for the public, and for physicians and their patients. * Encourage the police to show that the wearing of seatbelts at all times is rational and that the myths about the dangers of wearing seatbelts are irrational. * Urge the federal government to review its standards for seatbelt construction in areas of strength, belt width and comfort. * Inform the Ontario government that any increase in incidence of injury or death attributable to the nonuse of seatbelts is unacceptable to the medical profession. JAMES R. MACKENZIE, MD Chairman, committee on accidental injuries Ontario Medical Association
To the editor: In writing his article Jim Garner has performed a real service for readers of the Journal. Many will now appreciate what he writes and the depth of thought behind the articles featured regularly in Ottawa File. The readers of the Journal deserve an apology for the publication of this article. The title qualifies it for a second-rate tabloid. It does nothing to enhance the value of the Journal or to enhance public relations for our profession at a time when we need the best we can muster. The article casts deprecatory remarks at another group of professionals with whom many of us work closely. In addition, assumptions are made in the opening paragraphs that gradually become facts upon which an asinine hypothetical situation is built. Finally, our intelligence is insulted by a "Pearly Gates" situation. Surely* any person contributing regularly to the Journal has sufficient experience and knowledge to know that only good legislation is enforcible, that the role of a good policeman is more complex than just seeing that seatbelts are worn because of legislation, and that the passage of this legislation does nothing to address the basic problem as regards the reasons for vehicular accidents and deaths. What a pity that Mr. Garner does not recognize speed, alcohol and discourtesy as common causative factors in these accidents and that he makes no mention of our duty as citizens to uphold the law. It is ludicrous to place the entire responsibility on law enforcement officers. Our complex society has many ills. The failure of individuals to care for themselves and others is only one of the symptoms. Speed, alcohol and discourtesy are expressions of this lack of care, but these are only the tip of an iceberg of social problems that have resulted in the creation of rape crisis centres, suicide hotlines, halfway houses and neighbourhood-watch, as well as seatbelt legislation. Interestingly, this
legislation has been passed in many instances by the same legislators that, not so long ago, lowered the legal age for consumption of alcoholic beverages. The most distressing aspect of this type of irresponsible journalism is its effect on the general population. Through such journalism our society has become informed and knowledgeable in all things. Citizens have been prepared to criticize and direct the affairs of all manner of professionals, including physicians (who, fortunately, have been taught to read critically). Nevertheless, there is neither reason nor excuse for such an article in a usually responsible journal. J.E. NEWELL, MD 103 Medical Arts building Calgary, Alta.
gration inhibition give a better index of cellular immunity, both in patients and in healthy controls tested against purified protein derivative of tuberculin1 and breast cancer antigen.' The reason is that a significant variation of results is observed in the leukocyte migration inhibition test in all subjects tested on a week-to-week basis. Had Sheremata and colleagues tested all groups sequentially the findings might have been very different from those reported. I suggest that before hypothesizing that the leukocyte migration inhibition test might be a useful diagnostic aid in predicting exacerbations of multiple sclerosis the authors undertake a double-blind sequential study of their patient groups and include a much larger number of individuals. LORNE J. BRANDES, MD Department of medicine University of Manitoba Winnipeg, Man.
