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THE THREE FACES OF JOAN
1443 EPIDEMICS OF TYPHOID FEVER
SIR,-In your discussion of the occasional contamination of tinned foods by the entry of dirty cooling water through leaky seams (June’ 13) you state the orthodox view that these accidents can be prevented if water of drinking standard be used for cooling sterilised tins. This will usually prevent typhoid bacilli getting into tins, but it does not prevent an occasional tin becoming contaminated with enterotoxigenic Staphylococcus aureus; even the products of the most careful manufacturer may occasionally be rendered toxic in this way. The clean water gets contaminated by a person carrying Staph. aureus on his or her skin. I suggest that the purified water used for cooling sterilised tins of food should be deliberately contaminated with bacteria which will spoil the food and " blow " the tin if they get inside. A proteolytic anaerobic organism (such as Clostridium sporogenes) added to the cooling water as a spore suspension, in known quantities, should ensure that leaky tins are made unfit to eat and therefore safe. The spores could be prepared from a readily recognisable biochemical mutant strain of clostridium, and might be distributed from some central source; in this way all manufacturers could use the same strain and all laboratories could easily recognise it. Perhaps by such means the safetv of tinned foods could be ensured. Public Health Laboratory, Royal Hampshire County Hospital, Winchester.
M. H. HUGHES.
SEIZURES IN PSYCHOTIC CHILDREN SIR,-The work of Miss Seller and Dr. Gold (June
is
encouraging
and
13) probably of fundamental importance.
in Britain and other countries have for psychotic children and adults with " convulsive " E.E.G.S form a separate group. These are often distinguishable by psychiatric examination, and sometimes by minor neurological abnormalities, or rarely show a clinical picture indistinguishable from a formal diagnostic category. The retrospective study on adults by Treffert1 showed that this group is distinguishable at a significant level. Fish2 " regards many psychotics as temporal lobe epileptics who do not have fits ". I had regarded the condition as a variant of epilepsy with all its implications. Several
some
psychiatrists
years felt that
some
It is encouraging to learn from the humoral studies of Seller and Gold that a pathogenic substance may be the cause of this disorder of cerebral physiology. Parkside Hospital, Macclesfield.
R. H. BOARDMAN
THE THREE FACES OF JOAN
SIR,-We find it interesting that Dr. Shirlaw and Dr. Longmore (June 13) should rise so rapidly to Dr. Clyne’s bait. It seemed to us that the point was that, after reaching his clinical diagnosis and prescribing pharmacological treatment, any doctor attending Joan would also have to face the problem of her husband’s absence, even if the action decided upon was negative. Many of us would have taken the decision in ignorance of the role we were playing in Joan’s recurrent fantasies. Without the extra information so ably obtained by Dr. Clyne, the doctor would be acting instinctively and not scientifically. Blind action is surely to be abhorred in any form of medical treatment.
Dr. Clyne’s article seems to us a vivid demonstration of what we have called the special function of the general practitioner (Feb. 22)-namely, to learn the language of the communications of our patients. The effectiveness of the doctor’s certificate in this example may be magnified by the peculiarly 1. Treffert D. A. Amer. J. Psychiat. 1964, 128, 8. 2. Fish, F. Personal communication.
rigid organisation of the Army, but every general practitioner wields similar sanctions many times every day in his ordinary work, usually with little knowledge of their ultimate effect in the patient’s real and fantasy life. Blind sympathy is as dangerous as blind anger. As Dr. Shirlaw implies, we can only compute what we know; and to practise medicine we must be prepared to elicit this further information. KEVIN BROWNE PAUL FREELING.
Hillingdon, Middlesex.
