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DETECTION OF LUNG CANCER
1354 (3) There was no interference with subsequent involution of the uterus.
the lochia
or
with the
The only disadvantage is a large diuresis. Its nuisance value was minimised by taking the second tablet in midafternoon. Most mothers agree that their babies require attention at least once a night, and a call to micturate then is not troublesome.
If this method of
suppressing lactation became widely further used, advantage would be that synthetic would be less readily available to the general oestrogens for abortions. public procuring MAURICE HEALY. London, N.19. a
IRON IN RHEUMATOID-ARTHRITIS ANÆMIA SIR,-In view of the recent fears that intramuscular
iron injections caused cancer, and the obvious dangers and difficulties of intravenous therapy, a further short therapeutic trial has been carried out of oral and parenteral treatment of the anaemia in rheumatoid arthritis. It has been suggested that intravenous therapy, besides its effect on the anaemia, may be of therapeutic benefit otherwise. Hence sedimentation-rate, general improvement, and degree of pain in joints were also noted. cases of typical rheumatoid arthritis admitted hospital with positive differential agglutination tests and haemoglobin levels below 75% were divided by random sampling into three groups. Group A was given intravenously 1’5 ml., and then five doses of 10 ml. saccharated oxide of iron’Ferrivenin’ (Bengers), 200 mg. in 10 ml.-a total of 1-03 g. Group B received intramuscularly 1 ml., and then four doses of 5 ml. ferric-hydroxide dextran-’ Imferon’ (Bengers), 250 mg. in 5 ml.-a total of 1-05 g. Group C were given by mouth 600 mg. (gr. 10) ferrous sulphate (’ Fersolate’, Glaxo) three times a day for the period of the experiment-i.e., three months. The patients were all assessed monthly by the same observer, who did not know to which group each belonged. All patients were in hospital for the first month, receiving only physical treatment, and thereafter they were treated as outpatients. The sedimentation-rate tended to improve in all groups (see accompanying table), but improvement was not significant at
30 consecutive
to
RESULTS OF TREATMENT OF
"RHEUMATOID"ANaeMIA
WITH IRON
forms of iron therapy are valuable in treating " rheumatoid " anasmia. The absence of a statistically significant increased benefit from parenteral iron, together with the dangers of such therapy, suggests that such treatment should be reserved for patients who fail to respond to oral treatment, and not given as a routine to all patients with rheumatoid anaemia. G. D. KERSLEY. Bath. DETECTION OF LUNG CANCER
SIR,-Your leading article of June 3 quotes records Philadelphia Tuberculosis Health Association an incidence of lung cancer of 10-8 per 1000 showing examined by 70 mm. photofluorograms in a group of men aged 45 years and older (66 cases in 6137 volunteers). In 1959 and 1960 the Surrey mass-radiography units examined 35,037 men in this age-group by normal massradiography methods and found 60 cases of lung cancer (1’7 per 1000 examinees). At the same time a mobile " generalpractitioner chest X-ray service " has operated in the area and examined 3852 men aged 45 years and older. 88 cases of lung
from the
found (22-8 per 1000 examinees). Follow-up of these patients confirmed the higher operabilityrate in the normal mass-radiography group reported by Brett. Despite the lower operability-rate in patients referred by their own doctors, more cases of operable cancer were found in this group than in normal mass radiography. Older men seem reluctant to volunteer for normal massradiography examination, and there are not the facilities in Surrey to offer a routine chest X-ray to every older man every six months, even if this were desirable. With the cooperation of general practitioners, men of 45 years and older attending their surgeries, who have not had a chest X-ray within the last six months, could be referred for a routine film, even if no chest symptoms were present. Shortage of radiographers may limit the number of generalcancer were
practitioner
cases
acceptable by hospital X-ray departments,
but because of the diminished incidence of pulmonary tuberculosis in the population some mass-radiography units are now able to offer a general-practitioner chest X-ray service in their area to meet this demand. A combined effort by the general practitioners and massradiography units could be of immense help in the early
diagnosis of lung cancer. South West Metropolitan Regional Hospital Board Mass Radiography Service, Worcester Park, Surrey.
