SMOKING AND DISEASE

769 examination of the right ovary showed serious cystadeno.:arcinoma. The patient’s general condition after operation was never very satisfactory, and she eventually showed signs of relvic recurrence in the form of recurrent painful phlebitis in both lower limbs. She was readmitted on Dec. 6, 1963, with grossly swollen and painful lower limbs. There was a fairly obvious indurated swelling, the size of a hen’s egg, in the lower end of the recent abdominal scar, and rectal examination suggested pelvic recurrence. X-ray of the chest showed a very obvious secondary deposit in the right lower lung. The patient was given prolothan G intravenously, and was able to tolerate 100 ml. over 5 days, followed by intramuscular injections of prolothan A, 10 ml. twice daily, for 6 days and 10 ml. daily for a further 4 days. Within a few days the swelling and pain in both limbs had definitely improved, and the patient was eating better; but the ultimate prognosis here cannot be in doubt. The swelling in the abdominal scar, however, became clinically smaller and appreciably softer.

From the evidence of these three

widely different types with carcinoma, systemic prolothan seems justifiable; and the results support the claim of O’Meara and O’Halloranthat prolothan inhibits cancer growth. Local applications of prolothan cream are undoubtedly efficacious. I wish to thank Dr. E. M. Glaser, of Evans Medical Research Laboratories, for his interest in these cases and supplies of prolothan cream; Dr. W. E. Smithson, Dr. T. B. Madden, and Dr. M. Elder for their help; Dr. S. H. Grant and Dr. M. Symons, of the pathological department, Salop Royal Infirmary, for section reports; and the nursing staff of the Oswestrv and District Hospital. of

treatment

Oswestry and District Hospital, Oswestry, Shropshire.

A. LUTTON.

UNUSUAL POLIOMYELITIS

SIR,-I should like to reply very briefly to Dr. Taylor’s criticism (March 21) of my letter reporting an unusual case of poliomyelitis. I agree with him that the finding of poliovirus in a patient’s fxces does not per se justify a diagnosis of poliomyelitis. But if such a patient has a paresis, and if his cerebrospinal-fluid protein and cell-count resemble, particularly in respect of the former, what is found in poliomyelitis rather than ECHO and Coxsackie virus infections of the nervous system, then I think it not unreasonable to assume that the isolation of poliovirus was not a coincidence.

In clinical medicine

one

has

to

weigh probability

against possibility, and, as added weight to a diagnosis of poliomyelitis, the severity of my patient’s back and limb Dains

must

be considered.

Military Hospital, Colchester,

H. FOSTER.

Essex.

MANAGEMENT OF INFECTIVE HEPATITIS " SIR,-In your leader of Feb. 29 you say: It is conventional to employ barrier-nursing, as for any other

fxces-borne infection." Is this convention either valuable or valid ?The spread of the hepatitis virus in family communities is well recognised, but personal experience leads me to believe that it is uncommon for cases to arise from cross-infection in hospital wards. " Barrier-nursing"" as usually carried out in hospital is notable for the frequency with which barriers are disregarded, particularly by the medical staff, and is rapidly brought into disrepute. Should it not be confined to those cases where dangers of cross-infection are well attested, such as infection w ith multiresistant organisms like the hospital staphylococcus ? If barrier-nursing is to be used at all. it must be rigidly , and, under modern hospital conditions where the is fortunately becoming largely redundant, the danger of cross-transmission of fxcal-bome disease should be small. 1.

O’Meara,

R. A.

Q., O’Halloran, M. J. Lancet, 1963, ii, 613.

Let

advocate the continuance of time-consuming nursing procedures unless there are firm grounds for believing them to be essential. D. G. H. SYLVESTER. us not

NOTHING TO EAT BUT FOOD

SIR,—I have read with interest your leading article of March 14. The question of weight loss in obesity is indeed important. I am not sure, however, that even in hospital it is easy to supervise dietary discipline. We have in our wards at the moment a lady with severe circumferential gravitational ulceration. Her weight on admission was 151/2 st. The local condition responded well to strict bed rest and applications. Despite a dietary intake of 800 calories per day, her weight, some 3112 weeks later, was 161/2 st. Since she is an intelligent and reliable person, there is no apparent reason for our discrediting her assurances that she takes no extra food. It is equally apparent, however, that there must be some surreptitious supply somehow. Department of Plastic Surgery, SYDNEY COHEN. University of Edinburgh.

