- Email: [email protected]
CANCER RESEARCH
527 doctor’s list. And why drag in the fact that mothers are sometimes attended in confinement by a doctor othert han the one they are registered with ? Hospital doctors deliver a lot of babies. Dr. McPhail does not seem to worry about this. The statistical efforts in this paper would appear to have been stacked to make out a case against the reorientation of the
domiciliary
team.
A health visitor attached to a practice would get to know her patients just as well as, if not better, than the health visitor attached to a neighbourhood, the advantage being that the health visitor in possession of all the medical facts of most of the members of the household will transgress her present traditional field and become the health visitor of the future. All other aspects of her work can be maintained and there is no need to assume that by redrawing the lists of her visits she is not going to have access to the people " as before. In their table ill, it is shown that 55-5% of the action taken by health visitors in a sample of 1000 cases is advice and discussion only. There is no reason to suppose that a good deal of this advice and discussion could not take place at the doctor’s professional premises-maybe the professional premises of the future-but at any rate an important point in forward planning. What is even more important, however, 50% of their work might, under direct attachment, consist of supervision and action on advice given in cooperation with the family doctor. Further, we would need to know, in order to judge the authors’ cold douche to any progress, whether the health visitors in Leeds have their own transport. It is clear that without it, any thorough health-visitor attachment scheme will creak. A great deal is made of the cheapness of the present service in Leeds. The bicycle is also cheaper than the motorcar, but unless we improve our standards " the cheap services " do not seem to attract enough entrants overall-general practitioners and health visitors alike. Miss Akester and Dr. MacPhail make play with the administrative nightmare of passing messages and health visitors contacting other health visitors. It is just this nightmare that faces the general practitioner with his occupational disease " the telephone elbow " as he tries to contact the appropriate health visitor through the official mouthpiece at the M.O.H.’s department, where all personal contact and human events are transferred as entries into notebooks and forms. Failures in attachment schemes are inevitable, but that does not mean that schemes in similar areas must be doomed to failure. When Miss Akester and Dr. MacPhail say " they know of no quicker method of ensuring the death of a century of health visiting " than by attaching health visitors to general practice, then I would say this is to be welcomed because it will lead to the rebirth of health visiting in a different content and scope suitable for the ’60s and ’70s. E. V. KUENSSBERG. Edinburgh. "
CANCER RESEARCH
SIR,-The identification of substances used in the chemical and rubber industries, capable of causing bladder cancer in man, is an advance in cancer research with direct practical application. The manufacture of 2-naphthylamine has ceased in most countries of the world, and it is hoped that the remaining countries will follow suit. The isomeric 1-naphthylamine also causes in man, although commercial 1-naphthylamine contains some 2-naphthylamine. In his letter of Aug. 22, Dr. Parkes implies that because aldol-alpha-naphthylamine which is being used in the rubber industry no longer contains beta-naphthylamine, it is unlikely to be carcinogenic. The " Code of Working Practice recommended by the British Dyestuffs Industry for the Manufacture and Use of Products causing Tumours of the Bladder"contains the statement that " even if cancer
1.
Scott, T. S., Williams, M. H. C. Brit. J. industr. Med. 1957, 14, 150.
alpha-naphthylamine can be manufactured free of its beta-isomer impurity, it should be regarded as dangerous, unless overwhelming proof to the contrary could be adduced ". No such proof is available and 1-naphthylamine must still be considered a potential hazard to man, particularly as carcinogenic metabolites of this amine have been detected in urine. So long as the incidence of bladder cancer is rising or high in workers in the rubber industry, all the substances used in rubber manufacture must be considered as possible hazards until evidence of their harmlessness is obtained. This applies to aldol-alpha-naphthylamine and many of the numerous chemical substances which are used in the manufacture of rubber and plastics. We regard as admirable the suggestion made by Dr. Case (Aug. 8) and Dr. Parkes (Aug. 22) that the occurrence of cancer in the rubber industry be independently and
impartially investigated. E. BOYLAND A. HADDOW.
Chester Beatty Research Institute, Fulham
Road,
London, S.W.3.
