330 of our patients, and this depends little upon our terms of service. Royal Infirmary, care
Lindley,
mainly
on us
and
W. GRAHAM HARRIS.
Huddersfield HD3 3EA.
SIR,-While not wishing to accuse you of mischief, I should point out inaccuracies in your review of the new proposed consultants’ contract (Jan. 11, p. 92). Most importantly, under the heading, Existing Contracts, your article says that " the choice would be between taking the whole of the new contract and retaining existing rights and obligations ". This is misleading, for it makes no mention of the very severe qualifications which the Secretary of State put upon the option of retaining the existing contract. In fact, what she produced was effectively a non-choice, because of the undesirable qualifications attached to retention of one’s existing contract under her proposals. In fact, I think that the whole article was very much slanted to her point of view and represents an unjust piece of journalism. It certainly cannot be said to be an objective account. Radcliffe Infirmary, Oxford OX2 6HE.
C. W. BURKE.
EFFECTS OF NEW N.H.S. CONTRACTS ON RECRUITMENT
SIR,-Your editorial (Nov. 9, p. 1123) drew attention to problem of recruiting trainees in some branches of
the
pathology. The review of mangenerally by Professor Parkhouse and Cynthia McLaughlin (Jan. 25, p. 211) did little I believe that the present situation to relieve the gloom. could be exacerbated by new contracts for consultants and junior hospital staff. While it is a just principle that those who work long hours should be paid more than those who work fewer hours, if the pricing of overtime work distorts the present pattern too drastically, it is inevitable in such a materialistic age that specialties with little or no prospect of overtime will be less popular than specialties where overtime could make a large contribution to income. This is particularly important for junior staff, so that " jam tomorrow " awards for consultant practice, in unpopular specialties would be unlikely to make much difference. Unfortunately, the professions’ negotiators seem so obsessed with obtaining justice for part-time consultants and overworked junior staff that the long-term effects on recruitment between the branches of hospital medicine are being totally ignored. Competition in even the most popular specialties seems to be at an all-time low, and as pointed out in your editorial is not much of a deterrent. Since recruitment in some specialties is already difficult,
hospital practice,
such
as
power in the Health Service
small decrease would be very serious. Two basic problems need more attention. First, over the years the delicate financial balance between hospital and general practice is in general changing to favour the latter, in spite of the long training and passing of higher qualifications generally essential for consultant appointment. This has resulted in an alarming number of consultant vacancies especially in the less glamorous specialties. Second, changes in conditions of work, for consultants and even more for junior staff, are not evolving gradually but being rushed through so fast that there is no chance to observe or even consider carefully the long-term effects. Several correspondents have stressed the need for unity in the medical profession. Surely there should be not only a common stand by whole-time and part-time consultants, but also by those practising in all specialties, since the hospital service can be no stronger than its weakest link. I only hope that my conviction that the present changes in
even a
contract will ruin some specialties is due to endogenous depression rather than a premonition of what is to come.
Clinical Chemistry Department, Queen Elizabeth Hospital, Queen Elizabeth Medical
Centre, Edgbaston, Birmingham B15 2TH.
A. M. BOLD.
CLOSURE OF ST. WULSTAN’S HOSPITAL Siram appalled to hear that the Birmingham Regional Health Authority is being advised to consider closing St. Wulstan’s Hospital, the Birmingham regional rehabilitation unit for mentally ill patients (Jan. 25, p. 229). I have been engaged almost continuously since 1966 in research on the problems of rehabilitation and employment of those who have been mentally ill, and I am well aware of the enormous difficulties faced by those who work in this neglected, but increasingly important, field. The majority of psychiatrists are not interested in the rehabilitation and employment side of psychiatry-possibly because training still leans heavily to the clinical side. All the more valuable, therefore, is the specialist pioneering work of the Donal Earlys, Douglas Bennetts, and Roger Morgans of this world, surrounded by the enthusiasm and knowhow of the supporting teams which they have built up over the years. To dissipate a team of this eminence would, I submit, be the grossest folly, and would constitute a grave disservice to patients who often cannot speak for themselves. I hope that all the community health councils in the Birmingham region will rise to the occasion and inform their public of the issues involved. Department of Sociology and Social Administration, University of Southampton, SO9 5NH.
