PRINCESS TSAHAI MEMORIAL HOSPITAL

91 pressure is to fill shallow domestic baking-trays with talcum, wrap in brown kraft paper, and then sterilise by dry heat in an oven, allowing sufficient time for the whole of the contents to be at 150°C for at least two hours. One practice I have met which is particularly undesirable consists in putting up a relatively large quantity of unsterile talcum (up to 25 g.) in a gauze bag ; one such bag is then placed inside each pair of gloves, with the idea that it can be repeatedly used and resterilised, thus avoiding the labour of

refilling each time. It is permissible, however, to use very small quantities of talcum in gauze folders packed inside the cuffs of gloves. Dr. Sevitt mentions the desirability of ensuring the of " superheated steam " when he presumeasy entry "

ably means ing agent.l0

saturated steam," which is a better sterilisHis excellent article emphasises once again the necessity for all sterilising processes to be supervised by responsible and trained personnel. In this connexion I have found Carl Walter’s textbook 9

invaluable. JOHN C. H. HANSON.

Hertford.

GRAPHITE PNEUMOCONIOSIS

pneumoconiosis is a prime requirement, yet I know no record.

of which

as

It is known that in coal workers tubercle bacilli occur much less frequently in the sputum than in the lesions post MorteM.14 Thus in this connexion clinical evidence is not as reliable as post-mortem evidence. Dr. Dunner’s failure to find tubercle bacilli in the sputum of one or two of his cases is therefore not surprising. Dr. Dunner is right in demanding prolonged animal experiments to assist in deciding the roles of graphite dust and infection in the genesis of pulmonary disease. As graphite and coal dust are not very dissimilar in their silica contents, my experience in connexion with the inhalation of airborne coal dust by rabbits underground for over 31/2 years is relevant. Massive fibrosis of the lungs does not occur, but focal dust lesions with very little tissue reaction do develop. This is quite a different type of response to that induced by the inhalation of silica dust. The purpose of my former letter was to draw attention to an alternative interpretation of the pathogenesis of graphite pneumoconiosis to that put forward by other investigators. In this department over 700 autopsies have now been performed on coal workers from many of whom X-ray films are available.15 When therefore another industrial dust hazard is found to produce very similar radiological and pathological appearances in, the lungs, there is good reason for considering the possibility that its pathogenesis resembles that now believed to operate in coal workers.

Sm,-In his comments on my letter of Nov. 19, Dr. Dunner (Dec. 3) claims to refute the possibility of an infective origin for massive’lesions in graphite pneumoconiosis, on the basis of his clinical and radiological findings in 9 cases (so far as I can determine from his articles), including post-mortem observations on one of them. I agree with Dr. Dunner that the " miliary snowstorm " appearance on the X-ray film probably reflects Department of Pathology, A. G. HEPPLESTON. the changes produced by dust alone, but because massive Welsh National School of Medicine, Cardiff. shadows sometimes develop subsequently to the miliary ones it does not necessarily follow that the massive fibrosis PRINCESS TSAHAI MEMORIAL HOSPITAL represents a later stage in the development of the focal dust lesions. The results of radiological investigations SiR,-I was delighted to observe the support for Lord into coal-workers’ pneumoconiosis show that large Winster’s appeal on behalf of this hospital which Dr. Goodman gave in his letter of Dec. 31. I am glad to localised shadows, representing massive .lesions, quite is no doubt of the commonly develop in cases showing the generalised X-ray observe his testimony that there " appearances known to result from simple pneumo- ’potential value of the hospital, especially as a training coniosis ; and the conclusion of Davies et al.11 favours centre for nurses." I cannot, however, concur in his the view that such massive shadows are infective suggestion that the scheme should be abandoned unless in nature and often tuberculous. Dr. Dunner’s cases the hospital is opened forthwith. follow a similar radiological course and hence on this Four years is a long time to wait ; yet. the period is not ground the infective origin of massive shadows in graphite very long for carrying through so important and ambitious a scheme as a hospital involving the raising of £ 100,000 workers cannot be lightly dismissed. For the pathological and bacteriological reasons by purely voluntary subscriptions. I observe that even in days an offer of E60,000 for an annexe to one of our previously given, there is justification in the case of pre-warBritish great hospitalswas made on the condition that coal workers for regarding massive fibrosis as the result a further 60,000 was raised by voluntary subscriptions of another disease process superimposed on the purely within five years. That was for a British hospital; the sum dust lesions. All the available evidence points to the which had to be collected in easier times than these was infective and often this is clearly added process considerably less than 100,000. The council of the Princess Tsahai Memorial Hospital has -had to contend with very tuberculous. Even in the absence of specific evidence of tuberculosis, the general pathological appearances of difficult circumstances in raising funds in Britain ; in the first instance, the competing claims of a host of war charities massive lesions are so consistent as to suggest that the for countries in which the war was still being actively waged, in all It cases. similar is pathogenesis fundamentally whereas in Ethiopia the war had ceased ; then the very may well be that in some cases the infection is ultimately cost of paying for the war, which has fallen to so heavy overcome, just as occurs in uncomplicated tuberculosis. an extent on the shoulders of the people disproportionate Although the operation of some other infection than of Britain. tuberculosis cannot be excluded, this appears to me Our council appreciates to the full the sums which have been contributed towards the hospital fund in Ethiopia, but unlikely. From the pathological evidence in Dr. Goodman is in error in describing these as coming solely workers provided by Gloyne et al.,12 Harding and Oliver,13 from the British and Ethiopian communities. The Greeks, the and Dr. Dunner, as well as from a case personally and the Indians have contributed very substantial observed, there is a close correspondence between the Armenians, sums, and of course the Ethiopians themselves, including disease in these workers and that in coal workers, and His Imperial Majesty, who has given very substantially, as hence the distinction between infective and simple dust well as providing the site and the partly constructed building. lesions also appears applicable to graphite pneumoMy knowledge of the sources of the large contributions coniosis. Post-mortem study directed to the isolation to the fund which have been raised and expended on the of the tubercle bacillus from massive lesions in graphite building itself in Ethiopia is by no means complete, but