SMOKING AND DISEASE SiR,—The concluding statement in your leading article of Jan. 18-" But the case against cigarettes has been

amply proved; and no debate should be allowed to obscure that fact "-leaves the impression that you advocate that knowledge of smoking as a cause of disease be frozen at the current level. Such an approach appears to me to be unfortunate. "

"

Progress in science has generally been achieved by debate and inquiry and eventual discovery of facts and phenomena which could not be explained by a prevailing theory. This resulted in the development of a new theory which accommodated the old and the new facts. If this is true in areas of science where the prevailing theory was sufficient to explain all the facts then known, debate and inquiry are even more needed in the area of cigarette smoking as a causative agent of disease in which there are so many large gaps in our knowledge. Even the U.S. Public Health Service report on Smoking and Health,1 in discussing certain associations, is replete with statements such as: " their causal implications cannot at present be stated " (p. 205); are not sufficient to support a judgment on the causal significance of this association" (p. 225); " Male cigarette smokers have a higher death rate from coronary artery disease than non-smoking males, but it is not clear that the association has causal significance " (p. 327); " Information is lacking on the mechanism by which this decrease in birth weight is produced " (p. 343)-not to mention other observed associations which the report chose to ignore. The adoption of your dictum of " no debate should be allowed to obscure that fact " will, I fear, have deterring effects on the eventual elimination of the very important questionmarks still existing. The immediate effect is that it is becoming increasingly more difficult to find outlets for publication of articles which do not follow the accepted view. This has already become manifest in the last few years. I have personal knowledge of articles which have been rejected not on scientific grounds but because of a reluctance on the part of the editors to open their pages to an emotionally charged topic for fear of " stirring up a hornet’s nest ". It is also becoming increasingly difficult to obtain support from public and private granting agencies (exclusive, of course, of the tobacco industry’s own funds) for investigations in which the design manifests a scepticism of the accepted views.

submit, Sir, that a more reasonable and, in the long a more promising approach to the difficult problems of smoking and disease is one which rather encourages debate " and.further inquiry. A total acceptance of the causal hypothesis as proven may retard the discovery I

run, "

1. U.S.

Department

of

Health, Education, and Welfare, 1964.

770 of the real factors in the event that the association of smoking with disease is eventually found to be not one of cause and effect. One definite conclusion which emerges from a review of the various investigations is that the phenomenon of smoking and its relation to disease is complex and calls for continued exploration and vigorous and energetic investigation.

J. YERUSHALMY.

CHLOROQUINE AND THE EYE SIR Your interesting annotation (Feb. 22) does not mention an additional ocular complication recently described-namely uveitis.1 This complication is pro-

bably very rare. Nevertheless chloroquine damage should be excluded in every case of uveitis of unknown origin. M. LAZAR L. REGENBOGEN R. STEIN.

Eye Department, Tel-Hashomer Hospital, Israel.

AN INTERESTING CASE IN WARD 6

SIR,-Few clinical teachers of medicine will disagree in general with the sentiments expressed in your leading article of March 28. The happiness and comfort of the patient who is taught upon depend to a large extent on the communication-perhaps the word " rapport " would be better-between the medical and nursing staff and him. However, it is hard to believe that you have attended a teaching hospital in recent years if you think that a patient is " questioned and examined by relays of students " (in fact students are very sensitive of a patient’s feelings) or that their ills are discussed in the hearing of other patients. There is one aspect of this matter which you have not mentioned and which is of extreme importance to the benefit of the patient. Inexactitudes or even errors of diagnosis or management are much less likely to occur when the consultant is under the critical eye of students, and when house-staff and senior residents raise doubts and queries which lead to a more fundamental understanding of the patient’s disease. In my experience, even private patients in hospital greatly appreciate the contribution made to their care by junior and senior residents. They realise that the privacy for which they have paid is physical or geographic, not scientific or intellectual. Not infrequently I have asked private patients if I may bring my students to see them. All have agreed, and afterwards at

the

insight

and

understanding they

have obtained concerning their condition and its treatment. Two or three heads are often better than one; standards are raised; and most patients, whether private or in the general wards, seem to understand instinctively that to be taught on is to their advantage. Dean’s Office, Westminster Medical School, London, S.W.1.

