1235 to suggest that patients who visit their general with minor conditions should make a direct paypractitioner ment of a consultation charge. Furthermore, employed people requiring a routine check-up (e.g., for hypertension) or repeat prescriptions for night sedation, should also pay a fee. Dr Hill suggests that such a "retrograde step" might discourage some ttenders; if we consider that payment for service rendered is immoral, then perhaps an all-wise Government should pay our domestic recurring costs for gas, television licences, and so on. The only erosion I wish to see in the National Health Service is that of relentless increases in the cost of administration and the salaries of staff whose work does not benefit the sick. On Nov. 22 the Daily Mail published a National Opinion Poll survey which suggests that the general public would be prepared to make direct financial contributions for their health
fore, prepared
care.
Christie Hospital & Holt Radium Institute, Manchester M20 9BX
F. D. SKIDMORE
MEDIA’S VIEWS ON HEALTH
other large "anti-health" advertisements which were published on the very same pages seems not only legitimate but desirable. Finally, we hope that your correspondent’s reservations will not deter other doctors (or journalists) from reading the book. Public discussion of medical issues seems to pose sufficient problems for some doctors to take seriously the sociologically oriented studies of mass communication. A little effort to master unfamiliar terminology does not seem an unreasonable burden-and only one of us (J.D.) is a sociologist by training. Unit for Study of Health Policy, Department of Community Medicine, GORDON BEST Guy’s Hospital Medical School, JOHN DENNIS 8 Newcomen Street, London SE1 1YR PETER DRAPER
***In their book Dr Draper and his colleagues make
a strong for their view that many of the media’s activities overlook and even obscure the deeper issues in health care. We believe, however, that the two criticisms by our Parliamentary correspondent (who certainly expressed much sympathy with the book’s central themes and who did not use the word "jargon") will coincide with the reactions of many journalists and editors.-ED.L.
case
SIR,-Your Parliamentary correspondent’s review (Nov. 12, p. 1039) of our paperback, Health, the Mass Media and the National Health Service, seems to agree with the central themes of the book, but we were surprised by two of his criticisms. He objects to the jargon-to the sociological terms we used, particularly in the chapter explaining what researchers into mass communication have to say about the reporting of news and current affairs. For example, the term "cognitive-ideological school of thought" apparently strikes several clinicians who have read our books as neither unnecessary nor "irritating" when seen in context and with the explanation that we gave. It is, after all, an intelligible shorthand term for a large and amorphous body of sociological work-and complex, detailed work at that. Is your correspondent really irritated by sociology-any sociology-rather than the reviewing and discussion of sociologically oriented studies of mass communication? Furthermore, it seems strange for a medical journal to criticise others for the use of jargon. If social issues are to receive systematic study it does not seem unreasonable, theoretically, eventually to expect perhaps as many technical terms as biological issues seem to merit. Clearly we are nowhere near that point. Medical criticism of sociology simply on the grounds of the language being technical and sometimes inaccessible carries the danger of providing too ready an excuse for the casual and superficial study of the social problems of medicine. Perhaps many of the problems that we are now having to cope with-from reorganisation of the N.H.S. to an "anti-public sector" economic policy-have arisen because medicine has taken its social (and economic) context too much for granted and failed to articulate its own experience of organisational issues, with the unhappy result that a motley crew of outside advisers has held undue influence. The second main criticism alleges that we "may have failed to understand how the media actually work" by "confusing news reporting with comment and mixing it all up with newspaper advertisements". As we understand the criticism of television news advanced by Birt and Jay (discussed in our book), one of the main points in their argument is that news "facts" cannot be neatly separated from news choices, value judgments, and interpretations. One may or may not agree with this view, but it seems inaccurate to accuse either Birt and Jay or us of "confusing reporting with comment". As to the charge that we are not only confusing reports with comments but also "mixing it all up with newspaper advertisements", it seems to us that it is the newspaper industry itself that is responsible for the mixing. To draw attention, for example, to the contrast between the very short Press reports of the publication of the consultative document on prevention and the tobacco and
ANIMAL EXPERIMENTS
