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CYTOLOGY OF THE CERVIX
884
Letters to the Editor HOSPITAL FINANCE
SiRj—Your timely leader of April 6 refers
to per-
centage increases in the cost of the Hospital Service. May I illustrate further how confused the present situation is and how difficult it has become for those working in hospitals to know where they stand ? It will be seen from the accompanying figure that the cost of the hospitals since 1955 has been going up at an average rate of 9% a year, but when this figure is translated into 1955 prices the increase of purchasing power by hospitals has gone up at a steady 2% a year. The Chancellor of the Exchequer announced in 1961 that for the next four years the annual increment in National Health Service revenue expenditure would be restricted to 21/2%, and it was decided that 2% of this should go to hospitals. This surely must refer to increased purchasing power and not to
expenditure. Hospital management committees have received an extra z-2%. This is the money that has gone on the running hospitals but not for paying extra salary awards. (It is of course these salary awards and capital
gross
works which make up the difference between the extra 2% which the hospitals have received and the extra 9% which has been the true expenditure). When hospitals have been allocated their extra 2% it would seem a reason-
able assumption that they have extra purchasing power under their control during the coming year. This is not so, because rising prices have largely neutralised this increased allocation. For some time it has been proving impossible to introduce some advances in treatment on account of the financial stringency, and this has been a matter of great concern to medical staff. My colleagues have sent a detailed memorandum on the subject to our regional board, but our anxiety stems not only from our feeling of inadequacy in maintaining medical progress but also in seemingly being unable to get the true position appreciated. For us vour leader has been very heartening. Central Middlesex Hospital, London, N.W.10
F. AVERY
JONES.
CYTOLOGY OF THE CERVIX
SIR,-Ifind the most eloquent testimony to the value of cytology in gynxcological practice is the utter amazement of visitors at the lack of facilities for diagnostic cytology in England. Compared with, say, the Auckland region of New Zealand, this is an underdeveloped country. Every reason I have read for failure to provide a service in diagnostic cytology is false. Some morbid anatomists have said it is unreliable, and in any case may require two glances instead of one. Many have said that the service is prohibitively expensive whereas it is by far the cheapest section of our pathology department. We read recently that it is dangerous to diagnose carcinomain-situ of the cervix because many gynaecologists are performing extended radical hysterectomies for it. Surgeons have been known to perform radical mastectomies for fat necrosis and other benign breast lesions, this does not make us say it is dangerous to diagnose a breast lesion. Those who operate should know the rules so well that needlessly mutilating operations are not performed. The position is illustrated very simply by the first picture in Mr. Stanley Way’s recent book on The Diagnosis of Early Carcinoma of the Cervix. An inadequate cone will have the " radical" mastecsame unfortunate results as an inadequate local recurrences. for cancer-far, too many tomy We are often assured that because some women with carcinoma-in-situ of the cervix have not developed frank cancer within 15-20 years there is uncertainty about the nature of the lesion. It astonishes me that so few appear to worry about the women who have developed cancer and died of it while these " scientific " observations are being made. It is said that the two most dangerous things in the world are an unloaded gun and a tame bull; to this pair might be added a harmless carcinoma-in-situ of the cervix. This condition does not " belong " to the gynxcologists; it is almost the same as Bowen’s disease of the skin--this is not neglected by the
dermatologists. The latest in this nationally embarrassing series of letters is from Mr. Taylor (April 6). It now appears that Britain cannot have a service because it would prove boring to laboratory technicians. I do not share Mr. Taylor’s low view of laboratory technicians-in fact, I rank them with nurses in being if anything more conscientious in their service to patients than doctors. Pathology departments do not exist to entertain either pathologists or technicians. The most interesting tests we perform are often of far less importance to the patient than the simplest. What means more to a patient than the discovery of tubercle bacilli in a sputum? What means more to a family than a young woman who has a child and does not develop cancer after conisation of the cervix for
885
