138
AGE (years) 5U-
QU-
)U-
OU-0.)-6
5u-
4u-
>U-
OU’
OYDY
AGE (years)
Fig. 5-Change
in
lung-cancer mortality
in
to
Wales from t9St-M
1969-73.
England and Wales from
1956-60 to 1969-73.
surrounding the tip are an exception since the smoke is diluted with air which enters through these perforations.9 In some cigarettes tobacco smoke has been diluted in this way by as much as 70%. Cigarettes of this type constitute less than 5% of the current U.K. market.’ Since 1955 lung-cancer mortality under the age of sixty in England and Wales has been falling among men but increasing among women (fig. 5). The increased mortality among women is likely to be due to their more recent adoption of the smoking habit, while the reduction in male mortality is probably explained by the reduced tar yield of cigarettes smoked in the absence of much change in their cigarette consumption. In support of this Wynder and his colleagues showed that the smoking of filter-tipped cigarettes by men for ten years or more reduced the risk of lung cancer by about a third’° compared with persons who smoked plain cigarettes. Over the same period C.H.D. mortality in England and Wales has increased in both sexes, more so among women (fig. 6). The increased mortality among women may be partly due to other factors such as the wider use of oral contraceptives, 11but in both sexes some of the increase may be related to cigarette smoking. A reduction in C.H.D. mortality after giving up smoking seems to happen in two or three years,3 so if nicotine were the main constituent of tobacco smoke to affect C.H.D. mortality, it should be possible to detect some reduction in mortality a few years after changing to filter cigarettes. Although there has been a slight reduction in the rate of increase of C.H.D. mortality in men since 1960, this change has been small and certainly much less than the large reduction in the nicotine yield of cigarettes. On the other hand, if CO is the important factor in smoking related to the development of C.H.D., as has been suggested,12 then mortality in men after 1960 would be expected to continue to rise, while that among women should have increased to an even greater extent. These, in fact, are the changes which have occurred. Although it is necessary to be cautious in making inferences about secular changes in national mortality figures, the increase in C.H.D. mortality among men and women is consistent with the hypothesis that a
paper
Fig. 6-Chaage in C.H.D. mortality in England and
gaseous constituent of tobacco smoke, such as CO, is a cause of this disease. The possibility that smoking filter-tipped cigarettes might be more harmful in relation to C.H.D. than smoking plain cigarettes is of considerable importance in view of the large number of filter cigarettes which are now smoked. Further epidemiological investigation is urgently required to determine if the death-rate from C.H.D. among smokers of filter-tipped cigarettes is greater than among smokers of plain cigarettes. REFERENCES
Doll, R., Hill, A. B. Br. med. J. 1964, i, 1399, 1460. Kahn, H. A. Natn. Cancer Inst. Monogr. 1966, 19, 1. 3. Hammond, E. C. in Proceedings of the Second World Conference on Smoking and Health (edited by R. G. Richardson); p. 24. London, 1972. 4. Todd, G. F. (editor) Statistics of Smoking in the United Kingdom. Tobacco Research Council, London, 1972. 5. Wald, N. J., Howard, S., Evans, J. Br. med. J. (in the press). 6. Registrar General’s Statistical Reviews of England and Wales (1956-73): part I, tables, medical. H.M. Stationery Office. 7. Todd, G. F. Changes in Smoking Patterns in the U.K. Tobacco Research Council, London, 1975. 8. Wynder, E. L., Hoffmann, D. J. natn. Cancer Inst. 1972, 48, 1749. 9. Wald, N., Smith, P. G. Lancet, 1973, ii, 907. 10. Wynder, E. L., Mabuchi, K., Beattie, E. J., Jr. J. Am. med. Ass. 1970, 213, 1. 2.
2221. 11.
Mann, J. I., Vessey, M. P., Thorogood, M., Doll, R. Br. med. J. 1975, ii,
12.
Astrup, P. ibid. 1972, iv, 447.
241.
