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HEALTH INSURANCE IN THE UNITED STATES
464 JOINT CHANGES IN CANCER OF THE LUNG SIR,-Your annotation of March 22 almost coincided with a report by me to the section of medicine of the Royal Society of Medicine of 3 cases of gross pulmonary osteoarthropathy with lung cancer, which have come under my care during the past three years. In these cases the lung tumours were practically symptomless, and the connexion between the joint and lung conditions In all, however, chest was not immediately apparent. radiology in the anteroposterior and lateral planes revealed a tumour, while additional investigations revealed the precise nature of the lung lesion. All 3 me cases were referred to as examples of atypical rheumatoid arthritis. CASE I.-This was a man of 55 whom I- saw at the Rheumatism Unit of the London County Council on account of pain, swelling, and stiffness of both knees, thickening of the long hones, and marked crippling. Examination revealed a rheumatoid type of lesion with effusions into both knee-joints. Examination of the synovial fluid showed a cytology typical of a non-specific rheumatoid lesion. The condition was complicated by gross pulmonary osteoarthropathy with an ossifying periostitis of the radius, ulna, femora, tibiae, and nbulse. The fingers, toes, and even the nose showed gross clubbing. There were no symptoms referable to the chest, but investigation showed a well-defined opacity in the right upper lobe. Mr. R. C. Brock, who kindly saw the patient for me, decided that his condition would only permit a lobectomy. Subsequent histological investigations showed the growth to Almost immediately after its ’ be a bronchial carcinoma. removal the knee-joint swellings began to subside, and the fingers, toes, and nose became less clubbed ; now, nearly two years later, the joint and soft-tissue swellings have almost completely subsided. CASE 2.-A man, aged 48, had similar physical signs and was likewise operated on by Mr. Brock. Secondary mediastinal-gland involvement was treated with deep X-ray therapy, which unfortunately flared up a latent tuberculous focus that was not revealed clinically or radiologically ; and he succumbed to this. CASE 3.-This patient, a man aged 53, is at present under investigation. I first saw him a month ago as a case of " polyarthritis." The history was of rather sudden onset of pain, swelling, and stiffness of the knees some twelve months previously, followed within a month by swellings of the ankles, fingers, and toes. The swellings subsided after a month in bed, and the patient resumed work in spite of disablement. Six months later recurring joint swellings increased his crippledom, and three months ago he was obliged to give up his work. When I saw him he presented a clinical picture’ of a somewhat acute rheumatoid arthritis ; he was febrile (99-100° F) ; there was pronounced anemia, with lymphadenopathy but no clinical enlargement of the spleen. The joint changes included effusions into both knees and some involvement of the wrists, left elbow, left shoulder, and ankles ; and the condition was complicated by gross clubbing of the fingers and toes and thickening of the long bones. Clinical examination of the chest showed no localising physical signs. The knee-joint fluid was typical of a non-specific rheumatoid lesion. X-ray examination of the chest showed in the lateral view a well-defined rounded opacity, 21/2 in. in diameter, lying in the posterior basal segment of the right lower lobe. Although bronchoscopy has revealed little abnormal the findings favour a peripheral carcinoma of the lung. Mr. Brock will be seeing the case for me with a view to thoracotomy and possibly pneumonectomy.
In neither of the first 2 cases was there any real evidence of extensive tissue breakdown or appreciable infection ; and the association of the joint and lung conditions on the basis of infection alone or of anoxia (suggested as possible causes) is difficult to explain. The potential significance of the pituitary in relation to the aetiology of chronic arthritis has received some attention in recent years, and the connexion between acromegaly and pulmonary osteoarthropathy has been noted by Fried1 in his work on lung cancer. He has advanced the theory that the diffuse pulmonary osteoarthropathy found in some cases is probably due to a akin to acromegaly. The possible relation of endocrine imbalance to chronic arthritis and pulmonary
dyspituitarism
1. Fried, B. M.
Arch. intern. Med. 1943, 72, 565.