S. N. WANSBROUGH.
IMMUNOLOGICAL APPROACH TO ATHEROSCLEROSIS SiR,—Your initiative in drawing further attention to the immunological approach to atherosclerosisis welcome, but there are certain points in your editorial (Jan. 25, p. 208) which require comment. We were careful to avoid suggesting that circulating immune complexes were the only link between our findings and atherosclerosis, stating that " An immunological mechanism... could operate in several ways, either the formation of toxic complexes, through disturbance of complement, or indirectly by action on platelets or fibrinogen." Even if complexes are formed it is possible that they are rapidly removed from the circulation and so the hypothesis implicating food antibodies is not entirely dependent upon the demonstration of circulating
directly through
complexes. The hypothesis is backed not only by the reference cited but also by extensive evidence recently reviewed.2 It is incorrect to state that the sequence of events begins with immune complexes and ends in the vascular wall. This may happen, but the hypothesis is not confined to this possibility. You suggest that in a prospective trial it may be more practical to screen for circulating immune complexes. For the reasons already given, this may not necessarily be so. Moreover, the technology for estimating these complexes is far from satisfactory. Referring to the final sentence in your editorial, I suggest that an attractive feature of the hypothesis is that, in theory 1. Davies, D. F. J. Atheroscler. Res. 1969, 10, 253. 2. Poston, R. N., Davies, D. F. Atherosclerosis, 1974,
19, 353.
331 at least, prophylaxis is simple. One avoids the food if one possesses the related antibody.
Department of Pathology, West Wales General Hospital, Carmarthen.
antigen
D. F. DAVIES.
MALIGNANT MELANOMA ARISING DE NOVO WITHIN A B.C.G. SCARIFICATION SITE
SIR,-Bacillus Calmette-Guerin (B.c.G.) is being tested in the immunotherapy and immunoprophylaxis of malignant disease. In malignant melanoma B.c.G., applied either by direct intralesional injection or by scarification or intradermal vaccination, has been shown to lead to involution of cutaneous primary or secondary lesions and prolongation of disease-free interval and survival.1-3 I describe here the development of a malignant melanoma within an area of B.C.G. scarification in a patient with cutaneous malignant melanomas. A 53-year-old woman was found in 1963 to have a melanotic lesion on the volar surface of the left wrist. Surgical excision and pathological study revealed the characteristic features of malignant melanoma and the patient then had an epitrochlear and axillary-’ node dissection without evidence of disease. The patient noted no recurrence until December, 1973, when multiple benignappearing melanotic lesions were excised from the inner side of the left arm and the right side of the neck. These lesions were all consistent with superficial spreading malignant melanoma.
Fig. 2-Histopathological section of malignant melanoma, superficial spreading type, demonstrating (a) confinement to dermal level (reduced by half from x80) and (b) typical cellular features with melanin pigment ( x 400). 4 weeks after the fifth B.c.G treatment a 5 mm. melanoma-like lesion developed within the most recent scarification field (fig. 1). Surgical excision was carried out, and histological examination
revealed malignant melanoma of the superficial spreading type witnout infiltration by lymphocytes, plasma cells, or macrophages (fig. 2). Repeat skin testing with recall antigens revealed the same qualitative and quantitative responses as the pre-B.c.G.
therapy
Fig. I-Melanoma arising in a site of B.C.G. scarification applied 4 weeks earlier.
Because of the multiplicity of skin lesions at disparate locations, the patient was referred to the Sidney Farber Cancer Center for further evaluation.
hepatomegaly, and multiple without the specific clinical cutaneous criteria for a diagnosis of malignant melanoma.4 Prophylactic immunotherapy was initiated with B.c.G. (Pasteur Institute type) applied by scarification. Pre-therapy skin testing with a battery of antigens including S.K.S.D., mumps, monilia, and P.P.D. intermediate-strength demonstrated immunological. reactivity to all but monilia antigen. B.C.G. scarification was applied weekly from February to March, 1974, for a total of five applications. Inflammatory reactions at the site-of local application were consistently observed 3-5 days after application. There
was
no
junctional nsevi
1.