SIR,-I have been named as being responsible for the idea that 3ymillion licensed animal experiments each year "are not done for medical purposes but to test the safety of commercial products such as cosmetics" (Oct. 29, p. 913). As you point out, I never said this. What I wrote in Victims of Science (1975) was that "less than a third of all licensed experiments on animals can be seen to be medical". Nobody knows exactly how many experiments are for medical purposes each year. Prof. Sam Shuster does not know (his information being based upon a non-representative pilot sample of returns from only 146 out of a total of 18 666 licensed experimenters), nor does the Home Office, nor do I. Much depends upon a realistic definition of "medical", but if medical science wishes to be associated with the routine toxicity testing of new toiletries, then so be it. Fortunately, the Home Office is now trying to gather more information about the purposes of the research, and within a year or two we may have some reliable data. The confusion has arisen because of the chance coincidence of two separate statistics: (1) The Home Office annual returns under the Cruelty to Animals Act 1876 show that 31.6% of the 5 300 000 licensed experiments in 1973 fell into the total of the medical categories of "diagnostic procedures" (4.1%), "mandatory tests for the standardisation of sera,- vaccines or drugs" (20.1%), and "cancer research" (7.5%). These categories have been for years the only breakdown of the figures by purpose of experiment, and they cover what are almost certainly the three major medical areas in which animals are used. This explains my statement that less than a third "can be seen to be medical". The exact purpose of the remaining 3 700 000 experiments remains unknown. (The latest returns show that the comparable total for these three medical categories for 1976 was 32.8% of all licensed experiments.) (2) In the same year (1973) 61.5% of all licensed experiments were "for or under a grant from commercial undertakings" (answer to Parliamentary question given by Dr S. Summerskill, March 8, 1976). In subsequent years the commercial proportion of all experiments has been higher, ranging from 65.7% in 1974 to 64-6% in 1976. This category explains my contention that about two-thirds of all licensed experiments on animals have been for commercial undertakings. It does not follow that (1) (about a third) and (2) (about two-thirds) are mutually exclusive, but some journalists have made this understandable error. Most drug experiments, for
.
1236 will fall into the commercial category. However, 2 303 000 commercial experiments in 1976 that
example, there
were
diagnostic, cancer research, or mandatory drug testing. Exactly what this enormous figure consists of we do not were not
yet know, but it will include the miserable deaths of hundreds of animals in the testing of new cosmetics, toiletries, non-nutritive food additives, and other inessential consumer products. Professor Shuster is also mistaken if he believes that the reformer’s creed "rests on no absolute moral standards". The idea that all sentients have rights is rapidly gaining ground in philosophical and theological circles and should make sense to scientists.. If we accept the darwinian idea of biological kinship then what is the logical reason why there should not be moral kinship? On what grounds, other than sentimentality, do we discriminate so unfairly against other species? Warneford
Hospital, Headington, Oxford OX3 7JX
RICHARD D. RYDER
relieved or cured with bone-marrow, syngeneic or H-2 compatible. Further experiences indicate that the degree of clearance of juvenile scaffolding bone is related to the cell dose given. Even clones of syngeneic cells may not expand sufficiently to produce ultimate cure and H-2 compatible but allogeneic cells are usually rejected in time. The radiographs of the case of Ballet et al., not ideally reproduced on Lancet paper, are reminiscent of pictures we see in mice4where, after initial resolution, relapse is occurring. The data given (594 mg/day calcium accretion, 594 mg/day positive calcium balance) also suggest that bone resorption must be low at this time. We, therefore, question the statement about the cells transplanted: "their persistence can be anticipated according to the observation made in the Op/Op rat", and it remains to be seen whether the rat or the mouse is the better model for man. Work on both should proceed. Charles Salt Research Centre, Robert Jones and Agnes Hunt
Orthopædic Hospital, Oswestry, Shropshire SY10 7AG M.R.C. Radiobiology Unit,
REFERRING URGENT PSYCHIATRIC PROBLEMS your caption Mental Health for the report by Dr Bowman and Dr Sturgeon upon urgent psychiatric cases (Nov. 19, p. 1067). Whose health? The report reveals much more than it states. Bowman and Sturgeon examine cases perceived as urgent by the referring agencies in one setting and assessed by themselves in another, and note disagreements. They conclude that referring agents "find assessment difficult" and that students in their clinic "will learn to cope better". The narrow sympathy astounds, excused I hope by as narrow experience. Long ago house-physicians understood that asthma often got better in the ambulance. House-surgeons know that some acute abdominal pain settles under observation. Referral is sometimes therapeutic. To be exposed as a specialist in one discipline to the problems of another is the experience of psychiatrists too; I wonder how Bowman and
SIR,-I
was
dismayed by
Sturgeon perform then. To be exposed without relief in the community to the extraordinary pressures of agitated, demanding, sometimes manipulative, disturbed people surrounded by neighbours, relatives, and even social services is hard indeed. There are psychiatrists willing to provide asylum as well as diagnose cases-an exclusive range of diagnoses too-without leaping to the conclusion that ignorance and inability to cope amount to
two-thirds of my troubles.