carcinoma-in-situ first detected by cytology ? In laboratories it is easy for us to develop perverted minds; we get excited over the unusually rapid spread of a cancer-unless we stop to imagine the section was from a member of our own family. We must not think that negative results are a waste of time; negative cytology means a lot to the gynaecologist and even more to his patient. It is nonsense to say that we cannot run cytology sections in our large hospitals; we have been doing it since 1948 and others in the British Isles have been doing the same. Of one thing I am certain, cytology should be governed by histology; if pathology departments do not provide the service then the gynaecologists will. Much of the absurd nomenclature that has grown up in cytology is the result of gynaecological pathologists ignoring the subject instead of directing it. There is no doubt that there is a shortage of technicians who are trained in cytology. This is partly the fault of the pathologists and partly the fault of the I.M.L.T. The post of senior cytology technician is a very important one. It is intolerable that when we find a technician with an aptitude for cytology she should have to obtain certificates in two other subjects for appropriate grading to be given. Until this position is remedied I would urge pathologists to appoint science graduates so that the work can be done. I am pleased to think that our technicians do not have the outlook that Mr. Taylor says exists in Bradford. If they did I would see to it that we did have " an astronomical wastage rate ". There is no doubt that because of the work of our cytology department over the past 15 years some hundreds of women are walking around Derby who would otherwise have had radical operative procedures or be dead. If the Bradford technicians could appreciate the human side of the work, I hope their attitude would change. I am in a good position to deny the common assertion that gynaecological cytology is too boring to do. For years I did it all myself, and in times of staff shortage (as at present) I do it all again. Fishing is boring because you may go for days without catching a fish, but it is no use telling this to a fisherman. Gynaecological cytology is better than fishing because there are more things than cancer cells that we look for. In spite of this I would urge all gynxcologists to supply the cytologists with brief clinical notes to maintain the human interest. Cytologists, like pathologists, appreciate variety in their work. My cytologists have ready access to all the relevant histological material; they help with frozen sections for the immediate diagnosis of breast lesions and make smears for the rapid diagnosis of brain tumours. They also perform special histological investigations for me. I realise my attitude is now out of date, but I shall continue to encourage technicians in all departments of our
laboratory
to
avoid
working in water-tight
com-
partments. Derbyshire Royal Infirmary. Derby.
G. R. OSBORN.
THE AUTISTIC CHILD
SIR,-May we be allowed to comment on one statement in your annotation of March 30 ? The literature on psychotic children contains many stateabout the personality of the parents, but there are very few controlled studies of parental personalities, in which standardised personality tests have been used. These tests have their limitations, but their value as evidence may perhaps be thought to be as admissible as the " clinical impressions with which the literature abounds. We have recently reported1a preliminary study of the parents of 34 psychotic children in a hospital unit for psychotic children (Smith Hospital, Henley-on-Thames), using the Maudsley personality inventory and the parent attitude inventory, developed in this country by Oppenheim. On the Maudsley personality inventory, mean scores for mothers on ments
1.
Gillies, S., Mittler, P., Simon, G. B. Some Characteristics of Psychotic Children and Their Families. Annual Conference of British Psychological Society, March, 1963.
neuroticism and extraversion are not significantly different from the normal standardisation sample. Fathers, however, were found to have significantly higher scores on neuroticism (P=0.05). The fathers tend to be both more introverted, and more neurotic than the mothers. These differences are not significant, but they are of interest because in the standardisation sample men were found to be less neurotic and more extraverted than women. The parent attitude inventory results, which are controlled for social class, indicate that the mothers of psychotic children are less strict than the mothers of normal children, but there is no evidence that they are less warm or more perplexed in their attitudes to child rearing. P. MITTLER Smith Hospital, Henley-on-Thames. Principal Psychologist.
VASCULAR BRUITS IN THE NECK SIR,-Dr. Mills’ interesting paper (April 6) has drawn attention to the diagnostic usefulness of vascular bruits in the neck. It may sometimes be difficult to be certain of the exact site and cause of these, but a venous hum can usually be identified as such if it can be abolished by
occluding
venous return
distally.