NEEDS AND BEDS
SIR,-Dr. Gore and his colleagues (Aug. 29) once more draw attention to the desire on the part of those in authority to close psychiatric hospital beds. Anyone who has seen, for example, young patients with advanced disseminated sclerosis nursed in geriatric wards, or other chronic neurological and general medical conditions cared for in a variety of " homes " for want of more suitable alternatives, may also feel that this desire should be resisted. There are advantages of specialised skilled care and research to be gained by concentrating patients with like illnesses together in Health Service units, as long as these are not malignantly isolated either socially or academically. Moreover, even if the predicted 50% reduction in the need for psychiatric hospital beds by the mid-1970s occurs, the mentally ill will still greatly outnumber patients of any other specialty; and there is nothing in the number or complexity of psychiatric diagnostic entities to justify overloading general hospitals with the mentally ill. Ide Hill, P J P. J. Sevenoaks, Kent.
Ide Hiil,
CRAWFORD. CRAWFORD.
BLOOD-GROUPS AND DISEASE
SiR,—The use of the X2 test was popularised among blood-group workers by Race and Sanger’s Blood Groups in Man in which it was used with exemplary effect to demonstrate the genetic associations of the bloodfactors comprising the various blood-group systems. Some workers have extended the use of this test to illustrate other forms of association-notably of bloodgroups and disease-and it is remarkable and alarming to observe how uncritically such " evidence " is accepted both by editors and by readers of medical journals. Wienerhas repeatedly warned against attempts to " prove causal relationships by statistical methods in situations where there is no a-priori evidence of any association. But be that as it may, it is essential that, when statistics are employed to support an assertion, the arithmetic at least should be correct. Dr. Kaklamanis and her coworkersused the X2 method compare 94 rheumatic-fever subjects who were group-0 secretors with 98 normal " group-0 secretors. Each of the samples was divided into 7 cart-qories on the basis of the ratio of Lea/H activity in the saliv f2 is best used for coml-,-.mg whole numbers (e.g., of individuals) for characteristics which can be precisely defined (e.g., blood-groups or sex). Its validity for the comparison of
to
"
1. 2.
Wiener, A. S. Lancet, 1962, i, 813. Kaklamanis, E., Holborow, J., Glynn,
L. E. ibid.
1964, i, 788.
domiciliary
team.
A health visitor attached to a practice would get to know her patients just as well as, if not better, than the health visitor attached to a neighbourhood, the advantage being that the health visitor in possession of all the medical facts of most of the members of the household will transgress her present traditional field and become the health visitor of the future. All other aspects of her work can be maintained and there is no need to assume that by redrawing the lists of her visits she is not going to have access to the people " as before. In their table ill, it is shown that 55-5% of the action taken by health visitors in a sample of 1000 cases is advice and discussion only. There is no reason to suppose that a good deal of this advice and discussion could not take place at the doctor’s professional premises-maybe the professional premises of the future-but at any rate an important point in forward planning. What is even more important, however, 50% of their work might, under direct attachment, consist of supervision and action on advice given in cooperation with the family doctor. Further, we would need to know, in order to judge the authors’ cold douche to any progress, whether the health visitors in Leeds have their own transport. It is clear that without it, any thorough health-visitor attachment scheme will creak. A great deal is made of the cheapness of the present service in Leeds. The bicycle is also cheaper than the motorcar, but unless we improve our standards " the cheap services " do not seem to attract enough entrants overall-general practitioners and health visitors alike. Miss Akester and Dr. MacPhail make play with the administrative nightmare of passing messages and health visitors contacting other health visitors. It is just this nightmare that faces the general practitioner with his occupational disease " the telephone elbow " as he tries to contact the appropriate health visitor through the official mouthpiece at the M.O.H.’s department, where all personal contact and human events are transferred as entries into notebooks and forms. Failures in attachment schemes are inevitable, but that does not mean that schemes in similar areas must be doomed to failure. When Miss Akester and Dr. MacPhail say " they know of no quicker method of ensuring the death of a century of health visiting " than by attaching health visitors to general practice, then I would say this is to be welcomed because it will lead to the rebirth of health visiting in a different content and scope suitable for the ’60s and ’70s. E. V. KUENSSBERG. Edinburgh. "
CANCER RESEARCH
SIR,-The identification of substances used in the chemical and rubber industries, capable of causing bladder cancer in man, is an advance in cancer research with direct practical application. The manufacture of 2-naphthylamine has ceased in most countries of the world, and it is hoped that the remaining countries will follow suit. The isomeric 1-naphthylamine also causes in man, although commercial 1-naphthylamine contains some 2-naphthylamine. In his letter of Aug. 22, Dr. Parkes implies that because aldol-alpha-naphthylamine which is being used in the rubber industry no longer contains beta-naphthylamine, it is unlikely to be carcinogenic. The " Code of Working Practice recommended by the British Dyestuffs Industry for the Manufacture and Use of Products causing Tumours of the Bladder"contains the statement that " even if cancer
1.