being

graphite

10. Savage, R. M. Quart. J. Pharm. 1937, 10, 451. 11. Davies, I., Fletcher, C. M., Mann, K. J., Stewart. A. Proceedings of the Ninth International Congress of Industrial Medicine, London, 1948 ; p. 773. 12. Gloyne, S. R., Marshall, G., Hoyle, C. Thorax, 1949, 4, 31. 13. Harding, H. E., Oliver, G. B. Brit. J. industr. Med. 1949, 91. 6,

far as that knowledge goes it would appear that the nonBritish communities have taken the lead in this matter inside so

Ethiopia. 14. Fletcher, C. M. Brit. med. J. 1948, i, 1015. 15. Gough, J., James, W. R. L., Wentworth, J. E. 1949, 1, 28.

J. Fac. Radiol.

92 In thi colmtry, there has been a valiant British effort, and valiant efforts are still being made, but suggestions that the scheme should be abandoned for any consideration are

by

no means

helpful.

Dr. Goodman refers to the Russian hospital ; but the Russian contribution came from the Russian Government, and was not raised by private subscription. The memorial hospital council in Britain has had no Government grant. Her Majesty the Queen early signified her sympathy by a gracious donation of 9100 ; but it was not until 1948, when the proceeds of B.B.C. appeals had greatly diminished owing to the heavy taxation now borne by the British people, that an appeal for the Princess Tsahai Memorial Hospital Week’s Good Cause." was broadcast as the In the spring of last year the council was led to hope that jE10,000 which was collected by the late Dr. John Melly for medical work in Ethiopia, and is now in the keeping of the British Red Cross Society, would be granted to the hospital. This would have enabled the council to proceed with the remaining purchases, and to open the hospital as soon as the interior finishings and the fitting of the equipment are complete. Unfortunately, this hope has been deferred.. The harder way of the fund pound by pound, shilling by ,.

raising

pyrexial, and had well-marked tachycardia. There was a gross pleural rub on the right side suggesting a pulmonary infarct. On Sept. 11 a further radiograph showed that the diaphragm was flattened ; there was evidence of pleurisy, but the congestive changes had improved. He was discharged on Sept. 15, symptom-free and radiographically clear except for a small amount of fluid in the right costophrenic angle.

Normally, when performing an intercostal block on the conscious or unconscious patient, if the needle penetrates the pleura a warning cough is elicited, and, as a rule, provided that the needle is of small bore and aseptic precautions have been taken, no harm results. It would seem that in the aged, and particularly those with a history of chronic bronchitis, pleurisy, and emphysema, no warning signals are to be expected ; and the anæsthetist must exercise greater caution in performing intercostal blocks on these cases, especially when proctocaine is used. W. N. ROLLASON. Scunthorpe, Lines. TUBERCULOUS ABSCESS AT SITE OF PENICILLIN INJECTIONS

shilling, must proceed. Apart from the raising

of funds, it has taken approximately three years after the orders were placed to secure delivery of the electrical equipment made for the hospital in this country. As the equipment is paid for in this country, it does not receive the facilities granted to dollar-earning goods.

