- Email: [email protected]
RESECTION OF TRACHEAL STRICTURE FOLLOWING TRACHEOSTOMY
411
Hazards of radiation
are
such that Schell found it
necessary to limit the
investigation to a single test on each infant; it was, therefore, impossible to compare the emptying of different solutions within subjects. A further disadvantage of the technique is that barium becomes entrapped in the folds of the gastric mucosa and complete emptying of the stomach, as assessed radiologically, is delayed. Vendel 15 measured gastric emptying of milk in infants between the ages of 1 week and 11 months. At regular intervals after the feed was given the gastric contents were aspirated, the volume measured, and the contents reinserted into the stomach. Therefore at the conclusion of a single test-meal seven observations had been made relating the volume of gastric contents to time. This is an advantage over serial test-meals where three to four tests are required to show the pattern of emptying, since different variables may be introduced on different days. However, the gastric contents recovered in Vendel’s subjects contained not only a proportion of the original meal but in addition an unknown quantity of gastric secretion and saliva. Thus the volume of original meal remaining in the stomach at a given time was not accurately known. The results obtained by Vendel are not comparable with those obtained by the method of serial test-meals in that the ages of the infants studied and the solutions used were different in the two series. It is a pleasure to acknowledge the help given by Prof. J. N. Hunt during the preparation of this paper. We thank Dr. L. Stimmler and Dr. H. Barrie for permission to study patients admitted under their care and for their continued help and encouragement; and Dr. A. E. Davies for statistical advice. Requests for reprints should be addressed to: P. H., Fulham Hospital, St. Dunstan’s Road, London W.6. REFERENCES
1. Creery, R. D. G. Lancet, 1963, i, 1423. 2. Abraham, J. M., Brown, R. J. K. Br. med. J. 1967, iii, 640. 3. Stoneman, M. E. R., Owens, R. M. Archs Dis. Childh. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
1968, 43, 155. Karel, L. Physiol. Rev. 1948, 28, 433. Hunt, J. N. J. Physiol., Lond. 1951, 113, 169. Hunt, J. N. ibid. 1956, 132, 267. Hunt, J. N., Knox, M. T. ibid. 1962, 163, 34. Hunt, J. N., Pathak, J. D. ibid. 1960, 154, 254. Elias, E., Gibson, G. J., Greenwood, L. F., Hunt, J. N., Tripp, J. H. ibid. 1968, 194, 317. Miller, D., Crane, R. K. Biochim. Biophys. Acta 1961, 52, 293. Hopkins, A. J. Physiol., Lond. 1966, 182, 144. Bouslog, J. S., Cunningham, T. D., Hanner, J. P., Walton, J. B., Waltz. H. D. J. Pediat. 1935, 6, 234. Henderson, S. G. Am. J. Rœntg. 1942, 48, 302. Schell, N. B., Karelitz, S., Epstein, B. S. J. Pediat. 1963, 62, 342. Vendel, S. Acta physiol. scand. 1946, 11, 380.
"... there are those who suggest that we can streamline the curriculum by identifying the core of each discipline and teaching just the core material in foreshortened courses. I contend that this is illusory and misguided. The dictionary defines core as ’the most essential part of anything.’ What comes into my mind when I think of core is the core of an apple, which leads me to quote the Chinese philosopher: ’Confucius say, today’s core is tomorrow’s garbage.’ To me a far more important objective is to establish what it takes-and for how long-for the student to learn the languages essential to medicine, the language of biology, of biochemistry, of anatomy, of physiology, of pathology and of psychology. Indeed, have we identified all the languages ?"-GEORGE L. ENGEL, New England Journal of Medicine, August 14, 1969, p. 351.