Leukocyte migration inhibition by myelin basic protein To the editor: In their recent article "Direct leukocyte migration inhibition by myelin basic protein in exacerbations of multiple sclerosis (Can Med Assoc J 116: 985, 1977) Sheremata and colleagues suggest that the finding of significant migration inhibition by myelin basic protein in patients with multiple sclerosis might be used to predict exacerbations of this disease. While this may be the case, we have several reservations about the interpretation of the data and the conclusions drawn by the authors. The arbitrary use of a cutoff point for significance of 86% may bias the results. It would be preferable to compare statistically each value of inhibition in the presence of antigen with that in the absence of antigen. The use of Student's two-tailed t-test for eight replicates in antigen chambers and control chambers would be one simple way of doing this. The mean migration inhibition noted in nine patients in the first 3 weeks of their exacerbation is largely influenced by three extreme values, whereas the values for at least four patients are in the negative range. Similarly, the number of patients studied 1 to 6 months after an exacerbation is much larger, so that even though there are some patients with extreme inhibition, they are outweighed by a larger group with less inhibition. The numbers in each group are significantly different; this makes interpretation difficult. Since the blood samples were not coded, the tests were done blind. The interpretation of leukocyte migration inhibition is subjective, so the status of the subjects being tested should not be known by those interpreting the results. We have shown that sequential tests over several weeks for leukocyte mi-
References 1. RAMSEY EW, BRANDES U, JACOB K, et al: An evaluation of the peripheral leukocyte migration inhibition test aa a correlate of delayed cutaneous hypersensitivity. Cell 3mmunol 23: 334, 1976 2. BRANDES U, GOLDENBERO 03: Peripheral leukocyte migration inhibition reactivity to breast cancer antigens in patients with breast cancer and in normal controls. Cancer Res 36: 3707. 1976
Dr. D.A.E. Shephard To the editor: Over the past 2 years the Canadian Medical Association Journal has undergone significant improvement in content and literary style. These changes reflect the journalistic skill and academic interests of the former scientific editor, Dr. David A.E. Shephard. I am indeed sorry to learn that he has left the Journal and I wish him well and thank him for his efforts to improve medical writing in Canada. GERALD D. HART, MD, FRcP(c] Physician in chief Toronto East General and Orthopaedic Hospital Toronto, Ont.
Biting insect summary To the editor: Again this year I am compiling a biting insect summary and would appreciate receiving case reports of unusual allergic reactions, especially systemic (sneezing, wheezing or urticaria), to bites of insects such as mosquitoes, fleas, gnats, kissing bugs, bedbugs, chiggers, black flies, horseflies, sandflies and deerflies. Please note that it is the biting (not stinging) insect in which I am interested. Included in the reports should be the type of reaction (immediate and delayed symptoms), treatment, age, sex and race of the patient, site of the bite(s), season of the year and any asso-
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
577
To the editor: In writing his article Jim Garner has performed a real service for readers of the Journal. Many will now appreciate what he writes and the depth of thought behind the articles featured regularly in Ottawa File. The readers of the Journal deserve an apology for the publication of this article. The title qualifies it for a second-rate tabloid. It does nothing to enhance the value of the Journal or to enhance public relations for our profession at a time when we need the best we can muster. The article casts deprecatory remarks at another group of professionals with whom many of us work closely. In addition, assumptions are made in the opening paragraphs that gradually become facts upon which an asinine hypothetical situation is built. Finally, our intelligence is insulted by a "Pearly Gates" situation. Surely* any person contributing regularly to the Journal has sufficient experience and knowledge to know that only good legislation is enforcible, that the role of a good policeman is more complex than just seeing that seatbelts are worn because of legislation, and that the passage of this legislation does nothing to address the basic problem as regards the reasons for vehicular accidents and deaths. What a pity that Mr. Garner does not recognize speed, alcohol and discourtesy as common causative factors in these accidents and that he makes no mention of our duty as citizens to uphold the law. It is ludicrous to place the entire responsibility on law enforcement officers. Our complex society has many ills. The failure of individuals to care for themselves and others is only one of the symptoms. Speed, alcohol and discourtesy are expressions of this lack of care, but these are only the tip of an iceberg of social problems that have resulted in the creation of rape crisis centres, suicide hotlines, halfway houses and neighbourhood-watch, as well as seatbelt legislation. Interestingly, this
legislation has been passed in many instances by the same legislators that, not so long ago, lowered the legal age for consumption of alcoholic beverages. The most distressing aspect of this type of irresponsible journalism is its effect on the general population. Through such journalism our society has become informed and knowledgeable in all things. Citizens have been prepared to criticize and direct the affairs of all manner of professionals, including physicians (who, fortunately, have been taught to read critically). Nevertheless, there is neither reason nor excuse for such an article in a usually responsible journal. J.E. NEWELL, MD 103 Medical Arts building Calgary, Alta.