osteoarthropathy
in these cases is significant, although pathogenesis of diffuse pulmonary osteoarthropathy;, (Bamberger-Marie’s disease) is as obscure today as when it was first described by Bamberger and Pierre Marie in 1889 and 1890 respectively. Can one postulate, as Crump2 has done, an abnormal substance circulating in the blood, affecting the periosteum, the bones, the joints, and the soft parts of the terminal phalanges as evidenced by clubbing of the fingers ? And might not the lungs-" pulmonary glands," as Aschoff 3 among others has suggested-take on additional functions as secretory organs ? Certainly the association of joint changes, osteoarthropathy, and lung cancer is worthy of more detailed investigation.
the
PHILIP ELLMAN.
London, W.l. HEALTH INSURANCE IN
THE
UNITED STATES
Sin,—The commercial insurance interests of America are seeing to it that the proposed Federal health insurance scheme, backed by President Truman, does not become law-not if they can help it. Here is a sample of one of their widely circulated leaflets, headed Socialised Medicine -Bad Medicine for You!! Dr. Edward H. Ochsner of
Chicago testified at the recent Bill hearings in Washington that This is how it was in .BfMM, :: The doctor got back to his office just at 2 o’clock. " How " many ? " he said to his nurse. Forty." Casually, without hurry, he put on his white jacket and poked his head into the waiting-room where the forty patients sat : "Will those of you with headache please stand ? he said. Six stood. The doctor took identical printed prescriptions out of his desk and handed one to each of the six and dismissed them. "Will those of you troubled with a cough please stand ? " Another group got up and again he handed them printed prescriptions and dismissed them. The others he took one by one into his private office for a few minutes. Two hours later the office was empty, the 40 patients gone, an average of 3 minutes per patient. In Germany, under compulsory insurance, some doctors did even better-30 to 40 patients in one hour !
Wagner-Murray
"
This same leaflet lectures insurance managers to be active on the political war-path. " It is, of course, not natural for executives whose job it is to smell a dollar to delve into this field, because there can’t be a profit-the objective being merely to avoid losing money. But it is a matter of large import to private insurance from the long-range standpoint. We need only recall that England has had a cash sickness scheme since 1911 and now industrial life insurance and workmen’s compensation have become lost to commercial insurers ! RONALD DAVISON. Shiplake.
more
"
SUCCESSFUL REVACCINATION SIR,-Ifrequently dispute two widely held inferences about revaccination : that an earlv reaction is evidence of immunity, and that " no reaction " is unacceptable because it is due to failure to vaccinate properly. I welcome Dr. Broom’s paper (March 22) as supporting my views. For revaccination to be properly performed and recorded there are four essentials : the lymph must be potent ; the technique must be correct ; the reading of the reactions must be accurate ; and the interpretations of the findings must be true. I maintain that today it is possible for every one of these factors to be at fault and yet for the subject to be certified as successfully vaccinated. Paradoxically it is the desire to eliminate such faults, by refusing to accept a "no reaction," which has been largely responsible for recent reports of a high incidence of smallpox among the recently vaccinated. It is but a short step from the standpoint that " there must be some reaction to vaccination " to the erroneous and dangerous assumption that any sort of reaction is evidence’ of successful vaccination and no reaction is proof of failure. It is precisely among those early" reactions which are called " reactions of immunity that the most serious errors of interpretation are made. The explanation of my views will be helped if the term immunity is avoided and the subject is considered ’
.
"
2. Crump, C. 3. Aschoff, L.
Virchours Arch. 1929, 271, 467. Z. ges. exp. Med. 1926, 50, 52.
