- Email: [email protected]
LUNG CANCER AND SMOKING
205 ences, and to make sure that at one meal at least his intake is adequate. A very important part of this work consists in the coordination of the home and hospital environment by a medical social case worker or a psychiatric social worker. I have found the services of the social worker
tends. The birth-rates refer to the interval between present and previous epidemic and therefore to the first of the epidemic years. It will be seen that in general the greater the difference between the birth-rates the shorter the period. BIRTH-RATES
AND
PERIODICITY
OF
MEASLES
EPIDEMICS
Period
quietly overcoming home difficulties, keeping the hospital informed of progress at home, and assessing the build-up of domestic emotional stresses, of the greatest value ; the serious stresses can be reduced by a,ppropriate temporary admission. Without this sociological assistance this method of treating many more patients without increasing the number of beds would be far more in
Hirth rate (% of population
Epidemic period
period
0-9) (b) ’
’ ’
Life-table birth-rate (% of
population 0-9) (lo)
(fortnights from peak of last epidemic to present peak) (T)
difficult. who at first have to attend the day for full days a week are later found to five hospital two, or three days a week. This is a one, only require valuable index of improvement or deterioration in the family group relationship as well as in the patient’s clinical status. The problem of transport, the help of voluntary organisations, nutritional factors, family group interpersonal relationships, techniques in occupational therapy, the administration of the scheme, and fields of expansion will be discussed in a more complete paper on this attempt to bridge the gap made between hospital and home. As all our patients attending the day hospital would have become early and permanent charges on chronic-sick or mental hospitals, each patient so treated means a hospital bed saved. The scheme helps to maintain the integrity of" the family group by affording the relatives a service of care without tears." Its principles are thus based on sound social, economic, and humanitarian foundations. L. Z. COSIN Clinical Director, Cowley Road Hospital,
Some
patients
Oxford.
Geriatric Unit.
From these obtained :
war.
After 1946 the birth-rate began to fall and the effect on measles soon became apparent. In 1950 instead of the usual annual epidemic, with a peak about the 13th week, there was a small midsummer outbreak followed almost immediately by the huge epidemic of 1950-51 with a peak in the 8th week. The interval between this peak and that of 1949 was 48 fortnights indicating that the period was lengthening as the birth-rate fell. The incidence in this epidemic was 101% of the population under the age of 10 per annum, the highest since notification became compulsory in 1938. The variation of the period with the birth-rate is shown in the accompanying table, in which the birth-rate and lifetable birth-rate, together with the period, are set out for the pre-war years 1923-38 and the years 1943-51. The birth-rate with which I am concerned is the number of annual births per cent. of the child population under 10 years (among which occur 95% of measles cases in an epidemic). This rate, of course, will vary from year to year, but if the number of births remained constant yearly for 10 years, no migration taking place in the interval, a life-table " population under 10 would result and the birth-rate per cent. of this population would be the life-table birth-rate (lo). This can be considered as a limiting value to which the birth-rate, as defined above, "
the
following regression equation
is
-3-35 (r = - 0967), &Dgr;T = -4502 &Dgr; b 52 and &Dgr; b = b &Dgr; T = T lo. The life-table rates have been obtained from the England and Wales life tables, allowing for differences in mortality between London and the rest of the country and interpolating between census years. According to this equation, the natural period for London &Dgr; b = 0) is 48-7 fortnights. For a period of 52 fortnights, the birth-rate under present conditions must fall =
where
-
-
9-6% (&Dgr; b = —0.74). With regard to the recent epidemic, the 1951 census has enabled the birth-rate figure to be fixed for the first time since the last census in 1931 ; the values of b and lo in 1951 were 10-66 and 10-30 respectively. It is estimated that by 1952 these rates had fallen to 10-50 and 10-29 respectively. + 0-21 in the equation, we get Hence, substituting &Dgr; b &Dgr; T 4-3, giving a period of 47-7 fortnights. Since the peak of the 1950-51 epidemic came in the 8th week of 1951, that of the present outbreak should occur therefore in the 51st week of 1952. Actually the peak (2705 cases) was recorded in the 53rd week, but it was probably really in the 52nd week, because of the carry-over of cases from Christmas week. Although, in general, one would not expect so close a prediction on each occasion, there does seem to be a connection between the birth-rate and period ; and as fresh data accumulate, it may be possible to increase accuracy in forecasting the probable interval between peaks. There is a similarity between the course of the recent epidemic and that of 1950-51, which is not unexpected, since there has only been a slight fall in the birthrate during the interim. They represent an intermediate stage between an annual and a biennial epidemic. It is of interest that the number of cases between the two peaks was 58,420, the interval being 97 weeks. Taking the average population (0-9) as 492,500, the average incidence is 6-4% per annum; the figure for the epidemics during 1940—52 to
=
=
PERIODICITY OF MEASLES IN LONDON SIR,—There seems to be a relationship between the proportion of susceptible people in a population, the birth-rate, and the periodicity of measles. In a stationary population maintained by a constant birth-rate (according to the current life-table), epidemics could be expected to occur at equal intervals, assuming a constant case-rate. The change from pre-war biennial epidemics to annual ones towards the end of the late war could therefore be explained by the increase in susceptibles due to mass evacuation, the absence of epidemics in the first two years, and the increase in the birth-rate during the
data
was
-
6-1%.
