- Email: [email protected]
REMUNERATION OF SENIOR PRACTITIONERS
444
addition, direct sensitivity tests have been performed by from
to sets of L6wenstein -Jensen sputum culturing slopes containing isoniazid with and without the addition of fraction-V albumin. It is hoped soon to publish an account comparing these results with those obtained This work has been done in by indirect methods. collaboration with my colleagues in this department, Dr. K. Anderson, Dr. D. G. Chalmers, Dr. P. Collard, and Dr. M. B. King. Our remarks on the effect of temperature on isoniazid sensitivity seem to have been misinterpreted. The effect of temperature is complicated, but our general conclusion was that the bactericidal efficiency of isoniazid appeared to be increased at temperatures above 37°C. The conclusions of Dr. Mitchison and his on
colleagues, however, do agree broadly with our own and with the experimental results of Goulding and Robson.1 Department of Bacteriology, Guy’s Hospital Medical School, London, S.E.1.
ROBERT KNOX.
PNEUMOTHORAX THERAPY
SIR,—Your leading article
on
this
subject (Feb. 14)
draws attention to the need for a rational policy with regard to the duration of pneumothorax therapy and the benefits that would ensue from such a policy. There is undoubtedly a good deal of evidence that an artificial pneumothorax which has not substantially achieved its object within three years should be abandoned in favour of some other method of achieving control of the disease in the affected lung. Even this period may possibly prove to be rather long, as sufficient time has not yet elapsed to assess the effects of combined chemotherapy and pneumothorax treatment. The use of the artificial pneumothorax may be becoming less popular, but that is surely right if the reason is a more critical selection of cases. If the patient is to finish with a good functioning lung the same critical standards should be applied to the management of the pneumothorax, and the period for which it is maintained, from the time it becomes effective. Much will depend on the size and extent of the initial lesion and its response to rest and chemotherapy ; but perhaps we should not necessarily wait the three years suggested by Harris et awl. before reviewing our pneumothorax cases with a view to termination, but should start a year or even eighteen months earlier. HUGH CLIMIE. FATALISM ABOUT CANCER OF LUNG SiR,,-The great majority of smoking doctors seem to have adopted a fatalistic attitude towards their developing cancer of lung. They usually argue that if they are going to develop cancer of lung, carcinogenesis has doubtless been going on in their bronchial stems for years, so why should they bother to stop smoking now, when it would almost certainly be too late ? The carcinogen has not so far been found, but it is probable that carcinogenesis resulting from chronic irritation by tobacco smoke goes on all the time in the bronchial stems of all smokers, to an extent which corresponds mainly with the heaviness of their smoking. Only occasionally does carcinogenesis go on to carcinoma, and so long as no symptoms of cancer of lung have developed, there is a good chance that stopping smoking - -cutting off fresh supplies of 3carcinogen—will prevent this happening. Doll and Hill found that out of 1350 male smokers who developed cancer of lung, 70 (5-1%) had given up smoking for a year or more, whereas in the case of 1296 matched control smokers, the corresponding
figure
was
124
(9.6%). LENNOX JOHNSTON.
REMUNERATION OF SENIOR PRACTITIONERS
senior member of our profession (being and have only a small list of National Health Service patients which it is virtually impossible for me to increase. Those who found themselves in the same position as myself were, prior to the Danckwerts award, allowed certain extra sums out of the general sums available for the payment of doctors. Following this award these sums are all to be reduced, and in my own case this will mean that I am likely to lose not less than £100 per annum. The loss may be greater, for the not are precise figures yet worked out. The sums which we lose are to find their way into the pockets of younger men with larger lists, most of whom have never been called upon to do the vast amount of unpaid work which was our lot when we entered the profession. It will be probably agreed by everyone that this state of affairs involves a flagrant injustice which should, since our own committees seem unable to cope with it, be corrected by Parliament itself. I recommend all those in the same position as myself to write forthwith to their Member of Parliament, and to their local representatives on any Professional Committees, asking that this matter may be given urgent attention. GORDON WARD.
SIR,-I
now
SIR,—In tuberculin
1952, 21, 447. 3. Brit. med. J. 1952, ii, 1275.