Venous hums in the neck are not uncommon, particularly in young subjects, and are sometimes heard in association with a goitre, with or without, hyperthyroidism. If the size and position of the goitre allows, it may be possible to determine that the bruit is probably caused by turbulent venous bloodflow from the thyroid itself when venous occlusion below the gland abolishes the bruit but occlusion at hyoid level does not. It should also be noted that a vascular goitre does not always indicate hyperthyroidism, but may occasionally be due to a metabolic defect of the thyroid, and the hyperdynamic circulation of hyperthyroidism may itself produce a venous hum in the neck independently of the vascular goitre. St. Thomas’s Hospital, T. M. D. GIMLETTE. London, S.E.1.
TERATOGENESIS
SIR,- In your leading article of March 30 on Drugs and the Human Embryo there is the statement that " before the impact of thalidomide, no deliberate search was made to discover teratogens ". This is far from the truth. To mention only two notable studies, the reader should be referred to those of Ingalls and his coworkers in America and of Duraiswami (first carried out in Liverpool); but there have been many others. Ingalls’ own work related specifically to the influence of anoxia upon pregnant mice and has particular significance in the consideration of conditions in the human under comparable circumstances. Duraiswami’s work related to the teratogenic effect of insulin injected into chick
embryos. Then, when mentioning
the inexplicable differences between individuals and between species in their responses to teratogens, you feel it necessary " to fall back rather lamely on the gene ". Why lamely ? I realise you are referring to the genetic differences of individuals and species: but there is another sense in which genes surely That is either by suppression or by are involved ? not necessarily of the genes of the germ cells dystrophy but of the somatic cells and their clones, as Macfarlane Burnet describes them in another but related context. Such clonal disorders would appear to be either very generalised (as where the defects occur coincidentally in different organs or limbs) or in more particular form in one limb or organ. I do not want to be understood as captious, for the difference in the reactions of individuals and species is probably equally true of different parts of the same individual. As one who is merely a clinical anatomist, I think we
Letters to the Editor HOSPITAL FINANCE
SiRj—Your timely leader of April 6 refers
to per-
centage increases in the cost of the Hospital Service. May I illustrate further how confused the present situation is and how difficult it has become for those working in hospitals to know where they stand ? It will be seen from the accompanying figure that the cost of the hospitals since 1955 has been going up at an average rate of 9% a year, but when this figure is translated into 1955 prices the increase of purchasing power by hospitals has gone up at a steady 2% a year. The Chancellor of the Exchequer announced in 1961 that for the next four years the annual increment in National Health Service revenue expenditure would be restricted to 21/2%, and it was decided that 2% of this should go to hospitals. This surely must refer to increased purchasing power and not to
expenditure. Hospital management committees have received an extra z-2%. This is the money that has gone on the running hospitals but not for paying extra salary awards. (It is of course these salary awards and capital
gross
works which make up the difference between the extra 2% which the hospitals have received and the extra 9% which has been the true expenditure). When hospitals have been allocated their extra 2% it would seem a reason-
able assumption that they have extra purchasing power under their control during the coming year. This is not so, because rising prices have largely neutralised this increased allocation. For some time it has been proving impossible to introduce some advances in treatment on account of the financial stringency, and this has been a matter of great concern to medical staff. My colleagues have sent a detailed memorandum on the subject to our regional board, but our anxiety stems not only from our feeling of inadequacy in maintaining medical progress but also in seemingly being unable to get the true position appreciated. For us vour leader has been very heartening. Central Middlesex Hospital, London, N.W.10
F. AVERY
JONES.