Bromley, Kent.
C. A. GOULD.
LUNG CANCER AND SMOKING
SiR,,-There appears to-be general agreement that- the exposure of living tissues to long-life radioactive isotopes may initiate the onset of a carcinoma. If an ordinary M 6 tube is filled with cigarette or cigar ash a reading varying from 70 to 170 counts per minute is recorded against a normal background of 12. The variability depends on the particular type of cigarette or cigar that is tested. These readings have been obtained using a’Panax’ type Geiger counter, model 44, with an
liquid castle. isotope in question is presumably the long-life radioactive isotope of potassium, K4o, which is present in all potassium to the extent of 11 parts in
E.R.D.
The radioactive
206
100,000 ; and also to a lesser extent the long-life radioisotope of rubidium, Rb87. Beta emanation from
active
potassium is very active, and is in the order of 1.4 MeV. These readings represent, of course, only an extremely minute dose, particularly as it is only cigarette or cigar smoke that is
of
however, to be
no
significance. There would appear, doubt that radioactive particles are actually deposited in the bronchial tree ; and, absorption here being very slow, these tissues must be continually subjected to bombardment by active beta particles. This fact would seem to support the statistical evidence linking inhalation of cigarette smoke with carcinoma of the lung. D. K. MULVANY. London, W.l.
Parliament Scottish
Endowments AT the third reading of the Hospital Endowments (Scotland) Bill,1 Commander T. D. GALBRAITH, joint under-secretary of State for Scotland, reminded members that it had two purposes : to set up a Scottish Hospital Endowments Research Trust, and to empower the Hospital Endowments Commission to transfer endowments to the trust. At the committee stage it appeared to be the general opinion that the commission should not have unlimited power to transfer endowments, and an amendment had accordingly been incorporated in the Bill limiting the transfer to " an aggregate of such amount as in the year ended March 31, 1952, produced an income of £ 120,000."
Hospital
QUESTION TIME Examination of National Service Recruits
Lieut.-colonel MARCUS LIPTON asked the Minister of Labour how doctors were selected for the medical examination of National Service recruits ; what fees were payable ; and what age limit was imposed on the doctors so selected.Sir NN-AT.TEP. MONCKTON replied : Vacancies on the panels of the National Service medical boards are filled on the recommendation of a regional medical officer of the Ministry of Health after consultation with the local medical committee No precise appointed under the National Health Acts. qualifications are laid down, but a minimum of 10 years’ professional experience is expected and the majority of practitioners appointed in recent years have had Service experience. Members of the boards are paid E212s. 6d. per session, normally of 21/2 hours, with an additional half-guinea for the chairman. No age-limit is imposed provided the doctor is fully fit and efficient, but, in general, a doctor over 65 years of age would not be nominated for appointment. Lieut.-colonel LIPTON: Is the Minister aware that some of the chairmen of these boards are over 70 years of age ? Is he also aware that his decision, just announced, that these doctors should themselves be examined would do a great deal Sir to dispel the anxiety caused by their recent activities ? WALTER MONCKTON: I know that some of these people serve until they are 70, and some of the best are that age. I did not intend to criticise these doctors who make up the boards, and have over the years rendered great service both in this administration and the last. All I intend to do-and I have already taken action in the matter-is to gather some of the chairmen of the boards throughout different parts of the country for consultation to see whether we can improve the
administration. Mr. BARNETT JANNER asked the Minister of Labour what were made to consult medical practitioners of men being called up for National Service who informed his department that they had been under the practitioners’ treatment in respect of previous ailments.-Sir WALTFR MONCKTON replied : If the chairman of a medical board is in any doubt about the effect of previous ailments on a man’s grading he would ask the man’s practitioner for a report. Alternativelv the chairman - should send a man to a consultant for full examination.