2. 3. 4.
adenopathy
were
or
present
Klein, E., Holtermann, O. A. Immunotherapeutic Approaches to the Management of Neoplasms. Natn. Cancer Inst. Monogr. no. 35, 1972, p. 379. Bluming, A. Z., Vogel, C. L., Ziegler, J. L. Ann. intern. Med. 1972, 76, 405. Gutterman, J. U. Lancet, 1973, ii, 1208. Mihm, M. C., Jr., Clark, W. H., Fromm, L. New Engl. J. Med. 1971, 284, 1078.
tests
The mechanism by which s.c.. leads to tumour regression is not precisely known.5 Intralesional B.C.G. may directly alter tumour antigenicity so that the host is capable of tumour recognition and the generation of a tumourspecific immunological reaction. Another theory suggests that the B.C.G. elicits a non-specific local inflammatory response which promotes the availability of immunos competent cells to interact with antigen. The development of a malignant melanoma within an area of B.C.G. scarification runs counter to current explanations for the therapeutic effects of B.C.G. The patient described here was immuno-competent as demonstrated by the cutaneous responses to standard antigens including P.P.D., and in fact an inflammatory reaction was induced by B.C.G. application. A possible explanation for the paradoxical development of melanoma within the B.C.G. site is that the tumour-associated antigen (T.A.A.) could not be recognised by the host despite augmentation with B.c.G. because the antigen was too " weak ". An inadequate immunological inflammatory response was elicited and simultaneously the local vascularity was facilitated by the traumatic scarification procedure promoting implantation of tumour cells. 5.
Bast, R. C., Jr., Zbar, B., Borsos, T., Rapp, H. J. ibid. 1974, 290,
6.
Zbar, B. Tumor Regression Mediated by Mycobacterium Bovis (strain BCG). Natn. Cancer Inst. Monogr. no. 35, 1972, p. 341.
1458.
Lindley,
mainly
on us
and
W. GRAHAM HARRIS.
Huddersfield HD3 3EA.
SIR,-While not wishing to accuse you of mischief, I should point out inaccuracies in your review of the new proposed consultants’ contract (Jan. 11, p. 92). Most importantly, under the heading, Existing Contracts, your article says that " the choice would be between taking the whole of the new contract and retaining existing rights and obligations ". This is misleading, for it makes no mention of the very severe qualifications which the Secretary of State put upon the option of retaining the existing contract. In fact, what she produced was effectively a non-choice, because of the undesirable qualifications attached to retention of one’s existing contract under her proposals. In fact, I think that the whole article was very much slanted to her point of view and represents an unjust piece of journalism. It certainly cannot be said to be an objective account. Radcliffe Infirmary, Oxford OX2 6HE.
C. W. BURKE.
EFFECTS OF NEW N.H.S. CONTRACTS ON RECRUITMENT
SIR,-Your editorial (Nov. 9, p. 1123) drew attention to problem of recruiting trainees in some branches of
the
pathology. The review of mangenerally by Professor Parkhouse and Cynthia McLaughlin (Jan. 25, p. 211) did little I believe that the present situation to relieve the gloom. could be exacerbated by new contracts for consultants and junior hospital staff. While it is a just principle that those who work long hours should be paid more than those who work fewer hours, if the pricing of overtime work distorts the present pattern too drastically, it is inevitable in such a materialistic age that specialties with little or no prospect of overtime will be less popular than specialties where overtime could make a large contribution to income. This is particularly important for junior staff, so that " jam tomorrow " awards for consultant practice, in unpopular specialties would be unlikely to make much difference. Unfortunately, the professions’ negotiators seem so obsessed with obtaining justice for part-time consultants and overworked junior staff that the long-term effects on recruitment between the branches of hospital medicine are being totally ignored. Competition in even the most popular specialties seems to be at an all-time low, and as pointed out in your editorial is not much of a deterrent. Since recruitment in some specialties is already difficult,
hospital practice,
such
as
power in the Health Service
small decrease would be very serious. Two basic problems need more attention. First, over the years the delicate financial balance between hospital and general practice is in general changing to favour the latter, in spite of the long training and passing of higher qualifications generally essential for consultant appointment. This has resulted in an alarming number of consultant vacancies especially in the less glamorous specialties. Second, changes in conditions of work, for consultants and even more for junior staff, are not evolving gradually but being rushed through so fast that there is no chance to observe or even consider carefully the long-term effects. Several correspondents have stressed the need for unity in the medical profession. Surely there should be not only a common stand by whole-time and part-time consultants, but also by those practising in all specialties, since the hospital service can be no stronger than its weakest link. I only hope that my conviction that the present changes in
even a
contract will ruin some specialties is due to endogenous depression rather than a premonition of what is to come.
