography during the ensuing months did not reveal any abnormality. Nine months after the incident a chest physician reported excellent general health, a recurrent dry cough, and rhonchi on auscultation, chiefly on the left side, with good air entry to the left lung. The result of bronchoscopy by the chest physician at this time was reported as follows : " Marked foetor. In the left stem bronchus, below the left upper lobe orifice, there is gangrene. The whole bronchus from this level down appears It is avascular and completely covered by to be involved. white slough. There is a sharp line of demarcation between this and the proximal part of the main bronchus, which is entirely healthy. Basal orifices can just be seen, and there is no
foreign body."
Summary The effect of the inhalation of prednisolone snuff was compared with that of placebo snuff in patients with
hay-fever. 38 patients were
studied : 18 in the prednisolone group and 20 in the control group. Treat rnent was given from June 1 to June 30, 1956. The results suggest that the daily inhalation of 2 mg. of prednisolone snuff is of considerable value in the control of symptoms due to hay-fever. No side-effects were observed after the inhalation of prednisolone, and this treatment is considered to be worthy of more extensive clinical trial.
-
Type
of
whistle
responsible for inharation of
two
foreign bodies shown.
770
Accordingly
the
unit, where he
patient
was
was
described
transferred to a chest surgery as being in excellent general
condition and apyrexial, with a wheeze present over both lungs but loudest at the left base. Nothing abnormal was found on radiography. Bronchoscopy was repeated, and a similar report was given of the appearances in the left lowerlobe bronchus. Coliform organisms were grown from the bronchus, and the patient was given a course of chloramphenicol. Once more he was submitted to bronchoscopy palpation (by a fourth bronchoscopist) and on this occasion " with forceps revealed the " gangrenous slough to be a tubular piece of yellow plastic, the original mouth-piece of the whistle. This was removed with some difficulty. It had fitted the left lower-lobe bronchus snugly between the apical and distal segmental bronchial orifices, thus producing no obstruction and allowing a clear view of all segmental orifices. The patient’s symptoms were relieved immediately, and the wheeze
disappeared
at once.
Comment The only previous report that we have been able to discover of bilateral bronchial foreign bodies is that of Orton (1924), who removed half a peanut from the right stem bronchus of a child and the other half two days later from the left side. Here also the left bronchial tree was not inspected at the original bronchoscopy. Orton states that Chevalier Jackson at that time had seen three cases in which peanuts acted as bilateral bronchial foreign bodies. Examining our patient’s X-ray films in retrospect we could just make out the faint outline of the plastic tube. It was very faintly radio-opaque, whereas the metal reed was, of course, distinctly so. It was unsuspected because of the raritv of simultaneous inhalation of dual foreign bodies and the very faint radio-opacity ; it was undiscovered at the first examination because the examination was incomplete, the left bronchus not being inspected. The appearances at two subsequent broncho-
Preliminary
Communication
NON-TUBERCULOUS JUVENILE BRONCHIECTASIS : A VIRUS DISEASE ? NoN-TUBERCULOUS bronchiectasis in the child is usually ascribed to some ill-defined episode of pyogenic bronchitis, perhaps complicating a specific fever. We suggest that, in a substantial number of such cases, the lesion is due to chronic infection of the bronchi with the adenovirus (A.P.C. virus), and that some of the characteristics of the lesion are due to the persistent presence of virus. This suggestion arose from the demonstration to us by Dr. W. F. H. Jarrett, of the veterinary pathology department of Glasgow University, of the lesions of the common respiratory disease of cattle which he has described1 under the name of "cuffing pneumonia" and has suggested might well be of virus ætiology. Since this work was begun, the description by Junes et a1.2 of similar lung changes in the rat, which they ascribe to infection by the Nelson rat-lung pneumonia virus, adds further support. Jarretthas shown that the cattle disease begins in the calf in an acute form with mild peribronchial lymphocytic infiltration, passes through a chronic stage in which lymphoid hyperplasia is the main feature, and ultimately develops into bronchiectasis with fibrosis. From early 1956 our morphological investigation of lobectomy specimens from patients with bronchiectasis indicated strongly the presence of a similar process in human lungs. In brief, the dominant feature present in about three-quarters of the cases was lymphoid hyperplasia affecting the hilar nodes and irregularly narrowing the lumen throughout the whole length of the bronchial 1. Jarrett, W. F. H. J. Path. Bact. 1954, 67, 441. 2. Innes, J. R. M., McAdams, A. J., Yevich, P. 1956, 32, 141.
Amer. J. Path.
scopic examinations, some months after the original one, did not arouse suspicion of this second foreign body because of apparent disease within the left bronchus, the preservation of a. clear lumen, and possibly because the bronchoscopists were lens familiar with the details of the original incident and examination. The immediate disappearance of the generalised bronchospasm on the removal of the offending foreign body was very striking. It brought to mind the reflex bronchospasm not infrequently found in patients with localised disease in the bronchus or in the lung. In such patients, perhaps also having chronic tuberculosis, bullous emphysema., or bronchial adenoma, operation may be long delayed because of associated " generalised bronchitis," only to find that the rhonchi, which have failed to respond even partly to medical measures, have disappeared immediately after resection. It is worth remembering that generalised, as distinct from local, bronchospasm may have a reflex aetiology from
a
focal
source
of irritation.
Summary A man inhaled the proximal end of a toy whistle. The metallic radio-opaque reed was removed from the right lower-lobe bronchus about four hours after the incident, but the plastic mouth-piece remained in the left lower-lobe bronchus for ten months and was recognised and removed at a, fourth bronchoscopy. No localising radiological signs were produced by this tubular plastic foreign body, but reflex bronchospasm was relieved immediately by its removal.
grateful to Mr. Bruce Dick, of the thoracic unit, for his encouragement and to nublish. We
are
Hospital
Hairmyres permission
REFERENCE Orton. H. B. (1924) Laryngoscope, 34, 811.
ramifications ill the affected segments or lobes (see figure). In 1948 Cruickshank3 investigated bronchiectasis in rats and suggested that lymphoid hyperplasia might 3.
Cruickshank, A. H. J. Path. Bact. 1948, 60, 520.
Characteristic hyperplastic lymphoid tissue ensheaths medium and small bronchi and extends almost to pleural surface. Lung parenchyma is not severely diseased. (Haematoxyjin and eosin. x
10.)