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SMOKERS BEWARE!
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examine during their bouts of acute abdominal pain, the immediate and ultimate cause of the pain is some abnormality within the abdomen, rather than emotional excitement or a disharmonious mental state (though they sometime suffer from these also). Department of Surgery, Postgraduate Medical School of London, London, W.12.
IAN
THE PROBLEM OF THE ELDERLY CONSUMPTIVE
AIRD.
SIR,—Dr. Mac Keith and Dr. O’Neill quote a personal communication from me to the effect that " in a series of 150 children with recurrent abdominal pain [I] noted that in only 4 was there a history of constipation, but that 26 remarked that defæcation was followed by relief of pain." This quotation should have read : "in 200 children with abdominal pain, the symptom was associated with constipation in 10%, with diarrhoea in 21%, and was relieved by defsecation in 38%." D. J. CONWAY. ,
SMOKERS BEWARE!
SIR,—In your leading article of July 28 you suggest that the increased incidence of cancer of the lung may be related to smoking. Being addicted to tobacco, I cannot let your remarks pass without comment. After the influenza pandemic of 1918-19, the late Prof. A. F. Bernard Shaw predicted that in the next 20-30 years there would be a great increase in the incidence of cancer of the lung ; and how right he was ! He based this prediction on the histological findings in an enormous mass of autopsy material resulting from the epidemic and its sequelae, quite a proportion of the cases showing what he regarded as precarcinomatous changes in the lungs. I can find no record of his ever having published this observation, but I am sure that many of the colleagues who were associated with him at that time will be able to recall his remarks. Perhaps I may still be able to smoke with an easy mind. W. E. M. WARDILL. Newcastle upon Tyne. ASPIRATION OF THE CHEST SIR,—Dr. Forbes and Dr. Starks record in your issue of Aug. 18 yet another method of aspirating chests, using an apparatus made up of many parts. I am often surprised how few people realise that the vast majority of chest effusions can be aspirated with ease and comfort to patient and doctor by the same method as is commonly used for the aspiration of ascitic fluid. A needle attached to a long thin length of rubber tubing is all that is required. Except for thick purulent effusions, the needle need not be thicker than the size commonly used for taking blood from a vein, and it rarely needs to be longer than 2 in. The needle is connected to the rubber tubing, and thrust the aneasthetised chest wall into the effusion, and a little suction applied with a syringe at the far end of the rubber tubing which hangs over the side of the bed and drains into a receiver. As soon as the fluid starts to flow, further suction with the syringe is unnecessary, since the height of the column of fluid in the tubing-usually 2-3 ft.-is itself enough to overcome any " negative pressure " inside the chest wall. With this system several litres of fluid can be aspirated slowly and with safety.
through
also suspicious of any gadget which holds an needle at right-angles to the chest wall. As the fluid is removed, the lung expands and will be impaled on the needle. Surely it is better, after the needle has been inserted, to strap down the head of the needle to the chest wall, so that the shaft of the needle tends to lie tangentially inside the pleural cavity ?Q This protects the lung to some extent when it re-expands. I
am
aspirating
Canadian Red Cross Memorial
Hospital, Taplow, Maidenhead, Berks.
ALLAN ST. JOHN DIXON.