RESECTION OF TRACHEAL STRICTURE FOLLOWING TRACHEOSTOMY P. JEWSBURY Victoria Hospital,
Blackpool
Tracheal strictures formed in two patients 8 and 4 weeks after closure of short-term tracheostomies. In both cases the strictures were related to the site of the cuff of the tracheostomy tube. Excision of the strictures with primary end-toend anastomosis gave good results. Summary
Introduction
STRICTURE of the trachea is
a
well-documented
complication of tracheal intubation and of tracheostomy,1 even when these measures have been used for a relatively short period. The development of tracheal stricture in a patient who is otherwise making a good recovery from a serious accidental injury, or from a major operation, may cause fresh concern. One has tended to think of these strictures forming gradually, many weeks or months after the tube has been withdrawn ; but the following two cases illustrate that it may be of rapid onset and may produce an acute emergency which can, nevertheless, be overcome
quickly. Case-reports Case1 The
patient was a man of 51 whose calcific aortic valve replaced under cardiopulmonary bypass on Feb. 27, 1968. His initial recovery was good. He was maintained on positive-pressure ventilation for 15 hours, through a cuffed endotracheal tube, after which spontaneous respiration returned and the tube was removed. Unfortunately, on the 4th postoperative day he relapsed because of the tamponade effect of a pericardial effusion. This was drained and tracheostomy was performed and maintained with a cuffed tube which was kept in place for 4 days. The tracheostomy healed within a week. He returned home 5 weeks after the original heart operation. 8 weeks postoperatively, he was readmitted with stridor and laboured respiration. An emergency tracheostomy was performed with difficulty by a registrar, who remarked on the narrowness of the lower trachea. Perhaps inadvisedly this tracheostomy was allowed to close after a few days, was
and stridor recurred. Tomograms of the trachea at this stage outlined a narrow stricture 3 cm. below the stomal site. (See accompanying figure.) It was believed that excision of this stricture afforded a better prospect than repeated dilatations; so this was done on May 29, 1968. Endotracheal anxsthesia was instituted a tube above the stricture, which was exposed short using through a transverse neck incision. The scar of the tracheostomy was excised. Dissecting close to the trachea, the 3 cm. long, was resected. Anxsthesia was then maintained by means of a tube passed through the wound into the lower tracheal segment, and the tracheal ends were united by interrupted single sutures of 000 ’ Mersilene’. The tube had to be removed momentarily to allow the posterior wall sutures to be inserted. These were then tied to reunite the trachea, and thus an oroendotracheal tube could be passed down through the anastomosis. The remaining anterior sutures were completed, and the neck wound was closed, a mediastinal waterseal drainage tube being left in place for 24 hours. The patient, awakening promptly, commented on the great relief in breathing. Subsequent progress was uneventful,
stricture,
412
recurrence
of the stricture in the 6 months since the
operation. Discussion
possibility of tracheal stricture developing after tracheostomy, especially in children, has been known for many years. However, following widespread immunisation against diphtheria, and with the use of modern antibiotics, tracheostomy has been needed much less often than it was in the past. Modern resuscitatory methods after road-traffic accidents, and after major surgery-particularly heart operations-have turned the wheel and brought tracheostomy back into frequent use. It is understandable that irritation from the prolonged presence of a tracheostomy tube, with or without a cuff, and however benign the plastic, may in time produce ulceration and eventual stenosis of the trachea. But it is perhaps not realised that this can happen quickly, following a few days of intubation, and that the consequences may be so dramatic, and yet so quickly recoverable, as in the above cases. The striking feature of these two cases was that the stricture did not form at the site of the stoma, but 3 cm. lower, at the site of the cuff. This also was the experience of Grillo2 from Boston who reported 20 cases of tracheal stricture, though most of these had arisen after a much longer period of intubation (13-119 days, with a mean of about 45 days). The principles of avoiding endotracheal trauma are much discussed by ansesthetists and intensivecare experts. Clearly if positive-pressure ventilation is to be adequate, a cuffed tube must be inflated sufficiently to make an air-tight fit in the trachea; but most would agree that any further pressure in the cuff damages the delicate tracheal mucosa.3 Management after intubation varies. Some authorities insist on regular deflation of the cuff at, say, hourly intervals.4 Others believe that the cuff should not be altered in any way, except perhaps to allow removal for cleaning every 2 or 3 days. Some trauma does seem to be unavoidable-for example, if the patient is turned from side to side some rotatory movement of the apparatus must occur. Furthermore, the piston-like effect of positive-pressure ventilation is likely to cause longitudinal movement of the cuff in the trachea. Infection probably plays as important a part as trauma, so a The
Tomogram of tracheal stricture in
and there has been no recurrence of following the operation.
case
dyspnoea
1.
