POST-RADIATION PNEUMONITIS

338 onset of bilateral pleural effusions in certain In 1949 I recorded2 the case of a woman of 38 who developed a right pneumothorax immediately after induction of a therapeutic pneumoperitoneum, and gave reasons for attributing the free passage of air from peritoneal to pleural cavity to the persistence of a pleuroperitoneal sinus (of Bochdalek). A further case recorded by Breathnach,3 in which a symptomless right pneumothorax was first detected two weeks after pneumoperitoneum induction, may also have been of the immediate type. The reason why pneumothorax appears almost invariably on the right side has not yet been satisfactorily explained, but the most theory seems to be that congenital weaknesses of the left side of the diaphragm, which are said to occur more commonly than on the right, are subjected to greater stress throughout life from abdominal contents, not being protected by the liver and herniation therefore frequently results on this side. Such

the

rapid

cases of ovarian tumour.

likely

herniations would be revealed

by routine radiography,

and pneumoperitoneum contra-indicated. Introduction of air into the peritoneal sac removes the protection of the liver from the right cupola, exposing the defects in the diaphragm, thus causing either an immediate pneumo-

thorax or delayed rupture from compression of air under the cupola by the piston-like action of the liver during a violent movement. The surface of the diaphragm being convex upwards the tear is likely often to be valvular, trapping more air, or in the case of ascites more fluid, in the pleural cavity with each inspiration and every thrust of the liver. Lancaster House Chest

Southend-on-Sea.

Clinic,

E. G. SITA LUMSDEN.

SIR,—There is at present no curative treatment for Hodgkin’s disease, but judiciously applied X-ray treat-

single palliative

measure

available. It would, therefore, be unfortunate if the case of pulmonary fibrosis reported by Dr. Whitfield and his colleagues in your issue of July 17 should cause this treatment to fall into disrepute. Their case was treated by deep X-radiation " a calculated minimum dose of 3000r in the mediastinum being given by cervicothoracic baths over a period of twenty-six days. First-degree skin erythema appeared ..." Some nine weeks later " the skin on the front and back of his chest showed slight post-radiation changes." In our combined experience of over thirty years of radiotherapy we have neither of us seen a case such as the one described, but neither have we used a dose of X rays, in this region and for this condition, exceeding two-thirds of that quoted. Neither would we consider it justifiable in this stage of the disease to use the " bath technique " Such a technique here offers no advantage over localised mediastinal treatment. but merely permits irradiation of large volumes of normal tissues. Moreover, it would be of interest to know whether the calculated minimum at the rnediastinum took into account the lack of absorption of radiation by air-containing lung or was based on conventional measurements, since in the latter case the mediastinal dose may have been nearer 4000r than the 3000r mentioned. In other words, the comment that " pneumonitis of this kind may follow radiotherapy in which the conventional dosage is not exceeded " is not a fair one. Having regard to the relationship of desirable tissue -dosage to the volume treated and the nature of the disease, the dosage reported cannot be regarded by any means as

"

customary."

The Churchill

Hospital,

Oxford.

point of importance. At the end of the section entitled A Subsidiary Survey, we should have added : " These 12 cases were the only of retrolental fibroplasia discovered in the examples subsidiary survey." We hope this will make it quite clear that the disease in Manchester has been almost entirelv confined to the two major units described. one

’

R. M. FORRESTER E. JEFFERSON W. J. NAUNTON.

St. Mary’s Hospitals for Women and Children, Manchester, 13.

CONNECTIVE-TISSUE DISEASES

SIR,—Considering the immense amount of literature of various kinds concerning the modern ideas on collagen or connective-tissue diseases, it seems to me surprising that acquired camptodactylia and Dupuytren’s contraction have almost escaped mention. I find it hard to account for this, for it seems to me that these conditions represent the least complicated and most striking examples of pathological states which ought to be discussed under the heading of collagen or connectivetissue diseases. Acquired camptodactylia is probably a rare variety of Dupuytren’s contraction. One form, which seems to result from repeated slight traumata, is limited at first to one hand, but eventually progresses to involve both, almost symmetrically.’ F. PARKES WEBER. London, N.W.1. .

PHÆOCHROMOCYTOMA

POST-RADIATION PNEUMONITIS

ment remains the most effective

OXYGEN AND RETROLENTAL FIBROPLASIA SIR,—It has been pointed out to us that in our article on retrolental fibroplasia in last week’s issue we omitted

FRANK ELLIS CHARLES L. LEWIS.

2. Sita Lumsden, E. G. Thorax, 1949, 4, 147. 3. Breathnach, C. S. J. Irish med. Ass. July 14, 1953.

SIR,—In your issue of Aug. 7, Dr. Baird and Dr. Cohen say that..there is no single reliable pharmacological test for phæochromocytoma." Of course no laboratory test is infallible, and the interpretation of a test may be at fault, but my experience of the estimation of the catecholamines in urine, in a total of 92 cases, suggests that this is a reliable guide. Of these patients, 85 had a 24-hour excretion of 80 µg. or less, and I reported these cases as negative ; 7 cases, however, had a 24-hour excretion of between 180 µg. and 3500 µg. and I reported these cases as positive. In all these 7 cases a phæochromocytoma was removed at operation. Accordingly, I can say that I have not yet reported a false positive. Whether any of the 85 negative cases was a false negative, only time will show ; 3 cases have so far come to necropsy, and no phæochromocytoma was found. The Radcliffe Infirmary, Oxford.

GEORGE P. BURN.

LUMBAR PUNCTURE IN POLIOMYELITIS

SIR,—Major Hamilton’s letter, in your issue of Aug. 7, is indeed timely, and he rightly expresses concern at the practice of performing lumbar puncture as a confirmatory diagnostic aid in poliomyelitis. His concern would no doubt have been even greater if he had had an opportunity of reading the medical memorandum on poliomyelitis by the Ministry of Health last month.2 In my opinion, -this otherwise very excellent document is at fault when it mentions examination of the cerebrospinal fluid (c.s.F.) as an apparently desirable procedure for early diagnosis. It is known that the C.S.F. is abnormal in approximately 90% of cases, but a physician with experience in the diagnosis and treatment of poliomyelitis should not be tempted to subject his patient to maintaining his

published

1. Parkes Weber, F. Further Rare p. 116. 2. See Lancet, July 24, 1954, p. 187.

Diseases.

London, 1949;