CHRONIC BRONCHITIS AND RADIOTHERAPY OF THE LUNG
SIR,-Contrary to what has been widely believed, the University College Hospital group1 find no evidence that chronic bronchitis renders a patient with carcinoma of the bronchus more liable to lung fibrosis after radiotherapy, and they conclude their very interesting paper by saying: " Patients should not be denied treatment, nor should the planned dose be reduced, because they also have chronic bronchitis." They do not mention how much lung should be exposed to radiation-a problem that is inevitably bound up with the question of how much lung fibrosis the severe chronic bronchitic can tolerate. It is not always appreciated outside radiotherapy departthat the radiotherapist can deliver any given dose of radiation to as large or as small a portion of the lung and mediastinum as he pleases. Since he can never be sure exactly how far the malignant process has spread, some sort of a balance has to be struck between the advantage of including all possible lines of local spread and the disadvantage of exposing a patient to the risk of more lung fibrosis than he can be expected to tolerate. It would be of great interest to know something of the policy adopted in this series with regard to this point. It is stated that " there is no significant difference between any of the groups [i.e., the non-bronchitic, the mild bronchitic, and the severe bronchitic] in the average dose, or in the average dose per treatment, or in the length of the course of treatment". Is there perhaps a difference in the amount of lung that was ments
to radiation ? Whether or not lung-carcinoma patients with gross chronic bronchitis are more liable to develop lung fibrosis after radiotherapy, it is difficult to see how their ability to tolerate it could possibly be anything but impaired. The smaller the patient’s respiratory reserve, the nearer he must be to permanent and disabling shortness of breath, should radiation fibrosis occur and still further reduce (as it must) the amount of available functioning lung. The patient who suffers more radiation lung fibrosis than he can tolerate is in much the same position as the patient who has more lung resected by the thoracic surgeon than he can tolerate. For the rest of his days he may feel, perhaps with some justification, that the treatment he was given did him more harm than good.
subjected
Possibly the authors considered it
unnecessary to
com-
this aspect, but it would be unfortunate if the impression was given that severe lung fibrosis can be as well tolerated by the severe bronchitic as by the patient with good lung function, or that there is no need for the radiotherapist to even consider this point when deciding how much lung to radiate. ment on
Royal Infirmary, Glasgow, C4.
T. B. BREWIN
*** Dr. Brewin’s letter has been shown to Dr. Gillam and his colleagues, whose reply follows.-ED. L. SIR,-In all
treated in this hospital, it is the aim lung free of tumour.
cases
to
avoid
1.
Gillam, P. M. S., Heaf, P. J. D., Hoffbrand, 1964, i, 1245.
irradiating
B.
I., Hilton, G. Lancet
SIR,-In your discussion of the occasional contamination of tinned foods by the entry of dirty cooling water through leaky seams (June’ 13) you state the orthodox view that these accidents can be prevented if water of drinking standard be used for cooling sterilised tins. This will usually prevent typhoid bacilli getting into tins, but it does not prevent an occasional tin becoming contaminated with enterotoxigenic Staphylococcus aureus; even the products of the most careful manufacturer may occasionally be rendered toxic in this way. The clean water gets contaminated by a person carrying Staph. aureus on his or her skin. I suggest that the purified water used for cooling sterilised tins of food should be deliberately contaminated with bacteria which will spoil the food and " blow " the tin if they get inside. A proteolytic anaerobic organism (such as Clostridium sporogenes) added to the cooling water as a spore suspension, in known quantities, should ensure that leaky tins are made unfit to eat and therefore safe. The spores could be prepared from a readily recognisable biochemical mutant strain of clostridium, and might be distributed from some central source; in this way all manufacturers could use the same strain and all laboratories could easily recognise it. Perhaps by such means the safetv of tinned foods could be ensured. Public Health Laboratory, Royal Hampshire County Hospital, Winchester.
M. H. HUGHES.
SEIZURES IN PSYCHOTIC CHILDREN SIR,-The work of Miss Seller and Dr. Gold (June
is
encouraging
and
13) probably of fundamental importance.
in Britain and other countries have for psychotic children and adults with " convulsive " E.E.G.S form a separate group. These are often distinguishable by psychiatric examination, and sometimes by minor neurological abnormalities, or rarely show a clinical picture indistinguishable from a formal diagnostic category. The retrospective study on adults by Treffert1 showed that this group is distinguishable at a significant level. Fish2 " regards many psychotics as temporal lobe epileptics who do not have fits ". I had regarded the condition as a variant of epilepsy with all its implications. Several
some
psychiatrists
years felt that
some
It is encouraging to learn from the humoral studies of Seller and Gold that a pathogenic substance may be the cause of this disorder of cerebral physiology. Parkside Hospital, Macclesfield.