in the year
Case 2 This patient was a boy of 16 who, on Aug. 20, 1968, borrowed a friend’s motor cycle, and set off for a trial ride without wearing a crash helmet. He soon met disaster, and was admitted to a general surgical unit unconscious with a compound depressed skull fracture, and fractured ribs. After resuscitation, he was operated on under endotracheal anarsthesia, when the scalp wound was excised, contaminated bone and brain fragments removed, and the scalp closed. After this procedure, spontaneous respiration was inadequate. Positive-pressure ventilation was continued through an oro-endotracheal tube for 48 hours, after which a tracheostomy was performed and assisted ventilation continued for a further 2 days. Sponthen returned, but the tracheostomy left in situ for aspiration of secretions. It was finally removed on the 12th day after insertion. The wound healed rapidly, though penicillin-resistant staphylococci were cultured from it soon after removal of the tube. Three weeks later, the boy was fully conscious, but had an obvious speech defect, and weakness of the right arm, hand, and leg. Respiration was now becoming more noisy and difficult, suggesting the onset of tracheal stenosis. Laryngoscopy at this stage showed no abnormality. On Sept. 29, 4 weeks after removal of the tracheostomy tube, breathing had become very laboured, with considerable stridor and indrawing of sternum and ribs. Bronchoscopy disclosed a narrow stricture, with a lumen of 3 mm., in the lower trachea. At this stage, I was called to see the patient for the first time. Dilation was attempted with bougies, but the stricture was very tough and unyielding, and it was apparent that if it could not be overcome the boy was unlikely to survive. After the experience with the first case excision of the stricture seemed to offer the best solution. This was done forthwith in a similar manner, though this time satisfactory access to the lower trachea could only be obtained by incising the manubrium vertically for 3 cm. and then laterally into the 2nd intercostal spaces. After excision of the stricture, the ends of the trachea were easily united as before, and the neck wound closed in the same way. Breathing quickly recovered. A transient episode of atelectasis of the right upper lobe was corrected by bronchoscopic aspiration on the 4th day, when the tracheal lumen was seen to be fully patent. Subsequent recovery was uneventful, and there has not been any sign of taneous
tube
respiration
was
scrupulous tracheostomy-toilet technique is necessary, with regular cultures from secretions, and prompt treatment with the appropriate antibiotics. The onset of stridor and laboured respiration several weeks after the healing of a tracheostomy is highly suggestive. The origin of the wheeze is easily located with the stethoscope even though pulmonary congestion or infection may be coexistent. There is usually an intermediate phase of moderate severity can be made which show the stricture clearly, thus obviating the need for inhalation of radio-opaque medium. Bronchoscopy may be dangerous once dyspnoea has become severe, and should only be done as a preliminary to a more definitive procedure such as a further tracheostomy, or, better still, excision of the stricture. (A further tracheostomy may be difficult, as case 1 showed.) Dilatation of these severe strictures is not likely to be curative and is not to be recommended6 since it may
when tomograms
413
haemorrhage with inhalation of blood. the stricture through a transverse incision Access was found to be adequate in these two in the neck a vertical extension down into the cases, though manubrium was helpful in case 2. It is doubtful if a right-thoracotomy approach as suggested by Flavell1 would have been more satisfactory here. The symptomatic relief, the speed of respiratory recovery, and the absence of recurrence of the stricture were impressive in both cases. My sincere thanks are due to the theatre, recovery room, and ward technical and nursing staffs for their excellent care and assistance, and to Mr. David Mansfield for reproducing the
produce
severe
to
tomoeram.
1. 2. 3. 4. 5.
_
____
__
_
_.
REFERENCES Flavell, G. Proc. R. Soc. Med. 1959, 52, 143. Grillo, H. C. J. Thorac. Cardiovasc. Surg. 1969, May, I. ibid. p. 68. Deverall, P. B. Thorax, 1967, 22, 575. McSwann, N. Personal communication.
57,
52.
Reviews of Books Renal Failure in
Paraplegia
C. R. TRIBE, M.A., D.M., M.C.PATH., consultant pathologist, Wycombe General Hospital, High Wycombe, Bucks; with additional material by J. R. SILVER, M.B., M.R.C.P.E., consultant in charge, Liverpool Regional Paraplegic Centre, Promenade Hospital, Southport, Lancs. London: Pitman Medical. 1969. Pp. 107. 70s.