ACUTE EYE DISEASE SECONDARY TO CONTACT-LENS WEAR
Report of a Census MONTAGUE RUBEN
Moorfields Eye Hospital, London WCIV 7AN In a three-month survey of some hospital consultant ophthalmic services, 82 instances of complications of contact-lens wearing were reported. Some of the complications gave rise to discomfort, but in only 5 cases was vision impaired.
Summary
THE last well-documented survey of the incidence of eye disease secondary to contact-lens wear was conducted retrospectively in the U.S.A. in 1960.1 Of a total
139 of 8181 questionairies sent out, 1904 were returned; and 14 cases of serious eye disease resulting in lost eye or vision were reported. The present prospective survey of parts of England and Scotland covered the three months from April to June, 1975. A request letter with a supply of forms (one for each patient) was sent to 170 consultant ophthalmologists in England and Scotland. At the end of the three months, 54 ophthalmologists answered: 16 returned a total of 82 forms; and 21 of these forms indicated that no patients with eye complications from wearing contact lenses had been seen in that period. 38 ophthalmologists returned no forms, but answered to say that no contact-lens patients had sought advice. Patients and Lenses The 82 patients (25 male, 57 female) were aged 6-65 (average 29) years. 42 presented with bilateral lesions and 40
with unilateral lesions. The types of lenses were: hard corneal 71, hard scleral 1, and soft 10 (’Perma’ [permanently worn] 2, ’Soflens’ 1, ’Hydron’ 7). The methods of disinfecting the soft lenses were: heat (boiling saline or pasteurisation) 5, cold (chemical solutions) 2, no method applied 3 (including 2 permanent users). Wearing-times.- The 82 patients had used contact lenses for the following total periods: 0-1 year, 20; 1-3 years, 22; 3-5 years 22, 5+ years, 18. The daily wearing-times were: under 12 hours, 30; over 12 hours, 52, including constant wear by 4 patients (2 with soft and 2 with hard corneal lenses).
Eye Lesions Corneal lesions.-Punctate keratitis 32, erosions and abrasions 18, ulceration 10-ulceration with infection 9, abscess 3. Conjunctiva and lids.-Follicular reaction 8, infection 3. Other lesions.-Herpes 1, iritis 1. Thus, the total of corneal infections in the 82 cases was 13. Of these 13 patients, 6 wore soft lenses.
Causes
of Lesions (58%) of the
47 lesions were attributable to contact lenses and overwear. Foreign body or injury ascribed to contact lenses accounted for 7 (8.5%) and poor fitting for 5 (6%). Another cause was sun exposure.’ In 20 (25%) no cause was stated. Regarding sight, there was no loss in 77 (94%) and some loss in 5 (6%), with only 1 case of severe loss. In 2 (2%) cases the lesions were not due to contact lenses. The proportion of abnormal eyes in the group (e.g., aphakia, keratoconus) was less than 1%. Bilateral lesions were reported in just over half the
patients.
Types of Lenses The majority of patients wore hard corneal lenses, but one-eighth wore soft lenses. In the latter group were 2 Perma (permanent wear) and 8 polyhydroxyethylmethacrylate lenses. Of these 8 patients, only 4 were disinfecting according to manufacturers’ instructions (heat). 1 did not disinfect at all and 3 used cold-solution methods. The apportionment of blame between manufacturer, practitioner, and patient could not be determined ; nor could it be said whether infection was avoidable. But, among the patients with eye infections, the soft-lens wearers were disproportionately high.