Prescription Charge Mr. ARTHUR BLENKINSOP asked the Minister of Health whether he would abolish the 18. prescription charge, in view of the recommendation of the British Medical Association annual meeting.-Mr. MACLEOD replied : No, Sir.
Clinical Research In answer to a question, Mr. J. A. BoYD-CARPENTER, financial secretary to the Treasury, stated that for some time a joint committee representing the Standing Medical Advisory Committee of the Central Health Services Council and the Medical Research Council, who had worked in close consultation with the Advisory Committee on Medical Research in Scotland, had been studying the best ways and means of coordinating and developing clinical research work - that is to say, research directly concerned with sick persons. Their report was published on July 14. The recommenda. tions provided both for centralised and decentralised research. The former would be directed through a Clinical Research Board covering the whole country, to be appointed by the Medical Research Council, the latter through the hospital boards. These proposals had been welcomed and accepted, subject to detailed consideration of their practical application, by the responsible Ministers-namely, the Lord President of the Council, the Secretary of State for Scotland, and the Minister of Health, as well as by thChancellor of the Exchequer. All concerned were agreed that the time was ripe for reorganisation and development in this field. No additional burden on public funds would be involved this year, but the Chancellor was ready to agree in principle to reasonable additional financial provision from the Exchequer, on the lines suggested in the report, as the work developed. In Scotland the Advisory Committee on Medical Research would continue to advise on the allocation of National Health Service funds for decentralised research projects, and would also advise on the allocation of funds by the Hospital Endowments Research Trust to be constituted under current
Onchocerciasis Survey in West Africa Mr. LESLIE HALE asked the Secretary of State for the Colonies what progress had now been made with the survey of the incidence of onchocerciasis in the Gold Coast, Cameroons, and Nigeria entrusted to the British Empire Society for the Blind, whether sufficient finance was available to enable the full originally planned survey to be completed within three years, and what portion of the total cost would be borne from Government funds.-Mr. OLIVER LYTTELTON replied : The main survey began in the Gold Coast last November. It is hoped to extend it to Nigeria and the Cameroons early The cost is being borne by the British Empire next year. Society for the Blind, but the local governments are providing medical facilities and accommodation. The society inform me that although the scheme has proved a heavy drain on their finances, they hope to be able to complete the survey within the allotted time. If the British Empire Society for the Blind should be short of money for this purpose, then another situation will arise.
Diary JULY
Monday,
Lancet, 1953, i, 349, 446.
of the Week 26
TO AUG.
1
27th
ROYAL CoLLEGE OF SURGEONS, Lincoln’s Inn Fields, W.C.2 5 P.M. Three-dimensional colour film (made by Ethicon Suture Laboratories Ltd.) on Mediastinal Tumours ; operation performed by Mr. Brian Blades.
Tuesday,
28th
INSTITUTE OF NEUROLOGY, National Hospital, Queen 5 P.M. Prof. Kurt Goldstein (U.S.A.) : Aphasia.
arrangements
1. See
legislation.
Square, W.C.1
Appointments BoRTHWioE,
R.
D.,
M.R.c.s. :
appointed factory doctor, Dumfries.
