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takes place, advice on family planning should beavailable without charge as an integral part of thematernity service.The goal of 100% deliveries in hospital will appeal

to most doctors because of its promise of increasedsafety, and to the public because socially the trendis overwhelmingly towards regarding hospital as theright place for delivery. Furthermore, in lookingbeyond improved cooperation to actual integration thecommittee will command general support. No servicehas been more severely impeded than maternity by thetripartite structure of the N.H.S. Integration is not tobe won without hurting some interests: local healthauthorities cannot be expected to welcome the threat-ened loss of their clinical contribution; nor will all

general-practitioner obstetricians cheer the prospect ofa service centred on the district hospital, with theirown maternity units condemned to reduction andeventual extinction. The success of the scheme will

depend on how solidly the various workers are weldedinto a single team, and on the effectiveness of a

hospital-based service in reaching out into the com-munity to provide continuous care. But, if the serviceis to be unified, it has to be based somewhere; and, allin all, the committee’s recommendations are bothsensible and realistic.

NASAL CANCER IN WOODWORKERS

Macbeth reported a strong clinical impressionthat adenocarcinoma of the nasal sinuses was un-

usually common among woodworkers in the Bucking-hamshire furniture industry. Further evidence 2

from Oxford and Wycombe in 1967 showed that

the incidence of these otherwise rare nasal tum-ours was as high among woodworkers as that ofbronchial carcinoma, and they were to be regarded asof industrial origin. In an elegant account of adeno-carcinoma of the paranasal sinuses, Hadfield 3 analyses92 nasal carcinomas seen in Oxfordshire and Bucking-hamshire between 1956 and 1969. A remarkably highincidence of adenocarcinoma is confirmed in Bucking-hamshire, compared with the neighbouring county, andmost of the cases were in High Wycombe. Out of35 patients 29 were or had been woodworkers in thefurniture industry. All the adenocarcinomas originatedin the ethmoid sinuses, and most of the squamoustumours arose in the antra. Unilateral bloodstainednasal discharge and unilateral nasal obstruction werethe earliest presenting symptoms, and epiphora wasoften noted. None of the patients with adenocarcinomahad any signs of cervical lymph-node metastases

during the disease, nor was any found in those examinedpost mortem. Death was invariably associated withintracranial extension of the growth. Antral tumourson the whole kill by blood-borne metastases. All

patients were treated with a combination of irradiationand radical surgery. Of the 92 patients, 31 are aliveand 13 have survived five years.

In an effort to discover early cases or to identify apremalignant lesion, a survey was started of the men1. Macbeth, R. G. J. Lar. Otol. 1965, 79, 592.2. Acheson, E. D., Hadfield, E. H., Macbeth, R. G. Lancet, 1967,

i, 311.3. Hadfield, E. H. Ann. R. Coll. Surg. Engl. 1970, 46, 301.

in the woodworking side of the furniture industry.It was found that wood dust was deposited in twoareas anteriorly on the nasal septum and on the anteriorpart of the middle turbinate. Biopsy examination ofthe middle turbinate regularly showed squamousmetaplasia-which accounts for the persistence of thedeposits over non-ciliated epithelium, since particleswill be entrapped in the mucus but will not be carriedaway if there are no cilia to propel it. If the wood dustdoes contain a carcinogen, as seems likely, then pro-longed contact with mucous membrane of the middleturbinate would provide an adequate stimulus to

tumour formation.

STREPTOKINASE FOR PULMONARY EMBOLISM

PULMONARY embolism, the only potentially lethalcomplication of venous thrombosis, as often as not

happens without warning, for about half of all deepvenous thrombi are clinically undetectable. Possiblemethods of prevention range from raising the legsduring operations 2 to the preoperative administrationof fibrinolytic drugs, such as phenformin plus ethyl-oestrenol.3 Until such measures have been more

fully explored, reliance must be placed on conventionalanticoagulant therapy in patients with establishedvenous thrombosis and/or pulmonary embolism andin patients at special risk. While such treatment is ofsome value in suitable cases, it provides no answer tothe sudden, unheralded, major pulmonary embolism.Many patients die within 15 minutes and are clearlyuntreatable. Some make a complete recovery withouttreatment (presumably by spontaneous lysis of theembolus by endogenous fibrinolysis); others die withinhours or days of the incident; and yet others survivewith respiratory incapacity due to irreversible obstruc-tion of branches of the pulmonary arteries.

Since it is hard to predict the outcome in thosepatients who survive long enough to be treated, pul-monary embolectomy or the infusion of herapin havebeen used-with varying success. The advent of

thrombolytic therapy with streptokinase or urokinase(extremely expensive, but having the advantage of notbeing antigenic) provides a new approach. Experiencein Britain is limited, and how to identify patientslikely to benefit is far from clear. On p. 237 Mr. Kakkarand Dr. Raftery report their experience with strepto-kinase in 6 patients with massive pulmonary embolism:4 patients recovered and 2 died. Pulmonary angio-graphy before treatment showed good peripheralperfusion of the lungs in the survivors, whereas thiswas not so in the fatal cases. Our contributors tenta-

tively suggest that the angiographic appearances maybe the best guide to the prospects for streptokinasetherapy, since hxmodynamic measurements and theclinical state in general were comparable in the 6

patients.This interesting suggestion requires a much larger

series for confirmation, but it should certainly be

investigated further. All of the patients except one1. Lancet, 1970, i, 395.2. Doran, F. S. A., White, M., Drury, M. Br. J. Surg. 1970, 57, 20.3. Fearnley, G. R., Chakrabarti, R., Hocking, E. D. Lancet, 1967, ii,

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(who died) had had heparin for varying periods beforestreptokinase was given, and since heparin in largedoses may be anti fibrinolytic it seems advisable infuture to use streptokinase from the outset. 3 of the

patients were given streptokinase by pulmonarycatheter and 3 by peripheral venous infusion-anotherpossible source of discrepancy because the first methodmakes a more concentrated local attack. Nevertheless

thrombolytic therapy already looks promising, at leaston the venous side of the circulatory system.

