- Email: [email protected]
TREATMENT OF PULMONARY TUBERCULOSIS
584
pneumothorax two entirely limited to
Letters to the Editor
she has
THE NEED FOR AN OCCUPATIONAL HYGIENE SERVICE SIR,—The points made by Dr. Nash in his article (Sept. 6) require periodic emphasis. It is time that industrial medicine in this country was placed on a more scientific basis. Expert advice on all aspects of health in industry should be readily available to the management of all firms and also to trade-unions so that conditions can be improved and doubts and
suspicions allayed. The work is essentially practical-to ensure good working conditions through skilled advice. By routine supervision and air-sampling, clinical findings may be assessed in terms of the environment and vice versa on a long-term as well as a short-term basis. Experience is available from all countries through the International Labour Office. My article on the Health Engineer and Industrial Medicinestressed the need for an occupational health service of the type now suggested. Such centres depend in the first place on the availability of suitably trained Firms might be more willing to consult an men. occupational hygiene centre based on a university teaching department than one directly controlled by the Factory Department of the Ministry of Labour and National Service. The academic affiliation would give stimulus and independence of action ; the link with the Factory Department would be close. Personnel might be seconded as in the U.S.A. Whatever the form of the service, the ultimate aim is to make factories good to live in as well as good enough to work in. Advice from the centres must be imaginative and constructive. It has been said that the next great advances in public health would be in the field of industrial medicine ; and if the purely medical aspects of industrial health are closely linked through an occupational health service with the chemical and engineering aspects, the advance will be greatly assisted. The fruits will be improved health and increased productivity, on which the future of the country depends. Community Centre, Slough, Bucks.
M. E. M. HERFORD.
TREATMENT
OF PULMONARY TUBERCULOSIS feel a certain sympathy with Dr. Anderson SIR,—I in his plea (Sept. 6) for the retention of pneumothorax in the treatment of limited disease which has shown some indication of progression. Even here, however, the reservations are such that it is more than doubtful whether this can be accepted as one of the " positive criteria " for induction.
First, the
term
"
minimal disease " is too
indefinite ; it
indication of the nature of the lesion-whether gives progressive primary, recrudescent primary, haematogenous, recrudescent haematogenous, or bronchogenic. Nor does it indicate whether the lesion is a simple infiltration which will absorb with bed-rest and chemotherapy, or a caseous no
focus which will not. It does not define whether or not a small cavity is present, and I doubt whether a clear indication for collapse therapy exists unless a cavity either is present or has been evident recently. Moreover, the term minimal lesion gives no indication of its duration, and I fear that One authority even as a definition of extent it is far too vague. indicated recently that it might include lesions containing up to 30 ml. of diseased tissue ; and I must confess that when I visualise a volume of caseation equivalent to that contained " by even a 10 or 20 ml. syringe, the term 4’minimal seems extraordinarily inappropriate and not without a certain danger. Finally, the complications of pneumothorax therapy even for limited lesions can still be serious. I have this week seen a patient readmitted to hospital for whom I advised a ’’
"
1.
Lancet, 1951, ii, 73.
an
years ago. Then she had the area above the right
a
small lesion now
bronchopleural fistula and will pleurectomy combined with a right upper
empyema with
probably require lobectomy.