-
SIR,—The homeless elderly consumptive has been called" the hard core " of the tuberculosis problem, and Dr. Paul (Aug. 11, p. 263) has stressed the need for residential hostels for those who are homeless, or who live in overcrowdedhomes. Though such accommodation will provide a welcome and satisfactory solution to the problem as-it affects the area sending cases, the difficulties and dangers that may arise in the district where the hostel is situated must not be disregarded, and these have hitherto received little attention. The risk to the local population admittedly cannot be assessed ; but the influx of fifty highly infectious men-, some excreting streptomycin-resistant organisms, a few of low intelligence and difficult to train in the elements of hygiene, cannot be viewed with equanimity by those responsible for the control of tuberculosis. No restriction is-or can be at the present time-placed on their freedom, and they mix with the local population in buses, cinemas, cafes, and public-houses. It is over-simplifying the problem to say, as Dr. Paul does, that " the provision of such hostels would solve the problem of segregation ... for many patients." If this new danger is to be minimised, careful attention must be given to the siting of the hostel, and to the provision of amenities. A remote and inaccessible hostel would make visits into town difficult and therefore infrequent, but-as long as segregation is voluntary-would defeat its own object, for men would not stay there long and in time would refuse to go to it. If in or very near a town, there will be free and frequent mixing with the local population. A compromise is necessary ; the hostel must be near enough to a town to make men content to remain but far enough away to require a definite effort to get there ! Above all the hostel must be made attractive. The men must not regard it as a penal institution to be escaped from whenever possible, but as a comfortable home in which to spend their remaining days. Occupational therapy must be provided, and men encouraged, when their condition allows, to do light work in house or garden.- Suitable recreations, indoor and outdoor, must be available, and regular entertainment given, including film shows. The provision of a bar might serve to reduce the number of visits to " the local." The demand these men will make on the facilities provided by the local chest clinic and hospital must not be overlooked. Contrary to what Dr. Paul says, their medical care should not be the responsibility of the local chest physician. He would undertake their supervision just as he would for any other consumptive living in his district, and he would undertake treatment as necessary for their tuberculosis. Most of these men, however, will require treatment for non-tuberculous conditions-e.g., sore throats and dyspepsia, bronchitis and emphysema, or heart-failure. Such conditions should be, and can best be, treated by a general practitioner who would take these men on his list. If a hostel of this kind is to be saved from becoming a mere repository for infectious individuals whom society is putting away for its own safety, it needs constant inspiration and guidance from someone who is familiar with and sympathetic towards the problems of the chronic consumptive. It is unlikely that existing clinic staffs will have time to pay the frequent visits necessary to achieve this. In the London County Council hostel. already opened (which incidentally is for those unabl.e to work) a happy solution has been reached by finding a general practitioner who has had several years’ experience in tuberculosis. In addition to giving general medical care to these men, he is able to give skilled help and guidance on their tuberculosis problems. He has been taken on the staff of the local chest clinic as a clinicalassistant for duties at the hostel. Weekly meetings are .
examine during their bouts of acute abdominal pain, the immediate and ultimate cause of the pain is some abnormality within the abdomen, rather than emotional excitement or a disharmonious mental state (though they sometime suffer from these also). Department of Surgery, Postgraduate Medical School of London, London, W.12.
IAN
THE PROBLEM OF THE ELDERLY CONSUMPTIVE
AIRD.
SIR,—Dr. Mac Keith and Dr. O’Neill quote a personal communication from me to the effect that " in a series of 150 children with recurrent abdominal pain [I] noted that in only 4 was there a history of constipation, but that 26 remarked that defæcation was followed by relief of pain." This quotation should have read : "in 200 children with abdominal pain, the symptom was associated with constipation in 10%, with diarrhoea in 21%, and was relieved by defsecation in 38%." D. J. CONWAY. ,
SMOKERS BEWARE!
SIR,—In your leading article of July 28 you suggest that the increased incidence of cancer of the lung may be related to smoking. Being addicted to tobacco, I cannot let your remarks pass without comment. After the influenza pandemic of 1918-19, the late Prof. A. F. Bernard Shaw predicted that in the next 20-30 years there would be a great increase in the incidence of cancer of the lung ; and how right he was ! He based this prediction on the histological findings in an enormous mass of autopsy material resulting from the epidemic and its sequelae, quite a proportion of the cases showing what he regarded as precarcinomatous changes in the lungs. I can find no record of his ever having published this observation, but I am sure that many of the colleagues who were associated with him at that time will be able to recall his remarks. Perhaps I may still be able to smoke with an easy mind. W. E. M. WARDILL. Newcastle upon Tyne. ASPIRATION OF THE CHEST SIR,—Dr. Forbes and Dr. Starks record in your issue of Aug. 18 yet another method of aspirating chests, using an apparatus made up of many parts. I am often surprised how few people realise that the vast majority of chest effusions can be aspirated with ease and comfort to patient and doctor by the same method as is commonly used for the aspiration of ascitic fluid. A needle attached to a long thin length of rubber tubing is all that is required. Except for thick purulent effusions, the needle need not be thicker than the size commonly used for taking blood from a vein, and it rarely needs to be longer than 2 in. The needle is connected to the rubber tubing, and thrust the aneasthetised chest wall into the effusion, and a little suction applied with a syringe at the far end of the rubber tubing which hangs over the side of the bed and drains into a receiver. As soon as the fluid starts to flow, further suction with the syringe is unnecessary, since the height of the column of fluid in the tubing-usually 2-3 ft.-is itself enough to overcome any " negative pressure " inside the chest wall. With this system several litres of fluid can be aspirated slowly and with safety.
