- Email: [email protected]
PREVENTION OF ULCERATION DURING USE OF CUFFED TRACHEOSTOMY TUBE
1074 be reweighed as the weight per vial may differ much as 15-20%. We have calculated that the dose used by Dr. Purtilo and his colleagues was 700-800 {g. per culture tube, or 350-400 g. per ml., which in our experience is well above the peak dose response for the type of lymphocyte tested. We too have recorded less reactivity in lymphocytes from pregnant women versus non-pregnant controls at such a relatively high P.H.A. dose, but the differences were not significantly different between any of the trimester groups and non-pregnant controls. Our calculations, based on the data in the paper by Dr. Purtilo and colleagues, have shown that the 1st and 2nd trimester groupings were not significantly different from the nonpregnant controls, although the 3rdtrimester was (r > 0’001). We have found that pregnant women’s lymphocytes at optimal, and particularly at suboptimal, P.H.A. doses are significantly more reactive than control lymphocytes. We intend to publish this work soon. Testing lymphocyte reactivity in other situations at single P.H.A. doses has led to disparate findings by other investigators. By using a dose-response curve, we have been able to reconcile many discrepant findings on the responsiveness of human cord-blood lymphocytes to P.H.A. and have demonstrated that relations changed according to the dose used.A problem in comparing the response of lymphocytes to P.H.A. of Down’s syndrome patients and normal controls3 was similarly resolved.
P.H.A. must
by
as
Department of Obstetrics and Gynecology. Section
on
Hematology
MARTIN C. CARR.
and
Immunology, Department of Medicine, University of California School of Medicine, San Francisco, California 94122, U.S.A.
DANIEL P. STITES.
BRODRICK’S CORONER
SIR,-I wonder if the full implication of Mr. Justice Brodrick’s report on Medical Certification and Coroners has been appreciated by the profession or was indeed by its compiling committee. Very briefly, Brodrick proposes to keep the title of coroner but unbenches him in every other respect. He loses his rights of committal, he becomes subject to appeal and stricter rules of evidence, his jury is deemed unnecessary, he must not name culprits, his riders are to be curtailed, he is even to lose his officer. You might wonder what is left. Brodrick’s coroner in fact turns away from the judiciary and heads towards the N.H.S. His criminal function does not now apply (nearly all his reported cases are " natural " deaths), his main place is on the social road of accurate death certification (admittedly erratic at times); he is therefore to be handier at arranging necropsies, and less ready to conduct inquests, he is to act with more discretion and sympathy, and that obvious policeman, his officer, is to be replaced by secretaries and a " designated officer ", who is to be N.H.S. consultant or S.A.M.O. rank. To complete the " integration ", all necropsies are to be done in N.H.S. hospitals by N.H.S.
pathologists. The Brodrick report therefore discloses an important trend in our social future and one which I cannot see the clinical wing of the profession wanting to oppose. But, if the coroner is to become a death-certification officer, it has to be accepted, first, that the homicide’s softest target is the man or woman who already carries a death diagnosis in his medical record; second, that all deaths should be vetted in the same office; and, third, that the Human Tissue Carr, M. C., Stites, D. P., Fudenberg, H. H. Cell. Immun. (in the press). 3. Rigas, D. A., Elasser, P., Hetch, F. Int. Archs Allergy appl. Immun. 1970, 39, 587. 2.
Act, 1961, requires absorption into the new idea. This measure gave dangerous rights of organ and necropsy permission to a surviving spouse or any surviving "
careful to avoid the coroner’s established of summary necropsy. In its turn, the Brodrick right committee has failed to see that the Human Tissue Act is a clinical deterrent and likely falsifier of death certificates. Fully implemented, the idea of a Death Enquiry Office within the area health board becomes a logical development, " to survey all natural " deaths (the term includes suicides, anaesthetic and other drug-contributed deaths, dropdeads, and industrial effects), to supervise cremation problems, and to establish a quick link with the police or criminal machinery, which was originally the coroner’s strongest position, but is now his weakest.
relative " but
8a St.
was
John Street,
OLIVER JELLY.
Manchester 3.
