- Email: [email protected]
Smoking and health
917
countries.
This test has been used successfully as a screening device by the United States, Canada, and New Zealand; and there is no reason why it should not be used by the United Kingdom. On arrival, the candidate, already screened by the E.C.F.M.G., could be given an oral examination by the British authorities in order to receive the G.M.C.’s temporary registration. Department of Radiology, Southern California Permanente Medical Group, 1505 North Edgemont Street, Los Angeles, California 90027, U.S.A.
RICHARD KALINOWSKI.
MEDICAL AUDIT SIR,-" Those who eschew medical audit... should take note of Ivan Illich’s vociferous attacks " writes Dr Johnson (March 22, p. 679), and he adds that " Illich’s barbs are fundamentally misconceived and induce more confusion than clarity ". He does so immediately after discussing, as an aid to medical audit, the keeping of records that would give a doctor " feed-back on his own activities, and directly improve his therapeutic decisions "; so the implication is that Illich is greatly concerned with injuries inflicted by individual doctors on individual patients in the course of therapy-or clinical iatrogenesis, to use Illich’s own term. I think it is Dr Johnson who has formed a misconception. As Illich indicates in Medical Nemesis,! the real gravamen of his attack is not on clinical or what he calls first-level iatrogenesis but on what he calls its second and third levels, social and structural iatrogenesis-meaning, respectively, and perhaps misleadingly briefly, invasion of and reinforcement of the industrial mode, and deprivation of the right of the individual to make his own decisions about his own health. In any case, medical audit might well increase, not diminish, the clinical variety of iatrogenesis, as well, indeed, as the two other more important varieties. In that connection I should like to draw attention to a seminal though understandably neglected recent paper.2 I will not attempt to summarise it as the paper needs to be savoured in its entirety for its true import to be taken. However, it does indicate just how irrelevant, indeed positively counter-productive, certain audit criteria, and the audit judgments of academic clinicians, may be to the health and wellbeing of patients. When it has friends of the kind involved in the audit reported in that paper, one might well ask what need has high-technology medicine of Illichian enemies.
I think Dr Johnson has perhaps not fully appreciated Illich’s message or the enormous interest he has aroused in the profession, especially among its younger members; which is as significant for the future as his message is subtle, forceful, and compelling. It is especially significant at this moment when, sadly if understandably, most of their elders and betters are otherwise engaged. Garraway House, How Caple, Hereford.
JOHN S. BRADSHAW.
SMOKING AND HEALTH
Sm,—Russell 3 cites the work of Lucchesi
We have all seen patients and colleagues who desperately wish to stop smoking, but cannot. If their inability is, in fact, related to nicotine, would it not be helpful if nicotine were available to them in inhalable aerosol sprays, similar to those for the relief of asthma ? When overwhelmed by desire for a cigarette, the ex-smoker could take a premeasured dose of nicotine, and save himself the toxicity of tars and carbon monoxide. Community Hospital of San Diego, 446 26th Street, San Diego, California 92102, U.S.A. JOSEPH R. ABRAHAMSON. NEW SMOKING PRODUCTS
SIR,-Professor Burch (April 5, p. 797) concedes that cigarette smoking causes chronic bronchitis, but follows this by stating that smoking has not been implicated in fatal diseases (my italics). If he imagines that chronic bronchitis is not fatal, he is sadly mistaken. Or perhaps he consider that a disease which often takes ten years kill is fatal. Would he prefer to spend ten years dying of chronic bronchitis rather than a few weeks or months dying of oat-cell carcinoma ? In the course of his work he probably sees patients with the latter condition, but he should visit patients with chronic bronchitis before making his decision.
does
not
or more to
Department of Pathology, North Middlesex Hospital, London N18 1QX.
W.