Medical Centre,
Shipston-on-Stour, Warwickshire CV36
GUY HARRIS
4BQ
BONE-MARROW TRANSPLANTATION IN OSTEOPETROSIS
SIR,-We welcome the report by Dr Ballet and his colleagues (Nov. 26, p. 1137) of the results of treatment of congenital osteopetrosis with bone-marrow of a sibling. The rationale was
based
op/op atrophy’
these workers’ experience with the osteopetrotic This genotype is said to be associated with thymic as well as osteopetrosis, and this may facilitate accepon
rat.
of a graft. Our preliminary experiencez.3 with osteopetrotic mt1mi mice (in which osteopetrosis is associated with microphthalmia and other phenotypic features) was that the osteopetrosis was tance
2.
Milhaud, G., Labat, M.-L., Parant, M., Damais, C., Chedid, L. Proc. natn. Acad. Sci. U.S.A. 1977, 74, 339. Barnes, D. W. H., Loutit, J. F., Sansom, J. M. Proc. R. Soc. B. 1975, 188,
3.
Loutit, J. F., Sansom, J. M. Calcif. Tiss. Res. 1976, 20, 251.
1.
501.
Harwell, Didcot, Oxon OX 11 0RD
N. W. NISBET J. MENAGE
J. F. LOUTIT
HÆMORRHAGE AND LOW-DOSE HEPARIN
SIR,-Icannot understand the concern expressed by Mr Britton and his colleagues (Sept. 17, p. 604) about the safety of low-dose heparin prophylaxis in the prevention of postoperative fatal pulmonary embolism. 3 (0.3%) out of their 1000 patients receiving heparin had life-threatening postoperative bleeding. This has nothing to do with the administration of heparin because it represents the expected frequency of this complication after elective and emergency major abdominal surgery. In the multicentre trial’ 5 out of 2076 controls died from postoperative haemorrhage. Dr Sharnoffs comments (Nov. 19, p. 1087) are equally disappointing. He maintains that 5000 units of heparin administered 2 h before surgery is likely to produce "hypocoagulation" and serious haemorrhage because heparin is given too close to the time of surgery; when 10 000 units of heparin has been administered 8-10 h preoperatively no serious haemorrhage has occurred during surgery. However, no significant difference in plasma-heparin concentraton has been observed when the samples were withdrawn 8 h after administration of 10 000 units of heparin compared with the samples obtained 2 h after injection of 5000 units.2 Furthermore, no evidence has ever been presented in randomised prospective studies that monitoring the dose of heparin to be administered during the postoperative period will reduce the frequency of bleeding complications. Yet Sharnoff considers this to be the most crucial part of low-dose heparin prophylaxis. The evidence that low-dose heparin prophylaxis prevents death from pulmonary embolism is convincing. In the international multicentre trial,’ 2 out of 2045 heparin-treated patients died from massive pulmonary embolism compared with 16 out of 2076 controls. These findings are further supported by the data presented by Britton et at, since only 1 out of 1000 patients receiving heparin prophylaxis died from massive pulmonary embolism. The most persuasive evidence for the efficacy of low-dose heparin is presented in the review by Matt and Gruber;3 42 (0-8%) out of 3943 control patients had fatal postoperative pulmonarv tnbolism compared with 8 (0.2%) out of 3919 heparin-treated patients (P
fore, prepared
care.