TUBERCULIN SENSITIVITY his letter of Feb. 14 about our paper on sensitivity (Jan. 10), Dr. Daniels says:
"
there is no doubt they mean [’ low-grade’ sensitivity] Even in our most expansive is always non-specific." moods we should hesitate (I hope) to suggest such an absolute and uncompromising concept, particularly in medical-biological sciences. I believe our results show that groups of persons may be characterised as having high-grade, low-grade, or relatively no sensitivity ; and this is quite different from implying that every single person can be precisely allocated to one group or another. With the tuberculins in use today the different kinds of sensitivity overlap to some extent on the quantitative scale ; a perfect separation of one group from another cannot be made. If for no other reason than errors of observation, some persons will be incorrectly classified. One of the points we tried to make, and this was based on the results in that paper (and in some half-dozen other papers in the last ten years), - was simply that a special kind of low-grade sensitivity exists : it is characterised in groups of persons by small reactions to a weak dose of tuberculin (5-10 T.u.) and larger reactions to a strong dose (100 T.u. or more); this low-grade kind of sensitivity has not been shown to be related to other evidences of tuberculous infection, but is clearly related to still unidentified geographic factors. I do not think this is a surprising " postulate in view of the findings reported during recent years, and especially as I know of no strong evidence which contradicts it in the literature on tuberculin sensitivity of human beings. Evidence that high-grade (specific) tuberculin seiisitivity wanes in the absence of repeated infection is, I One must be confident believe, very difficult to assess. of the uniformity of the tuberculin and of the methods of testing (especially the reading of reactions) and, above all, of the absence of bias. I would not disagree that tuberculin sensitivity has been observed to fluctuate. but I am not at all convinced that it generally or even frequently wanes in persons below 50 or 60 years of age. Other attempts have been made to explain troublesome questions in the epidemiology and pathology of tuberculosis in terms of waning tuberculin sensitivity. It was used a number of years ago to discourage the search for a cause other than tuberculosis of pulmonary calcification in negative " tuberculin reactors ; and it was advocated as a reason for disbelieving that histoplasmosis causes pulmonary calcification. "
"
Goulding, R., Robson, J. M. Lancet, 1952, ii, 849. 2. Harris, W. C., Poles, F. C., Anderson, A. W. Quart. J. Med. 1.
am a
aged 68)
addition, direct sensitivity tests have been performed by from
to sets of L6wenstein -Jensen sputum culturing slopes containing isoniazid with and without the addition of fraction-V albumin. It is hoped soon to publish an account comparing these results with those obtained This work has been done in by indirect methods. collaboration with my colleagues in this department, Dr. K. Anderson, Dr. D. G. Chalmers, Dr. P. Collard, and Dr. M. B. King. Our remarks on the effect of temperature on isoniazid sensitivity seem to have been misinterpreted. The effect of temperature is complicated, but our general conclusion was that the bactericidal efficiency of isoniazid appeared to be increased at temperatures above 37°C. The conclusions of Dr. Mitchison and his on
colleagues, however, do agree broadly with our own and with the experimental results of Goulding and Robson.1 Department of Bacteriology, Guy’s Hospital Medical School, London, S.E.1.
ROBERT KNOX.
PNEUMOTHORAX THERAPY
SIR,—Your leading article
on
this
subject (Feb. 14)
draws attention to the need for a rational policy with regard to the duration of pneumothorax therapy and the benefits that would ensue from such a policy. There is undoubtedly a good deal of evidence that an artificial pneumothorax which has not substantially achieved its object within three years should be abandoned in favour of some other method of achieving control of the disease in the affected lung. Even this period may possibly prove to be rather long, as sufficient time has not yet elapsed to assess the effects of combined chemotherapy and pneumothorax treatment. The use of the artificial pneumothorax may be becoming less popular, but that is surely right if the reason is a more critical selection of cases. If the patient is to finish with a good functioning lung the same critical standards should be applied to the management of the pneumothorax, and the period for which it is maintained, from the time it becomes effective. Much will depend on the size and extent of the initial lesion and its response to rest and chemotherapy ; but perhaps we should not necessarily wait the three years suggested by Harris et awl. before reviewing our pneumothorax cases with a view to termination, but should start a year or even eighteen months earlier. HUGH CLIMIE. FATALISM ABOUT CANCER OF LUNG SiR,,-The great majority of smoking doctors seem to have adopted a fatalistic attitude towards their developing cancer of lung. They usually argue that if they are going to develop cancer of lung, carcinogenesis has doubtless been going on in their bronchial stems for years, so why should they bother to stop smoking now, when it would almost certainly be too late ? The carcinogen has not so far been found, but it is probable that carcinogenesis resulting from chronic irritation by tobacco smoke goes on all the time in the bronchial stems of all smokers, to an extent which corresponds mainly with the heaviness of their smoking. Only occasionally does carcinogenesis go on to carcinoma, and so long as no symptoms of cancer of lung have developed, there is a good chance that stopping smoking - -cutting off fresh supplies of 3carcinogen—will prevent this happening. Doll and Hill found that out of 1350 male smokers who developed cancer of lung, 70 (5-1%) had given up smoking for a year or more, whereas in the case of 1296 matched control smokers, the corresponding
figure
was
124
(9.6%). LENNOX JOHNSTON.