IT is
fortunate paradox that specialisation tends to not only workers in a particular branch of medicine but also those following quite different disciplines. Nowhere is this more apparent than in paraplegia, which necessitates cooperation between neurologists and neurosurgeons, orthopaedic, urological, and plastic surgeons, pathologists, and radiologists, as well as those directing the nursing and ancillary services. (In this connection it is interesting to note that experience in paraplegia is likely to be compulsory for those taking a urological training in the future.) This book has, therefore, a potentially wide appeal which is increased by the devotion of separate chapters to such important subjects as pyelonephritis, amyloidosis, and hypertension. No clinician or pathologist can afford to ignore the special way in which these conditions are manifest in the paraplegic. The substance of the book is unshakably founded upon a careful study by Dr. Tribe of the necropsy findings in 220 paraplegics. Correlation with the clinical records has resulted in a convincing picture of the relentless progression of these cases to a fatal outcome. After the first three months, death is usually due to chronic pyelonephritis aggravated at times by the renal effects of amyloidosis and hypertension. Since urinary infection in these cases can be prevented or curtailed by proper bladder management, it is appropriate that Dr. Silver’s excellent section on diagnostic tests lays special emphasis on the early signs of ascending infection. The book is excellently produced and well illustrated and documented; errata are few. Some of the statements on urological matters require amendment or clarification. For example, the obstruction at the external sphincter is " (p. 29); on p. 24, intracertainly not a " true stricture vesical pressure is said to be " largely dependent upon the condition of the intrinsic ganglia of the bladder wall " and yet to be unaffected by ganglionic paralysis; and, though the benefits of intermittent catheterisation are now widely acknowledged, it is doubtful if they can be put on a sound pathological basis by comparing (p. 49) the terminal state of the bladder in a series of chronic patients almost half of whom were treated initially by cystostomy, with the condition of the bladder in patients who died within the first three months on intermittent catheterisation. a
bring together
Cytotoxic Drugs in the Treatment of Cancer EVELYN BoESEN, M.B., Chester Beatty Research Institute: Institute of Cancer Research, London, clinical assistant, Royal Marsden Hospital, Royal Free Hospital, Brompton Hospital; WALTER DAVIS, PH.D., chief, education and fellowship unit, International Agency for Research in Cancer, Lyons, France. London: Edward Arnold. 1969. Pp. 208. 60s.
THIS book, which contains 14 chapters, should be particularly useful for all those involved in the treatment of cancer, and those whose aim is to discover more efficacious drugs, besides the more general reader. The historical approach used to describe the evolution of this most interesting area of pharmacology helps to make the book very readable and should help to make clear the practical difficulties which face clinicians, organic chemists, pharmacologists, and biochemists who work in this complex area. After briefly introducing the various classes of compound which are used in cancer chemotherapy, the authors draw the general inference that almost without exception their cytotoxic action depends on interference with the synthesis or function of the nucleic acids. The chapters which follow, on drug development, methods of drug screening, methods of administration, and the general principles of therapy, are especially valuable for an understanding of the clinical usefulness and limitations of the compounds, taking into account such factors as the varying sensitivity of tumour cells, toxic effects involving other parts of the organism, and the development of resistance. Other chapters discuss the alkylating agents, antimetabolites, plant products, antibiotics, and miscellaneous compounds, including some of the newer agents. In each case a comprehensive discussion is included of the discovery of the agents, where possible their mechanism of action at the molecular level, their clinical efficacy relative to radiotherapy and surgery, and their other pharmacological properties. The book is comprehensive, and lucid, and it is amply illustrated with formulae and with diagrams of case-histories.
The Human Bronchial Circulation in Health and Disease LEON CUDKOWICZ, M.D., M.R.C.P., F.A.C.P., director, cardiopulmonary laboratory, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada. Edinburgh: E. & S. Livingstone. Baltimore: Williams & Wilkins Co. 1968. Pp. 424. t810s.
FOR a system which was described by Galen in the 2nd century and to which a nutritional role was attributed by Leonardo da Vinci in the 15th century, we still know relatively little about the bronchial circulation. Much of what we do know is due to or has been explored by Dr. Cudkowicz, and is reviewed in this monograph. The book is attractively produced and contains numerous references, and the subject matter is important for a proper understanding of chest diseases. Thus, an increase in bronchial blood-flow both preserves the structure of the lung in lobar pneumonia or after pulmonary embolism and may be a source of htmoptysis as in bronchial carcinoma. The development of precapillary bronchopulmonary anastomoses in a number of
conditions, including bronchiectasis, seems to cause finger clubbing, though the exact mechanism is uncertain. In addition, a reduction in bronchial blood-flow may possibly give rise to parenchymal disease of the lung. Dr. Cudkowicz reviews the steps by which our present knowledge has been acquired and describes in a series of chapters his own contribution, including the limitations to the methods he has used. All who are interested in the bronchial circulation should read this book. However, a rather haphazard presentation of material and absence of concise summaries to chapters will reduce its usefulness to the general reader.