Analysis of Lesions Among the 7 patients who had an injury or foreign body in the eye while wearing contact lenses, there was
instance of a severe lesion. 5 patients were stated to have a poor fitting, but this opinion may have been based only on information supplied by the patient. 2 instances of broken lenses in the eye were recorded. 1 patient had a lens dislodged and presumed to be lost, but a lid granuloma resulted. Punctate keratitis was the commonest lesion. It is often found in association with contact-lens wear and it may cause no symptoms.2 Erosions and abrasions with symptoms requiring a hospital visit are treated more seriously, since such lesions can lead to ulceration and scarring of the cornea. This survey discloses a significant proportion of corneal lesions which must be considered as severe, such as ulceration and abscess. Fortunately, with hospital treatment, only 5 patients suffered loss of sight. The conjunctival lesions were mostly follicular and, according to Spring,3 they may represent allergy to degradation of patient’s protein adherent to the lens. It is not possible to indicate from these figures a morbidity factor since the number of patients wearing contact lenses in the population is unknown and cannot be extrapolated from practitioners’ and manufacturers’ figures. An estimate of the number of complications likely to be seen in hospital can, however, be attempted. Thus, the 54 consultants who reported for this census represent about a seventh of all consultant ophthalmologists in England, Scotland, and Wales, so the annual total for the three countries might be about 2300. one
Discussion
figures exist for the number of people wearing contact lenses at any one time-
No accurate
likely
to
be
with vanity as the sole motivation. But, in my view, 50 000 patients may begin wearing contact lenses each year in Britain, basing the estimate on the number of contact-lens practitioners and an average of 3 new patients per week. Over ten years, with a 50% discontinuation-rate, the contact-lens population would be 250 000, which is likely to be an underestimate. In the immediate future the total will increase because of the use of the modern soft and hard lenses which are better tolerated. Evan constant-wear lenses are being made available to
the
public by advertisement, thus increasing the demand
among those who are unable to wear conventional lenses. Thus, more people are being put at risk, and this census attempts to assess the size and severity of the risk. The average patient who has eye troubles because he wears contact lenses is unlikely to seek emergency hospital care or attend outpatients unless he is in pain, losing vision, or having repeated complications. The usual course is for him to return to the contact-lens practitioner. Thus, the number of eye complications reported in this census may be low. Nevertheless, it seems that almost 1 in every 100 contact-lens wearers has problems which require hospital treatment. At least 8% of these patients have evidence of eye infection, sometimes with loss of vision. The figures also indicate that infection could be higher in the group wearing soft lenses. Soft contact lenses, and some large hard lenses, can act as occlusive membranes with deleterious effects on the eye, and such eyes are at risk when infection is introduced. The hazard for normal eyes with soft lenses worn daily and disinfected correctly is slight, judging from trials in my department involving over 200 patients for
140 years. But this point has yet to be demonstrated by controlled clinical trials for constant-wear contact lenses.
two
I thank the ophthalmologists who cooperated in this survey and Dr A. Ross, of the Department of Health and Social Security, for his opinion on the questionary. The expenses of the survey were met by the Godfrey Research Fund, Moorfields Eye Hospital. REFERENCES
Young, C. A., Baldane, J. A., Halbeye, W., Sampson, W., Stone, W. J. Am. med. Ass. 1966, 195, 901. 2. Ruben, M. Contact Lens Practice; p. 257. London, 1975. 1. Dixon, J. M.,
3. Spring, T. Med. J. Aust. 1974, i, 449. 4. Brown, N. A., Lobascher, D. Proc. R. Soc. Med.
1975, 68, 62.
