Volume 70 April 1977
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Letters to the Editor Periodic Reregistration From Dr D Naidoo Cuddington, Cheam, Surrey Sir, I was concerned at the suggestion by Professor Smart (November Proceedings, p 813) that the profession might be subjected to monitoring with a view to questioning continued registration of individual doctors. Modern computerized data in the wrong hands could ravage a profession already sorely tried by misfortune. Social values and attitudes change more rapidly than many minds can, and the social and clinical context in which contemporary doctors work is often outside the understanding of those who spent their formative youth nearly half a century ago. Lord Gardiner, Professor Christopher Pile, and Morton Halperin who refers to the Pentagon data banks, have all called attention to the monstrous consequences of putting the powers of surveillance in the hands of those who ask for them, allegedly in the national interest and, in our case, in the professional interest. These well known precedents issue a solemn warning. A more profitable matter for discussion may be the possible deregistration of those who can no longer recognize the world for what it is or has become. When such men monitor a whole profession they are either dangerous or in their dotage. This profession must remain free. Yours truly D NAIDOO
22 December 1976
Pulmonary Changes Among Titanium Workers From Dr W Raymond Parkes Leatherhead, Surrey Dear Sir, This short paper (Daum et al., January Proceedings, p 31) describes a study of workers in the sulphuric acid process for extracting titanium dioxide from ilmenite ore for pigment manufacture. Inevitably, because it is an abstract, it leaves one with some uncertainty about the methods of analysis employed and the significance of the
figures quoted. Respiratory symptoms and objective evidence of air-flow obstruction, though most prominent in smokers, did occur in nonsmokers. It would have been helpful, therefore, to have had some information (if available) about the concentrations of
fume and mist to which workers in the digestion, purification and reclamation processes were exposed and any differences, and their degree, which may have existed in the different groups. Although the chest radiographs of a small number of subjects who had had previous 'silica' or asbestos exposure showed evidence of irregular or 'nodular' opacities 'of limited extent and intensity' it is not stated whether pneumoconiosis attributable to titanium dioxide was observed - seemingly not. Again, it would have been interesting to know the concentrations of titanium dioxide fume and dust of aerodynamically 'respirable' size in the ambient air. Were they, in fact, present? Titanium having an atomic number (22) only slightly less than that of iron (26) is capable of causing radiographic appearances similar to those of siderosis when retained in the alveolar regions of the lungs. But in spite of the extensive use of titanium dioxide in industry (for example in dyes, paints, pigments, plastics, rubber, glass, electroceramics and a variety of metal alloys) it is remarkable that benign titanium dioxide pneumoconiosis seems only occasionally to have been reported. This could be due, in part at least, to the duration of exposure and concentrations of titanium dioxide in various manufacturing processes being insufficient to give rise to radioopacities; for the lower its atomic number the greater is the content of an inert dust required in the lungs to cause these opacities. But, also, the opacities may have been missed or wrongly interpreted in some instances. It is worth noting that titanium dioxide is inert in animal as well as human lungs (Christie et al. 1963, Dale 1973, Schmitz-Moorman et al. 1964) although other minerals associated with it may provoke a mild degree of diffuse interstitial fibrosis (Elo et al. 1972). The inertness of titanium dioxide, incidentally, is made use of in animal studies as a marker of the effect that various inhaled gases, fumes and minerals have on alveolobronchial clearance (Ferin & Leach 1976). Unlike quartz it is not cytotoxic having no evident effect upon the viability of alveolar macrophages (Maatta & Arstila 1975) and does not cause fibroblasts to produce hydroxyproline which indicates lack of fibrogenic potential (Heppleston 1971). So, it can be concluded that the irritation of the upper and lower respiratory tract reported by
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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.
289
Letters to the Editor Periodic Reregistration From Dr D Naidoo Cuddington, Cheam, Surrey Sir, I was concerned at the suggestion by Professor Smart (November Proceedings, p 813) that the profession might be subjected to monitoring with a view to questioning continued registration of individual doctors. Modern computerized data in the wrong hands could ravage a profession already sorely tried by misfortune. Social values and attitudes change more rapidly than many minds can, and the social and clinical context in which contemporary doctors work is often outside the understanding of those who spent their formative youth nearly half a century ago. Lord Gardiner, Professor Christopher Pile, and Morton Halperin who refers to the Pentagon data banks, have all called attention to the monstrous consequences of putting the powers of surveillance in the hands of those who ask for them, allegedly in the national interest and, in our case, in the professional interest. These well known precedents issue a solemn warning. A more profitable matter for discussion may be the possible deregistration of those who can no longer recognize the world for what it is or has become. When such men monitor a whole profession they are either dangerous or in their dotage. This profession must remain free. Yours truly D NAIDOO
22 December 1976
Pulmonary Changes Among Titanium Workers From Dr W Raymond Parkes Leatherhead, Surrey Dear Sir, This short paper (Daum et al., January Proceedings, p 31) describes a study of workers in the sulphuric acid process for extracting titanium dioxide from ilmenite ore for pigment manufacture. Inevitably, because it is an abstract, it leaves one with some uncertainty about the methods of analysis employed and the significance of the
figures quoted. Respiratory symptoms and objective evidence of air-flow obstruction, though most prominent in smokers, did occur in nonsmokers. It would have been helpful, therefore, to have had some information (if available) about the concentrations of
fume and mist to which workers in the digestion, purification and reclamation processes were exposed and any differences, and their degree, which may have existed in the different groups. Although the chest radiographs of a small number of subjects who had had previous 'silica' or asbestos exposure showed evidence of irregular or 'nodular' opacities 'of limited extent and intensity' it is not stated whether pneumoconiosis attributable to titanium dioxide was observed - seemingly not. Again, it would have been interesting to know the concentrations of titanium dioxide fume and dust of aerodynamically 'respirable' size in the ambient air. Were they, in fact, present? Titanium having an atomic number (22) only slightly less than that of iron (26) is capable of causing radiographic appearances similar to those of siderosis when retained in the alveolar regions of the lungs. But in spite of the extensive use of titanium dioxide in industry (for example in dyes, paints, pigments, plastics, rubber, glass, electroceramics and a variety of metal alloys) it is remarkable that benign titanium dioxide pneumoconiosis seems only occasionally to have been reported. This could be due, in part at least, to the duration of exposure and concentrations of titanium dioxide in various manufacturing processes being insufficient to give rise to radioopacities; for the lower its atomic number the greater is the content of an inert dust required in the lungs to cause these opacities. But, also, the opacities may have been missed or wrongly interpreted in some instances. It is worth noting that titanium dioxide is inert in animal as well as human lungs (Christie et al. 1963, Dale 1973, Schmitz-Moorman et al. 1964) although other minerals associated with it may provoke a mild degree of diffuse interstitial fibrosis (Elo et al. 1972). The inertness of titanium dioxide, incidentally, is made use of in animal studies as a marker of the effect that various inhaled gases, fumes and minerals have on alveolobronchial clearance (Ferin & Leach 1976). Unlike quartz it is not cytotoxic having no evident effect upon the viability of alveolar macrophages (Maatta & Arstila 1975) and does not cause fibroblasts to produce hydroxyproline which indicates lack of fibrogenic potential (Heppleston 1971). So, it can be concluded that the irritation of the upper and lower respiratory tract reported by
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.
