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RESPIRATORY INVOLVEMENT IN POLIOMYELITIS
859
(2) Those in which there is considerable delay in removing clothing which has been saturated in boiling liquid. Most
of these scalds occur in the region of the axilla and upper arm, or in the groin-both sites where hot liquid tends to "pool." In our survey last year we found 15 cases, all in children, in which there was definite delay in removing clothing after a scalding injury. All of these children required skin-grafting, 5 needing two, and2 needing three, grafting children, woollen garments, such as operations. In all thesewere worn at the time of the accident, cardigans and knickers, and it is our impression that these knitted garments hold the heat much longer than other materials.
The
importance
of
early
removal of
clothing
from
scalded patients is not widely appreciated, and the of Health advice note 5/54 states that " in the event of a burn or scald no attempt should be made to pull the clothes off the skin..." This is no doubt put forward in order to prevent further shock by rough handling of the patient, but certainly in the case of scalds retention of sodden hot clothing may cause unnecessarily deep destruction of the skin.
Ministry
Plastic Surgery, Burns, and Jaw Injuries Centre, St. Lawrence Hospital, Chepstow, Mon.
MICHAEL N. TEMPEST.
RESPIRATORY INVOLVEMENT IN POLIOMYELITIS SiE,—We welcome the discussion on the management of bulbo-respiratory complications in poliomyelitis which has taken place in your journal, and particularly the consideration given to the correct place of tracheotomy. It is timely that experience in this field should be pooled at the beginning of the poliomyelitis season as it is no longer necessary to be guided by the data collected during the Copenhagen epidemic of 1953, which was responsible for the great increase in the method in the U.K. Dr. Scott and Dr. Knox (April 21), in an interesting
discussion on their experience in transporting twelve of bulbo-respiratory paralysis last year, suggest that it might be better to perform tracheotomy before the journey, so that the trachea can be protected by the cuffed tube from aspiration from the pharynx, and positive-pressure respiration can be given by the same tube if necessary. Dr. Crampton Smith and Dr. Spalding (May 5) reply suggesting that for the period of transport it is better to use an oral cuffed tube passed under local anesthesia and to perform the tracheotomy once the patient is under good conditions on arrival at the final hospital." We should like to support the first part of the latter recommendation but to add that by the time the patient has reached " good conditions " one of the two cases
"
major hurdles-namely, transport-is already passed, and that instead of performing a tracheotomy on arrival the resources of the hospital should be directed to avoiding this intervention if at all possible. Thus, while the oral tube is in place the patient can be prepared for its removal, and for the use of negative-pressure respiration by (a) emptying the stomach and lower bowel (vomiting, associated with restlessness, is probably the other major hurdle), (b) effective sedation, (e) transfer to a cabinet respirator to be maintained in a steep head-down tilt after removal of the tube, and (d) the establishment of effective replacement therapy. If necessary the lungs can be cleared by direct vision with a bronchoscope, and of course effective suction must be constantly available to keep the pharynx clear. It has been our unfortunate lot for the past eighteen months to observe what a tragic’coxnplication a tracheotomy can be in a condition such as poliomyelitis, which may leave behind severe residual respiratory paralysis. Such patients have virtually no cough, and chronic pulmonary infection appears to be an inevitable consequence of the stoma. This infection reduces both the effective ventilation obtained by the residual respiratory power, and also the area of healthy lung tissue available
for
respiratory exchange. Consequently
the recovery of
spontaneous respiration is severely handicapped, and,
so
therefore the chronic infection aid may be impossible. Yet closure of the stoma is fraught with danger because of the chronic infection in the absence of a useful vital capacity and effective cough. The patient is, in fact, trapped in a vicious circle ; and the period of rehabilitation is either grossly prolonged by months or even years, or closure, and consequently rehabilitation, may have to be abandoned altogether, with the result that the patient may be condemned to permanent stay in hospital for the rest of his days. There are, in fact, a number of cases with severe respiratory paralysis now living in relative happiness at home for whom such a solution would have been impossible had a tracheotomy been performed in the acute stage ; and some of these cases would have been in real danger of this complication had they fallen into less conservative hands at that time. Obviously, the decision to perform a tracheotomy in a particular case must rest with the man on the spot. Our object in writing is simply to pass on to him the product of our own experience in managing such cases of severe respiratory paralysis complicated by stomata in the recovery period, so that he may take our viewpoint into consideration when making his decision. In practice, we believe that the suggestion made by Dr. Crampton Smith and Dr. Spalding-that the danger period of transport should be tided over by means of an oral endotracheal tube-should be extended to tide over the rest of the acute episode, and that both " prophylactic " tracheotomy and tracheotomy for the sake of administering artificial respiration by positive pressure should be almost limited to patients who fall ill beyond the reach of full hospital facilities and thus have mainly a " geographical " indication. The time for which an oral tube can be left in situ is still, we understand, sub judice. Figures varying from eight to forty-eight hours or more have been cited to us by different authorities. Certainly in one case a duration of forty-eight hours was risked with impunity. The danger period in poliomyelitis is fortunately often relatively short, and for this reason one should be the more reluctant to superimpose a complication which may have such lasting serious consequences if there is any hope that it can be avoided. J. TRUETA Nuffield Orthopædic Centre, M. AGERHOLM. Oxford.