Christie Hospital & Holt Radium Institute, Manchester M20 9BX
F. D. SKIDMORE
MEDIA’S VIEWS ON HEALTH
other large "anti-health" advertisements which were published on the very same pages seems not only legitimate but desirable. Finally, we hope that your correspondent’s reservations will not deter other doctors (or journalists) from reading the book. Public discussion of medical issues seems to pose sufficient problems for some doctors to take seriously the sociologically oriented studies of mass communication. A little effort to master unfamiliar terminology does not seem an unreasonable burden-and only one of us (J.D.) is a sociologist by training. Unit for Study of Health Policy, Department of Community Medicine, GORDON BEST Guy’s Hospital Medical School, JOHN DENNIS 8 Newcomen Street, London SE1 1YR PETER DRAPER
***In their book Dr Draper and his colleagues make
a strong for their view that many of the media’s activities overlook and even obscure the deeper issues in health care. We believe, however, that the two criticisms by our Parliamentary correspondent (who certainly expressed much sympathy with the book’s central themes and who did not use the word "jargon") will coincide with the reactions of many journalists and editors.-ED.L.
case
SIR,-Your Parliamentary correspondent’s review (Nov. 12, p. 1039) of our paperback, Health, the Mass Media and the National Health Service, seems to agree with the central themes of the book, but we were surprised by two of his criticisms. He objects to the jargon-to the sociological terms we used, particularly in the chapter explaining what researchers into mass communication have to say about the reporting of news and current affairs. For example, the term "cognitive-ideological school of thought" apparently strikes several clinicians who have read our books as neither unnecessary nor "irritating" when seen in context and with the explanation that we gave. It is, after all, an intelligible shorthand term for a large and amorphous body of sociological work-and complex, detailed work at that. Is your correspondent really irritated by sociology-any sociology-rather than the reviewing and discussion of sociologically oriented studies of mass communication? Furthermore, it seems strange for a medical journal to criticise others for the use of jargon. If social issues are to receive systematic study it does not seem unreasonable, theoretically, eventually to expect perhaps as many technical terms as biological issues seem to merit. Clearly we are nowhere near that point. Medical criticism of sociology simply on the grounds of the language being technical and sometimes inaccessible carries the danger of providing too ready an excuse for the casual and superficial study of the social problems of medicine. Perhaps many of the problems that we are now having to cope with-from reorganisation of the N.H.S. to an "anti-public sector" economic policy-have arisen because medicine has taken its social (and economic) context too much for granted and failed to articulate its own experience of organisational issues, with the unhappy result that a motley crew of outside advisers has held undue influence. The second main criticism alleges that we "may have failed to understand how the media actually work" by "confusing news reporting with comment and mixing it all up with newspaper advertisements". As we understand the criticism of television news advanced by Birt and Jay (discussed in our book), one of the main points in their argument is that news "facts" cannot be neatly separated from news choices, value judgments, and interpretations. One may or may not agree with this view, but it seems inaccurate to accuse either Birt and Jay or us of "confusing reporting with comment". As to the charge that we are not only confusing reports with comments but also "mixing it all up with newspaper advertisements", it seems to us that it is the newspaper industry itself that is responsible for the mixing. To draw attention, for example, to the contrast between the very short Press reports of the publication of the consultative document on prevention and the tobacco and
ANIMAL EXPERIMENTS
SIR,-I have been named as being responsible for the idea that 3ymillion licensed animal experiments each year "are not done for medical purposes but to test the safety of commercial products such as cosmetics" (Oct. 29, p. 913). As you point out, I never said this. What I wrote in Victims of Science (1975) was that "less than a third of all licensed experiments on animals can be seen to be medical". Nobody knows exactly how many experiments are for medical purposes each year. Prof. Sam Shuster does not know (his information being based upon a non-representative pilot sample of returns from only 146 out of a total of 18 666 licensed experimenters), nor does the Home Office, nor do I. Much depends upon a realistic definition of "medical", but if medical science wishes to be associated with the routine toxicity testing of new toiletries, then so be it. Fortunately, the Home Office is now trying to gather more