SIR,-May I editorial

on

R. I. S. BAYLISS.

comment on one or two

points

in your

clinical medical education.

The first concerns the designation and status in the hospital of those whom you, following the usual custom, call " medical students ", and whom I, following my late colleague the late Mr. Carnac Rivett, prefer to call " student doctors ". Before starting their clinical work, student doctors have become, in fact or in substanee, graduates in preclinical medical science. In their various clinical appointments they are, or should be, just as much an integral part of the clinical unit in which they 1.

"

become nurses " and " medical students "students", as in your editorial, and are often treated accordthey have in fact " The student doctor " should have just as definite ingly. a responsible position in relation to patients in the wards or the " outpatient department as the student nurse" ". In this atmosphere, the statement in your editorial that patients may be asked to allow medical students to examine them becomes as irrelevant as would be a similar statement that they may be asked to allow student nurses to deal with them. (Incidentally, I have just discovered that the term " student doctorwas used as long ago as 1888 by Chekhov in one of his short stories.) Most people will agree with you that the open ward round should go, together with its open discussion of the patient’s illness in front of other patients and a crowd of onlookers, but the difficulty at the present time is often less one of objective than of accommodation. Clinical teachers can only carry out their obligations to the community in medical education within the limits of the facilities provided by the community. "

"

School of Public Health, University of California, Berkeley, California.

expressed gratitude

working as the student nurse or the student physiotherapist. But, by a curious selectivity of abbreviation, " student nurses are

Lazar, M., Regenbogen, L., Stein,

R.

Ophthalmologica, 1963, 146,

411.

Your attack on the clinical conference, however, is both surprising and unjustified. Of all the techniques of clinical medical education, this is the one in which it is easiest, provided that it is conducted with sympathy and due regard for human dignity, to obtain the full and helpful cooperation of patients. So much is this so that one wonders how much experience you have in these matters. The clinical conference is becoming such an important technique of medical education, not only in teaching hospitals but also in postgraduate education in the country at large, that in the interests both of truth and of medical education I hope you will be prepared to recon"

"

sider

vour

London,

iudgment

W.1.

on

this noint.

DAVID H. PATEY.

HYPOFIBRINOGENÆAMIA IN PREGNANCY

SIR,—The case described by Professor Baker and his colleagues (Feb. 22) resembles one we treated in 1962. The patient, who was under the care of Mr. C. J. K. Hamilton, was a para-5 (plus 1 abortion) aged 41. The estimated date of delivery was May 8, although there was considerable doubt. Previous pregnancies had been normal; she had had no serious illness; and, part from a blood-pressure of 140/90 mm, Hg, she was perfectly fit when seen on Jan. 23. Her pregnancy progressed, the baby being noted as small for dates, until May 30 when the blood-pressure was 155/100. mm Hg. and the urine contained a trace of albumin. Attempts at induction made on June 1, 4, and 8. On the last occasion it was successful. Contractions began at 3.30 P.M. and labour was quickly established. At 5.15 P.M. the patient was unconscious for one minute, her blood-pressure being 160/100, and it was thought that she might have had an eclamptic fit. Fifteen minutes later she had a small blood-loss per vaginam, the uterus became tender on the right side, and the foetal heart could no longer be heard. Abruptio placenta: was diagnosed. At 5.45 P.M. she was having very strong contractions; her blood-pressure was 175/120, and, as she seemed to be on the verge of a further fit, morphine 15 mg. was given intravenously. A specimen of blood taken at this point clotted. At 5.30 P.M. a fresh stillborn male infant was delivered; the placenta was complete and 10 oz. of blood-clot was passed at the same time. The patient was unconscious. At 6 P.M. 20 oz. of blood-clot was expressed from the uterus, at 6.10 P.M. the blood-pressure was 30/0, and one pint of plasma followed by one pint of blood was infused. At 6.25 P.M. 20 oz. of blood was expressed from the uterus; and, as it failed to clot, 10 ml. calcium gluconate was given and the second bottle of blood changed to triple-strength plasma. At 6.35 P.M., the patient was seen to be cyanosed; she was intubated and given oxygen. At this stage the blood appeared to be clotting. were