R. H. BOARDMAN
THE THREE FACES OF JOAN
SIR,-We find it interesting that Dr. Shirlaw and Dr. Longmore (June 13) should rise so rapidly to Dr. Clyne’s bait. It seemed to us that the point was that, after reaching his clinical diagnosis and prescribing pharmacological treatment, any doctor attending Joan would also have to face the problem of her husband’s absence, even if the action decided upon was negative. Many of us would have taken the decision in ignorance of the role we were playing in Joan’s recurrent fantasies. Without the extra information so ably obtained by Dr. Clyne, the doctor would be acting instinctively and not scientifically. Blind action is surely to be abhorred in any form of medical treatment.
Dr. Clyne’s article seems to us a vivid demonstration of what we have called the special function of the general practitioner (Feb. 22)-namely, to learn the language of the communications of our patients. The effectiveness of the doctor’s certificate in this example may be magnified by the peculiarly 1. Treffert D. A. Amer. J. Psychiat. 1964, 128, 8. 2. Fish, F. Personal communication.
rigid organisation of the Army, but every general practitioner wields similar sanctions many times every day in his ordinary work, usually with little knowledge of their ultimate effect in the patient’s real and fantasy life. Blind sympathy is as dangerous as blind anger. As Dr. Shirlaw implies, we can only compute what we know; and to practise medicine we must be prepared to elicit this further information. KEVIN BROWNE PAUL FREELING.
Hillingdon, Middlesex.
CHRONIC BRONCHITIS AND RADIOTHERAPY OF THE LUNG
SIR,-Contrary to what has been widely believed, the University College Hospital group1 find no evidence that chronic bronchitis renders a patient with carcinoma of the bronchus more liable to lung fibrosis after radiotherapy, and they conclude their very interesting paper by saying: " Patients should not be denied treatment, nor should the planned dose be reduced, because they also have chronic bronchitis." They do not mention how much lung should be exposed to radiation-a problem that is inevitably bound up with the question of how much lung fibrosis the severe chronic bronchitic can tolerate. It is not always appreciated outside radiotherapy departthat the radiotherapist can deliver any given dose of radiation to as large or as small a portion of the lung and mediastinum as he pleases. Since he can never be sure exactly how far the malignant process has spread, some sort of a balance has to be struck between the advantage of including all possible lines of local spread and the disadvantage of exposing a patient to the risk of more lung fibrosis than he can be expected to tolerate. It would be of great interest to know something of the policy adopted in this series with regard to this point. It is stated that " there is no significant difference between any of the groups [i.e., the non-bronchitic, the mild bronchitic, and the severe bronchitic] in the average dose, or in the average dose per treatment, or in the length of the course of treatment". Is there perhaps a difference in the amount of lung that was ments
to radiation ? Whether or not lung-carcinoma patients with gross chronic bronchitis are more liable to develop lung fibrosis after radiotherapy, it is difficult to see how their ability to tolerate it could possibly be anything but impaired. The smaller the patient’s respiratory reserve, the nearer he must be to permanent and disabling shortness of breath, should radiation fibrosis occur and still further reduce (as it must) the amount of available functioning lung. The patient who suffers more radiation lung fibrosis than he can tolerate is in much the same position as the patient who has more lung resected by the thoracic surgeon than he can tolerate. For the rest of his days he may feel, perhaps with some justification, that the treatment he was given did him more harm than good.
subjected
Possibly the authors considered it
unnecessary to
com-
this aspect, but it would be unfortunate if the impression was given that severe lung fibrosis can be as well tolerated by the severe bronchitic as by the patient with good lung function, or that there is no need for the radiotherapist to even consider this point when deciding how much lung to radiate. ment on
Royal Infirmary, Glasgow, C4.
T. B. BREWIN
*** Dr. Brewin’s letter has been shown to Dr. Gillam and his colleagues, whose reply follows.-ED. L. SIR,-In all
treated in this hospital, it is the aim lung free of tumour.
cases
to
avoid
1.
Gillam, P. M. S., Heaf, P. J. D., Hoffbrand, 1964, i, 1245.
irradiating
B.
I., Hilton, G. Lancet