For the comfort and encouragement of the many who have generously contributed to the memorial hospital fund, and all who desire it to be opened at an early date, I would add that though approximately 15,000 is required to complete the scheme, 5000 would enable the hospital to be opened. My appeal to Dr. Goodman, and all who desire the early success of the effort, is for cheerfulness and confidence in the project, and practical assistance to " see it through." Practical assistance at the present stage involves donations, which will be gratefully acknowledged by the hon. treasurers, Lord Horder and Lord Amulree, c/o Messrs. Gould & Prideaux, 88. Bishonss-ate. London. E.C.2. ‘

3, Charteris Road, Woodford Green, Essex.

E. SYLVIA PANKHURST

Hon.

Secretary.

THERAPEUTIC INTERCOSTAL BLOCK

SIR,—In these days, when therapeutic blocks form part. of an anaesthetist’s routine work, the following

case-report A man,

may be of

some

interest.

aged 69, with a history of chronic bronchitis, pleurisy, emphysema, and secondary cardiac failure was referred to our nerve-block clinic because of intractable pain along his right costal margin following a fall from his bicycle twelve months previously. He was ambulatory and had a good colour, and there was no dyspnaea at rest. There was, however, some oedema round his ankles with pitting His chest was clinically clear, and on Aug. 31, on pressure. 1949, radiographs revealed a normal diaphragm, no cardiac enlargement, clear lung-fields, and no bony injury. On Sept. 7 a block of the 8th-12th right intercostal nerves was performed in the posterior axillary line; ’Proctocaine ’ 10 ml. was used for each nerve. The patient complained of no symptoms and showed no signs of distress during any of the injections, and at the end volunteered that his pain had gone. He was. transferred on a theatre-trolley to the recoveryroom and was told he could get dressed in a few minutes if he continued to feel all right. Shortly afterwards, however, he became cyanosed and dyspnceic with some bronchospasm and pain in the right lower chest on inspiration. Oxygen was administered, and an hour later he was referred to the X-ray department where a radiograph of the chest revealed evidence of a small effusion on the right side- and some generalised hyperaemia in the lungs, particularly at the right base. There was no evidence of pneumothorax. He was admitted to the ward, where oxygen therapy was continued. Penicillin was administered, and heroin, adrenaline, and ephedrine were given to relieve his pain and bronchoTwo days later, on Sept. 9, he developed severe pain spasm. in the right side of his chest and collapsed. The following day he coughed up some blood, was distressed and slightly

SIR,—Elek1 believes that the appearance of tuberculous abscesses at the site of penicillin injections is by no -means so rare as the paucity of reported cases may suggest. I feel sure that he is right. I have to hand the records of nine children, who for one reason or another were given soluble penicillin intramuscularly at some period during the last 2 years, and who subsequently developed tuberculous abscesses at the site of the injections. As none of them were under my care at the time the penicillin was given (they had been treated in a number of different hospitals), the difficulty in reporting them in full will be appreciated ; and it may be that others have been presented with the same

problem ! My series comprises

children

varying from the age of penicillin injections. In all cases soluble penicillin had been given intramuscularly. In five cases solitary abscesses appeared 5-7 weeks after the completion of the penicillin course ; in four cases multiple abscesses appeared 6-18 weeks 1 month to 7 years at the time of the

afterwards. In all cases tubercle bacilli were isolated from the lesions. In no case was there a history of contact with tuberculosis. In no case was evidence found of tuberculosis elsewhere in the body at the time the abscesses were first noted. In those cases in which a single abscess occurred the regional lymph-glands were much enlarged, but this was not so in the cases with multiple abscesses. Unfortunately, Mantoux reactions had not been carried out before the penicillin courses were given, but they were all positive by the time the One child died of miliary abscesses were diagnosed. tuberculosis. Six have chronically discharging ulcers or sinuses. Two were treated by radical excision of all the abscesses as soon as the diagnosis was made, and these children have done well. (The regional lymph-glands in these two cases were apparently not involved.) I am convinced that in early cases this is the treatment of choice. The aetiology has been discussed by Ebrill and -Elek,2 Hounslow,3 Hindenach,4and Forbes and Strange.5 The five cases with solitary abscesses in this series which had enlarged regional lymph-nodes suggest at once that primary tuberculous complexes had been produced, and this is supported by the fact that one of these children was only 2 months old when the tuberculous lesion first appeared. The four cases with multiple abscesses and no lymph-gland enlargement looked clinically less like primary lesions, but it so happened that these 1. 2. 3. 4. 5.

Elek, S. D. Lancet, 1949, i, 628. Ebrill, D., Elek, S. D. Ibid, 1946, ii, 379. Hounslow, A. G. Ibid, p. 617. Hindenach, J. C. R. Proc. R. Soc. Med. 1947, 40, 161. Forbes, G. B., Strange, F. G. St.C. Lancet, 1949, i, 478.