Round the World United States EXPECTED NEW UPROAR
The medical malpractice uproar season is on us again, and in various States legislative assemblies will soon be gathering to grapple, or to refuse, as previously, to grapple with the problems. It appears that, despite much talk, there have not been any substantial changes since the close of the last season, and no new proposals which really deal with the issues have been made. As expected, new premium increase demands have been made by the insurance carriers-up to$45 000 for neurosurgeons in California. The A.M.A.’s view is that the federal Government should keep out, and that it should be left to the States to deal with the problems, and at a recent meeting the Association turned down a motion that all physicians should refuse to buy malpractice insurance coverage and should practise without it. But faced by such exorbitant premium increases this is just what many are doing, and it’s a good indication of the pressure there is on members of the medical profession here. No help is expected from the legal profession, which has been steadily and successfully undermining and diminishing the benefits of no-fault auto insurance, while there has been much talk of binding arbitration, though no-one quite knows how to make it binding, and no-one has really come out for nofault medical malpractice legislation. It is, of course, the public at large who ultimately pay the price; the ever higher premiums simply swell the medical costs. This is perhaps most evident in those institutions-medical schools and hospitalswhich have provided coverage for their medical staffs as a "fringe benefit". This is increasingly turning out to be a crippling load, but also one not easily shaken off. Internal policing and auditing of medical work in many such centres has gone just about as far as it can go, and is indeed taking up an exorbitant amount of time. Overall, of course, and not to be forgotten in this Bicentennial Year, is the question of the constitutional rights guaranteed in our written constitution. It is still being argued whether there is a constitutional right to sue, and indeed unless this is ruled out it’s difficult to see any complete solution
to our
BAN THE BAN
S!R,—At a time when the representatives of the profession have given their united opinion in opposition to the Government’s proposals on private practice, it is good for our conscience that you should present the contrary view (Jan. 3, p. 23). However, the concern you express that the present action of consultants will cause inconvenience, discomfort, distress, and even danger to some patients ignores the threat to other patients that lies behind the Government’s proposals. Hospital consultants have, for eighteen months, been under increasing pressure to withdraw their services from those citizens, and foreigners, who have hitherto sought to escape inconvenience, discomfort, distress, and even danger by entering into a private and personal relationship with their doctors. Private patients are no less sick and no less in need of sympathy and help than those whose personal needs have successfully been met by the N.H.S. It is our privilege and duty to serve all those who seek our help to the full extent of our ability. The proposals that we should limit our care to those eligible under the N.H.S, is entirely unethical and arises only from political considerations. There is a most important principle at stake here, and one which your readers should be invited to recognise. Doctors are not obliged to serve uncritically under a potitical directive that is in conflict with their moral judgement. The extreme case of the psychiatrists in the Soviet Union comes to mind. How, other than by our present action, are we, Sir, to influence a Government that seems intent on pushing through their policy despite unanimous reasoned opposition? St Mary’s Hospital, Praed Street, London W2 1NY.
A.
J. HARROLD
Sirwelcomed your unqualified condemnation of actions by doctors directed against their patients (Dec. 27, p. 1293). The year just ended has been a tragic one for the medical profession in the United Kingdom. It has responded to provocation by swelling the ranks of those who in recent years have exercised power without regard for the rights of others, not excluding the helpless. Further it has committed the folly of trading some of its inestimable capital of idealism and goodwill for cash in a rapidly depreciating currency. (It concerns me not at all whether it was seniors, juniors, or both who perpetrated this folly, for as a profession we fall or rise together.) Just how much has been lost may be measured by posing the question-which group in 1976 will have the moral authority to challenge an action by a union in the Health Service (or come to that in a private hospital) which increases suffering or endangers life? Until 1975 it could have been the medical profession but, alas, not now, and not for many a year to come. The question for 1976 is whether these actions will be seen as an aberration totally out of character with our heritage or whether they will become assimilated as the normal negotiating practice of a sadly diminished profession. South
(Academic) Block, Southampton General Hospital, Southampton SO9 4XY.
E. D. ACHESON
problems.
Another question is whether the federal Government can stay out of the matter while it remains a major source of medical funding. We have heard little of any national health insurance schemes lately, but the recession is increasingly demonstrating the need for a scheme of some sort, and there is a presidential election coming up which may well provide an opportunity. It’s even more difficult than ever to imagine what might happen, but that a lot of noise will be generated is a safe guess.
Letters to the Editor
seems to muddle the principles behind profession’s disaffection with the Government, and the practical problems of running the N.H.S. The profession fean that legislation, even as mediated by Lord Goodman, will destroy professionalism in medicine with all that it implies, including the internal self-regulating mechanisms that maintain its high standards of service to the patient and excellence in the
SiR,—Your editorial
the
world for research. It is no more amazing that
we
have been
provoked to take
AGE (years) 5U-
QU-
)U-
OU-0.)-6
5u-
4u-
>U-
OU’
OYDY
AGE (years)
Fig. 5-Change
in
lung-cancer mortality
in
to
Wales from t9St-M
1969-73.