In neither of the first 2 cases was there any real evidence of extensive tissue breakdown or appreciable infection ; and the association of the joint and lung conditions on the basis of infection alone or of anoxia (suggested as possible causes) is difficult to explain. The potential significance of the pituitary in relation to the aetiology of chronic arthritis has received some attention in recent years, and the connexion between acromegaly and pulmonary osteoarthropathy has been noted by Fried1 in his work on lung cancer. He has advanced the theory that the diffuse pulmonary osteoarthropathy found in some cases is probably due to a akin to acromegaly. The possible relation of endocrine imbalance to chronic arthritis and pulmonary
dyspituitarism
1. Fried, B. M.
Arch. intern. Med. 1943, 72, 565.
osteoarthropathy
in these cases is significant, although pathogenesis of diffuse pulmonary osteoarthropathy;, (Bamberger-Marie’s disease) is as obscure today as when it was first described by Bamberger and Pierre Marie in 1889 and 1890 respectively. Can one postulate, as Crump2 has done, an abnormal substance circulating in the blood, affecting the periosteum, the bones, the joints, and the soft parts of the terminal phalanges as evidenced by clubbing of the fingers ? And might not the lungs-" pulmonary glands," as Aschoff 3 among others has suggested-take on additional functions as secretory organs ? Certainly the association of joint changes, osteoarthropathy, and lung cancer is worthy of more detailed investigation.
the
PHILIP ELLMAN.
London, W.l. HEALTH INSURANCE IN
THE
UNITED STATES
Sin,—The commercial insurance interests of America are seeing to it that the proposed Federal health insurance scheme, backed by President Truman, does not become law-not if they can help it. Here is a sample of one of their widely circulated leaflets, headed Socialised Medicine -Bad Medicine for You!! Dr. Edward H. Ochsner of
Chicago testified at the recent Bill hearings in Washington that This is how it was in .BfMM, :: The doctor got back to his office just at 2 o’clock. " How " many ? " he said to his nurse. Forty." Casually, without hurry, he put on his white jacket and poked his head into the waiting-room where the forty patients sat : "Will those of you with headache please stand ? he said. Six stood. The doctor took identical printed prescriptions out of his desk and handed one to each of the six and dismissed them. "Will those of you troubled with a cough please stand ? " Another group got up and again he handed them printed prescriptions and dismissed them. The others he took one by one into his private office for a few minutes. Two hours later the office was empty, the 40 patients gone, an average of 3 minutes per patient. In Germany, under compulsory insurance, some doctors did even better-30 to 40 patients in one hour !
Wagner-Murray
"
This same leaflet lectures insurance managers to be active on the political war-path. " It is, of course, not natural for executives whose job it is to smell a dollar to delve into this field, because there can’t be a profit-the objective being merely to avoid losing money. But it is a matter of large import to private insurance from the long-range standpoint. We need only recall that England has had a cash sickness scheme since 1911 and now industrial life insurance and workmen’s compensation have become lost to commercial insurers ! RONALD DAVISON. Shiplake.
more
"
SUCCESSFUL REVACCINATION SIR,-Ifrequently dispute two widely held inferences about revaccination : that an earlv reaction is evidence of immunity, and that " no reaction " is unacceptable because it is due to failure to vaccinate properly. I welcome Dr. Broom’s paper (March 22) as supporting my views. For revaccination to be properly performed and recorded there are four essentials : the lymph must be potent ; the technique must be correct ; the reading of the reactions must be accurate ; and the interpretations of the findings must be true. I maintain that today it is possible for every one of these factors to be at fault and yet for the subject to be certified as successfully vaccinated. Paradoxically it is the desire to eliminate such faults, by refusing to accept a "no reaction," which has been largely responsible for recent reports of a high incidence of smallpox among the recently vaccinated. It is but a short step from the standpoint that " there must be some reaction to vaccination " to the erroneous and dangerous assumption that any sort of reaction is evidence’ of successful vaccination and no reaction is proof of failure. It is precisely among those early" reactions which are called " reactions of immunity that the most serious errors of interpretation are made. The explanation of my views will be helped if the term immunity is avoided and the subject is considered ’
.
"
2. Crump, C. 3. Aschoff, L.
Virchours Arch. 1929, 271, 467. Z. ges. exp. Med. 1926, 50, 52.