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Journal of the Royal Society of Medicine Volume 87 September 1994

Empyema thoracis in AIDS Empyema thoracis in patients who are HIV positive is a rare event in the West, although tuberculous empyema is not uncommon in patients who are HIV positive in Africa. The treatment should probably be as in other patient groups should it occur (February 1994 JRSM, pp 65-66). For the small number of patients who are HIV positive and who have an empyema, minimally invasive methods of treatment should be advocated. Video assisted thoracic surgery (VATS) is becoming increasingly utilized in performing surgical procedures within the thoracic cavity without having to resort to thoracotomy. Video technology provides superior endoscopic images with a broader field and improved resolution, enabling simultaneous dissection while visualizing the lung or pleura1. Empyema thoracis remains a condition with considerable morbidity and mortality, in its treated and untreated forms2'3. Initial management is usually by repeat thoracocentesis or closed thoracostomy, which may produce cure4. When unsuccessful, treatment may proceed by; rib resection and open drainage, open window thoracostomy, decortication, and thoracoplasty566. Video-assisted procedures are safely employed in all age groups and do not exclude or make more complicated a second surgical procedure if necessary. An empyema in a patient with pulmonary tuberculosis has been successfully managed by thoracoscopy5. The natural history of an evolving empyema has been characterized by Barrett7. For effective treatment of empyema thoracis by thoracoscopy, the earlier the patient is referred following failure of tube thoracostomy, or thoracocentesis, the more likely will the treatment be successful. The technique is a debridement of the empyema space, with evacuation of pus using strong suction devices, and breakdown of loculi allowing for lung re-expansion. A decortication is not performed via the thoracoscope. For the patient with a chronic empyema, the presence of a fibrous walled cavity associated with lung collapse is still likely to result in a formal decortication.
P HORNICK
Department of Cardiothoracic Surgery

P L C SMITH

Hammersmith Hospital, London, UK

References 1 Coltharp WH, Arnold JH, Alford AC, et aL Videothoracoscopy: improved technique and expanded applications. Ann Thorac Surg 1992;53:776-9 2 Lemmer JH, Botham MJ, Orriger MB. Modern management of adult thoracic empyema. J Thorac Cardiovasc Surg 1985;
90:849-55 3 Muskett A, Burton NA, Karwande SV, et al. Management of refractory empyema with early decortication. Am J Surg 1988;156(6):529-32 4 Mandal AK, Thadepalli H. Treatment of spontaneous bacterial empyema thoracis. J Thorac Cardiovasc Surg 1987;94:414-18 5 Hutter JA, Harari D, Braimbridge MV. The management of empyema thoracis by thoracoscopy and irrigation. Ann Thorac

Condom's modern history, linked to its early mass production and technical advances in England, may help explain the continuous and steady increase of breast cancer incidence and mortality in the country, since the turn of the century. With the recent introduction into the population of technical effects of (absolute) male sterility on unprecedented scale, by enforced emphasis upon and the promotion of indiscriminate condom use in the general population, as a barrier against the spread of the AIDS/HIV virus2, a natural experiment of an upsurge of breast cancer, and other accompanying phenomena in women, was predicted and anticipated8. Within the framework of the tested semen-factor deficiency hypothesis in the aetiology of breast cancer in married American women1, the observed upsurge and the epidemic extent of the disease worldwide, especially in the advanced countries of the West, including the UK, since the early 1980s, seems to support to a great extent both, the condombreast cancer link, and the potential for primary (nonchemical) prevention of the disease in the community4. The ongoing history of the condom is that this unlikely device is related to the cause of epidemic diseases, breast cancer and AIDS, which seem to inversely depend to a considerable degree on the condom use/nonuse for their prevention and control. Is it right to accord less importance on one potentially fatal disease than to another? Given the accumulated supportive evidence of carcinogenic effects of marital (long-term) condom use, I believe that condom will eventually prove to have been one of the greatest, albeit overlooked, killers in the twentieth century medical history. Since the profiles of the populations at risk have been quite distinct for both epidemic diseases, breast cancer and AIDS5, and because of the renewed public awareness about the increased risk of breast cancer6, along with the subsided estimates of possible risk of AIDS in heterosexual transmissions7, an alternative and balanced approach for control of these two epidemic diseases in advanced countries, the UK included, could be translated into action. The objectives of such an action for control and prevention of breast cancer as an epidemic disease could include the main emphasis that the condom use should be eliminated as a family planning method in marital relations. The conventional explanation could relegate the condom to its targeted use as a casual prophylactic device only in special human circumstances, if necessary. With regard to the breast cancer epidemic, such an alternate action for elimination of the marital condom use might prove to bring about the postulated immediate preventive impact in the community. ARNE GJORGOv Department of Community Medicine
Kuwait University, PO Box 24923, Safat, Kuwait

Surg 1985;39:517-20 6 Ridley PD, Braimbridge MV. Thoracoscopic debridement and pleural irrigation in the management of empyema thoracis. Ann Thorac Surg 1991;51:461-4 7 Barrett NR. The treatment of acute empyema. Ann R Coll Surg Engl 1954;15:25-33

History of the condom: the overlooked adverse effects With reference to the letter by Dooley (January 1994 JRSM, p 58) and to the referred article by Youssef (April 1993 JRSM, pp 226-8), I would like to briefly remark on the point of the entrenched belief that condom 'has no side effects'. In fact, there is accumulated evidence to support the tested hypothesis of the significant association between a long-term condom use and the development ofbreast cancer in married women1, which study was not mentioned in either of the aforementioned articles. Since the assumed benefits of the 'conventional family-planning use' of condom have been taken for granted, the full story of the adverse effects of marital condom use might exceed the scope of this letter.

References 1 Gjorgov AN. Barrier Contraception and Breast Cancer. Basel: S Karger, 1980:X+164 2 Koop CE. Surgeon General's Report on AIDS. US Public Service. JAMA 1986;256:2783-9 3 Gjorgov AN. Breast cancer risk from use of condoms: Interim evidence of an unplanned experiment. Child Family 1990;21:91-101 4 Gjorgov AN. Emerging worldwide trends of breast cancer incidence in the 1970s and 1980s: Data from 23 cancer registration centres. Eur J Cancer Prevent 1993;2:423-40 5 Anonymous. AIDS: Poor man's plague. Economist 1991;September: 21-4 6 Editorial. Breast cancer: have we lost our way? Lancet 1993; 341:343-4 7 Editorial. AIDS turn-around. Daily Telegraph 1993;May 6

Value of performing an autopsy in a teaching hospital One value of performing an autopsy in a teaching hospital not referred to in the article by Dr Charlton (April 1994 JRSM, pp 232-236), nor in any ofthe many similar articles on that subject which I have read, is that of demonstrating normal anatomy to medical students. Such autopsies provide an excellent opportunity for reinforcing medical students'