Clinical Chemistry Department, Queen Elizabeth Hospital, Queen Elizabeth Medical
Centre, Edgbaston, Birmingham B15 2TH.
A. M. BOLD.
CLOSURE OF ST. WULSTAN’S HOSPITAL Siram appalled to hear that the Birmingham Regional Health Authority is being advised to consider closing St. Wulstan’s Hospital, the Birmingham regional rehabilitation unit for mentally ill patients (Jan. 25, p. 229). I have been engaged almost continuously since 1966 in research on the problems of rehabilitation and employment of those who have been mentally ill, and I am well aware of the enormous difficulties faced by those who work in this neglected, but increasingly important, field. The majority of psychiatrists are not interested in the rehabilitation and employment side of psychiatry-possibly because training still leans heavily to the clinical side. All the more valuable, therefore, is the specialist pioneering work of the Donal Earlys, Douglas Bennetts, and Roger Morgans of this world, surrounded by the enthusiasm and knowhow of the supporting teams which they have built up over the years. To dissipate a team of this eminence would, I submit, be the grossest folly, and would constitute a grave disservice to patients who often cannot speak for themselves. I hope that all the community health councils in the Birmingham region will rise to the occasion and inform their public of the issues involved. Department of Sociology and Social Administration, University of Southampton, SO9 5NH.
S. N. WANSBROUGH.
IMMUNOLOGICAL APPROACH TO ATHEROSCLEROSIS SiR,—Your initiative in drawing further attention to the immunological approach to atherosclerosisis welcome, but there are certain points in your editorial (Jan. 25, p. 208) which require comment. We were careful to avoid suggesting that circulating immune complexes were the only link between our findings and atherosclerosis, stating that " An immunological mechanism... could operate in several ways, either the formation of toxic complexes, through disturbance of complement, or indirectly by action on platelets or fibrinogen." Even if complexes are formed it is possible that they are rapidly removed from the circulation and so the hypothesis implicating food antibodies is not entirely dependent upon the demonstration of circulating
directly through
complexes. The hypothesis is backed not only by the reference cited but also by extensive evidence recently reviewed.2 It is incorrect to state that the sequence of events begins with immune complexes and ends in the vascular wall. This may happen, but the hypothesis is not confined to this possibility. You suggest that in a prospective trial it may be more practical to screen for circulating immune complexes. For the reasons already given, this may not necessarily be so. Moreover, the technology for estimating these complexes is far from satisfactory. Referring to the final sentence in your editorial, I suggest that an attractive feature of the hypothesis is that, in theory 1. Davies, D. F. J. Atheroscler. Res. 1969, 10, 253. 2. Poston, R. N., Davies, D. F. Atherosclerosis, 1974,
19, 353.
331 at least, prophylaxis is simple. One avoids the food if one possesses the related antibody.