information about the purposes of the research, and within a year or two we may have some reliable data. The confusion has arisen because of the chance coincidence of two separate statistics: (1) The Home Office annual returns under the Cruelty to Animals Act 1876 show that 31.6% of the 5 300 000 licensed experiments in 1973 fell into the total of the medical categories of "diagnostic procedures" (4.1%), "mandatory tests for the standardisation of sera,- vaccines or drugs" (20.1%), and "cancer research" (7.5%). These categories have been for years the only breakdown of the figures by purpose of experiment, and they cover what are almost certainly the three major medical areas in which animals are used. This explains my statement that less than a third "can be seen to be medical". The exact purpose of the remaining 3 700 000 experiments remains unknown. (The latest returns show that the comparable total for these three medical categories for 1976 was 32.8% of all licensed experiments.) (2) In the same year (1973) 61.5% of all licensed experiments were "for or under a grant from commercial undertakings" (answer to Parliamentary question given by Dr S. Summerskill, March 8, 1976). In subsequent years the commercial proportion of all experiments has been higher, ranging from 65.7% in 1974 to 64-6% in 1976. This category explains my contention that about two-thirds of all licensed experiments on animals have been for commercial undertakings. It does not follow that (1) (about a third) and (2) (about two-thirds) are mutually exclusive, but some journalists have made this understandable error. Most drug experiments, for
.
1236 will fall into the commercial category. However, 2 303 000 commercial experiments in 1976 that
example, there
were
diagnostic, cancer research, or mandatory drug testing. Exactly what this enormous figure consists of we do not were not
yet know, but it will include the miserable deaths of hundreds of animals in the testing of new cosmetics, toiletries, non-nutritive food additives, and other inessential consumer products. Professor Shuster is also mistaken if he believes that the reformer’s creed "rests on no absolute moral standards". The idea that all sentients have rights is rapidly gaining ground in philosophical and theological circles and should make sense to scientists.. If we accept the darwinian idea of biological kinship then what is the logical reason why there should not be moral kinship? On what grounds, other than sentimentality, do we discriminate so unfairly against other species? Warneford
Hospital, Headington, Oxford OX3 7JX
RICHARD D. RYDER
relieved or cured with bone-marrow, syngeneic or H-2 compatible. Further experiences indicate that the degree of clearance of juvenile scaffolding bone is related to the cell dose given. Even clones of syngeneic cells may not expand sufficiently to produce ultimate cure and H-2 compatible but allogeneic cells are usually rejected in time. The radiographs of the case of Ballet et al., not ideally reproduced on Lancet paper, are reminiscent of pictures we see in mice4where, after initial resolution, relapse is occurring. The data given (594 mg/day calcium accretion, 594 mg/day positive calcium balance) also suggest that bone resorption must be low at this time. We, therefore, question the statement about the cells transplanted: "their persistence can be anticipated according to the observation made in the Op/Op rat", and it remains to be seen whether the rat or the mouse is the better model for man. Work on both should proceed. Charles Salt Research Centre, Robert Jones and Agnes Hunt
Orthopædic Hospital, Oswestry, Shropshire SY10 7AG M.R.C. Radiobiology Unit,
REFERRING URGENT PSYCHIATRIC PROBLEMS your caption Mental Health for the report by Dr Bowman and Dr Sturgeon upon urgent psychiatric cases (Nov. 19, p. 1067). Whose health? The report reveals much more than it states. Bowman and Sturgeon examine cases perceived as urgent by the referring agencies in one setting and assessed by themselves in another, and note disagreements. They conclude that referring agents "find assessment difficult" and that students in their clinic "will learn to cope better". The narrow sympathy astounds, excused I hope by as narrow experience. Long ago house-physicians understood that asthma often got better in the ambulance. House-surgeons know that some acute abdominal pain settles under observation. Referral is sometimes therapeutic. To be exposed as a specialist in one discipline to the problems of another is the experience of psychiatrists too; I wonder how Bowman and
SIR,-I
was
dismayed by
Sturgeon perform then. To be exposed without relief in the community to the extraordinary pressures of agitated, demanding, sometimes manipulative, disturbed people surrounded by neighbours, relatives, and even social services is hard indeed. There are psychiatrists willing to provide asylum as well as diagnose cases-an exclusive range of diagnoses too-without leaping to the conclusion that ignorance and inability to cope amount to
two-thirds of my troubles.