England and Wales from
1956-60 to 1969-73.
surrounding the tip are an exception since the smoke is diluted with air which enters through these perforations.9 In some cigarettes tobacco smoke has been diluted in this way by as much as 70%. Cigarettes of this type constitute less than 5% of the current U.K. market.’ Since 1955 lung-cancer mortality under the age of sixty in England and Wales has been falling among men but increasing among women (fig. 5). The increased mortality among women is likely to be due to their more recent adoption of the smoking habit, while the reduction in male mortality is probably explained by the reduced tar yield of cigarettes smoked in the absence of much change in their cigarette consumption. In support of this Wynder and his colleagues showed that the smoking of filter-tipped cigarettes by men for ten years or more reduced the risk of lung cancer by about a third’° compared with persons who smoked plain cigarettes. Over the same period C.H.D. mortality in England and Wales has increased in both sexes, more so among women (fig. 6). The increased mortality among women may be partly due to other factors such as the wider use of oral contraceptives, 11but in both sexes some of the increase may be related to cigarette smoking. A reduction in C.H.D. mortality after giving up smoking seems to happen in two or three years,3 so if nicotine were the main constituent of tobacco smoke to affect C.H.D. mortality, it should be possible to detect some reduction in mortality a few years after changing to filter cigarettes. Although there has been a slight reduction in the rate of increase of C.H.D. mortality in men since 1960, this change has been small and certainly much less than the large reduction in the nicotine yield of cigarettes. On the other hand, if CO is the important factor in smoking related to the development of C.H.D., as has been suggested,12 then mortality in men after 1960 would be expected to continue to rise, while that among women should have increased to an even greater extent. These, in fact, are the changes which have occurred. Although it is necessary to be cautious in making inferences about secular changes in national mortality figures, the increase in C.H.D. mortality among men and women is consistent with the hypothesis that a
paper
Fig. 6-Chaage in C.H.D. mortality in England and
gaseous constituent of tobacco smoke, such as CO, is a cause of this disease. The possibility that smoking filter-tipped cigarettes might be more harmful in relation to C.H.D. than smoking plain cigarettes is of considerable importance in view of the large number of filter cigarettes which are now smoked. Further epidemiological investigation is urgently required to determine if the death-rate from C.H.D. among smokers of filter-tipped cigarettes is greater than among smokers of plain cigarettes. REFERENCES
Doll, R., Hill, A. B. Br. med. J. 1964, i, 1399, 1460. Kahn, H. A. Natn. Cancer Inst. Monogr. 1966, 19, 1. 3. Hammond, E. C. in Proceedings of the Second World Conference on Smoking and Health (edited by R. G. Richardson); p. 24. London, 1972. 4. Todd, G. F. (editor) Statistics of Smoking in the United Kingdom. Tobacco Research Council, London, 1972. 5. Wald, N. J., Howard, S., Evans, J. Br. med. J. (in the press). 6. Registrar General’s Statistical Reviews of England and Wales (1956-73): part I, tables, medical. H.M. Stationery Office. 7. Todd, G. F. Changes in Smoking Patterns in the U.K. Tobacco Research Council, London, 1975. 8. Wynder, E. L., Hoffmann, D. J. natn. Cancer Inst. 1972, 48, 1749. 9. Wald, N., Smith, P. G. Lancet, 1973, ii, 907. 10. Wynder, E. L., Mabuchi, K., Beattie, E. J., Jr. J. Am. med. Ass. 1970, 213, 1. 2.
2221. 11.
Mann, J. I., Vessey, M. P., Thorogood, M., Doll, R. Br. med. J. 1975, ii,
12.
Astrup, P. ibid. 1972, iv, 447.
241.