Colonial Service ; BYER, M. A., M.B. : M.o.H., Barbados. FOSTER, H. C., M.D. Toronto, D.T.M.&.H. : A.D.M.s., Tanganyika. GtTiNN, D. R., M.B. Edin., F.R.C.S.: orthopaedic surgeon, Federation of Malaya. HATCHER, LUENA, M.B. Lond. : M.O., Fiji. MILLER, L. J., L.M.S.S.A. : M.o., Zanzibar. SPERBER, KAREL, O.B.E., m.D. Prague, D.P.H. : M.O., Gold Coast.
tends. The birth-rates refer to the interval between present and previous epidemic and therefore to the first of the epidemic years. It will be seen that in general the greater the difference between the birth-rates the shorter the period. BIRTH-RATES
AND
PERIODICITY
OF
MEASLES
EPIDEMICS
Period
quietly overcoming home difficulties, keeping the hospital informed of progress at home, and assessing the build-up of domestic emotional stresses, of the greatest value ; the serious stresses can be reduced by a,ppropriate temporary admission. Without this sociological assistance this method of treating many more patients without increasing the number of beds would be far more in
Hirth rate (% of population
Epidemic period
period
0-9) (b) ’
’ ’
Life-table birth-rate (% of
population 0-9) (lo)
(fortnights from peak of last epidemic to present peak) (T)
difficult. who at first have to attend the day for full days a week are later found to five hospital two, or three days a week. This is a one, only require valuable index of improvement or deterioration in the family group relationship as well as in the patient’s clinical status. The problem of transport, the help of voluntary organisations, nutritional factors, family group interpersonal relationships, techniques in occupational therapy, the administration of the scheme, and fields of expansion will be discussed in a more complete paper on this attempt to bridge the gap made between hospital and home. As all our patients attending the day hospital would have become early and permanent charges on chronic-sick or mental hospitals, each patient so treated means a hospital bed saved. The scheme helps to maintain the integrity of" the family group by affording the relatives a service of care without tears." Its principles are thus based on sound social, economic, and humanitarian foundations. L. Z. COSIN Clinical Director, Cowley Road Hospital,
Some
patients
Oxford.
Geriatric Unit.
From these obtained :
war.
After 1946 the birth-rate began to fall and the effect on measles soon became apparent. In 1950 instead of the usual annual epidemic, with a peak about the 13th week, there was a small midsummer outbreak followed almost immediately by the huge epidemic of 1950-51 with a peak in the 8th week. The interval between this peak and that of 1949 was 48 fortnights indicating that the period was lengthening as the birth-rate fell. The incidence in this epidemic was 101% of the population under the age of 10 per annum, the highest since notification became compulsory in 1938. The variation of the period with the birth-rate is shown in the accompanying table, in which the birth-rate and lifetable birth-rate, together with the period, are set out for the pre-war years 1923-38 and the years 1943-51. The birth-rate with which I am concerned is the number of annual births per cent. of the child population under 10 years (among which occur 95% of measles cases in an epidemic). This rate, of course, will vary from year to year, but if the number of births remained constant yearly for 10 years, no migration taking place in the interval, a life-table " population under 10 would result and the birth-rate per cent. of this population would be the life-table birth-rate (lo). This can be considered as a limiting value to which the birth-rate, as defined above, "
the
following regression equation
is
-3-35 (r = - 0967), &Dgr;T = -4502 &Dgr; b 52 and &Dgr; b = b &Dgr; T = T lo. The life-table rates have been obtained from the England and Wales life tables, allowing for differences in mortality between London and the rest of the country and interpolating between census years. According to this equation, the natural period for London &Dgr; b = 0) is 48-7 fortnights. For a period of 52 fortnights, the birth-rate under present conditions must fall =
where
-
-
9-6% (&Dgr; b = —0.74). With regard to the recent epidemic, the 1951 census has enabled the birth-rate figure to be fixed for the first time since the last census in 1931 ; the values of b and lo in 1951 were 10-66 and 10-30 respectively. It is estimated that by 1952 these rates had fallen to 10-50 and 10-29 respectively. + 0-21 in the equation, we get Hence, substituting &Dgr; b &Dgr; T 4-3, giving a period of 47-7 fortnights. Since the peak of the 1950-51 epidemic came in the 8th week of 1951, that of the present outbreak should occur therefore in the 51st week of 1952. Actually the peak (2705 cases) was recorded in the 53rd week, but it was probably really in the 52nd week, because of the carry-over of cases from Christmas week. Although, in general, one would not expect so close a prediction on each occasion, there does seem to be a connection between the birth-rate and period ; and as fresh data accumulate, it may be possible to increase accuracy in forecasting the probable interval between peaks. There is a similarity between the course of the recent epidemic and that of 1950-51, which is not unexpected, since there has only been a slight fall in the birthrate during the interim. They represent an intermediate stage between an annual and a biennial epidemic. It is of interest that the number of cases between the two peaks was 58,420, the interval being 97 weeks. Taking the average population (0-9) as 492,500, the average incidence is 6-4% per annum; the figure for the epidemics during 1940—52 to
=
=
PERIODICITY OF MEASLES IN LONDON SIR,—There seems to be a relationship between the proportion of susceptible people in a population, the birth-rate, and the periodicity of measles. In a stationary population maintained by a constant birth-rate (according to the current life-table), epidemics could be expected to occur at equal intervals, assuming a constant case-rate. The change from pre-war biennial epidemics to annual ones towards the end of the late war could therefore be explained by the increase in susceptibles due to mass evacuation, the absence of epidemics in the first two years, and the increase in the birth-rate during the
data
was
-
6-1%.