Hazards of radiation
are
such that Schell found it
necessary to limit the
investigation to a single test on each infant; it was, therefore, impossible to compare the emptying of different solutions within subjects. A further disadvantage of the technique is that barium becomes entrapped in the folds of the gastric mucosa and complete emptying of the stomach, as assessed radiologically, is delayed. Vendel 15 measured gastric emptying of milk in infants between the ages of 1 week and 11 months. At regular intervals after the feed was given the gastric contents were aspirated, the volume measured, and the contents reinserted into the stomach. Therefore at the conclusion of a single test-meal seven observations had been made relating the volume of gastric contents to time. This is an advantage over serial test-meals where three to four tests are required to show the pattern of emptying, since different variables may be introduced on different days. However, the gastric contents recovered in Vendel’s subjects contained not only a proportion of the original meal but in addition an unknown quantity of gastric secretion and saliva. Thus the volume of original meal remaining in the stomach at a given time was not accurately known. The results obtained by Vendel are not comparable with those obtained by the method of serial test-meals in that the ages of the infants studied and the solutions used were different in the two series. It is a pleasure to acknowledge the help given by Prof. J. N. Hunt during the preparation of this paper. We thank Dr. L. Stimmler and Dr. H. Barrie for permission to study patients admitted under their care and for their continued help and encouragement; and Dr. A. E. Davies for statistical advice. Requests for reprints should be addressed to: P. H., Fulham Hospital, St. Dunstan’s Road, London W.6. REFERENCES
1. Creery, R. D. G. Lancet, 1963, i, 1423. 2. Abraham, J. M., Brown, R. J. K. Br. med. J. 1967, iii, 640. 3. Stoneman, M. E. R., Owens, R. M. Archs Dis. Childh. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
1968, 43, 155. Karel, L. Physiol. Rev. 1948, 28, 433. Hunt, J. N. J. Physiol., Lond. 1951, 113, 169. Hunt, J. N. ibid. 1956, 132, 267. Hunt, J. N., Knox, M. T. ibid. 1962, 163, 34. Hunt, J. N., Pathak, J. D. ibid. 1960, 154, 254. Elias, E., Gibson, G. J., Greenwood, L. F., Hunt, J. N., Tripp, J. H. ibid. 1968, 194, 317. Miller, D., Crane, R. K. Biochim. Biophys. Acta 1961, 52, 293. Hopkins, A. J. Physiol., Lond. 1966, 182, 144. Bouslog, J. S., Cunningham, T. D., Hanner, J. P., Walton, J. B., Waltz. H. D. J. Pediat. 1935, 6, 234. Henderson, S. G. Am. J. Rœntg. 1942, 48, 302. Schell, N. B., Karelitz, S., Epstein, B. S. J. Pediat. 1963, 62, 342. Vendel, S. Acta physiol. scand. 1946, 11, 380.
"... there are those who suggest that we can streamline the curriculum by identifying the core of each discipline and teaching just the core material in foreshortened courses. I contend that this is illusory and misguided. The dictionary defines core as ’the most essential part of anything.’ What comes into my mind when I think of core is the core of an apple, which leads me to quote the Chinese philosopher: ’Confucius say, today’s core is tomorrow’s garbage.’ To me a far more important objective is to establish what it takes-and for how long-for the student to learn the languages essential to medicine, the language of biology, of biochemistry, of anatomy, of physiology, of pathology and of psychology. Indeed, have we identified all the languages ?"-GEORGE L. ENGEL, New England Journal of Medicine, August 14, 1969, p. 351.