PREVENTION OF ULCERATION DURING USE OF CUFFED TRACHEOSTOMY TUBE
SIR,-There is now convincing evidence that a floppy redundant cuff is the only way of preventing ulceration with a cuffed tracheostomy tube. For some time I have tried, without success, to get several manufacturers to make a plastic tracheostomy tube with such a cuff. Technical difficulties may be one factor, since plastic lacks the characteristics of latex rubber, the most suitable material, and this cannot be easily bonded to plastic. But a ’Cellophane ’ cuff has been used experimentally. One company has produced an unacceptable compromise-a plastic cuff whose walls are initially parallel on inflation. Certainly double-cuffed tubes are valueless, and they even increase the risk of damage and stenosis.2,3 Even the minimal occlusive pressure is likely to exceed capillary pressure,4,5 and, since ulceration is partly due to friction as well as pressure, a continuous leak does not solve the problem. Alternate inflation and deflation allows secretions to enter the trachea and may produce hypoxia, as may routine deflation of the cuff for several minutes per hour.6 Stretching the plastic cuff is another methodbut extensive necrosis may still occur when the tissues are ischsmic from a low cardiacoutput state.8 Some centres believe such methods are helpful, but the floppy cuff is the only one of proven value. Is the plastic tracheostomy tube obsolescent, and should an armoured latex tube with a floppy cuff completely replace it in adults ? National Heart Hospital, Westmoreland Street, London W1M 8BA.
ALAN GILSTON.
PSYCHOSIS AFTER L.S.D.
SiR,—This
psychosis after the taking of L.S.D. reported earlier-in the absence of a occurrence of depressive features with by the victim, and the failure to respond
case
of
differs from those latent interval, the
self-harming acts chlorpromazine and a shortened course of four sessions of E.C.T., the holding of the condition by anti-depressives
to
alone, and the final resolution of the disorder by
seven
E.C.T.S.
A
27-year-old professional
man
of stable
personality
was
Cooper, J. D., Grillo, H. C. Surgery Gynec. Obstet. 1969, 129, 1235. Arens, J. F., Ochsner, J. L., Gee, G. J. thorac. cardiovasc. Surg. 1969, 58, 837. 3. Carroll, R., Hedden, M., Safar, P. Anesthesiology, 1969, 31, 275. 4. Cooper, J. D., Grillo, H. C. Ann. Surg. 1969, 169, 334. 5. Knowlson, G. T. G., Bassett, H. F. M. Br. J. Anœsth. 1970, 42, 834. 6. Jones, J. Unpublished. 7. Geffin, B., Pontoppidan, H. Anesthesiology, 1969, 31, 462. 8. Martinez, L. R., Kalter, R. D. ibid. 1971, 34, 488.
1. 2.
P.H.A. must
by
as
Department of Obstetrics and Gynecology. Section
on
Hematology
MARTIN C. CARR.
and
Immunology, Department of Medicine, University of California School of Medicine, San Francisco, California 94122, U.S.A.
DANIEL P. STITES.
BRODRICK’S CORONER
SIR,-I wonder if the full implication of Mr. Justice Brodrick’s report on Medical Certification and Coroners has been appreciated by the profession or was indeed by its compiling committee. Very briefly, Brodrick proposes to keep the title of coroner but unbenches him in every other respect. He loses his rights of committal, he becomes subject to appeal and stricter rules of evidence, his jury is deemed unnecessary, he must not name culprits, his riders are to be curtailed, he is even to lose his officer. You might wonder what is left. Brodrick’s coroner in fact turns away from the judiciary and heads towards the N.H.S. His criminal function does not now apply (nearly all his reported cases are " natural " deaths), his main place is on the social road of accurate death certification (admittedly erratic at times); he is therefore to be handier at arranging necropsies, and less ready to conduct inquests, he is to act with more discretion and sympathy, and that obvious policeman, his officer, is to be replaced by secretaries and a " designated officer ", who is to be N.H.S. consultant or S.A.M.O. rank. To complete the " integration ", all necropsies are to be done in N.H.S. hospitals by N.H.S.
pathologists. The Brodrick report therefore discloses an important trend in our social future and one which I cannot see the clinical wing of the profession wanting to oppose. But, if the coroner is to become a death-certification officer, it has to be accepted, first, that the homicide’s softest target is the man or woman who already carries a death diagnosis in his medical record; second, that all deaths should be vetted in the same office; and, third, that the Human Tissue Carr, M. C., Stites, D. P., Fudenberg, H. H. Cell. Immun. (in the press). 3. Rigas, D. A., Elasser, P., Hetch, F. Int. Archs Allergy appl. Immun. 1970, 39, 587. 2.
