290
Proc. roy. Soc. Med. Volume 70 April 1977
Daum and her colleagues in some workers in the sulphuric acid extraction process, is a completely different entity from the benign pneumoconiosis which may result from exposure to titanium dioxide dust or fume in a high state of purity. Furthermore, it is of practical interest that men working in the winning, drying and electromagnetic purification of ilmenite ore prior to processing have no excess of respiratory symptoms or abnormal radiographs compared with a control population (Uragoda & Pinto 1972). Yours sincerely W RAYMOND PARKES
5 January 1977 REFERENCES Christie H, Mackay R J & Fisher A M (1963) American Industrial Hygiene Association Journal 24, 42-46 Dale K (1973) Scandinavian Journal of Respiratory Diseases 54, 168-184 Elo R, Maitti K, Uksila E & Arstila A U (1972) Archives ofPathology 94, 417-424 Ferin J & Leach L J (1976) Environmental Research 12, 250-254 Heppleston A G (1971) In: Inhaled Particles and Vapours III. Ed. W H Walton. Unwin, Woking; pp 357-369 Maitta K & Arstila A U (1975) Laboratory Investigation 33, 342-346 Schmitz-Moorman P, Horlein H & Hanefeld F (1964) Beitrige zur Silikose-Forschung 80, 1-17 Uragoda C G & Pinto M R M (1972) Medical Journal of Australia 1, 167-169
On Dying and Dying Well From Dr Cicely Saunders Medical Director, St Christopher's Hospice, Sydenham, SE26 6DZ Dear Sir, The Archbishop of Canterbury was evidently prepared to accept the risk of misinterpretation in the media and elsewhere when he delivered the Edwin Stevens Lecture (February Proceedings, pp 75-81) and for this we should certainly be grateful. Some misunderstanding has been engendered by two phrases which I believe did not convey exactly what he meant. On page 76 he refers to the 'prolongation of the life of one aged patient' and a few lines later (p 77) to the 'extension of the life of a terminal patient'. From the context we can see that he was referring to such medical activities as occurred in the case of Karen Quinlan and in the case referred to by Hugh Trowell. Unfortunately the context is frequently omitted and as these statements stand they have produced the unfortunate implication that the elderly are being cared for at the expense of other members of society. Surely it is the prolongation of life of an irreversibly unconscious patient who may be of any age
that poses this particular problem. Treatment appropriate to the acute remediable situation is inappropriately and expensively (in money and beds) applied to the patient who needs skilled care for his dying. I fear that recent programmes, unconnected with the Edwin Stevens Lecture, have reinforced the not uncommon feeling among the elderly that their continued existence is unwelcome. Many of us can give poignant examples of this. The social pressures aroused by discussion are great - those of law would be greater. Any form of legislation allowing a 'quick way out' must inevitably erode the right for care. As the Bishop of Durham, Dr J S Habgood, said in the House of Lords Debate on Baroness Wooton's Incurable Patients Bill, 'This is where the confusion often takes place - by "the right to die" people mean the right to die in peace and dignity, and this surely is a right which exists already. If one endeavours to strengthen it by the kind of legislation proposed here, then inevitably one widens it to include, for some people, a presumed duty to die, because rights have always the dangerous propensity to turn into quasiduties.' (1976, Parliamentary Debates, House of Lords 368, Columns 195-300). I believe that the Archbishop's lecture has opened up this subject in a helpful way. He brings together writers of widely differing backgrounds and outlook and in so doing has stirred up much useful debate. As the late Bishop of Durham, Dr I T Ramsey, wrote in his lecture to the British Medical Association 15th Annual Clinical Meeting, Nicosia, Cyprus, 'As always, when we come to a complicated moral problem yielding no easy decision, we must hold together all the relevant moral principles we can collect, analyse the facts further and yet further, and continue this rhythm all the time holding together facts and principles until a creative decision emerges.' The Archbishop has spoken kindly of the work of the various hospices, old and new, and the other units of different titles which are working in this field. St Christopher's has been developing knowledge which has roots in the work of St Luke's Hospital in the 1940s and 1950s which was later developed in St Joseph's Hospice. In turn, other centres such as the Palliative Care Unit in the Royal Victoria Hospital, Montreal (Mount, 1976, Canadian Medical Association Journal 115, 119121) and the Hospice, or Symptom Control, Team in St Luke's Hospital Center, New York have now shown how eminently transferable such work is. I am sure the Archbishop did not mean that dying well is or will be limited to such centres. At St Christopher's we are increasingly involved with those who will be interpreting the work on the control of physical, mental and family distress in a wide variety of settings.