F. J. H. WALTERS Medical Director.
METFORMIN HYDROCHLORIDE IN DIABETES
SIR,-Having used phenformin and metformin fairly extensively in the past three years, we find the letter of Dr. Jackson and Dr. Herman (May 27) interesting. They make two criticisms of phenformin and base their preference for metformin on these : the end of the experiment in any group, because of the scatter and variability. When joint pain and general feeling of fitness were assessed, 6 or 7 in each group of 10 claimed definite improvement. Only 1, treated with ferrivenin, stated that she was getting more pain in the joints at the end of the three months, as compared with the pre-treatment assessment. The haemoglobin changes were examined by the randomised block method. This showed that in all groups the treatment had a significant effect upon the haemoglobin levels. The difference was highly significant in the groups treated with intravenous and oral preparations. The greater p value for imferon is accounted for by the greater variability of response in patients in that group. There was no significant difference between the increases in hxmoglobin levels in the three groups.
This small series of
cases
therefore suggests that all
(1) The incidence of gastrointestinal irritation with phenformin is high and they quote " up to 50% ". (2) The necessity of using small initial doses with gradual increments is a disadvantage. These statements are misleading without qualification. The high incidence of gastrointestinal irritation is based on early studies with phenformin in large initial doses and is not sustained in later work.1 On reviewing our first 62 cases (the number of cases reported by Dr. Jackson and Dr. Herman), in which phenformin was used, gastrointestinal irritation necessitated withdrawal in 7 cases, while in the last 62 cases, when smaller doses were used initially, gastrointestinal irritation necessitated withdrawal in only 4. These figures compare with the incidence of 6 in 62 quoted by Dr. Jackson and Dr. Herman for metformin. 1. Walker, R. S., Hannah, R. Diabetes (in the press).
the lochia
or
with the
The only disadvantage is a large diuresis. Its nuisance value was minimised by taking the second tablet in midafternoon. Most mothers agree that their babies require attention at least once a night, and a call to micturate then is not troublesome.
If this method of
suppressing lactation became widely further used, advantage would be that synthetic would be less readily available to the general oestrogens for abortions. public procuring MAURICE HEALY. London, N.19. a
IRON IN RHEUMATOID-ARTHRITIS ANÆMIA SIR,-In view of the recent fears that intramuscular
iron injections caused cancer, and the obvious dangers and difficulties of intravenous therapy, a further short therapeutic trial has been carried out of oral and parenteral treatment of the anaemia in rheumatoid arthritis. It has been suggested that intravenous therapy, besides its effect on the anaemia, may be of therapeutic benefit otherwise. Hence sedimentation-rate, general improvement, and degree of pain in joints were also noted. cases of typical rheumatoid arthritis admitted hospital with positive differential agglutination tests and haemoglobin levels below 75% were divided by random sampling into three groups. Group A was given intravenously 1’5 ml., and then five doses of 10 ml. saccharated oxide of iron’Ferrivenin’ (Bengers), 200 mg. in 10 ml.-a total of 1-03 g. Group B received intramuscularly 1 ml., and then four doses of 5 ml. ferric-hydroxide dextran-’ Imferon’ (Bengers), 250 mg. in 5 ml.-a total of 1-05 g. Group C were given by mouth 600 mg. (gr. 10) ferrous sulphate (’ Fersolate’, Glaxo) three times a day for the period of the experiment-i.e., three months. The patients were all assessed monthly by the same observer, who did not know to which group each belonged. All patients were in hospital for the first month, receiving only physical treatment, and thereafter they were treated as outpatients. The sedimentation-rate tended to improve in all groups (see accompanying table), but improvement was not significant at
30 consecutive
to
RESULTS OF TREATMENT OF
"RHEUMATOID"ANaeMIA
WITH IRON