Scott, T. S., Williams, M. H. C. Brit. J. industr. Med. 1957, 14, 150.
alpha-naphthylamine can be manufactured free of its beta-isomer impurity, it should be regarded as dangerous, unless overwhelming proof to the contrary could be adduced ". No such proof is available and 1-naphthylamine must still be considered a potential hazard to man, particularly as carcinogenic metabolites of this amine have been detected in urine. So long as the incidence of bladder cancer is rising or high in workers in the rubber industry, all the substances used in rubber manufacture must be considered as possible hazards until evidence of their harmlessness is obtained. This applies to aldol-alpha-naphthylamine and many of the numerous chemical substances which are used in the manufacture of rubber and plastics. We regard as admirable the suggestion made by Dr. Case (Aug. 8) and Dr. Parkes (Aug. 22) that the occurrence of cancer in the rubber industry be independently and
impartially investigated. E. BOYLAND A. HADDOW.
Chester Beatty Research Institute, Fulham
Road,
London, S.W.3.
NEEDS AND BEDS
SIR,-Dr. Gore and his colleagues (Aug. 29) once more draw attention to the desire on the part of those in authority to close psychiatric hospital beds. Anyone who has seen, for example, young patients with advanced disseminated sclerosis nursed in geriatric wards, or other chronic neurological and general medical conditions cared for in a variety of " homes " for want of more suitable alternatives, may also feel that this desire should be resisted. There are advantages of specialised skilled care and research to be gained by concentrating patients with like illnesses together in Health Service units, as long as these are not malignantly isolated either socially or academically. Moreover, even if the predicted 50% reduction in the need for psychiatric hospital beds by the mid-1970s occurs, the mentally ill will still greatly outnumber patients of any other specialty; and there is nothing in the number or complexity of psychiatric diagnostic entities to justify overloading general hospitals with the mentally ill. Ide Hill, P J P. J. Sevenoaks, Kent.
Ide Hiil,
CRAWFORD. CRAWFORD.
BLOOD-GROUPS AND DISEASE
SiR,—The use of the X2 test was popularised among blood-group workers by Race and Sanger’s Blood Groups in Man in which it was used with exemplary effect to demonstrate the genetic associations of the bloodfactors comprising the various blood-group systems. Some workers have extended the use of this test to illustrate other forms of association-notably of bloodgroups and disease-and it is remarkable and alarming to observe how uncritically such " evidence " is accepted both by editors and by readers of medical journals. Wienerhas repeatedly warned against attempts to " prove causal relationships by statistical methods in situations where there is no a-priori evidence of any association. But be that as it may, it is essential that, when statistics are employed to support an assertion, the arithmetic at least should be correct. Dr. Kaklamanis and her coworkersused the X2 method compare 94 rheumatic-fever subjects who were group-0 secretors with 98 normal " group-0 secretors. Each of the samples was divided into 7 cart-qories on the basis of the ratio of Lea/H activity in the saliv f2 is best used for coml-,-.mg whole numbers (e.g., of individuals) for characteristics which can be precisely defined (e.g., blood-groups or sex). Its validity for the comparison of
to
"
1. 2.
Wiener, A. S. Lancet, 1962, i, 813. Kaklamanis, E., Holborow, J., Glynn,
L. E. ibid.
1964, i, 788.