ACUTE EYE DISEASE SECONDARY TO CONTACT-LENS WEAR
Report of a Census MONTAGUE RUBEN
Moorfields Eye Hospital, London WCIV 7AN In a three-month survey of some hospital consultant ophthalmic services, 82 instances of complications of contact-lens wearing were reported. Some of the complications gave rise to discomfort, but in only 5 cases was vision impaired.
Summary
THE last well-documented survey of the incidence of eye disease secondary to contact-lens wear was conducted retrospectively in the U.S.A. in 1960.1 Of a total
139 of 8181 questionairies sent out, 1904 were returned; and 14 cases of serious eye disease resulting in lost eye or vision were reported. The present prospective survey of parts of England and Scotland covered the three months from April to June, 1975. A request letter with a supply of forms (one for each patient) was sent to 170 consultant ophthalmologists in England and Scotland. At the end of the three months, 54 ophthalmologists answered: 16 returned a total of 82 forms; and 21 of these forms indicated that no patients with eye complications from wearing contact lenses had been seen in that period. 38 ophthalmologists returned no forms, but answered to say that no contact-lens patients had sought advice. Patients and Lenses The 82 patients (25 male, 57 female) were aged 6-65 (average 29) years. 42 presented with bilateral lesions and 40
with unilateral lesions. The types of lenses were: hard corneal 71, hard scleral 1, and soft 10 (’Perma’ [permanently worn] 2, ’Soflens’ 1, ’Hydron’ 7). The methods of disinfecting the soft lenses were: heat (boiling saline or pasteurisation) 5, cold (chemical solutions) 2, no method applied 3 (including 2 permanent users). Wearing-times.- The 82 patients had used contact lenses for the following total periods: 0-1 year, 20; 1-3 years, 22; 3-5 years 22, 5+ years, 18. The daily wearing-times were: under 12 hours, 30; over 12 hours, 52, including constant wear by 4 patients (2 with soft and 2 with hard corneal lenses).
Eye Lesions Corneal lesions.-Punctate keratitis 32, erosions and abrasions 18, ulceration 10-ulceration with infection 9, abscess 3. Conjunctiva and lids.-Follicular reaction 8, infection 3. Other lesions.-Herpes 1, iritis 1. Thus, the total of corneal infections in the 82 cases was 13. Of these 13 patients, 6 wore soft lenses.
Causes
of Lesions (58%) of the
47 lesions were attributable to contact lenses and overwear. Foreign body or injury ascribed to contact lenses accounted for 7 (8.5%) and poor fitting for 5 (6%). Another cause was sun exposure.’ In 20 (25%) no cause was stated. Regarding sight, there was no loss in 77 (94%) and some loss in 5 (6%), with only 1 case of severe loss. In 2 (2%) cases the lesions were not due to contact lenses. The proportion of abnormal eyes in the group (e.g., aphakia, keratoconus) was less than 1%. Bilateral lesions were reported in just over half the
patients.
Types of Lenses The majority of patients wore hard corneal lenses, but one-eighth wore soft lenses. In the latter group were 2 Perma (permanent wear) and 8 polyhydroxyethylmethacrylate lenses. Of these 8 patients, only 4 were disinfecting according to manufacturers’ instructions (heat). 1 did not disinfect at all and 3 used cold-solution methods. The apportionment of blame between manufacturer, practitioner, and patient could not be determined ; nor could it be said whether infection was avoidable. But, among the patients with eye infections, the soft-lens wearers were disproportionately high.
