207 an insulin-dependent diabetic who develops metabolic decompensation will present with non-ketotic hyperosmolar
tion,
coma
and not with ketoacidosis.
Diabetic and Dietetic
’
IAN W. CAMPBELL
Department,
J. F. MUNRO L. J. P. DUNCAN
Royal Infirmary, Edinburgh EH3 9YW
PULMONARY TUBERCULOSIS AND BRONCHIAL CARCINOMA
SIR,-Dr Edlin,l in his report of a small series of cases of active tuberculosis unrecognised until necropsy, implied that there was a negative correlation between tuberculosis and carcinoma, and in support of this referred to papers by Fortune (1929)2 and Cooper (1932).3 However, a careful reading of these two papers shows that Fortune’s and Cooper’s conclusions were quite the opposite-viz., that there was no definite correlation between these two diseases-and these papers give no support to the hypothesis that tuberculosis and carcinoma are in some way mutually antagonistic, as originally propounded in 1854 by von Rokitansky4 and later by Pearly In 1955, I described six cases of bronchial carcinoma in association with active pulmonary tuberculosis, distinguishing those in which the carcinoma developed in known cases of pulmonary tuberculosis from others in which tuberculosis was first discovered when the carcinoma was diagnosed.6 I forecast that we would probably see more patients with these two diseases in association. Springett later showed that pulmonary tuberculosis and bronchial carcinoma not uncommonly coexist, and possibly more often than by chance. The explanation of this has been controversial. Some maintain that carcinoma may develop in scar tissue at sites of healed tuberculous disease.8-10 Alternatively, healed tuberculous lesions may be invaded by carcinoma and the tuberculous disease become reactivated.6 While I agree with Dr Howie’s view on this matterll I cannot accept the suggestion of Dr Healy 12 that "tuberculosis is a common opportunist infection in patients with carcinoma of the lung". In opportunist infection, the offending organism is not a usual human pathogen, and its proliferation results from diminished host defences. However, Mycobacterium tuberculosis is pathogenic to man, and it is therefore incorrect to apply the term "opportunist infection" in this context. Redhill General Hospital, Redhill, Surrey RH1 6LA
***This
letter has been shown
A. SAKULA
to
Dr
Edlin, whose reply fol-
lows.-ED.L.
SIR,-Dr Sakula equates "negative correlation" with Both Fortune and Cooper found a negative correlation between carcinoma and tuberculosis, but also showed statistically that this was due, not to mutual antagonism, but to death from tuberculosis before the individual would have developed carcinoma. My basic point was that carcinoma was not of value as a marker of occult tuberculosis, as
"antagonism".
1. 2.
Edlin, G. P. Lancet, 1978, i, 650. Fortune, C. H. Ann. intern. Med. 1929, 3, 495. 3. Cooper, F. G.Am. Rev. Tuberc. 1932, 25, 108. 4. von Rokitansky, C. A. Manual of Pathological Anatomy;
vol I,
p. 313. Lon-
don, 1854. 5. Pearl, R. Am. J. Hyg. 1929, 9, 97. 6. Sakula, A. Br. med. J. 1955, i, 739. 7. Springett, V. H. Tubercle, 1971, 52, 73. 8. Cherry, T. Lancet, 1931, i, 285. 9. Woodruff, C. E., Nahas, H. C.Am. Rev. Tuberc. 1951, 64, 620. 10. Wofford, J. L., Webb, W. R., Strauss, H. K. Arch. Surg. 1962, 85, 928. 11. Howie, A. J. Lancet, 1978, i, 881. 12. Healy, T. M. ibid. p. 1267.
leukaemia and other reticuloses have been associated with tuberculosis. 1,2 This does not affect the question of the coexistence of tuberculosis and carcinoma. Previously tuberculosis was a disease of youth, but in my series the average age of death with active tuberculosis was 67.4 as opposed to 67.8 for controls. My apparent rate for active tuberculosis not causing death was 1 in 400 necropsies, so a clinician seeing a large number of cases of bronchial carcinoma can expect to see it with the frequency of that age-group (in Dundee 1 in 400) rather than at the rate of incidence in the general population, and so may gain a false impression of its frequency. Pathology Department, Royal Hampshire County Hospital, Winchester
G. EDLIN
ITALY’S ABORTION LAW
SIR,-Your Round the World correspondent3 is misleading.