Letters to the Editor
Teaching in terminal care has always, perhaps of necessity, been a matter of individual effort on the part of interested clinicians. As a student on Sir John Richardson's firm I remember an excellent session when he brought a family doctor to join one of several rounds on this subject. Too often, however, this is honoured in the breach rather than in the observance. Lectures, often arranged by the students themselves, attract large audiences. Students do not receive enough reinforcement in the practice and teaching they observe in acute wards and only rarely is it recognized that the patient and family is the unit for terminal care. We are trying to pass on the guidelines worked out in the special centres, and the thrust now is surely to introduce them so that appropriate and competent treatment is available to every dying patient. Yours faithfully CICELY SAUNDERS
17 February 1977
Asbestos Content of Dust Encountered in Brake Maintenance and Repair From Dr Muriel L Newhouse TUC Centenary Institute of Occupational Health, London School of Hygiene and Tropical Medicine, London WCIE 7HT Dear Sir, It is of interest to read the article by Rohl et al. (January Proceedings, p 32) on concentrations of asbestos dust during brake maintenance and repair. The subject was fully reviewed in Great Britain in 1970 (Hickish & Knight 1970, Knight & Hickish 1970, Lee 1970). At that time dust control by use of vacuum brushes and vacuum funnels was suggested which reduced concentration of fibre in air very considerably, but these methods do not seem to have been widely accepted. The present article lays emphasis on the high exposure levels encountered in truck brake repair, particularly when bevelling new linings. It is possible to control exposure in this type of wo'rk, the chief difficulty is in gaining the cooperation of operatives who work independently or in small groups often without supervision, and for whom the brake maintenance job may be only one of many undertaken during the day. The authors lay emphasis on the large number of very short fibres detected by transmission electron microscopy and point out that many of these would not be detected by optical microscopy and indeed are not considered either in the US or British standard. Interest in recent years has been concentrated on the physical properties of fibres. It has been shown that their carcinogenicity is related to diameter and length. Crocidolite, with the finest short fibres, has the highest carcinogenicity, but
291
mesothelial tumours have been experimentally induced in rats, with fibre glass reduced to a diameter of < 3 gm (Stanton & Wrench 1972) and it may be the presence of these very small fibres which gives the high yield of mesothelial tumours in animal experiments with chrysotile asbestos (Wagner & Berry 1969). At present when assessing exposure levels, fibres shorter than 5 gm are not counted although the diameter of the fibre must be less than 3 gm. As the authors suggest, a critical look should be taken at these criteria. Yours sincerely MURIEL L NEWHOUSE
11 January 1977 REFERENCES Hickish D E & Knight K L (1970) Annals of Occupational Hygiene 13, 17-21 Knight K L & Hickish D E (1970) Annals of Occupational Hygiene 13, 37-39 Lee G L (1970) Annals ofOccupational Hygiene 13, 33-36 Stanton M F & Wrench C (1972) Journal of the National Cancer Institute 48, 797-821 Wagner J C & Berry G (1969) British Journal of Cancer 23, 567-581
The Modern Management and Therapy of Pulmonary Tuberculosis From Dr N C Oswald Thurlestone, South Devon Dear Sir, In his Phillip Ellman Lecture (January Proceedings, pp 4-15) Dr Fox describes the stages through which the management and therapy of pulmonary tuberculosis have passed in the last twenty years. Prolonged institutional care is no longer necessary and the duration of chemotherapy has been reduced from two years to about six months. At first sight, these gains may seem to be rather unimportant, but for a chronic disease which still probably kills more than two million people each year worldwide, they represent major changes in clinical practice which have already saved many thousands of lives and much unnecessary expenditure. The lecture is, in a sense, a tribute to the foresight of the Medical Research Council (MRC) in assuming responsibility for the scientific management of antituberculosis chemotherapy. Thirty years ago, the MRC started to take charge of the original supplies of streptomycin, PAS and isoniazid and issued them only to controlled trials of their own design. The succeeding second-line drugs were no less rigorously scrutinized. With Wallace Fox to pose the questions and Mitchison to advise upon the bacteriological aspects, the MRC has been able to mount large clinical trials at home and in East Africa, Madras, Hong Kong and Singapore involving several hundred participants
Proc. roy. Soc. Med. Volume 70 April 1977