Act, 1961, requires absorption into the new idea. This measure gave dangerous rights of organ and necropsy permission to a surviving spouse or any surviving "
careful to avoid the coroner’s established of summary necropsy. In its turn, the Brodrick right committee has failed to see that the Human Tissue Act is a clinical deterrent and likely falsifier of death certificates. Fully implemented, the idea of a Death Enquiry Office within the area health board becomes a logical development, " to survey all natural " deaths (the term includes suicides, anaesthetic and other drug-contributed deaths, dropdeads, and industrial effects), to supervise cremation problems, and to establish a quick link with the police or criminal machinery, which was originally the coroner’s strongest position, but is now his weakest.
relative " but
8a St.
was
John Street,
OLIVER JELLY.
Manchester 3.
PREVENTION OF ULCERATION DURING USE OF CUFFED TRACHEOSTOMY TUBE
SIR,-There is now convincing evidence that a floppy redundant cuff is the only way of preventing ulceration with a cuffed tracheostomy tube. For some time I have tried, without success, to get several manufacturers to make a plastic tracheostomy tube with such a cuff. Technical difficulties may be one factor, since plastic lacks the characteristics of latex rubber, the most suitable material, and this cannot be easily bonded to plastic. But a ’Cellophane ’ cuff has been used experimentally. One company has produced an unacceptable compromise-a plastic cuff whose walls are initially parallel on inflation. Certainly double-cuffed tubes are valueless, and they even increase the risk of damage and stenosis.2,3 Even the minimal occlusive pressure is likely to exceed capillary pressure,4,5 and, since ulceration is partly due to friction as well as pressure, a continuous leak does not solve the problem. Alternate inflation and deflation allows secretions to enter the trachea and may produce hypoxia, as may routine deflation of the cuff for several minutes per hour.6 Stretching the plastic cuff is another methodbut extensive necrosis may still occur when the tissues are ischsmic from a low cardiacoutput state.8 Some centres believe such methods are helpful, but the floppy cuff is the only one of proven value. Is the plastic tracheostomy tube obsolescent, and should an armoured latex tube with a floppy cuff completely replace it in adults ? National Heart Hospital, Westmoreland Street, London W1M 8BA.
ALAN GILSTON.
PSYCHOSIS AFTER L.S.D.
SiR,—This
psychosis after the taking of L.S.D. reported earlier-in the absence of a occurrence of depressive features with by the victim, and the failure to respond
case
of
differs from those latent interval, the
self-harming acts chlorpromazine and a shortened course of four sessions of E.C.T., the holding of the condition by anti-depressives
to
alone, and the final resolution of the disorder by
seven
E.C.T.S.
A
27-year-old professional
man
of stable
personality
was
Cooper, J. D., Grillo, H. C. Surgery Gynec. Obstet. 1969, 129, 1235. Arens, J. F., Ochsner, J. L., Gee, G. J. thorac. cardiovasc. Surg. 1969, 58, 837. 3. Carroll, R., Hedden, M., Safar, P. Anesthesiology, 1969, 31, 275. 4. Cooper, J. D., Grillo, H. C. Ann. Surg. 1969, 169, 334. 5. Knowlson, G. T. G., Bassett, H. F. M. Br. J. Anœsth. 1970, 42, 834. 6. Jones, J. Unpublished. 7. Geffin, B., Pontoppidan, H. Anesthesiology, 1969, 31, 462. 8. Martinez, L. R., Kalter, R. D. ibid. 1971, 34, 488.
1. 2.