a
clavicle ;
a
I feel that it is extremely difficult to define precise indications for pneumothorax therapy, and I use it mostly where, for some reason, other measures seem inappropriate. I think, too, that there is something to be said for its more common use as a deliberately interim measure, with the specific intention of abandoning it after four to six weeks or even earlier ; cavity closure does sometimes result from the prompt abandonment of even a technically unsatisfactory pneumothorax ; and major complications in this short period are generally
controllable. Mr. Temple is, of course, entirely right in pointing out (Sept. 6) that clinicians in the region are not addicted to resection to the exclusion of all else ; indeed, to judge from his letter, this area should not suffer from any lack of an independent viewpoint in its approach
Liverpool
to the
problem of treatment. May I say that the term used-I scarcely dare mention it now was not intended to be accusatory or even critical, but merely to indicate that this is a centre where resection is practised on a considerable scale ? I agree that for this purpose it is altogether too loose and casual and open to other intera trifle youthful to have pretations-though perhaps obtained the status of a " bogy " ! Clare Hall Hospital, NORMAN MACDONALD. South Mimms,
Barnet, Hertfordshire. WATERHOUSE-FRIDERICHSEN SYNDROME TREATED WITH CORTISONE SIR,—In connection with the article by Dr. Breen and his colleagues,’ the following case-record may be of interest. A male child, aged 4 months, was admitted to hospital at 6.30 P.M. on June 8. He had been perfectly well until that morning, when he vomited the early morning feed and seemed listless and fretful. At 4 P.M. a purpuric rash appeared, and the child became cyanosed and collapsed. On admission the temperature was 1036°F, the pulse was barely palpable, and the blood-pressure could not be taken owing to the lack of a cuff of appropriate size. The child was collapsed and cyanosed but conscious ; and there were purpuric eruptions on the legs, buttocks, face, and back. No neck stiffness was present, and Kernig’s sign was negative; the chest appeared to be clear ; there were no abnormal findings in the abdomen. Treatment was instituted immediately on admission with continuous oxygen by nasal catheter. ’Eucortone’ 5 ml. was given intramuscularly. Penicillin was administered intramuscularly in a dose of 500,000 units followed by 250,000 units 6-hourly, and sulphathiazole intramuscularly in a dose of 1 g., followed by 0-25 g. 4-hourly. Cortisone was obtained at 8.30 r.M. ; and 25 mg. was given by mouth 6-hourly for the first 24 hours. The white blood-cell count was 22,000 per c.mm. (polymorphs 77%, large lymphocytes 20%, and mono-
cytes 3%). The next day (June 9) the child was very much better. The cyanosis had disappeared, and there were no further purpuric eruptions. There was no vomiting, and the urinary output was satisfactory. Treatment was continued as before except that cortisone was given in doses of 12-5 mg. 6-hourly, and eucortone in doses of 2 ml. twice daily in the second 24 hours. Thereafter cortisone 6-25 mg. was given 6-hourly for the next 3 days, together with eucortone 1 ml. daily. On the 6th day cortisone was given in doses of 6-25 mg. three times daily, and eucortone 0-5 ml. once. On the 7th and 8th days cortisone 6-25 mg. was given twice daily and eucortone 0.25 ml. once daily. On each of the 9th and 10th days cortisone 6-25 mg. was given and eucortone 0-25 ml. Thereafter cortisone and eucortone were discontinued, but treatment with penicillin and sulphonamides was continued. On June 11 (3rd day after admission) there was a suggestion of neck stiffness although Kernig’s sign remained negative. Lumbar puncture yielded slightly turbid cerebro1.
Breen, G. E., Emond, R. T. D., Walley, R.V. Lancet, 1952, i, 1140.
pneumothorax two entirely limited to
Letters to the Editor
she has
THE NEED FOR AN OCCUPATIONAL HYGIENE SERVICE SIR,—The points made by Dr. Nash in his article (Sept. 6) require periodic emphasis. It is time that industrial medicine in this country was placed on a more scientific basis. Expert advice on all aspects of health in industry should be readily available to the management of all firms and also to trade-unions so that conditions can be improved and doubts and
suspicions allayed. The work is essentially practical-to ensure good working conditions through skilled advice. By routine supervision and air-sampling, clinical findings may be assessed in terms of the environment and vice versa on a long-term as well as a short-term basis. Experience is available from all countries through the International Labour Office. My article on the Health Engineer and Industrial Medicinestressed the need for an occupational health service of the type now suggested. Such centres depend in the first place on the availability of suitably trained Firms might be more willing to consult an men. occupational hygiene centre based on a university teaching department than one directly controlled by the Factory Department of the Ministry of Labour and National Service. The academic affiliation would give stimulus and independence of action ; the link with the Factory Department would be close. Personnel might be seconded as in the U.S.A. Whatever the form of the service, the ultimate aim is to make factories good to live in as well as good enough to work in. Advice from the centres must be imaginative and constructive. It has been said that the next great advances in public health would be in the field of industrial medicine ; and if the purely medical aspects of industrial health are closely linked through an occupational health service with the chemical and engineering aspects, the advance will be greatly assisted. The fruits will be improved health and increased productivity, on which the future of the country depends. Community Centre, Slough, Bucks.
M. E. M. HERFORD.
TREATMENT
OF PULMONARY TUBERCULOSIS feel a certain sympathy with Dr. Anderson SIR,—I in his plea (Sept. 6) for the retention of pneumothorax in the treatment of limited disease which has shown some indication of progression. Even here, however, the reservations are such that it is more than doubtful whether this can be accepted as one of the " positive criteria " for induction.