SOURCES OF ESCHERICHIA COLI

THE findings reported by Professor Shooter and hiscolleagues on p. 226 will cause no surprise. Anyonewho has penetrated an abattoir knows that fxcalcontamination of the carcass is almost unavoidable.Now that wiping of the carcass with a cloth is no

longer permitted, reliance is placed on cleaning witha spray of water which may or may not contain adisinfectant. There is some uncertainty on the bestmethod of spraying and the most suitable disinfectant.Nor is it easy to think of ways by which the kitchenmight be kept free of Escherichia coli. In theory, thismight be possible in a private house where the lady incharge has more interest in microbiology than in thetaste of food, but the conditions of work and the staffemployed in a hospital or other institutional kitchenoffer problems which seem insuperable. No doubtworking surfaces and utensils in the kitchen could besterilised, but the value of these measures is open toreasonable doubt. Every employee is a carrier ofE. coli, and no-one seems to have made a quantitativeassessment of the worth of the notice in the lavatoryabout washing the hands.Human parasites might be put into two groups:

those such as the anthrax bacillus and the gonococcuswhich can be avoided by reasonable care; and thosewith which humans must learn to live, like the coldvirus and E. coli (without E. coli in his gut it is possiblethat man would not survive at all). Everyone has astrain or strains of this organism in the bowel: somepeople seem to change these frequently and some onlyoccasionally. The reason why one strain replacesanother is unknown. Most of the known serotypes seemto be common to man and other animals, but it isremarkable that those strains which cause enteritis doso in one host species only. It is clear from the paperby Professor Shooter and his colleagues that there aremany serotypes, probably of both human and animalorigin, at large in St. Bartholomew’s Hospital, London,and doubtless the same is true of any large institution.There is no evidence that such a mixed flora carries

any special risk to health.Possibly, but by no means certainly, some of the

strains of animal origin derived from farms whereantibiotics are added to food or used prophylacticallyare responsible for antibiotic resistance in the hospitalstrains. Directly or indirectly, they may be, but theargument would be stronger if it were possible to tracea single identifiable strain from the farm through theabattoir and kitchen to the patient in the ward. A morequantitative approach might be of some value. It isnot enough to show that working surfaces and utensils

harbour E. coli. All experience goes to show that thenumber of any parasite is as important as its presence.Bacteriological technique is now so exact that it mayreveal in a saucepan numbers of E. coli far too smallto be of any significance. The paper we publish thisweek is filled with interesting ideas, but have theauthors examined the flora of the Smithfield porterswho from time to time come into the casualty depart-ment or visit their friends in the wards ? In keeping ahospital clean there may be much to be said for theJapanese habit of leaving their shoes at the front door.

ISOLATED COLD ABSCESS

COLD abscess is a familiar complication of tuber-culosis of bones and joints and of lymph-nodes.Tuberculous abscesses arising at the site of penicillininjections have also been described.1-5 But solitarytuberculous lesions arising spontaneously in soft tissueare uncommon. Shaw and Basu 6 have described 15such cases in young adults (aged 13-37 years) seen inBradford between 1957 and 1967. Of these, 4 hadactive and 3 inactive pulmonary tuberculosis; and 1had tuberculous epididymo-orchitis. The commonestpicture was swelling and a dull, aching pain. The skinover the abscesses, although always warm, was neverred, and there was no tendency to sinus formation,probably because most of the patients sought adviceearly. The sites varied: 4 of the abscesses were in theperiscapular area, 3 in the gluteal region, 2 each inforearm, shin, and thigh, 1 in the pectoral region, and1 in the abdominal wall. The erythrocyte-sedimenta-tion rate was invariably very high (40-100 mm. inthe first hour); and Mycobacterium tuberculosis wasisolated from all the abscesses. Treatment was

incision, evacuation of the pus, and curettage of thegranulation tissue lining the abscess. Streptomycin1 g. intramuscularly was given for three months plusp-aminosalicylic acid and isoniazid; and the oral drugswere continued after discharge from hospital. Primaryhealing occurred in 12 patients; 2 with leg lesions hadsecondary infection and delay in healing; and 1 had tohave the abscess evacuated again after three weeks, thewound taking six months to heal. Despite the rathershort period of chemotherapy (three to six months),no patients relapsed during a follow-up ranging fromnine to twenty months. 13 of the 15 patients werefrom overseas, 10 from the Indian subcontinent and 3from East Africa. As with other acute types of tuber-culous lesion in such patients, the level of naturalresistance is probably low 7,8 8 and breakdown in

persons already infected may follow slight trauma intissues which are usually immune. The response to

treatment, however, is satisfactory. But a risk remainsof lesions developing in other sites, and chemotherapyshould be continued for at least a year. The customaryfive-year period of observation should also be observed

1. Ebrill, D., Elek, S. D. Lancet, 1946, ii, 379.2. Hindenach, J. C. R. Proc. R. Soc. Med. 1947, 40, 161.3. Hounslow, A. G. Lancet, 1946, ii, 617.4. Hounslow, A. G. ibid. 1949, i, 709.5. Forbes, G. B., Strange, G. ibid. p. 748.6. Shaw, N. M., Basu, A. K. Br. J. Surg. 1970, 57, 418.7. Cummins, S. L. Primitive Tuberculosis; p. 134. London, 1939.8. Pagel, W., Simmonds, F. A. H., Macdonald, N. Pulmonary

Tuberculosis; p. 445. Oxford, 1963.