Italy’s new law does not permit "abortion on demand" in the first 90 days of pregnancy. Abortion is only allowed within 90 days if continuing the pregnancy would involve a serious danger to the women’s physical and mental health or if there is serious risk that the child would be deformed. The term "serious" is not defined and so is open to the widely varying interpretations of individual doctors. 90% of doctors in Rome and over 70% of doctors in Florence have publicly stated that they will not participate in terminations, so, while the law grants legal abortion, the medical profession is denying it. Your R.T.W. item suggests that women have the right of decision up to 90 days. In fact this is far from what is stated in the law which requires the doctor to determine the consequences of not having a termination. The dioxin incident at Seveso was not considered by local doctors to constitute a serious danger, even though the evidence shows that dioxin can cause severe fetal malformations. One section of the law states that the father of the conceived child can accompany the woman to discuss the abortion in front of the doctor unless the woman objects. Only self-confident women will feel able to object, while many will feel embarassed and confused as two men discuss the question of terminating her pregnancy. If an abortion is requested on social or economic grounds, the doctor must first attempt to remove these grounds by informing the woman about adoption, charitable organisations, help for single mothers, and so on-and only after a thorough investigation would he be able to grant her request for termination. You implied that, once termination has been agreed to, the woman then has 7 days to think about it, after which she is admitted to hospital. This is not true. She has first to return to the original doctor and argue for her decision again. This is, for women, one of the most humiliating aspects of the new law-because it assumes that pregnant women do not know their own minds and must be compelled to rethink. As a counsellor for a C.I.S.A. (information centre on sterilisation and abortion) my experience is that women who apply for a termination have already been through the arguments and made up their minds. The 7-day rule is simply a way of increasing the length of time it takes to get a termination-and the only person who will suffer will be the woman herself. The woman’s problems are not over even if the doctor agrees after the statutory 7 days. She then has to join the queue for a Health Service termination (no private clinics). Since doctors object and many hospitals are run by nuns and
Fortunanto, A Gazz. Osp. Clin. 1931, 59, 843. Ulrich, H., Parks, H. New Engl. J Med. 1940, 222, 711. 3. Lancet, 1978, i, 1252. 1 2.
tion,
coma
and not with ketoacidosis.
Diabetic and Dietetic
’
IAN W. CAMPBELL
Department,
J. F. MUNRO L. J. P. DUNCAN
Royal Infirmary, Edinburgh EH3 9YW
PULMONARY TUBERCULOSIS AND BRONCHIAL CARCINOMA
SIR,-Dr Edlin,l in his report of a small series of cases of active tuberculosis unrecognised until necropsy, implied that there was a negative correlation between tuberculosis and carcinoma, and in support of this referred to papers by Fortune (1929)2 and Cooper (1932).3 However, a careful reading of these two papers shows that Fortune’s and Cooper’s conclusions were quite the opposite-viz., that there was no definite correlation between these two diseases-and these papers give no support to the hypothesis that tuberculosis and carcinoma are in some way mutually antagonistic, as originally propounded in 1854 by von Rokitansky4 and later by Pearly In 1955, I described six cases of bronchial carcinoma in association with active pulmonary tuberculosis, distinguishing those in which the carcinoma developed in known cases of pulmonary tuberculosis from others in which tuberculosis was first discovered when the carcinoma was diagnosed.6 I forecast that we would probably see more patients with these two diseases in association. Springett later showed that pulmonary tuberculosis and bronchial carcinoma not uncommonly coexist, and possibly more often than by chance. The explanation of this has been controversial. Some maintain that carcinoma may develop in scar tissue at sites of healed tuberculous disease.8-10 Alternatively, healed tuberculous lesions may be invaded by carcinoma and the tuberculous disease become reactivated.6 While I agree with Dr Howie’s view on this matterll I cannot accept the suggestion of Dr Healy 12 that "tuberculosis is a common opportunist infection in patients with carcinoma of the lung". In opportunist infection, the offending organism is not a usual human pathogen, and its proliferation results from diminished host defences. However, Mycobacterium tuberculosis is pathogenic to man, and it is therefore incorrect to apply the term "opportunist infection" in this context. Redhill General Hospital, Redhill, Surrey RH1 6LA
***This
letter has been shown
A. SAKULA
to
Dr
Edlin, whose reply fol-
lows.-ED.L.
