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prevalence of chronic bronchitis among the smokers of twenty or more cigarettes a day was almost six times that for non-smokers.8 Ashford has corns closest to the aim of the present study in his survey of the relationship between Health Service usage and smoking habits.9 He showed that male smokers up to the age of 60 have an average G.p.-contact rate about four times that of non-smokers, and furthermore, when admissions to hospital for all causes were compared, male smokers aged 15-29 spent 1 day per year in hospital compared with 0-4 of a day for nonsmokers. Our findings, confined to the two small but dis.tinct subgroups of consistent non-smokers and regular heavy smokers, demonstrate a significant and important difference between them in the 10-year record of admissions for both acute respiratory diseases and the rather less well defined category (I.C.D. 470-527) of all respiratory diseases. The broad implication of this difference is that 1000 heavy smokers aged under 28 are likely to need 130 days a year more of inpatient care in respect of respiratory disease than an equal number of non-smokers. Although this extrapolation cannot be extended to include all the regular smokers (the differences between regular smokers and nonsmokers could have happened by chance) the trend goes strongly in the same direction as for the heavy smokers. If this larger group were taken into account the probable excess would be considerably greater than 130 days. While the findings demonstrate a difference in respiratory morbidity between heavy smokers and nonsmokers they cannot prove that smoking is the cause. The fact that respiratory diseases are related to smoking whereas other disease groups are not, supports an effect due to smoking among this relatively restricted group of physically fit young adults. This paper is concerned with the findings of a positive association between heavy smoking and respiratory ill health, not with the mechanisms of causation, which must remain a matter for speculation. Genetic determinants may of smoking and of respiin the causation play a part ratory disease; it has been suggested that it is probably at least as dangerous to have a propensity for bronchitis as it is to smoke without propensity.1O Nonetheless it is reasonable in the circumstances of the present findings to postulate that smoking has been the direct cause of a higher morbidity experience. If the hypothesis is translated into quantified terms the cost of the extra medical care needed to cope with the ill-health caused by smoking is considerable.

Requests for reprints should be addressed

to

J. P. C.

REFERENCES 1.

Richards, H. J. A., Crowdy, J.

P. Br.

J. prev.

soc.

Med. 1961, 15,

84. 2. Crowdy, J. P., Gould, A. H. Jl R. Army med. Cps, 1969, 115, 107. 3. Todd, G. F. Statistics of Smoking in the United Kingdom. Tobacco Research Council, London, 1972. 4. Ashford, J. R., Morgan, D. C., Rae, S., Sowden, R. R. Am. Rev. resp. Dis. 1970, 102, 370. 5. Hammond, E. C. J. natn. Cancer Inst. 1964, 32, 1161. 6. Holcomb, H. S., Meigs, J. W. Archs envir. Hlth, 1972, 25, 295. 7. Wilson, R. W. J. occup. Med. 1973, 15, 236. 8. Rimington, J. Br. J. Dis. Chest, 1969, 63, 193. 9. Ashford, J. R. Br. J. prev. soc. Med. 1972, 27, 8. 10. Cederlöf, R., Friberg, L., Hrubec, Z. Archs envir. Hlth, 1969, 18, 934.

Talking Politics FAREWELL**

bright sunshine on the terrace of the House of Commons, above the malodorous waters of the River Thames, the Conservative spokesmen on the health services, Mr Norman Fowler and Dr Gerard Vaughan, IN

last week announced the formation of a Conservative medical society which will hold its inaugural meeting next month. Together with supporting speakers working in various areas of the service, they described it as a rallying point for moderate opinion at a time when the rallying of moderates has rarely been more necessary. On the face of it, the appearance of such an organisation at such a time looks like a predominantly defensive tactic-an alliance of politicians and Health Service professionals in common resistance to the depredations of Mrs Barbara Castle. And to some extent, this must be true: the dialogue between the Conservative Party and the professionals has quickened in recent months with the confrontation over the consultants’ contract, the fears (despite a wealth of denial) of a possible elimination of private practice, and now the assault on pay-beds. The protagonists, however, tend to stress the more positive side of the society’s activities : as a forum for the exchange of ideas between people within and outside the N.H.S.; as a stimulating influence on public debate; and as a producer of research and findings which the politicians can discuss and possibly use as the basis for new policy-making. The preferred comparison is with the Society of Conservative Lawyers, which has played a far from inconsiderable part in the formation of Conservative policy across the legal and home affairs field (Mr Fowler himself was a home affairs spokesman in his previous incarnation). Asked if they saw a comparison between their new offspring and the Socialist Medical Association, the Conservative spokesmen replied that they rather hoped it would be larger. The society is to be built.up a bit at a time: doctors first, then nurses, dentists, and pharmacists, with other arms of the service to be included later on-a concept which some may regard as curiously hierarchical. Nothing was said about the particular role of healthservice administrators, though they would seem to be of special importance in the present condition of the service. Now that even its architects publicly deplore the way the Health Service was reorganised, one can fervently hope that this wider debate between the Party and the service will at least temper the sort of rarefied mechanical zeal which fired Sir Keith Joseph’s reconstruction. The keynote of the Press conference was the low spirits of the N.H.S., with Dr Vaughan declaring that morale had never been worse, and especially citing emigration, on which new figures were put out by the H.C.S.A. on the same day. It is, of course, the perpetual complaint of oppositions that morale in even’ great sector of our national life is being irreparably * David McKie, a member of the political staff of The Guardian, has been appointed a deputy editor of that newspaper, so, unhappily for The Lancet, this must be his last contribution.-ED. L.