CYTOLOGY OF THE CERVIX
SIR,-Ifind the most eloquent testimony to the value of cytology in gynxcological practice is the utter amazement of visitors at the lack of facilities for diagnostic cytology in England. Compared with, say, the Auckland region of New Zealand, this is an underdeveloped country. Every reason I have read for failure to provide a service in diagnostic cytology is false. Some morbid anatomists have said it is unreliable, and in any case may require two glances instead of one. Many have said that the service is prohibitively expensive whereas it is by far the cheapest section of our pathology department. We read recently that it is dangerous to diagnose carcinomain-situ of the cervix because many gynaecologists are performing extended radical hysterectomies for it. Surgeons have been known to perform radical mastectomies for fat necrosis and other benign breast lesions, this does not make us say it is dangerous to diagnose a breast lesion. Those who operate should know the rules so well that needlessly mutilating operations are not performed. The position is illustrated very simply by the first picture in Mr. Stanley Way’s recent book on The Diagnosis of Early Carcinoma of the Cervix. An inadequate cone will have the " radical" mastecsame unfortunate results as an inadequate local recurrences. for cancer-far, too many tomy We are often assured that because some women with carcinoma-in-situ of the cervix have not developed frank cancer within 15-20 years there is uncertainty about the nature of the lesion. It astonishes me that so few appear to worry about the women who have developed cancer and died of it while these " scientific " observations are being made. It is said that the two most dangerous things in the world are an unloaded gun and a tame bull; to this pair might be added a harmless carcinoma-in-situ of the cervix. This condition does not " belong " to the gynxcologists; it is almost the same as Bowen’s disease of the skin--this is not neglected by the
dermatologists. The latest in this nationally embarrassing series of letters is from Mr. Taylor (April 6). It now appears that Britain cannot have a service because it would prove boring to laboratory technicians. I do not share Mr. Taylor’s low view of laboratory technicians-in fact, I rank them with nurses in being if anything more conscientious in their service to patients than doctors. Pathology departments do not exist to entertain either pathologists or technicians. The most interesting tests we perform are often of far less importance to the patient than the simplest. What means more to a patient than the discovery of tubercle bacilli in a sputum? What means more to a family than a young woman who has a child and does not develop cancer after conisation of the cervix for
885
carcinoma-in-situ first detected by cytology ? In laboratories it is easy for us to develop perverted minds; we get excited over the unusually rapid spread of a cancer-unless we stop to imagine the section was from a member of our own family. We must not think that negative results are a waste of time; negative cytology means a lot to the gynaecologist and even more to his patient. It is nonsense to say that we cannot run cytology sections in our large hospitals; we have been doing it since 1948 and others in the British Isles have been doing the same. Of one thing I am certain, cytology should be governed by histology; if pathology departments do not provide the service then the gynaecologists will. Much of the absurd nomenclature that has grown up in cytology is the result of gynaecological pathologists ignoring the subject instead of directing it. There is no doubt that there is a shortage of technicians who are trained in cytology. This is partly the fault of the pathologists and partly the fault of the I.M.L.T. The post of senior cytology technician is a very important one. It is intolerable that when we find a technician with an aptitude for cytology she should have to obtain certificates in two other subjects for appropriate grading to be given. Until this position is remedied I would urge pathologists to appoint science graduates so that the work can be done. I am pleased to think that our technicians do not have the outlook that Mr. Taylor says exists in Bradford. If they did I would see to it that we did have " an astronomical wastage rate ". There is no doubt that because of the work of our cytology department over the past 15 years some hundreds of women are walking around Derby who would otherwise have had radical operative procedures or be dead. If the Bradford technicians could appreciate the human side of the work, I hope their attitude would change. I am in a good position to deny the common assertion that gynaecological cytology is too boring to do. For years I did it all myself, and in times of staff shortage (as at present) I do it all again. Fishing is boring because you may go for days without catching a fish, but it is no use telling this to a fisherman. Gynaecological cytology is better than fishing because there are more things than cancer cells that we look for. In spite of this I would urge all gynxcologists to supply the cytologists with brief clinical notes to maintain the human interest. Cytologists, like pathologists, appreciate variety in their work. My cytologists have ready access to all the relevant histological material; they help with frozen sections for the immediate diagnosis of breast lesions and make smears for the rapid diagnosis of brain tumours. They also perform special histological investigations for me. I realise my attitude is now out of date, but I shall continue to encourage technicians in all departments of our
laboratory
to
avoid
working in water-tight
com-
partments. Derbyshire Royal Infirmary. Derby.