J. HARRISON.
LEVAMISOLE
SIR,-Since your editorial of Jan. 18 (p. 151) calling for clinical trials elicited responses on the use of levamisole in two clinical trials’,2 two further correspondents 3,44 have expressed concern over their existence. We had not intended to re-enter this correspondence, but we feel that two implications of their criticisms are of such importance to the whole question of clinical tumour immunology that we should make the following observations. Firstly, both letters imply that we are using levamisole in the treatment of cancer. This is not so, and our letter made it clear that we are evaluating the possible immunostimulant effect of this substance in cancer patients. We would not expect a therapeutic effect from such a short course.
Secondly, both letters suggest that any decision to investigate this substance in man should be based on findings related to results of animal experiments. We believe this to be fallacious. While there is a place for preliminary screening trials in this situation, the disparate biological behaviour of animal transplanted tumours and autochthonous human tumours, and the differences in immune mechanisms between rodents and humans, are so great that information from one system cannot be transferred to the other. In addition, most animal tumour work is in immunocompetent animals and the suggested activity of levamisole is to restore a depressed immune response.
et
aI.,4 who
showed that smokers receiving a saline intravenous drip would decrease or stop smoking when nicotine was added to the infusion. The conclusion from this and other studies 1. 2. 3. 4.
that the habituating factor in cigarettes was nicotine, while the physiologically harmful constituents included not only nicotine but also tars and carbon monoxide. was
Illich, I. Medical Nemesis. London, 1975. Brook, R. H., Appel, F. A. New Engl. J. Med. 1973, 288, 1323. Russell, M. A H. Lancet, 1974, i, 254. Lucchesi, B. R., Schuster, C. R., Emley, G. S. Clin. pharm. Ther. 1967, 8, 789.
We hold that our approach is the logical one in this situation. Having reasonable preliminary evidence that levamisole reverses immunodepression in cancer and 1. 2. 3.
Webster, D. J. T., Hughes, L. E. Lancet, Feb. 15, 1975, p. 389. Avery, W. ibid. Hopper, D. G., Pimm, M. V., Baldwin, R. W. ibid. March 8, 1975,
4.
Flannery, G. R., Rolland, J. M., Nairn, R. C. ibid. March 29,
p. 574.
p. 750.
1975
countries.
This test has been used successfully as a screening device by the United States, Canada, and New Zealand; and there is no reason why it should not be used by the United Kingdom. On arrival, the candidate, already screened by the E.C.F.M.G., could be given an oral examination by the British authorities in order to receive the G.M.C.’s temporary registration. Department of Radiology, Southern California Permanente Medical Group, 1505 North Edgemont Street, Los Angeles, California 90027, U.S.A.
RICHARD KALINOWSKI.
MEDICAL AUDIT SIR,-" Those who eschew medical audit... should take note of Ivan Illich’s vociferous attacks " writes Dr Johnson (March 22, p. 679), and he adds that " Illich’s barbs are fundamentally misconceived and induce more confusion than clarity ". He does so immediately after discussing, as an aid to medical audit, the keeping of records that would give a doctor " feed-back on his own activities, and directly improve his therapeutic decisions "; so the implication is that Illich is greatly concerned with injuries inflicted by individual doctors on individual patients in the course of therapy-or clinical iatrogenesis, to use Illich’s own term. I think it is Dr Johnson who has formed a misconception. As Illich indicates in Medical Nemesis,! the real gravamen of his attack is not on clinical or what he calls first-level iatrogenesis but on what he calls its second and third levels, social and structural iatrogenesis-meaning, respectively, and perhaps misleadingly briefly, invasion of and reinforcement of the industrial mode, and deprivation of the right of the individual to make his own decisions about his own health. In any case, medical audit might well increase, not diminish, the clinical variety of iatrogenesis, as well, indeed, as the two other more important varieties. In that connection I should like to draw attention to a seminal though understandably neglected recent paper.2 I will not attempt to summarise it as the paper needs to be savoured in its entirety for its true import to be taken. However, it does indicate just how irrelevant, indeed positively counter-productive, certain audit criteria, and the audit judgments of academic clinicians, may be to the health and wellbeing of patients. When it has friends of the kind involved in the audit reported in that paper, one might well ask what need has high-technology medicine of Illichian enemies.