Analysis of Lesions Among the 7 patients who had an injury or foreign body in the eye while wearing contact lenses, there was
instance of a severe lesion. 5 patients were stated to have a poor fitting, but this opinion may have been based only on information supplied by the patient. 2 instances of broken lenses in the eye were recorded. 1 patient had a lens dislodged and presumed to be lost, but a lid granuloma resulted. Punctate keratitis was the commonest lesion. It is often found in association with contact-lens wear and it may cause no symptoms.2 Erosions and abrasions with symptoms requiring a hospital visit are treated more seriously, since such lesions can lead to ulceration and scarring of the cornea. This survey discloses a significant proportion of corneal lesions which must be considered as severe, such as ulceration and abscess. Fortunately, with hospital treatment, only 5 patients suffered loss of sight. The conjunctival lesions were mostly follicular and, according to Spring,3 they may represent allergy to degradation of patient’s protein adherent to the lens. It is not possible to indicate from these figures a morbidity factor since the number of patients wearing contact lenses in the population is unknown and cannot be extrapolated from practitioners’ and manufacturers’ figures. An estimate of the number of complications likely to be seen in hospital can, however, be attempted. Thus, the 54 consultants who reported for this census represent about a seventh of all consultant ophthalmologists in England, Scotland, and Wales, so the annual total for the three countries might be about 2300. one
Discussion
figures exist for the number of people wearing contact lenses at any one time-
No accurate
likely
to
be
with vanity as the sole motivation. But, in my view, 50 000 patients may begin wearing contact lenses each year in Britain, basing the estimate on the number of contact-lens practitioners and an average of 3 new patients per week. Over ten years, with a 50% discontinuation-rate, the contact-lens population would be 250 000, which is likely to be an underestimate. In the immediate future the total will increase because of the use of the modern soft and hard lenses which are better tolerated. Evan constant-wear lenses are being made available to
the
public by advertisement, thus increasing the demand
among those who are unable to wear conventional lenses. Thus, more people are being put at risk, and this census attempts to assess the size and severity of the risk. The average patient who has eye troubles because he wears contact lenses is unlikely to seek emergency hospital care or attend outpatients unless he is in pain, losing vision, or having repeated complications. The usual course is for him to return to the contact-lens practitioner. Thus, the number of eye complications reported in this census may be low. Nevertheless, it seems that almost 1 in every 100 contact-lens wearers has problems which require hospital treatment. At least 8% of these patients have evidence of eye infection, sometimes with loss of vision. The figures also indicate that infection could be higher in the group wearing soft lenses. Soft contact lenses, and some large hard lenses, can act as occlusive membranes with deleterious effects on the eye, and such eyes are at risk when infection is introduced. The hazard for normal eyes with soft lenses worn daily and disinfected correctly is slight, judging from trials in my department involving over 200 patients for
140 years. But this point has yet to be demonstrated by controlled clinical trials for constant-wear contact lenses.
two
I thank the ophthalmologists who cooperated in this survey and Dr A. Ross, of the Department of Health and Social Security, for his opinion on the questionary. The expenses of the survey were met by the Godfrey Research Fund, Moorfields Eye Hospital. REFERENCES
Young, C. A., Baldane, J. A., Halbeye, W., Sampson, W., Stone, W. J. Am. med. Ass. 1966, 195, 901. 2. Ruben, M. Contact Lens Practice; p. 257. London, 1975. 1. Dixon, J. M.,
3. Spring, T. Med. J. Aust. 1974, i, 449. 4. Brown, N. A., Lobascher, D. Proc. R. Soc. Med.
1975, 68, 62.