gration inhibition give a better index of cellular immunity, both in patients and in healthy controls tested against purified protein derivative of tuberculin1 and breast cancer antigen.' The reason is that a significant variation of results is observed in the leukocyte migration inhibition test in all subjects tested on a week-to-week basis. Had Sheremata and colleagues tested all groups sequentially the findings might have been very different from those reported. I suggest that before hypothesizing that the leukocyte migration inhibition test might be a useful diagnostic aid in predicting exacerbations of multiple sclerosis the authors undertake a double-blind sequential study of their patient groups and include a much larger number of individuals. LORNE J. BRANDES, MD Department of medicine University of Manitoba Winnipeg, Man.
Leukocyte migration inhibition by myelin basic protein To the editor: In their recent article "Direct leukocyte migration inhibition by myelin basic protein in exacerbations of multiple sclerosis (Can Med Assoc J 116: 985, 1977) Sheremata and colleagues suggest that the finding of significant migration inhibition by myelin basic protein in patients with multiple sclerosis might be used to predict exacerbations of this disease. While this may be the case, we have several reservations about the interpretation of the data and the conclusions drawn by the authors. The arbitrary use of a cutoff point for significance of 86% may bias the results. It would be preferable to compare statistically each value of inhibition in the presence of antigen with that in the absence of antigen. The use of Student's two-tailed t-test for eight replicates in antigen chambers and control chambers would be one simple way of doing this. The mean migration inhibition noted in nine patients in the first 3 weeks of their exacerbation is largely influenced by three extreme values, whereas the values for at least four patients are in the negative range. Similarly, the number of patients studied 1 to 6 months after an exacerbation is much larger, so that even though there are some patients with extreme inhibition, they are outweighed by a larger group with less inhibition. The numbers in each group are significantly different; this makes interpretation difficult. Since the blood samples were not coded, the tests were done blind. The interpretation of leukocyte migration inhibition is subjective, so the status of the subjects being tested should not be known by those interpreting the results. We have shown that sequential tests over several weeks for leukocyte mi-
References 1. RAMSEY EW, BRANDES U, JACOB K, et al: An evaluation of the peripheral leukocyte migration inhibition test aa a correlate of delayed cutaneous hypersensitivity. Cell 3mmunol 23: 334, 1976 2. BRANDES U, GOLDENBERO 03: Peripheral leukocyte migration inhibition reactivity to breast cancer antigens in patients with breast cancer and in normal controls. Cancer Res 36: 3707. 1976
Dr. D.A.E. Shephard To the editor: Over the past 2 years the Canadian Medical Association Journal has undergone significant improvement in content and literary style. These changes reflect the journalistic skill and academic interests of the former scientific editor, Dr. David A.E. Shephard. I am indeed sorry to learn that he has left the Journal and I wish him well and thank him for his efforts to improve medical writing in Canada. GERALD D. HART, MD, FRcP(c] Physician in chief Toronto East General and Orthopaedic Hospital Toronto, Ont.
Biting insect summary To the editor: Again this year I am compiling a biting insect summary and would appreciate receiving case reports of unusual allergic reactions, especially systemic (sneezing, wheezing or urticaria), to bites of insects such as mosquitoes, fleas, gnats, kissing bugs, bedbugs, chiggers, black flies, horseflies, sandflies and deerflies. Please note that it is the biting (not stinging) insect in which I am interested. Included in the reports should be the type of reaction (immediate and delayed symptoms), treatment, age, sex and race of the patient, site of the bite(s), season of the year and any asso-
CMA JOURNAL/SEPTEMBER 17, 1977/VOL. 117
577
