1235
damaged by the activities of Government: Labour said the same thing when the Conservatives were in. But neither side would nowadays describe the morale of the service in purely party-political terms. However much the Conservatives may condemn Mrs Castle’s policies or personal style, the chief engine of low morale is undoubtedly the economic policies dictated by our present plight, of which any D.H.S.S. Minister must be, to a great extent, a helpless prisoner. It is a sad business to look back across two years or so of this column to the bright days of early 1973, when it opened with an account of one of Mr Barber’s budgets. That great year of bounty, 1972, when the Government was anxiously seeking ways to push up spending, was already behind us, though the shadow of the December, 1973, cuts was still far away. It was, even so, still a time when a Chancellor could happily lift taxation on such tools of national self-indulgence whereas the as chocolate biscuits and ice-cream; two years since have been a time of declining aspirations and a service driven on to the defensive-with the real threat that once the Common Market referendum is out of the way Mr Healey may have to prune public spending still further. Just as the Conservatives were long reluctant to curb the dash for growth on which they embarked in 1972, despite the accumulating warning signs that we were in trouble, so the Labour Government has been reluctant to accept that the Social Contract as now constituted has been an inadequate force to deal with rising wage demands. But the crisis in public expenditure has set some thoughtful M.p.s on the left of the Party, normally no friends to incomes policy, thinking much more sombrely about the implications of our present economic drift than they did before. Faced with a further cutback on schools, homes, and hospitals, they are beginning to consider whether they too should not be out on the streets publicly warning, as Mr Healey has already done, that there must now be a straight choice between satisfying the personal or the public needs of society. They know that some of their supporters will deeply suspect them if they do. But they also know what political consequences are likely to occur as the effects on the ground of curbs on public spending become clearer and deeper. For, however much Ministers may argue that a new and fitter service may emerge from this period of austerity, the queue of those presenting their needs for urgent attention shows no signs of slackening. In a well-organised all-party exercise this week, for example, M.P.s tabled nearly 200 questions designed to elicit the record of recent public spending on the mentally ill and mentally handicapped, in order to establish a national picture of provision and to document the regional inequalities within it. Cases like South Ockendon can of course occur in times ofprosperity too; but cuts in public spending must make them more likely rather than less. On which glum note I must gather up my typewriter and steal quietly out of this column, leaving behind me a last and heartfelt word of thanks to The Lancet for its hospitality over the past two years and to those who from time to time have written offering blame,
agreement,
or
information. DAVID MCKIE.
Letters to the Editor MEDICAL CARE OF CHILDHOOD LEUKÆMIA SIR,-It is disappointing to note that Dr McCarthy (May 17, p. 1128) has found that " many clinicians ... consider that the treatment of leukaemia is moving towards a semiroutine regimen, especially for A.L.L. [acute lymphatic leukaemiaJ, and ... can be as adequately given in a districthospital setting as in a special centre ". This attitude argues a quite unwarranted complacency, engendered by the recent encouraging advances in the treatment of this condition. Even the most optimistic and enthusiastic experts would not claim that more than half of all children with A.L.L. can be cured by current treatment regimens: how can a form of treatment which is known to be unsuccessful in at least 50% of cases be thought of as even " semiroutine "? The present position in the treatment of A.L.L. in childhood has been reached by the efforts of many special centres throughout the world, and it is to such centres-and particularly to collaborative groups of them-that we must look for further advances. While paediatricians and haematologists at district hospitals certainly have an important part to play in the management of these children, the pace of advance must inevitably be slowed if many of them settle for the status quo. Evidence is accumulating that the diagnosis of A.L.L. covers a heterogeneous group of disorders, some of which respond much less favourably to chemotherapy than others. Do the 30-50% of cases which appear to be curable by the best available treatment regimens represent the majority of a subgroup which can be recognised at diagnosis, and do the other types of A.L.L. (e.g., T-cell and B-cell leukxmias), which are known to carry a worse prognosis, require a radically different approach to treatment ? Such questions can only be answered by controlled therapeutic trials on large series of patients whose leukaemic cells have been studied before the start of treatment by modern immunological, cytochemical, and other techniques. This implies referral of as many cases as possible to special centres for initial investigation, though subsequent care may with advantage be shared between the special centre and the local hospital. To go it alone, and to use established methods- of treatment for all patients, is to obstruct further progress. Hospital for Sick Children, Great Ormond Street, London WC1N 3JH.
R. M. HARDISTY.
RECOGNITION OF DIPHTHERIA
SiR,—Icannot allow to go unchallenged the opinion expressed in two letters 1,2 that routine cultures for diphtheria, of throat swabs from patients with tonsillitis should be discontinued. Although the disease is rare, continued to culture are, I think, necessary for several attempts reasons.
The clinician tends to think of diphtheria when antibiotic has failed. If he has had the forethought to submit a swab for culture before treatment, he will not unreasonably feel aggrieved if no opinion can be expressed by the laboratory, other than the absence of hxmolytic streptococci. Cultures aimed at excluding this pathogen cannot be relied on to reveal diphtheria bacilli. Unless selective medium for Corymbacterium diphtheria is used routinely, it may not be available in good condition when urgently needed. Demands tend to be made late in the day, at weekends, and on Bank Holidays. Although a treatment
1. 2.