forms of iron therapy are valuable in treating " rheumatoid " anasmia. The absence of a statistically significant increased benefit from parenteral iron, together with the dangers of such therapy, suggests that such treatment should be reserved for patients who fail to respond to oral treatment, and not given as a routine to all patients with rheumatoid anaemia. G. D. KERSLEY. Bath. DETECTION OF LUNG CANCER
SIR,-Your leading article of June 3 quotes records Philadelphia Tuberculosis Health Association an incidence of lung cancer of 10-8 per 1000 showing examined by 70 mm. photofluorograms in a group of men aged 45 years and older (66 cases in 6137 volunteers). In 1959 and 1960 the Surrey mass-radiography units examined 35,037 men in this age-group by normal massradiography methods and found 60 cases of lung cancer (1’7 per 1000 examinees). At the same time a mobile " generalpractitioner chest X-ray service " has operated in the area and examined 3852 men aged 45 years and older. 88 cases of lung
from the
found (22-8 per 1000 examinees). Follow-up of these patients confirmed the higher operabilityrate in the normal mass-radiography group reported by Brett. Despite the lower operability-rate in patients referred by their own doctors, more cases of operable cancer were found in this group than in normal mass radiography. Older men seem reluctant to volunteer for normal massradiography examination, and there are not the facilities in Surrey to offer a routine chest X-ray to every older man every six months, even if this were desirable. With the cooperation of general practitioners, men of 45 years and older attending their surgeries, who have not had a chest X-ray within the last six months, could be referred for a routine film, even if no chest symptoms were present. Shortage of radiographers may limit the number of generalcancer were
practitioner
cases
acceptable by hospital X-ray departments,
but because of the diminished incidence of pulmonary tuberculosis in the population some mass-radiography units are now able to offer a general-practitioner chest X-ray service in their area to meet this demand. A combined effort by the general practitioners and massradiography units could be of immense help in the early
diagnosis of lung cancer. South West Metropolitan Regional Hospital Board Mass Radiography Service, Worcester Park, Surrey.
F. J. H. WALTERS Medical Director.
METFORMIN HYDROCHLORIDE IN DIABETES
SIR,-Having used phenformin and metformin fairly extensively in the past three years, we find the letter of Dr. Jackson and Dr. Herman (May 27) interesting. They make two criticisms of phenformin and base their preference for metformin on these : the end of the experiment in any group, because of the scatter and variability. When joint pain and general feeling of fitness were assessed, 6 or 7 in each group of 10 claimed definite improvement. Only 1, treated with ferrivenin, stated that she was getting more pain in the joints at the end of the three months, as compared with the pre-treatment assessment. The haemoglobin changes were examined by the randomised block method. This showed that in all groups the treatment had a significant effect upon the haemoglobin levels. The difference was highly significant in the groups treated with intravenous and oral preparations. The greater p value for imferon is accounted for by the greater variability of response in patients in that group. There was no significant difference between the increases in hxmoglobin levels in the three groups.
This small series of
cases
therefore suggests that all
(1) The incidence of gastrointestinal irritation with phenformin is high and they quote " up to 50% ". (2) The necessity of using small initial doses with gradual increments is a disadvantage. These statements are misleading without qualification. The high incidence of gastrointestinal irritation is based on early studies with phenformin in large initial doses and is not sustained in later work.1 On reviewing our first 62 cases (the number of cases reported by Dr. Jackson and Dr. Herman), in which phenformin was used, gastrointestinal irritation necessitated withdrawal in 7 cases, while in the last 62 cases, when smaller doses were used initially, gastrointestinal irritation necessitated withdrawal in only 4. These figures compare with the incidence of 6 in 62 quoted by Dr. Jackson and Dr. Herman for metformin. 1. Walker, R. S., Hannah, R. Diabetes (in the press).