RESECTION OF TRACHEAL STRICTURE FOLLOWING TRACHEOSTOMY P. JEWSBURY Victoria Hospital,
Blackpool
Tracheal strictures formed in two patients 8 and 4 weeks after closure of short-term tracheostomies. In both cases the strictures were related to the site of the cuff of the tracheostomy tube. Excision of the strictures with primary end-toend anastomosis gave good results. Summary
Introduction
STRICTURE of the trachea is
a
well-documented
complication of tracheal intubation and of tracheostomy,1 even when these measures have been used for a relatively short period. The development of tracheal stricture in a patient who is otherwise making a good recovery from a serious accidental injury, or from a major operation, may cause fresh concern. One has tended to think of these strictures forming gradually, many weeks or months after the tube has been withdrawn ; but the following two cases illustrate that it may be of rapid onset and may produce an acute emergency which can, nevertheless, be overcome
quickly. Case-reports Case1 The
patient was a man of 51 whose calcific aortic valve replaced under cardiopulmonary bypass on Feb. 27, 1968. His initial recovery was good. He was maintained on positive-pressure ventilation for 15 hours, through a cuffed endotracheal tube, after which spontaneous respiration returned and the tube was removed. Unfortunately, on the 4th postoperative day he relapsed because of the tamponade effect of a pericardial effusion. This was drained and tracheostomy was performed and maintained with a cuffed tube which was kept in place for 4 days. The tracheostomy healed within a week. He returned home 5 weeks after the original heart operation. 8 weeks postoperatively, he was readmitted with stridor and laboured respiration. An emergency tracheostomy was performed with difficulty by a registrar, who remarked on the narrowness of the lower trachea. Perhaps inadvisedly this tracheostomy was allowed to close after a few days, was
and stridor recurred. Tomograms of the trachea at this stage outlined a narrow stricture 3 cm. below the stomal site. (See accompanying figure.) It was believed that excision of this stricture afforded a better prospect than repeated dilatations; so this was done on May 29, 1968. Endotracheal anxsthesia was instituted a tube above the stricture, which was exposed short using through a transverse neck incision. The scar of the tracheostomy was excised. Dissecting close to the trachea, the 3 cm. long, was resected. Anxsthesia was then maintained by means of a tube passed through the wound into the lower tracheal segment, and the tracheal ends were united by interrupted single sutures of 000 ’ Mersilene’. The tube had to be removed momentarily to allow the posterior wall sutures to be inserted. These were then tied to reunite the trachea, and thus an oroendotracheal tube could be passed down through the anastomosis. The remaining anterior sutures were completed, and the neck wound was closed, a mediastinal waterseal drainage tube being left in place for 24 hours. The patient, awakening promptly, commented on the great relief in breathing. Subsequent progress was uneventful,
stricture,
412
recurrence
of the stricture in the 6 months since the
operation. Discussion
possibility of tracheal stricture developing after tracheostomy, especially in children, has been known for many years. However, following widespread immunisation against diphtheria, and with the use of modern antibiotics, tracheostomy has been needed much less often than it was in the past. Modern resuscitatory methods after road-traffic accidents, and after major surgery-particularly heart operations-have turned the wheel and brought tracheostomy back into frequent use. It is understandable that irritation from the prolonged presence of a tracheostomy tube, with or without a cuff, and however benign the plastic, may in time produce ulceration and eventual stenosis of the trachea. But it is perhaps not realised that this can happen quickly, following a few days of intubation, and that the consequences may be so dramatic, and yet so quickly recoverable, as in the above cases. The striking feature of these two cases was that the stricture did not form at the site of the stoma, but 3 cm. lower, at the site of the cuff. This also was the experience of Grillo2 from Boston who reported 20 cases of tracheal stricture, though most of these had arisen after a much longer period of intubation (13-119 days, with a mean of about 45 days). The principles of avoiding endotracheal trauma are much discussed by ansesthetists and intensivecare experts. Clearly if positive-pressure ventilation is to be adequate, a cuffed tube must be inflated sufficiently to make an air-tight fit in the trachea; but most would agree that any further pressure in the cuff damages the delicate tracheal mucosa.3 Management after intubation varies. Some authorities insist on regular deflation of the cuff at, say, hourly intervals.4 Others believe that the cuff should not be altered in any way, except perhaps to allow removal for cleaning every 2 or 3 days. Some trauma does seem to be unavoidable-for example, if the patient is turned from side to side some rotatory movement of the apparatus must occur. Furthermore, the piston-like effect of positive-pressure ventilation is likely to cause longitudinal movement of the cuff in the trachea. Infection probably plays as important a part as trauma, so a The
Tomogram of tracheal stricture in
and there has been no recurrence of following the operation.
case
dyspnoea
1.