SIR,-Dr Sakula equates "negative correlation" with Both Fortune and Cooper found a negative correlation between carcinoma and tuberculosis, but also showed statistically that this was due, not to mutual antagonism, but to death from tuberculosis before the individual would have developed carcinoma. My basic point was that carcinoma was not of value as a marker of occult tuberculosis, as
"antagonism".
1. 2.
Edlin, G. P. Lancet, 1978, i, 650. Fortune, C. H. Ann. intern. Med. 1929, 3, 495. 3. Cooper, F. G.Am. Rev. Tuberc. 1932, 25, 108. 4. von Rokitansky, C. A. Manual of Pathological Anatomy;
vol I,
p. 313. Lon-
don, 1854. 5. Pearl, R. Am. J. Hyg. 1929, 9, 97. 6. Sakula, A. Br. med. J. 1955, i, 739. 7. Springett, V. H. Tubercle, 1971, 52, 73. 8. Cherry, T. Lancet, 1931, i, 285. 9. Woodruff, C. E., Nahas, H. C.Am. Rev. Tuberc. 1951, 64, 620. 10. Wofford, J. L., Webb, W. R., Strauss, H. K. Arch. Surg. 1962, 85, 928. 11. Howie, A. J. Lancet, 1978, i, 881. 12. Healy, T. M. ibid. p. 1267.
leukaemia and other reticuloses have been associated with tuberculosis. 1,2 This does not affect the question of the coexistence of tuberculosis and carcinoma. Previously tuberculosis was a disease of youth, but in my series the average age of death with active tuberculosis was 67.4 as opposed to 67.8 for controls. My apparent rate for active tuberculosis not causing death was 1 in 400 necropsies, so a clinician seeing a large number of cases of bronchial carcinoma can expect to see it with the frequency of that age-group (in Dundee 1 in 400) rather than at the rate of incidence in the general population, and so may gain a false impression of its frequency. Pathology Department, Royal Hampshire County Hospital, Winchester
G. EDLIN
ITALY’S ABORTION LAW
SIR,-Your Round the World correspondent3 is misleading.
Italy’s new law does not permit "abortion on demand" in the first 90 days of pregnancy. Abortion is only allowed within 90 days if continuing the pregnancy would involve a serious danger to the women’s physical and mental health or if there is serious risk that the child would be deformed. The term "serious" is not defined and so is open to the widely varying interpretations of individual doctors. 90% of doctors in Rome and over 70% of doctors in Florence have publicly stated that they will not participate in terminations, so, while the law grants legal abortion, the medical profession is denying it. Your R.T.W. item suggests that women have the right of decision up to 90 days. In fact this is far from what is stated in the law which requires the doctor to determine the consequences of not having a termination. The dioxin incident at Seveso was not considered by local doctors to constitute a serious danger, even though the evidence shows that dioxin can cause severe fetal malformations. One section of the law states that the father of the conceived child can accompany the woman to discuss the abortion in front of the doctor unless the woman objects. Only self-confident women will feel able to object, while many will feel embarassed and confused as two men discuss the question of terminating her pregnancy. If an abortion is requested on social or economic grounds, the doctor must first attempt to remove these grounds by informing the woman about adoption, charitable organisations, help for single mothers, and so on-and only after a thorough investigation would he be able to grant her request for termination. You implied that, once termination has been agreed to, the woman then has 7 days to think about it, after which she is admitted to hospital. This is not true. She has first to return to the original doctor and argue for her decision again. This is, for women, one of the most humiliating aspects of the new law-because it assumes that pregnant women do not know their own minds and must be compelled to rethink. As a counsellor for a C.I.S.A. (information centre on sterilisation and abortion) my experience is that women who apply for a termination have already been through the arguments and made up their minds. The 7-day rule is simply a way of increasing the length of time it takes to get a termination-and the only person who will suffer will be the woman herself. The woman’s problems are not over even if the doctor agrees after the statutory 7 days. She then has to join the queue for a Health Service termination (no private clinics). Since doctors object and many hospitals are run by nuns and
Fortunanto, A Gazz. Osp. Clin. 1931, 59, 843. Ulrich, H., Parks, H. New Engl. J Med. 1940, 222, 711. 3. Lancet, 1978, i, 1252. 1 2.