Bromley, Kent.
C. A. GOULD.
LUNG CANCER AND SMOKING
SiR,,-There appears to-be general agreement that- the exposure of living tissues to long-life radioactive isotopes may initiate the onset of a carcinoma. If an ordinary M 6 tube is filled with cigarette or cigar ash a reading varying from 70 to 170 counts per minute is recorded against a normal background of 12. The variability depends on the particular type of cigarette or cigar that is tested. These readings have been obtained using a’Panax’ type Geiger counter, model 44, with an
liquid castle. isotope in question is presumably the long-life radioactive isotope of potassium, K4o, which is present in all potassium to the extent of 11 parts in
E.R.D.
The radioactive
206
100,000 ; and also to a lesser extent the long-life radioisotope of rubidium, Rb87. Beta emanation from
active
potassium is very active, and is in the order of 1.4 MeV. These readings represent, of course, only an extremely minute dose, particularly as it is only cigarette or cigar smoke that is
of
however, to be
no
significance. There would appear, doubt that radioactive particles are actually deposited in the bronchial tree ; and, absorption here being very slow, these tissues must be continually subjected to bombardment by active beta particles. This fact would seem to support the statistical evidence linking inhalation of cigarette smoke with carcinoma of the lung. D. K. MULVANY. London, W.l.
Parliament Scottish
Endowments AT the third reading of the Hospital Endowments (Scotland) Bill,1 Commander T. D. GALBRAITH, joint under-secretary of State for Scotland, reminded members that it had two purposes : to set up a Scottish Hospital Endowments Research Trust, and to empower the Hospital Endowments Commission to transfer endowments to the trust. At the committee stage it appeared to be the general opinion that the commission should not have unlimited power to transfer endowments, and an amendment had accordingly been incorporated in the Bill limiting the transfer to " an aggregate of such amount as in the year ended March 31, 1952, produced an income of £ 120,000."
Hospital
QUESTION TIME Examination of National Service Recruits
Lieut.-colonel MARCUS LIPTON asked the Minister of Labour how doctors were selected for the medical examination of National Service recruits ; what fees were payable ; and what age limit was imposed on the doctors so selected.Sir NN-AT.TEP. MONCKTON replied : Vacancies on the panels of the National Service medical boards are filled on the recommendation of a regional medical officer of the Ministry of Health after consultation with the local medical committee No precise appointed under the National Health Acts. qualifications are laid down, but a minimum of 10 years’ professional experience is expected and the majority of practitioners appointed in recent years have had Service experience. Members of the boards are paid E212s. 6d. per session, normally of 21/2 hours, with an additional half-guinea for the chairman. No age-limit is imposed provided the doctor is fully fit and efficient, but, in general, a doctor over 65 years of age would not be nominated for appointment. Lieut.-colonel LIPTON: Is the Minister aware that some of the chairmen of these boards are over 70 years of age ? Is he also aware that his decision, just announced, that these doctors should themselves be examined would do a great deal Sir to dispel the anxiety caused by their recent activities ? WALTER MONCKTON: I know that some of these people serve until they are 70, and some of the best are that age. I did not intend to criticise these doctors who make up the boards, and have over the years rendered great service both in this administration and the last. All I intend to do-and I have already taken action in the matter-is to gather some of the chairmen of the boards throughout different parts of the country for consultation to see whether we can improve the
administration. Mr. BARNETT JANNER asked the Minister of Labour what were made to consult medical practitioners of men being called up for National Service who informed his department that they had been under the practitioners’ treatment in respect of previous ailments.-Sir WALTFR MONCKTON replied : If the chairman of a medical board is in any doubt about the effect of previous ailments on a man’s grading he would ask the man’s practitioner for a report. Alternativelv the chairman - should send a man to a consultant for full examination.