long as the stoma and persist, weaning from
PARAPLEGIA FOLLOWING SPINAL ANÆSTHESIA
SiR,-Dr. Payne and Dr. Bergentz (May 12) do well to draw attention once more to the well-established clinical fact that paraplegia ensuing upon spinal anaesthesia may appear only several days after this procedure, and may then progress slowly for a further period of days or even weeks. Their case exemplifies also another established fact -that the immersion of ampoules of spinal anaesthetic in toxic solutions for purposes of sterilisation is by no means a constant factor in recorded cases of neurological complications after spinal anaesthesia. The only factor common to all these cases is the use of a spinal anaesthetic. The relevant literature makes it clear that the patient has often severed his ephemeral connection with the anaesthetist before his neurological syndromes-particularly the less severe ones-develop. Therefore what the anaesthetist does not hear about may nevertheless have
happened. Sir Robert Macintosh returns from Africa, notwith
something new," but with the old story that what he has not heard about has not happened. In his letter last week he cites again his single experience of the ampoule contaminated through invisible cracks by the coloured fluid in
(2) Those in which there is considerable delay in removing clothing which has been saturated in boiling liquid. Most
of these scalds occur in the region of the axilla and upper arm, or in the groin-both sites where hot liquid tends to "pool." In our survey last year we found 15 cases, all in children, in which there was definite delay in removing clothing after a scalding injury. All of these children required skin-grafting, 5 needing two, and2 needing three, grafting children, woollen garments, such as operations. In all thesewere worn at the time of the accident, cardigans and knickers, and it is our impression that these knitted garments hold the heat much longer than other materials.
The
importance
of
early
removal of
clothing
from
scalded patients is not widely appreciated, and the of Health advice note 5/54 states that " in the event of a burn or scald no attempt should be made to pull the clothes off the skin..." This is no doubt put forward in order to prevent further shock by rough handling of the patient, but certainly in the case of scalds retention of sodden hot clothing may cause unnecessarily deep destruction of the skin.
Ministry
Plastic Surgery, Burns, and Jaw Injuries Centre, St. Lawrence Hospital, Chepstow, Mon.
MICHAEL N. TEMPEST.