I think Dr Johnson has perhaps not fully appreciated Illich’s message or the enormous interest he has aroused in the profession, especially among its younger members; which is as significant for the future as his message is subtle, forceful, and compelling. It is especially significant at this moment when, sadly if understandably, most of their elders and betters are otherwise engaged. Garraway House, How Caple, Hereford.
JOHN S. BRADSHAW.
SMOKING AND HEALTH
Sm,—Russell 3 cites the work of Lucchesi
We have all seen patients and colleagues who desperately wish to stop smoking, but cannot. If their inability is, in fact, related to nicotine, would it not be helpful if nicotine were available to them in inhalable aerosol sprays, similar to those for the relief of asthma ? When overwhelmed by desire for a cigarette, the ex-smoker could take a premeasured dose of nicotine, and save himself the toxicity of tars and carbon monoxide. Community Hospital of San Diego, 446 26th Street, San Diego, California 92102, U.S.A. JOSEPH R. ABRAHAMSON. NEW SMOKING PRODUCTS
SIR,-Professor Burch (April 5, p. 797) concedes that cigarette smoking causes chronic bronchitis, but follows this by stating that smoking has not been implicated in fatal diseases (my italics). If he imagines that chronic bronchitis is not fatal, he is sadly mistaken. Or perhaps he consider that a disease which often takes ten years kill is fatal. Would he prefer to spend ten years dying of chronic bronchitis rather than a few weeks or months dying of oat-cell carcinoma ? In the course of his work he probably sees patients with the latter condition, but he should visit patients with chronic bronchitis before making his decision.
does
not
or more to
Department of Pathology, North Middlesex Hospital, London N18 1QX.
W.
J. HARRISON.
LEVAMISOLE
SIR,-Since your editorial of Jan. 18 (p. 151) calling for clinical trials elicited responses on the use of levamisole in two clinical trials’,2 two further correspondents 3,44 have expressed concern over their existence. We had not intended to re-enter this correspondence, but we feel that two implications of their criticisms are of such importance to the whole question of clinical tumour immunology that we should make the following observations. Firstly, both letters imply that we are using levamisole in the treatment of cancer. This is not so, and our letter made it clear that we are evaluating the possible immunostimulant effect of this substance in cancer patients. We would not expect a therapeutic effect from such a short course.
Secondly, both letters suggest that any decision to investigate this substance in man should be based on findings related to results of animal experiments. We believe this to be fallacious. While there is a place for preliminary screening trials in this situation, the disparate biological behaviour of animal transplanted tumours and autochthonous human tumours, and the differences in immune mechanisms between rodents and humans, are so great that information from one system cannot be transferred to the other. In addition, most animal tumour work is in immunocompetent animals and the suggested activity of levamisole is to restore a depressed immune response.
et
aI.,4 who
showed that smokers receiving a saline intravenous drip would decrease or stop smoking when nicotine was added to the infusion. The conclusion from this and other studies 1. 2. 3. 4.
that the habituating factor in cigarettes was nicotine, while the physiologically harmful constituents included not only nicotine but also tars and carbon monoxide. was
Illich, I. Medical Nemesis. London, 1975. Brook, R. H., Appel, F. A. New Engl. J. Med. 1973, 288, 1323. Russell, M. A H. Lancet, 1974, i, 254. Lucchesi, B. R., Schuster, C. R., Emley, G. S. Clin. pharm. Ther. 1967, 8, 789.
We hold that our approach is the logical one in this situation. Having reasonable preliminary evidence that levamisole reverses immunodepression in cancer and 1. 2. 3.
Webster, D. J. T., Hughes, L. E. Lancet, Feb. 15, 1975, p. 389. Avery, W. ibid. Hopper, D. G., Pimm, M. V., Baldwin, R. W. ibid. March 8, 1975,
4.
Flannery, G. R., Rolland, J. M., Nairn, R. C. ibid. March 29,
p. 574.
p. 750.
1975