Prescription Charge Mr. ARTHUR BLENKINSOP asked the Minister of Health whether he would abolish the 18. prescription charge, in view of the recommendation of the British Medical Association annual meeting.-Mr. MACLEOD replied : No, Sir.
Clinical Research In answer to a question, Mr. J. A. BoYD-CARPENTER, financial secretary to the Treasury, stated that for some time a joint committee representing the Standing Medical Advisory Committee of the Central Health Services Council and the Medical Research Council, who had worked in close consultation with the Advisory Committee on Medical Research in Scotland, had been studying the best ways and means of coordinating and developing clinical research work - that is to say, research directly concerned with sick persons. Their report was published on July 14. The recommenda. tions provided both for centralised and decentralised research. The former would be directed through a Clinical Research Board covering the whole country, to be appointed by the Medical Research Council, the latter through the hospital boards. These proposals had been welcomed and accepted, subject to detailed consideration of their practical application, by the responsible Ministers-namely, the Lord President of the Council, the Secretary of State for Scotland, and the Minister of Health, as well as by thChancellor of the Exchequer. All concerned were agreed that the time was ripe for reorganisation and development in this field. No additional burden on public funds would be involved this year, but the Chancellor was ready to agree in principle to reasonable additional financial provision from the Exchequer, on the lines suggested in the report, as the work developed. In Scotland the Advisory Committee on Medical Research would continue to advise on the allocation of National Health Service funds for decentralised research projects, and would also advise on the allocation of funds by the Hospital Endowments Research Trust to be constituted under current
Onchocerciasis Survey in West Africa Mr. LESLIE HALE asked the Secretary of State for the Colonies what progress had now been made with the survey of the incidence of onchocerciasis in the Gold Coast, Cameroons, and Nigeria entrusted to the British Empire Society for the Blind, whether sufficient finance was available to enable the full originally planned survey to be completed within three years, and what portion of the total cost would be borne from Government funds.-Mr. OLIVER LYTTELTON replied : The main survey began in the Gold Coast last November. It is hoped to extend it to Nigeria and the Cameroons early The cost is being borne by the British Empire next year. Society for the Blind, but the local governments are providing medical facilities and accommodation. The society inform me that although the scheme has proved a heavy drain on their finances, they hope to be able to complete the survey within the allotted time. If the British Empire Society for the Blind should be short of money for this purpose, then another situation will arise.
Diary JULY
Monday,
Lancet, 1953, i, 349, 446.
of the Week 26
TO AUG.
1
27th
ROYAL CoLLEGE OF SURGEONS, Lincoln’s Inn Fields, W.C.2 5 P.M. Three-dimensional colour film (made by Ethicon Suture Laboratories Ltd.) on Mediastinal Tumours ; operation performed by Mr. Brian Blades.
Tuesday,
28th
INSTITUTE OF NEUROLOGY, National Hospital, Queen 5 P.M. Prof. Kurt Goldstein (U.S.A.) : Aphasia.
arrangements
1. See
legislation.
Square, W.C.1
Appointments BoRTHWioE,
R.
D.,
M.R.c.s. :
appointed factory doctor, Dumfries.
Colonial Service ; BYER, M. A., M.B. : M.o.H., Barbados. FOSTER, H. C., M.D. Toronto, D.T.M.&.H. : A.D.M.s., Tanganyika. GtTiNN, D. R., M.B. Edin., F.R.C.S.: orthopaedic surgeon, Federation of Malaya. HATCHER, LUENA, M.B. Lond. : M.O., Fiji. MILLER, L. J., L.M.S.S.A. : M.o., Zanzibar. SPERBER, KAREL, O.B.E., m.D. Prague, D.P.H. : M.O., Gold Coast.