Daum and her colleagues in some workers in the sulphuric acid extraction process, is a completely different entity from the benign pneumoconiosis which may result from exposure to titanium dioxide dust or fume in a high state of purity. Furthermore, it is of practical interest that men working in the winning, drying and electromagnetic purification of ilmenite ore prior to processing have no excess of respiratory symptoms or abnormal radiographs compared with a control population (Uragoda & Pinto 1972). Yours sincerely W RAYMOND PARKES
5 January 1977 REFERENCES Christie H, Mackay R J & Fisher A M (1963) American Industrial Hygiene Association Journal 24, 42-46 Dale K (1973) Scandinavian Journal of Respiratory Diseases 54, 168-184 Elo R, Maitti K, Uksila E & Arstila A U (1972) Archives ofPathology 94, 417-424 Ferin J & Leach L J (1976) Environmental Research 12, 250-254 Heppleston A G (1971) In: Inhaled Particles and Vapours III. Ed. W H Walton. Unwin, Woking; pp 357-369 Maitta K & Arstila A U (1975) Laboratory Investigation 33, 342-346 Schmitz-Moorman P, Horlein H & Hanefeld F (1964) Beitrige zur Silikose-Forschung 80, 1-17 Uragoda C G & Pinto M R M (1972) Medical Journal of Australia 1, 167-169
On Dying and Dying Well From Dr Cicely Saunders Medical Director, St Christopher's Hospice, Sydenham, SE26 6DZ Dear Sir, The Archbishop of Canterbury was evidently prepared to accept the risk of misinterpretation in the media and elsewhere when he delivered the Edwin Stevens Lecture (February Proceedings, pp 75-81) and for this we should certainly be grateful. Some misunderstanding has been engendered by two phrases which I believe did not convey exactly what he meant. On page 76 he refers to the 'prolongation of the life of one aged patient' and a few lines later (p 77) to the 'extension of the life of a terminal patient'. From the context we can see that he was referring to such medical activities as occurred in the case of Karen Quinlan and in the case referred to by Hugh Trowell. Unfortunately the context is frequently omitted and as these statements stand they have produced the unfortunate implication that the elderly are being cared for at the expense of other members of society. Surely it is the prolongation of life of an irreversibly unconscious patient who may be of any age
that poses this particular problem. Treatment appropriate to the acute remediable situation is inappropriately and expensively (in money and beds) applied to the patient who needs skilled care for his dying. I fear that recent programmes, unconnected with the Edwin Stevens Lecture, have reinforced the not uncommon feeling among the elderly that their continued existence is unwelcome. Many of us can give poignant examples of this. The social pressures aroused by discussion are great - those of law would be greater. Any form of legislation allowing a 'quick way out' must inevitably erode the right for care. As the Bishop of Durham, Dr J S Habgood, said in the House of Lords Debate on Baroness Wooton's Incurable Patients Bill, 'This is where the confusion often takes place - by "the right to die" people mean the right to die in peace and dignity, and this surely is a right which exists already. If one endeavours to strengthen it by the kind of legislation proposed here, then inevitably one widens it to include, for some people, a presumed duty to die, because rights have always the dangerous propensity to turn into quasiduties.' (1976, Parliamentary Debates, House of Lords 368, Columns 195-300). I believe that the Archbishop's lecture has opened up this subject in a helpful way. He brings together writers of widely differing backgrounds and outlook and in so doing has stirred up much useful debate. As the late Bishop of Durham, Dr I T Ramsey, wrote in his lecture to the British Medical Association 15th Annual Clinical Meeting, Nicosia, Cyprus, 'As always, when we come to a complicated moral problem yielding no easy decision, we must hold together all the relevant moral principles we can collect, analyse the facts further and yet further, and continue this rhythm all the time holding together facts and principles until a creative decision emerges.' The Archbishop has spoken kindly of the work of the various hospices, old and new, and the other units of different titles which are working in this field. St Christopher's has been developing knowledge which has roots in the work of St Luke's Hospital in the 1940s and 1950s which was later developed in St Joseph's Hospice. In turn, other centres such as the Palliative Care Unit in the Royal Victoria Hospital, Montreal (Mount, 1976, Canadian Medical Association Journal 115, 119121) and the Hospice, or Symptom Control, Team in St Luke's Hospital Center, New York have now shown how eminently transferable such work is. I am sure the Archbishop did not mean that dying well is or will be limited to such centres. At St Christopher's we are increasingly involved with those who will be interpreting the work on the control of physical, mental and family distress in a wide variety of settings.