in the year
Case 2 This patient was a boy of 16 who, on Aug. 20, 1968, borrowed a friend’s motor cycle, and set off for a trial ride without wearing a crash helmet. He soon met disaster, and was admitted to a general surgical unit unconscious with a compound depressed skull fracture, and fractured ribs. After resuscitation, he was operated on under endotracheal anarsthesia, when the scalp wound was excised, contaminated bone and brain fragments removed, and the scalp closed. After this procedure, spontaneous respiration was inadequate. Positive-pressure ventilation was continued through an oro-endotracheal tube for 48 hours, after which a tracheostomy was performed and assisted ventilation continued for a further 2 days. Sponthen returned, but the tracheostomy left in situ for aspiration of secretions. It was finally removed on the 12th day after insertion. The wound healed rapidly, though penicillin-resistant staphylococci were cultured from it soon after removal of the tube. Three weeks later, the boy was fully conscious, but had an obvious speech defect, and weakness of the right arm, hand, and leg. Respiration was now becoming more noisy and difficult, suggesting the onset of tracheal stenosis. Laryngoscopy at this stage showed no abnormality. On Sept. 29, 4 weeks after removal of the tracheostomy tube, breathing had become very laboured, with considerable stridor and indrawing of sternum and ribs. Bronchoscopy disclosed a narrow stricture, with a lumen of 3 mm., in the lower trachea. At this stage, I was called to see the patient for the first time. Dilation was attempted with bougies, but the stricture was very tough and unyielding, and it was apparent that if it could not be overcome the boy was unlikely to survive. After the experience with the first case excision of the stricture seemed to offer the best solution. This was done forthwith in a similar manner, though this time satisfactory access to the lower trachea could only be obtained by incising the manubrium vertically for 3 cm. and then laterally into the 2nd intercostal spaces. After excision of the stricture, the ends of the trachea were easily united as before, and the neck wound closed in the same way. Breathing quickly recovered. A transient episode of atelectasis of the right upper lobe was corrected by bronchoscopic aspiration on the 4th day, when the tracheal lumen was seen to be fully patent. Subsequent recovery was uneventful, and there has not been any sign of taneous
tube
respiration
was
scrupulous tracheostomy-toilet technique is necessary, with regular cultures from secretions, and prompt treatment with the appropriate antibiotics. The onset of stridor and laboured respiration several weeks after the healing of a tracheostomy is highly suggestive. The origin of the wheeze is easily located with the stethoscope even though pulmonary congestion or infection may be coexistent. There is usually an intermediate phase of moderate severity can be made which show the stricture clearly, thus obviating the need for inhalation of radio-opaque medium. Bronchoscopy may be dangerous once dyspnoea has become severe, and should only be done as a preliminary to a more definitive procedure such as a further tracheostomy, or, better still, excision of the stricture. (A further tracheostomy may be difficult, as case 1 showed.) Dilatation of these severe strictures is not likely to be curative and is not to be recommended6 since it may
when tomograms
413
haemorrhage with inhalation of blood. the stricture through a transverse incision Access was found to be adequate in these two in the neck a vertical extension down into the cases, though manubrium was helpful in case 2. It is doubtful if a right-thoracotomy approach as suggested by Flavell1 would have been more satisfactory here. The symptomatic relief, the speed of respiratory recovery, and the absence of recurrence of the stricture were impressive in both cases. My sincere thanks are due to the theatre, recovery room, and ward technical and nursing staffs for their excellent care and assistance, and to Mr. David Mansfield for reproducing the
produce
severe
to
tomoeram.
1. 2. 3. 4. 5.
_
____
__
_
_.
REFERENCES Flavell, G. Proc. R. Soc. Med. 1959, 52, 143. Grillo, H. C. J. Thorac. Cardiovasc. Surg. 1969, May, I. ibid. p. 68. Deverall, P. B. Thorax, 1967, 22, 575. McSwann, N. Personal communication.
57,
52.
Reviews of Books Renal Failure in
Paraplegia
C. R. TRIBE, M.A., D.M., M.C.PATH., consultant pathologist, Wycombe General Hospital, High Wycombe, Bucks; with additional material by J. R. SILVER, M.B., M.R.C.P.E., consultant in charge, Liverpool Regional Paraplegic Centre, Promenade Hospital, Southport, Lancs. London: Pitman Medical. 1969. Pp. 107. 70s.