McSwiggin, D. A., Taylor, C. E. D. Lancet, March 1, 1975, p. 515. Bezjak, V. ibid. April 19, 1975, p. 924.
damaged by the activities of Government: Labour said the same thing when the Conservatives were in. But neither side would nowadays describe the morale of the service in purely party-political terms. However much the Conservatives may condemn Mrs Castle’s policies or personal style, the chief engine of low morale is undoubtedly the economic policies dictated by our present plight, of which any D.H.S.S. Minister must be, to a great extent, a helpless prisoner. It is a sad business to look back across two years or so of this column to the bright days of early 1973, when it opened with an account of one of Mr Barber’s budgets. That great year of bounty, 1972, when the Government was anxiously seeking ways to push up spending, was already behind us, though the shadow of the December, 1973, cuts was still far away. It was, even so, still a time when a Chancellor could happily lift taxation on such tools of national self-indulgence whereas the as chocolate biscuits and ice-cream; two years since have been a time of declining aspirations and a service driven on to the defensive-with the real threat that once the Common Market referendum is out of the way Mr Healey may have to prune public spending still further. Just as the Conservatives were long reluctant to curb the dash for growth on which they embarked in 1972, despite the accumulating warning signs that we were in trouble, so the Labour Government has been reluctant to accept that the Social Contract as now constituted has been an inadequate force to deal with rising wage demands. But the crisis in public expenditure has set some thoughtful M.p.s on the left of the Party, normally no friends to incomes policy, thinking much more sombrely about the implications of our present economic drift than they did before. Faced with a further cutback on schools, homes, and hospitals, they are beginning to consider whether they too should not be out on the streets publicly warning, as Mr Healey has already done, that there must now be a straight choice between satisfying the personal or the public needs of society. They know that some of their supporters will deeply suspect them if they do. But they also know what political consequences are likely to occur as the effects on the ground of curbs on public spending become clearer and deeper. For, however much Ministers may argue that a new and fitter service may emerge from this period of austerity, the queue of those presenting their needs for urgent attention shows no signs of slackening. In a well-organised all-party exercise this week, for example, M.P.s tabled nearly 200 questions designed to elicit the record of recent public spending on the mentally ill and mentally handicapped, in order to establish a national picture of provision and to document the regional inequalities within it. Cases like South Ockendon can of course occur in times ofprosperity too; but cuts in public spending must make them more likely rather than less. On which glum note I must gather up my typewriter and steal quietly out of this column, leaving behind me a last and heartfelt word of thanks to The Lancet for its hospitality over the past two years and to those who from time to time have written offering blame,
agreement,
or
information. DAVID MCKIE.
Letters to the Editor MEDICAL CARE OF CHILDHOOD LEUKÆMIA SIR,-It is disappointing to note that Dr McCarthy (May 17, p. 1128) has found that " many clinicians ... consider that the treatment of leukaemia is moving towards a semiroutine regimen, especially for A.L.L. [acute lymphatic leukaemiaJ, and ... can be as adequately given in a districthospital setting as in a special centre ". This attitude argues a quite unwarranted complacency, engendered by the recent encouraging advances in the treatment of this condition. Even the most optimistic and enthusiastic experts would not claim that more than half of all children with A.L.L. can be cured by current treatment regimens: how can a form of treatment which is known to be unsuccessful in at least 50% of cases be thought of as even " semiroutine "? The present position in the treatment of A.L.L. in childhood has been reached by the efforts of many special centres throughout the world, and it is to such centres-and particularly to collaborative groups of them-that we must look for further advances. While paediatricians and haematologists at district hospitals certainly have an important part to play in the management of these children, the pace of advance must inevitably be slowed if many of them settle for the status quo. Evidence is accumulating that the diagnosis of A.L.L. covers a heterogeneous group of disorders, some of which respond much less favourably to chemotherapy than others. Do the 30-50% of cases which appear to be curable by the best available treatment regimens represent the majority of a subgroup which can be recognised at diagnosis, and do the other types of A.L.L. (e.g., T-cell and B-cell leukxmias), which are known to carry a worse prognosis, require a radically different approach to treatment ? Such questions can only be answered by controlled therapeutic trials on large series of patients whose leukaemic cells have been studied before the start of treatment by modern immunological, cytochemical, and other techniques. This implies referral of as many cases as possible to special centres for initial investigation, though subsequent care may with advantage be shared between the special centre and the local hospital. To go it alone, and to use established methods- of treatment for all patients, is to obstruct further progress. Hospital for Sick Children, Great Ormond Street, London WC1N 3JH.
R. M. HARDISTY.
RECOGNITION OF DIPHTHERIA
SiR,—Icannot allow to go unchallenged the opinion expressed in two letters 1,2 that routine cultures for diphtheria, of throat swabs from patients with tonsillitis should be discontinued. Although the disease is rare, continued to culture are, I think, necessary for several attempts reasons.
The clinician tends to think of diphtheria when antibiotic has failed. If he has had the forethought to submit a swab for culture before treatment, he will not unreasonably feel aggrieved if no opinion can be expressed by the laboratory, other than the absence of hxmolytic streptococci. Cultures aimed at excluding this pathogen cannot be relied on to reveal diphtheria bacilli. Unless selective medium for Corymbacterium diphtheria is used routinely, it may not be available in good condition when urgently needed. Demands tend to be made late in the day, at weekends, and on Bank Holidays. Although a treatment
1. 2.
McSwiggin, D. A., Taylor, C. E. D. Lancet, March 1, 1975, p. 515. Bezjak, V. ibid. April 19, 1975, p. 924.