Round the World United States EXPECTED NEW UPROAR
The medical malpractice uproar season is on us again, and in various States legislative assemblies will soon be gathering to grapple, or to refuse, as previously, to grapple with the problems. It appears that, despite much talk, there have not been any substantial changes since the close of the last season, and no new proposals which really deal with the issues have been made. As expected, new premium increase demands have been made by the insurance carriers-up to$45 000 for neurosurgeons in California. The A.M.A.’s view is that the federal Government should keep out, and that it should be left to the States to deal with the problems, and at a recent meeting the Association turned down a motion that all physicians should refuse to buy malpractice insurance coverage and should practise without it. But faced by such exorbitant premium increases this is just what many are doing, and it’s a good indication of the pressure there is on members of the medical profession here. No help is expected from the legal profession, which has been steadily and successfully undermining and diminishing the benefits of no-fault auto insurance, while there has been much talk of binding arbitration, though no-one quite knows how to make it binding, and no-one has really come out for nofault medical malpractice legislation. It is, of course, the public at large who ultimately pay the price; the ever higher premiums simply swell the medical costs. This is perhaps most evident in those institutions-medical schools and hospitalswhich have provided coverage for their medical staffs as a "fringe benefit". This is increasingly turning out to be a crippling load, but also one not easily shaken off. Internal policing and auditing of medical work in many such centres has gone just about as far as it can go, and is indeed taking up an exorbitant amount of time. Overall, of course, and not to be forgotten in this Bicentennial Year, is the question of the constitutional rights guaranteed in our written constitution. It is still being argued whether there is a constitutional right to sue, and indeed unless this is ruled out it’s difficult to see any complete solution
to our
BAN THE BAN
S!R,—At a time when the representatives of the profession have given their united opinion in opposition to the Government’s proposals on private practice, it is good for our conscience that you should present the contrary view (Jan. 3, p. 23). However, the concern you express that the present action of consultants will cause inconvenience, discomfort, distress, and even danger to some patients ignores the threat to other patients that lies behind the Government’s proposals. Hospital consultants have, for eighteen months, been under increasing pressure to withdraw their services from those citizens, and foreigners, who have hitherto sought to escape inconvenience, discomfort, distress, and even danger by entering into a private and personal relationship with their doctors. Private patients are no less sick and no less in need of sympathy and help than those whose personal needs have successfully been met by the N.H.S. It is our privilege and duty to serve all those who seek our help to the full extent of our ability. The proposals that we should limit our care to those eligible under the N.H.S, is entirely unethical and arises only from political considerations. There is a most important principle at stake here, and one which your readers should be invited to recognise. Doctors are not obliged to serve uncritically under a potitical directive that is in conflict with their moral judgement. The extreme case of the psychiatrists in the Soviet Union comes to mind. How, other than by our present action, are we, Sir, to influence a Government that seems intent on pushing through their policy despite unanimous reasoned opposition? St Mary’s Hospital, Praed Street, London W2 1NY.
A.
J. HARROLD
Sirwelcomed your unqualified condemnation of actions by doctors directed against their patients (Dec. 27, p. 1293). The year just ended has been a tragic one for the medical profession in the United Kingdom. It has responded to provocation by swelling the ranks of those who in recent years have exercised power without regard for the rights of others, not excluding the helpless. Further it has committed the folly of trading some of its inestimable capital of idealism and goodwill for cash in a rapidly depreciating currency. (It concerns me not at all whether it was seniors, juniors, or both who perpetrated this folly, for as a profession we fall or rise together.) Just how much has been lost may be measured by posing the question-which group in 1976 will have the moral authority to challenge an action by a union in the Health Service (or come to that in a private hospital) which increases suffering or endangers life? Until 1975 it could have been the medical profession but, alas, not now, and not for many a year to come. The question for 1976 is whether these actions will be seen as an aberration totally out of character with our heritage or whether they will become assimilated as the normal negotiating practice of a sadly diminished profession. South
(Academic) Block, Southampton General Hospital, Southampton SO9 4XY.
E. D. ACHESON
problems.
Another question is whether the federal Government can stay out of the matter while it remains a major source of medical funding. We have heard little of any national health insurance schemes lately, but the recession is increasingly demonstrating the need for a scheme of some sort, and there is a presidential election coming up which may well provide an opportunity. It’s even more difficult than ever to imagine what might happen, but that a lot of noise will be generated is a safe guess.
Letters to the Editor
seems to muddle the principles behind profession’s disaffection with the Government, and the practical problems of running the N.H.S. The profession fean that legislation, even as mediated by Lord Goodman, will destroy professionalism in medicine with all that it implies, including the internal self-regulating mechanisms that maintain its high standards of service to the patient and excellence in the
SiR,—Your editorial
the
world for research. It is no more amazing that
we
have been
provoked to take