Medical Centre,
Shipston-on-Stour, Warwickshire CV36
GUY HARRIS
4BQ
BONE-MARROW TRANSPLANTATION IN OSTEOPETROSIS
SIR,-We welcome the report by Dr Ballet and his colleagues (Nov. 26, p. 1137) of the results of treatment of congenital osteopetrosis with bone-marrow of a sibling. The rationale was
based
op/op atrophy’
these workers’ experience with the osteopetrotic This genotype is said to be associated with thymic as well as osteopetrosis, and this may facilitate accepon
rat.
of a graft. Our preliminary experiencez.3 with osteopetrotic mt1mi mice (in which osteopetrosis is associated with microphthalmia and other phenotypic features) was that the osteopetrosis was tance
2.
Milhaud, G., Labat, M.-L., Parant, M., Damais, C., Chedid, L. Proc. natn. Acad. Sci. U.S.A. 1977, 74, 339. Barnes, D. W. H., Loutit, J. F., Sansom, J. M. Proc. R. Soc. B. 1975, 188,
3.
Loutit, J. F., Sansom, J. M. Calcif. Tiss. Res. 1976, 20, 251.
1.
501.
Harwell, Didcot, Oxon OX 11 0RD
N. W. NISBET J. MENAGE
J. F. LOUTIT
HÆMORRHAGE AND LOW-DOSE HEPARIN
SIR,-Icannot understand the concern expressed by Mr Britton and his colleagues (Sept. 17, p. 604) about the safety of low-dose heparin prophylaxis in the prevention of postoperative fatal pulmonary embolism. 3 (0.3%) out of their 1000 patients receiving heparin had life-threatening postoperative bleeding. This has nothing to do with the administration of heparin because it represents the expected frequency of this complication after elective and emergency major abdominal surgery. In the multicentre trial’ 5 out of 2076 controls died from postoperative haemorrhage. Dr Sharnoffs comments (Nov. 19, p. 1087) are equally disappointing. He maintains that 5000 units of heparin administered 2 h before surgery is likely to produce "hypocoagulation" and serious haemorrhage because heparin is given too close to the time of surgery; when 10 000 units of heparin has been administered 8-10 h preoperatively no serious haemorrhage has occurred during surgery. However, no significant difference in plasma-heparin concentraton has been observed when the samples were withdrawn 8 h after administration of 10 000 units of heparin compared with the samples obtained 2 h after injection of 5000 units.2 Furthermore, no evidence has ever been presented in randomised prospective studies that monitoring the dose of heparin to be administered during the postoperative period will reduce the frequency of bleeding complications. Yet Sharnoff considers this to be the most crucial part of low-dose heparin prophylaxis. The evidence that low-dose heparin prophylaxis prevents death from pulmonary embolism is convincing. In the international multicentre trial,’ 2 out of 2045 heparin-treated patients died from massive pulmonary embolism compared with 16 out of 2076 controls. These findings are further supported by the data presented by Britton et at, since only 1 out of 1000 patients receiving heparin prophylaxis died from massive pulmonary embolism. The most persuasive evidence for the efficacy of low-dose heparin is presented in the review by Matt and Gruber;3 42 (0-8%) out of 3943 control patients had fatal postoperative pulmonarv tnbolism compared with 8 (0.2%) out of 3919 heparin-treated patients (P