RESPIRATORY INVOLVEMENT IN POLIOMYELITIS SiE,—We welcome the discussion on the management of bulbo-respiratory complications in poliomyelitis which has taken place in your journal, and particularly the consideration given to the correct place of tracheotomy. It is timely that experience in this field should be pooled at the beginning of the poliomyelitis season as it is no longer necessary to be guided by the data collected during the Copenhagen epidemic of 1953, which was responsible for the great increase in the method in the U.K. Dr. Scott and Dr. Knox (April 21), in an interesting
discussion on their experience in transporting twelve of bulbo-respiratory paralysis last year, suggest that it might be better to perform tracheotomy before the journey, so that the trachea can be protected by the cuffed tube from aspiration from the pharynx, and positive-pressure respiration can be given by the same tube if necessary. Dr. Crampton Smith and Dr. Spalding (May 5) reply suggesting that for the period of transport it is better to use an oral cuffed tube passed under local anesthesia and to perform the tracheotomy once the patient is under good conditions on arrival at the final hospital." We should like to support the first part of the latter recommendation but to add that by the time the patient has reached " good conditions " one of the two cases
"
major hurdles-namely, transport-is already passed, and that instead of performing a tracheotomy on arrival the resources of the hospital should be directed to avoiding this intervention if at all possible. Thus, while the oral tube is in place the patient can be prepared for its removal, and for the use of negative-pressure respiration by (a) emptying the stomach and lower bowel (vomiting, associated with restlessness, is probably the other major hurdle), (b) effective sedation, (e) transfer to a cabinet respirator to be maintained in a steep head-down tilt after removal of the tube, and (d) the establishment of effective replacement therapy. If necessary the lungs can be cleared by direct vision with a bronchoscope, and of course effective suction must be constantly available to keep the pharynx clear. It has been our unfortunate lot for the past eighteen months to observe what a tragic’coxnplication a tracheotomy can be in a condition such as poliomyelitis, which may leave behind severe residual respiratory paralysis. Such patients have virtually no cough, and chronic pulmonary infection appears to be an inevitable consequence of the stoma. This infection reduces both the effective ventilation obtained by the residual respiratory power, and also the area of healthy lung tissue available
for
respiratory exchange. Consequently
the recovery of
spontaneous respiration is severely handicapped, and,
so
therefore the chronic infection aid may be impossible. Yet closure of the stoma is fraught with danger because of the chronic infection in the absence of a useful vital capacity and effective cough. The patient is, in fact, trapped in a vicious circle ; and the period of rehabilitation is either grossly prolonged by months or even years, or closure, and consequently rehabilitation, may have to be abandoned altogether, with the result that the patient may be condemned to permanent stay in hospital for the rest of his days. There are, in fact, a number of cases with severe respiratory paralysis now living in relative happiness at home for whom such a solution would have been impossible had a tracheotomy been performed in the acute stage ; and some of these cases would have been in real danger of this complication had they fallen into less conservative hands at that time. Obviously, the decision to perform a tracheotomy in a particular case must rest with the man on the spot. Our object in writing is simply to pass on to him the product of our own experience in managing such cases of severe respiratory paralysis complicated by stomata in the recovery period, so that he may take our viewpoint into consideration when making his decision. In practice, we believe that the suggestion made by Dr. Crampton Smith and Dr. Spalding-that the danger period of transport should be tided over by means of an oral endotracheal tube-should be extended to tide over the rest of the acute episode, and that both " prophylactic " tracheotomy and tracheotomy for the sake of administering artificial respiration by positive pressure should be almost limited to patients who fall ill beyond the reach of full hospital facilities and thus have mainly a " geographical " indication. The time for which an oral tube can be left in situ is still, we understand, sub judice. Figures varying from eight to forty-eight hours or more have been cited to us by different authorities. Certainly in one case a duration of forty-eight hours was risked with impunity. The danger period in poliomyelitis is fortunately often relatively short, and for this reason one should be the more reluctant to superimpose a complication which may have such lasting serious consequences if there is any hope that it can be avoided. J. TRUETA Nuffield Orthopædic Centre, M. AGERHOLM. Oxford.
long as the stoma and persist, weaning from
PARAPLEGIA FOLLOWING SPINAL ANÆSTHESIA
SiR,-Dr. Payne and Dr. Bergentz (May 12) do well to draw attention once more to the well-established clinical fact that paraplegia ensuing upon spinal anaesthesia may appear only several days after this procedure, and may then progress slowly for a further period of days or even weeks. Their case exemplifies also another established fact -that the immersion of ampoules of spinal anaesthetic in toxic solutions for purposes of sterilisation is by no means a constant factor in recorded cases of neurological complications after spinal anaesthesia. The only factor common to all these cases is the use of a spinal anaesthetic. The relevant literature makes it clear that the patient has often severed his ephemeral connection with the anaesthetist before his neurological syndromes-particularly the less severe ones-develop. Therefore what the anaesthetist does not hear about may nevertheless have
happened. Sir Robert Macintosh returns from Africa, notwith
something new," but with the old story that what he has not heard about has not happened. In his letter last week he cites again his single experience of the ampoule contaminated through invisible cracks by the coloured fluid in