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damaged by the activities of Government: Labour said the same thing when the Conservatives were in. But neither side would nowadays describe the morale of the service in purely party-political terms. However much the Conservatives may condemn Mrs Castle’s policies or personal style, the chief engine of low morale is undoubtedly the economic policies dictated by our present plight, of which any D.H.S.S. Minister must be, to a great extent, a helpless prisoner. It is a sad business to look back across two years or so of this column to the bright days of early 1973, when it opened with an account of one of Mr Barber’s budgets. That great year of bounty, 1972, when the Government was anxiously seeking ways to push up spending, was already behind us, though the shadow of the December, 1973, cuts was still far away. It was, even so, still a time when a Chancellor could happily lift taxation on such tools of national self-indulgence whereas the as chocolate biscuits and ice-cream; two years since have been a time of declining aspirations and a service driven on to the defensive-with the real threat that once the Common Market referendum is out of the way Mr Healey may have to prune public spending still further. Just as the Conservatives were long reluctant to curb the dash for growth on which they embarked in 1972, despite the accumulating warning signs that we were in trouble, so the Labour Government has been reluctant to accept that the Social Contract as now constituted has been an inadequate force to deal with rising wage demands. But the crisis in public expenditure has set some thoughtful M.p.s on the left of the Party, normally no friends to incomes policy, thinking much more sombrely about the implications of our present economic drift than they did before. Faced with a further cutback on schools, homes, and hospitals, they are beginning to consider whether they too should not be out on the streets publicly warning, as Mr Healey has already done, that there must now be a straight choice between satisfying the personal or the public needs of society. They know that some of their supporters will deeply suspect them if they do. But they also know what political consequences are likely to occur as the effects on the ground of curbs on public spending become clearer and deeper. For, however much Ministers may argue that a new and fitter service may emerge from this period of austerity, the queue of those presenting their needs for urgent attention shows no signs of slackening. In a well-organised all-party exercise this week, for example, M.P.s tabled nearly 200 questions designed to elicit the record of recent public spending on the mentally ill and mentally handicapped, in order to establish a national picture of provision and to document the regional inequalities within it. Cases like South Ockendon can of course occur in times ofprosperity too; but cuts in public spending must make them more likely rather than less. On which glum note I must gather up my typewriter and steal quietly out of this column, leaving behind me a last and heartfelt word of thanks to The Lancet for its hospitality over the past two years and to those who from time to time have written offering blame,

agreement,

or

information. DAVID MCKIE.

Letters to the Editor MEDICAL CARE OF CHILDHOOD LEUKÆMIA SIR,-It is disappointing to note that Dr McCarthy (May 17, p. 1128) has found that " many clinicians ... consider that the treatment of leukaemia is moving towards a semiroutine regimen, especially for A.L.L. [acute lymphatic leukaemiaJ, and ... can be as adequately given in a districthospital setting as in a special centre ". This attitude argues a quite unwarranted complacency, engendered by the recent encouraging advances in the treatment of this condition. Even the most optimistic and enthusiastic experts would not claim that more than half of all children with A.L.L. can be cured by current treatment regimens: how can a form of treatment which is known to be unsuccessful in at least 50% of cases be thought of as even " semiroutine "? The present position in the treatment of A.L.L. in childhood has been reached by the efforts of many special centres throughout the world, and it is to such centres-and particularly to collaborative groups of them-that we must look for further advances. While paediatricians and haematologists at district hospitals certainly have an important part to play in the management of these children, the pace of advance must inevitably be slowed if many of them settle for the status quo. Evidence is accumulating that the diagnosis of A.L.L. covers a heterogeneous group of disorders, some of which respond much less favourably to chemotherapy than others. Do the 30-50% of cases which appear to be curable by the best available treatment regimens represent the majority of a subgroup which can be recognised at diagnosis, and do the other types of A.L.L. (e.g., T-cell and B-cell leukxmias), which are known to carry a worse prognosis, require a radically different approach to treatment ? Such questions can only be answered by controlled therapeutic trials on large series of patients whose leukaemic cells have been studied before the start of treatment by modern immunological, cytochemical, and other techniques. This implies referral of as many cases as possible to special centres for initial investigation, though subsequent care may with advantage be shared between the special centre and the local hospital. To go it alone, and to use established methods- of treatment for all patients, is to obstruct further progress. Hospital for Sick Children, Great Ormond Street, London WC1N 3JH.

R. M. HARDISTY.

RECOGNITION OF DIPHTHERIA

SiR,—Icannot allow to go unchallenged the opinion expressed in two letters 1,2 that routine cultures for diphtheria, of throat swabs from patients with tonsillitis should be discontinued. Although the disease is rare, continued to culture are, I think, necessary for several attempts reasons.

The clinician tends to think of diphtheria when antibiotic has failed. If he has had the forethought to submit a swab for culture before treatment, he will not unreasonably feel aggrieved if no opinion can be expressed by the laboratory, other than the absence of hxmolytic streptococci. Cultures aimed at excluding this pathogen cannot be relied on to reveal diphtheria bacilli. Unless selective medium for Corymbacterium diphtheria is used routinely, it may not be available in good condition when urgently needed. Demands tend to be made late in the day, at weekends, and on Bank Holidays. Although a treatment

1. 2.

McSwiggin, D. A., Taylor, C. E. D. Lancet, March 1, 1975, p. 515. Bezjak, V. ibid. April 19, 1975, p. 924.