G. R. OSBORN.
THE AUTISTIC CHILD
SIR,-May we be allowed to comment on one statement in your annotation of March 30 ? The literature on psychotic children contains many stateabout the personality of the parents, but there are very few controlled studies of parental personalities, in which standardised personality tests have been used. These tests have their limitations, but their value as evidence may perhaps be thought to be as admissible as the " clinical impressions with which the literature abounds. We have recently reported1a preliminary study of the parents of 34 psychotic children in a hospital unit for psychotic children (Smith Hospital, Henley-on-Thames), using the Maudsley personality inventory and the parent attitude inventory, developed in this country by Oppenheim. On the Maudsley personality inventory, mean scores for mothers on ments
1.
Gillies, S., Mittler, P., Simon, G. B. Some Characteristics of Psychotic Children and Their Families. Annual Conference of British Psychological Society, March, 1963.
neuroticism and extraversion are not significantly different from the normal standardisation sample. Fathers, however, were found to have significantly higher scores on neuroticism (P=0.05). The fathers tend to be both more introverted, and more neurotic than the mothers. These differences are not significant, but they are of interest because in the standardisation sample men were found to be less neurotic and more extraverted than women. The parent attitude inventory results, which are controlled for social class, indicate that the mothers of psychotic children are less strict than the mothers of normal children, but there is no evidence that they are less warm or more perplexed in their attitudes to child rearing. P. MITTLER Smith Hospital, Henley-on-Thames. Principal Psychologist.
VASCULAR BRUITS IN THE NECK SIR,-Dr. Mills’ interesting paper (April 6) has drawn attention to the diagnostic usefulness of vascular bruits in the neck. It may sometimes be difficult to be certain of the exact site and cause of these, but a venous hum can usually be identified as such if it can be abolished by
occluding
venous return
distally.
Venous hums in the neck are not uncommon, particularly in young subjects, and are sometimes heard in association with a goitre, with or without, hyperthyroidism. If the size and position of the goitre allows, it may be possible to determine that the bruit is probably caused by turbulent venous bloodflow from the thyroid itself when venous occlusion below the gland abolishes the bruit but occlusion at hyoid level does not. It should also be noted that a vascular goitre does not always indicate hyperthyroidism, but may occasionally be due to a metabolic defect of the thyroid, and the hyperdynamic circulation of hyperthyroidism may itself produce a venous hum in the neck independently of the vascular goitre. St. Thomas’s Hospital, T. M. D. GIMLETTE. London, S.E.1.
TERATOGENESIS
SIR,- In your leading article of March 30 on Drugs and the Human Embryo there is the statement that " before the impact of thalidomide, no deliberate search was made to discover teratogens ". This is far from the truth. To mention only two notable studies, the reader should be referred to those of Ingalls and his coworkers in America and of Duraiswami (first carried out in Liverpool); but there have been many others. Ingalls’ own work related specifically to the influence of anoxia upon pregnant mice and has particular significance in the consideration of conditions in the human under comparable circumstances. Duraiswami’s work related to the teratogenic effect of insulin injected into chick
embryos. Then, when mentioning
the inexplicable differences between individuals and between species in their responses to teratogens, you feel it necessary " to fall back rather lamely on the gene ". Why lamely ? I realise you are referring to the genetic differences of individuals and species: but there is another sense in which genes surely That is either by suppression or by are involved ? not necessarily of the genes of the germ cells dystrophy but of the somatic cells and their clones, as Macfarlane Burnet describes them in another but related context. Such clonal disorders would appear to be either very generalised (as where the defects occur coincidentally in different organs or limbs) or in more particular form in one limb or organ. I do not want to be understood as captious, for the difference in the reactions of individuals and species is probably equally true of different parts of the same individual. As one who is merely a clinical anatomist, I think we