Department of Pathology, West Wales General Hospital, Carmarthen.
antigen
D. F. DAVIES.
MALIGNANT MELANOMA ARISING DE NOVO WITHIN A B.C.G. SCARIFICATION SITE
SIR,-Bacillus Calmette-Guerin (B.c.G.) is being tested in the immunotherapy and immunoprophylaxis of malignant disease. In malignant melanoma B.c.G., applied either by direct intralesional injection or by scarification or intradermal vaccination, has been shown to lead to involution of cutaneous primary or secondary lesions and prolongation of disease-free interval and survival.1-3 I describe here the development of a malignant melanoma within an area of B.C.G. scarification in a patient with cutaneous malignant melanomas. A 53-year-old woman was found in 1963 to have a melanotic lesion on the volar surface of the left wrist. Surgical excision and pathological study revealed the characteristic features of malignant melanoma and the patient then had an epitrochlear and axillary-’ node dissection without evidence of disease. The patient noted no recurrence until December, 1973, when multiple benignappearing melanotic lesions were excised from the inner side of the left arm and the right side of the neck. These lesions were all consistent with superficial spreading malignant melanoma.
Fig. 2-Histopathological section of malignant melanoma, superficial spreading type, demonstrating (a) confinement to dermal level (reduced by half from x80) and (b) typical cellular features with melanin pigment ( x 400). 4 weeks after the fifth B.c.G treatment a 5 mm. melanoma-like lesion developed within the most recent scarification field (fig. 1). Surgical excision was carried out, and histological examination
revealed malignant melanoma of the superficial spreading type witnout infiltration by lymphocytes, plasma cells, or macrophages (fig. 2). Repeat skin testing with recall antigens revealed the same qualitative and quantitative responses as the pre-B.c.G.
therapy
Fig. I-Melanoma arising in a site of B.C.G. scarification applied 4 weeks earlier.
Because of the multiplicity of skin lesions at disparate locations, the patient was referred to the Sidney Farber Cancer Center for further evaluation.
hepatomegaly, and multiple without the specific clinical cutaneous criteria for a diagnosis of malignant melanoma.4 Prophylactic immunotherapy was initiated with B.c.G. (Pasteur Institute type) applied by scarification. Pre-therapy skin testing with a battery of antigens including S.K.S.D., mumps, monilia, and P.P.D. intermediate-strength demonstrated immunological. reactivity to all but monilia antigen. B.C.G. scarification was applied weekly from February to March, 1974, for a total of five applications. Inflammatory reactions at the site-of local application were consistently observed 3-5 days after application. There
was
no
junctional nsevi
1.
2. 3. 4.
adenopathy
were
or
present
Klein, E., Holtermann, O. A. Immunotherapeutic Approaches to the Management of Neoplasms. Natn. Cancer Inst. Monogr. no. 35, 1972, p. 379. Bluming, A. Z., Vogel, C. L., Ziegler, J. L. Ann. intern. Med. 1972, 76, 405. Gutterman, J. U. Lancet, 1973, ii, 1208. Mihm, M. C., Jr., Clark, W. H., Fromm, L. New Engl. J. Med. 1971, 284, 1078.
tests
The mechanism by which s.c.. leads to tumour regression is not precisely known.5 Intralesional B.C.G. may directly alter tumour antigenicity so that the host is capable of tumour recognition and the generation of a tumourspecific immunological reaction. Another theory suggests that the B.C.G. elicits a non-specific local inflammatory response which promotes the availability of immunos competent cells to interact with antigen. The development of a malignant melanoma within an area of B.C.G. scarification runs counter to current explanations for the therapeutic effects of B.C.G. The patient described here was immuno-competent as demonstrated by the cutaneous responses to standard antigens including P.P.D., and in fact an inflammatory reaction was induced by B.C.G. application. A possible explanation for the paradoxical development of melanoma within the B.C.G. site is that the tumour-associated antigen (T.A.A.) could not be recognised by the host despite augmentation with B.c.G. because the antigen was too " weak ". An inadequate immunological inflammatory response was elicited and simultaneously the local vascularity was facilitated by the traumatic scarification procedure promoting implantation of tumour cells. 5.
Bast, R. C., Jr., Zbar, B., Borsos, T., Rapp, H. J. ibid. 1974, 290,
6.
Zbar, B. Tumor Regression Mediated by Mycobacterium Bovis (strain BCG). Natn. Cancer Inst. Monogr. no. 35, 1972, p. 341.
1458.