IT is
fortunate paradox that specialisation tends to not only workers in a particular branch of medicine but also those following quite different disciplines. Nowhere is this more apparent than in paraplegia, which necessitates cooperation between neurologists and neurosurgeons, orthopaedic, urological, and plastic surgeons, pathologists, and radiologists, as well as those directing the nursing and ancillary services. (In this connection it is interesting to note that experience in paraplegia is likely to be compulsory for those taking a urological training in the future.) This book has, therefore, a potentially wide appeal which is increased by the devotion of separate chapters to such important subjects as pyelonephritis, amyloidosis, and hypertension. No clinician or pathologist can afford to ignore the special way in which these conditions are manifest in the paraplegic. The substance of the book is unshakably founded upon a careful study by Dr. Tribe of the necropsy findings in 220 paraplegics. Correlation with the clinical records has resulted in a convincing picture of the relentless progression of these cases to a fatal outcome. After the first three months, death is usually due to chronic pyelonephritis aggravated at times by the renal effects of amyloidosis and hypertension. Since urinary infection in these cases can be prevented or curtailed by proper bladder management, it is appropriate that Dr. Silver’s excellent section on diagnostic tests lays special emphasis on the early signs of ascending infection. The book is excellently produced and well illustrated and documented; errata are few. Some of the statements on urological matters require amendment or clarification. For example, the obstruction at the external sphincter is " (p. 29); on p. 24, intracertainly not a " true stricture vesical pressure is said to be " largely dependent upon the condition of the intrinsic ganglia of the bladder wall " and yet to be unaffected by ganglionic paralysis; and, though the benefits of intermittent catheterisation are now widely acknowledged, it is doubtful if they can be put on a sound pathological basis by comparing (p. 49) the terminal state of the bladder in a series of chronic patients almost half of whom were treated initially by cystostomy, with the condition of the bladder in patients who died within the first three months on intermittent catheterisation. a
bring together
Cytotoxic Drugs in the Treatment of Cancer EVELYN BoESEN, M.B., Chester Beatty Research Institute: Institute of Cancer Research, London, clinical assistant, Royal Marsden Hospital, Royal Free Hospital, Brompton Hospital; WALTER DAVIS, PH.D., chief, education and fellowship unit, International Agency for Research in Cancer, Lyons, France. London: Edward Arnold. 1969. Pp. 208. 60s.
THIS book, which contains 14 chapters, should be particularly useful for all those involved in the treatment of cancer, and those whose aim is to discover more efficacious drugs, besides the more general reader. The historical approach used to describe the evolution of this most interesting area of pharmacology helps to make the book very readable and should help to make clear the practical difficulties which face clinicians, organic chemists, pharmacologists, and biochemists who work in this complex area. After briefly introducing the various classes of compound which are used in cancer chemotherapy, the authors draw the general inference that almost without exception their cytotoxic action depends on interference with the synthesis or function of the nucleic acids. The chapters which follow, on drug development, methods of drug screening, methods of administration, and the general principles of therapy, are especially valuable for an understanding of the clinical usefulness and limitations of the compounds, taking into account such factors as the varying sensitivity of tumour cells, toxic effects involving other parts of the organism, and the development of resistance. Other chapters discuss the alkylating agents, antimetabolites, plant products, antibiotics, and miscellaneous compounds, including some of the newer agents. In each case a comprehensive discussion is included of the discovery of the agents, where possible their mechanism of action at the molecular level, their clinical efficacy relative to radiotherapy and surgery, and their other pharmacological properties. The book is comprehensive, and lucid, and it is amply illustrated with formulae and with diagrams of case-histories.
The Human Bronchial Circulation in Health and Disease LEON CUDKOWICZ, M.D., M.R.C.P., F.A.C.P., director, cardiopulmonary laboratory, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada. Edinburgh: E. & S. Livingstone. Baltimore: Williams & Wilkins Co. 1968. Pp. 424. t810s.
FOR a system which was described by Galen in the 2nd century and to which a nutritional role was attributed by Leonardo da Vinci in the 15th century, we still know relatively little about the bronchial circulation. Much of what we do know is due to or has been explored by Dr. Cudkowicz, and is reviewed in this monograph. The book is attractively produced and contains numerous references, and the subject matter is important for a proper understanding of chest diseases. Thus, an increase in bronchial blood-flow both preserves the structure of the lung in lobar pneumonia or after pulmonary embolism and may be a source of htmoptysis as in bronchial carcinoma. The development of precapillary bronchopulmonary anastomoses in a number of
conditions, including bronchiectasis, seems to cause finger clubbing, though the exact mechanism is uncertain. In addition, a reduction in bronchial blood-flow may possibly give rise to parenchymal disease of the lung. Dr. Cudkowicz reviews the steps by which our present knowledge has been acquired and describes in a series of chapters his own contribution, including the limitations to the methods he has used. All who are interested in the bronchial circulation should read this book. However, a rather haphazard presentation of material and absence of concise summaries to chapters will reduce its usefulness to the general reader.