First, the
term
"
minimal disease " is too
indefinite ; it
indication of the nature of the lesion-whether gives progressive primary, recrudescent primary, haematogenous, recrudescent haematogenous, or bronchogenic. Nor does it indicate whether the lesion is a simple infiltration which will absorb with bed-rest and chemotherapy, or a caseous no
focus which will not. It does not define whether or not a small cavity is present, and I doubt whether a clear indication for collapse therapy exists unless a cavity either is present or has been evident recently. Moreover, the term minimal lesion gives no indication of its duration, and I fear that One authority even as a definition of extent it is far too vague. indicated recently that it might include lesions containing up to 30 ml. of diseased tissue ; and I must confess that when I visualise a volume of caseation equivalent to that contained " by even a 10 or 20 ml. syringe, the term 4’minimal seems extraordinarily inappropriate and not without a certain danger. Finally, the complications of pneumothorax therapy even for limited lesions can still be serious. I have this week seen a patient readmitted to hospital for whom I advised a ’’
"
1.
Lancet, 1951, ii, 73.
an
years ago. Then she had the area above the right
a
small lesion now
bronchopleural fistula and will pleurectomy combined with a right upper
empyema with
probably require lobectomy.
a
clavicle ;
a
I feel that it is extremely difficult to define precise indications for pneumothorax therapy, and I use it mostly where, for some reason, other measures seem inappropriate. I think, too, that there is something to be said for its more common use as a deliberately interim measure, with the specific intention of abandoning it after four to six weeks or even earlier ; cavity closure does sometimes result from the prompt abandonment of even a technically unsatisfactory pneumothorax ; and major complications in this short period are generally
controllable. Mr. Temple is, of course, entirely right in pointing out (Sept. 6) that clinicians in the region are not addicted to resection to the exclusion of all else ; indeed, to judge from his letter, this area should not suffer from any lack of an independent viewpoint in its approach
Liverpool
to the
problem of treatment. May I say that the term used-I scarcely dare mention it now was not intended to be accusatory or even critical, but merely to indicate that this is a centre where resection is practised on a considerable scale ? I agree that for this purpose it is altogether too loose and casual and open to other intera trifle youthful to have pretations-though perhaps obtained the status of a " bogy " ! Clare Hall Hospital, NORMAN MACDONALD. South Mimms,
Barnet, Hertfordshire. WATERHOUSE-FRIDERICHSEN SYNDROME TREATED WITH CORTISONE SIR,—In connection with the article by Dr. Breen and his colleagues,’ the following case-record may be of interest. A male child, aged 4 months, was admitted to hospital at 6.30 P.M. on June 8. He had been perfectly well until that morning, when he vomited the early morning feed and seemed listless and fretful. At 4 P.M. a purpuric rash appeared, and the child became cyanosed and collapsed. On admission the temperature was 1036°F, the pulse was barely palpable, and the blood-pressure could not be taken owing to the lack of a cuff of appropriate size. The child was collapsed and cyanosed but conscious ; and there were purpuric eruptions on the legs, buttocks, face, and back. No neck stiffness was present, and Kernig’s sign was negative; the chest appeared to be clear ; there were no abnormal findings in the abdomen. Treatment was instituted immediately on admission with continuous oxygen by nasal catheter. ’Eucortone’ 5 ml. was given intramuscularly. Penicillin was administered intramuscularly in a dose of 500,000 units followed by 250,000 units 6-hourly, and sulphathiazole intramuscularly in a dose of 1 g., followed by 0-25 g. 4-hourly. Cortisone was obtained at 8.30 r.M. ; and 25 mg. was given by mouth 6-hourly for the first 24 hours. The white blood-cell count was 22,000 per c.mm. (polymorphs 77%, large lymphocytes 20%, and mono-
cytes 3%). The next day (June 9) the child was very much better. The cyanosis had disappeared, and there were no further purpuric eruptions. There was no vomiting, and the urinary output was satisfactory. Treatment was continued as before except that cortisone was given in doses of 12-5 mg. 6-hourly, and eucortone in doses of 2 ml. twice daily in the second 24 hours. Thereafter cortisone 6-25 mg. was given 6-hourly for the next 3 days, together with eucortone 1 ml. daily. On the 6th day cortisone was given in doses of 6-25 mg. three times daily, and eucortone 0-5 ml. once. On the 7th and 8th days cortisone 6-25 mg. was given twice daily and eucortone 0.25 ml. once daily. On each of the 9th and 10th days cortisone 6-25 mg. was given and eucortone 0-25 ml. Thereafter cortisone and eucortone were discontinued, but treatment with penicillin and sulphonamides was continued. On June 11 (3rd day after admission) there was a suggestion of neck stiffness although Kernig’s sign remained negative. Lumbar puncture yielded slightly turbid cerebro1.
Breen, G. E., Emond, R. T. D., Walley, R.V. Lancet, 1952, i, 1140.