Letters to the Editor
Teaching in terminal care has always, perhaps of necessity, been a matter of individual effort on the part of interested clinicians. As a student on Sir John Richardson's firm I remember an excellent session when he brought a family doctor to join one of several rounds on this subject. Too often, however, this is honoured in the breach rather than in the observance. Lectures, often arranged by the students themselves, attract large audiences. Students do not receive enough reinforcement in the practice and teaching they observe in acute wards and only rarely is it recognized that the patient and family is the unit for terminal care. We are trying to pass on the guidelines worked out in the special centres, and the thrust now is surely to introduce them so that appropriate and competent treatment is available to every dying patient. Yours faithfully CICELY SAUNDERS
17 February 1977
Asbestos Content of Dust Encountered in Brake Maintenance and Repair From Dr Muriel L Newhouse TUC Centenary Institute of Occupational Health, London School of Hygiene and Tropical Medicine, London WCIE 7HT Dear Sir, It is of interest to read the article by Rohl et al. (January Proceedings, p 32) on concentrations of asbestos dust during brake maintenance and repair. The subject was fully reviewed in Great Britain in 1970 (Hickish & Knight 1970, Knight & Hickish 1970, Lee 1970). At that time dust control by use of vacuum brushes and vacuum funnels was suggested which reduced concentration of fibre in air very considerably, but these methods do not seem to have been widely accepted. The present article lays emphasis on the high exposure levels encountered in truck brake repair, particularly when bevelling new linings. It is possible to control exposure in this type of wo'rk, the chief difficulty is in gaining the cooperation of operatives who work independently or in small groups often without supervision, and for whom the brake maintenance job may be only one of many undertaken during the day. The authors lay emphasis on the large number of very short fibres detected by transmission electron microscopy and point out that many of these would not be detected by optical microscopy and indeed are not considered either in the US or British standard. Interest in recent years has been concentrated on the physical properties of fibres. It has been shown that their carcinogenicity is related to diameter and length. Crocidolite, with the finest short fibres, has the highest carcinogenicity, but
291
mesothelial tumours have been experimentally induced in rats, with fibre glass reduced to a diameter of < 3 gm (Stanton & Wrench 1972) and it may be the presence of these very small fibres which gives the high yield of mesothelial tumours in animal experiments with chrysotile asbestos (Wagner & Berry 1969). At present when assessing exposure levels, fibres shorter than 5 gm are not counted although the diameter of the fibre must be less than 3 gm. As the authors suggest, a critical look should be taken at these criteria. Yours sincerely MURIEL L NEWHOUSE
11 January 1977 REFERENCES Hickish D E & Knight K L (1970) Annals of Occupational Hygiene 13, 17-21 Knight K L & Hickish D E (1970) Annals of Occupational Hygiene 13, 37-39 Lee G L (1970) Annals ofOccupational Hygiene 13, 33-36 Stanton M F & Wrench C (1972) Journal of the National Cancer Institute 48, 797-821 Wagner J C & Berry G (1969) British Journal of Cancer 23, 567-581
The Modern Management and Therapy of Pulmonary Tuberculosis From Dr N C Oswald Thurlestone, South Devon Dear Sir, In his Phillip Ellman Lecture (January Proceedings, pp 4-15) Dr Fox describes the stages through which the management and therapy of pulmonary tuberculosis have passed in the last twenty years. Prolonged institutional care is no longer necessary and the duration of chemotherapy has been reduced from two years to about six months. At first sight, these gains may seem to be rather unimportant, but for a chronic disease which still probably kills more than two million people each year worldwide, they represent major changes in clinical practice which have already saved many thousands of lives and much unnecessary expenditure. The lecture is, in a sense, a tribute to the foresight of the Medical Research Council (MRC) in assuming responsibility for the scientific management of antituberculosis chemotherapy. Thirty years ago, the MRC started to take charge of the original supplies of streptomycin, PAS and isoniazid and issued them only to controlled trials of their own design. The succeeding second-line drugs were no less rigorously scrutinized. With Wallace Fox to pose the questions and Mitchison to advise upon the bacteriological aspects, the MRC has been able to mount large clinical trials at home and in East Africa, Madras, Hong Kong and Singapore involving several hundred participants