through
also suspicious of any gadget which holds an needle at right-angles to the chest wall. As the fluid is removed, the lung expands and will be impaled on the needle. Surely it is better, after the needle has been inserted, to strap down the head of the needle to the chest wall, so that the shaft of the needle tends to lie tangentially inside the pleural cavity ?Q This protects the lung to some extent when it re-expands. I
am
aspirating
Canadian Red Cross Memorial
Hospital, Taplow, Maidenhead, Berks.
ALLAN ST. JOHN DIXON.
-
SIR,—The homeless elderly consumptive has been called" the hard core " of the tuberculosis problem, and Dr. Paul (Aug. 11, p. 263) has stressed the need for residential hostels for those who are homeless, or who live in overcrowdedhomes. Though such accommodation will provide a welcome and satisfactory solution to the problem as-it affects the area sending cases, the difficulties and dangers that may arise in the district where the hostel is situated must not be disregarded, and these have hitherto received little attention. The risk to the local population admittedly cannot be assessed ; but the influx of fifty highly infectious men-, some excreting streptomycin-resistant organisms, a few of low intelligence and difficult to train in the elements of hygiene, cannot be viewed with equanimity by those responsible for the control of tuberculosis. No restriction is-or can be at the present time-placed on their freedom, and they mix with the local population in buses, cinemas, cafes, and public-houses. It is over-simplifying the problem to say, as Dr. Paul does, that " the provision of such hostels would solve the problem of segregation ... for many patients." If this new danger is to be minimised, careful attention must be given to the siting of the hostel, and to the provision of amenities. A remote and inaccessible hostel would make visits into town difficult and therefore infrequent, but-as long as segregation is voluntary-would defeat its own object, for men would not stay there long and in time would refuse to go to it. If in or very near a town, there will be free and frequent mixing with the local population. A compromise is necessary ; the hostel must be near enough to a town to make men content to remain but far enough away to require a definite effort to get there ! Above all the hostel must be made attractive. The men must not regard it as a penal institution to be escaped from whenever possible, but as a comfortable home in which to spend their remaining days. Occupational therapy must be provided, and men encouraged, when their condition allows, to do light work in house or garden.- Suitable recreations, indoor and outdoor, must be available, and regular entertainment given, including film shows. The provision of a bar might serve to reduce the number of visits to " the local." The demand these men will make on the facilities provided by the local chest clinic and hospital must not be overlooked. Contrary to what Dr. Paul says, their medical care should not be the responsibility of the local chest physician. He would undertake their supervision just as he would for any other consumptive living in his district, and he would undertake treatment as necessary for their tuberculosis. Most of these men, however, will require treatment for non-tuberculous conditions-e.g., sore throats and dyspepsia, bronchitis and emphysema, or heart-failure. Such conditions should be, and can best be, treated by a general practitioner who would take these men on his list. If a hostel of this kind is to be saved from becoming a mere repository for infectious individuals whom society is putting away for its own safety, it needs constant inspiration and guidance from someone who is familiar with and sympathetic towards the problems of the chronic consumptive. It is unlikely that existing clinic staffs will have time to pay the frequent visits necessary to achieve this. In the London County Council hostel. already opened (which incidentally is for those unabl.e to work) a happy solution has been reached by finding a general practitioner who has had several years’ experience in tuberculosis. In addition to giving general medical care to these men, he is able to give skilled help and guidance on their tuberculosis problems. He has been taken on the staff of the local chest clinic as a clinicalassistant for duties at the hostel. Weekly meetings are .