REMUNERATION OF SENIOR PRACTITIONERS
senior member of our profession (being and have only a small list of National Health Service patients which it is virtually impossible for me to increase. Those who found themselves in the same position as myself were, prior to the Danckwerts award, allowed certain extra sums out of the general sums available for the payment of doctors. Following this award these sums are all to be reduced, and in my own case this will mean that I am likely to lose not less than £100 per annum. The loss may be greater, for the not are precise figures yet worked out. The sums which we lose are to find their way into the pockets of younger men with larger lists, most of whom have never been called upon to do the vast amount of unpaid work which was our lot when we entered the profession. It will be probably agreed by everyone that this state of affairs involves a flagrant injustice which should, since our own committees seem unable to cope with it, be corrected by Parliament itself. I recommend all those in the same position as myself to write forthwith to their Member of Parliament, and to their local representatives on any Professional Committees, asking that this matter may be given urgent attention. GORDON WARD.
SIR,-I
now
SIR,—In tuberculin
1952, 21, 447. 3. Brit. med. J. 1952, ii, 1275.
TUBERCULIN SENSITIVITY his letter of Feb. 14 about our paper on sensitivity (Jan. 10), Dr. Daniels says:
"
there is no doubt they mean [’ low-grade’ sensitivity] Even in our most expansive is always non-specific." moods we should hesitate (I hope) to suggest such an absolute and uncompromising concept, particularly in medical-biological sciences. I believe our results show that groups of persons may be characterised as having high-grade, low-grade, or relatively no sensitivity ; and this is quite different from implying that every single person can be precisely allocated to one group or another. With the tuberculins in use today the different kinds of sensitivity overlap to some extent on the quantitative scale ; a perfect separation of one group from another cannot be made. If for no other reason than errors of observation, some persons will be incorrectly classified. One of the points we tried to make, and this was based on the results in that paper (and in some half-dozen other papers in the last ten years), - was simply that a special kind of low-grade sensitivity exists : it is characterised in groups of persons by small reactions to a weak dose of tuberculin (5-10 T.u.) and larger reactions to a strong dose (100 T.u. or more); this low-grade kind of sensitivity has not been shown to be related to other evidences of tuberculous infection, but is clearly related to still unidentified geographic factors. I do not think this is a surprising " postulate in view of the findings reported during recent years, and especially as I know of no strong evidence which contradicts it in the literature on tuberculin sensitivity of human beings. Evidence that high-grade (specific) tuberculin seiisitivity wanes in the absence of repeated infection is, I One must be confident believe, very difficult to assess. of the uniformity of the tuberculin and of the methods of testing (especially the reading of reactions) and, above all, of the absence of bias. I would not disagree that tuberculin sensitivity has been observed to fluctuate. but I am not at all convinced that it generally or even frequently wanes in persons below 50 or 60 years of age. Other attempts have been made to explain troublesome questions in the epidemiology and pathology of tuberculosis in terms of waning tuberculin sensitivity. It was used a number of years ago to discourage the search for a cause other than tuberculosis of pulmonary calcification in negative " tuberculin reactors ; and it was advocated as a reason for disbelieving that histoplasmosis causes pulmonary calcification. "
"
Goulding, R., Robson, J. M. Lancet, 1952, ii, 849. 2. Harris, W. C., Poles, F. C., Anderson, A. W. Quart. J. Med. 1.
am a
aged 68)