tion of the radiological shadows and in radiographic technique. It is through the further development of radiolo~, that we can confidently hope to increase our knowledge of the disease in children and this in turn will provide a firmer basis for our understanding of tuberculosis in general.
Acknowledgments My grateful thanks are due to Dr F. J. Bentley, Senior Physician, High "~Vood
Hospital, Brentwood, for his encouragement, criticism and help. I would also like to thank Miss J. M. Tomkinson for her secretarial assistance. Bibliography Bentley, F. J., Grzybowski, S., and Benjamin, B. (1954) Tuberculosis in Childhood and Adolescence. N.A.P.T. London. Brock, R. C. 0950) Post-tuberculous bronchostenosis and bronehiectasis of the middle lobe, Thorax, v, 5; Westermark, N. (I948) Roentgen Studies of the Lungs and Ileart. University of Minnesota Press. Minneapolis.
Smoking and Cancer A Point of View There is no evidence statistical or clinical that smoking is a factor in the causation of cancer of the lung. In Britain men who smoke out-number those who do not smoke by ht least ten to one. Therefore we should expect more cases of all diseases among smokers than among non-smokers. For example there is more baldness among smokers but no one says that smoking is a cause of baldness. Women smoke less than men and are less liable to develop cancer of the lung. That proves nothing because women are also less liable to all other diseases of the lungs and heart. There has been a great increase of cigarette smoking in Britain during the present century. From i9oo to z952 the annual sale of cigarettes per adult head of population has increased from 1-9 kilos to 22"o kilos. During this time the death-rate in England and Wales from cancer of the lips and tongue per million living has fallen from 29 to 16. This I attribute to the disappearance of the old clay pipe. Incidentally, no one has suggested that pipe smoking is a cause of cancer of the lung. From z9o 5 to i952 the death-rate from cancer of the lung and pleura per million living and standardized to the z95o population of England and Wales had increased from IO in males and IO in females to 56o in males and IOO in females. The death-rate
among women had increased by ten times and among men by fifty-six timcs. At the beginning of the century it was impossible to diagnose cancer of the lung without a post-mortem examination. Where this was not made many of these cases were diagnosed as tuberculosis. With the advent of x-rays diagnosis became more and more accurate. Thus in z943 the first Mass Radiography Unit began to operate among the cMlian population o f England and Wales. By the end of I952 there were 62 Units in operation, and each Unit can examine at least 5o,ooo people. During that time the death-rate rose from 28o in men and 6o in women to 56o in males and zoo in females. In these ten years the incidence of cancer of the lung had almost doubled; but tile sale of cigarettes to men had fallen from I9.z to I6"9 kilos. The cigarettes sold to females in I943 and I952 were at tile rate of 5 kilos per head. Since I949 death-rates per million living have been given by the Registrar-General for: (a) Cancer of the trachea, bronchus and lung specified as primary. These are the only forms of cancer which could be caused by smoking. In x953 the rate was 99. (b) Cancer of the lung and bronchus unspecified as to whether primary or secondary. In I953 the rate for these w a s 22 4 .
I n the U.S.A. an extract o f tobacco when applied on the skin o f a mouse has p r o d u c e d cancer. But mice are not men; and t o d a y millions o f m e n carry a nicotine stain o n the first and second fingers o f the right hand. Y e t cancer o f these fingers is unknown. M o r e o v e r tobacco smoke is not radio-active. T w o radio-active substances have been found in cigarette ash. But who ever saw a n y o n e inhaling the ash from his cigarette? I n fact there is no evidence that smoking is a factor in the causation o f cancer o f the lung. T h e highest male mortality from this cause is between the ages o f 65 a n d 74; and in females at 75 years a n d over. As the
Minister o f H e a l t h told tile H o u s e o f C o m m o n s on F e b r u a r y I2, I954: ' I would d r a w attention to the fact t h a t there is no firm evidence o f the w a y in which smoking m a y cause lung c a n c e r or the extent to which it does so'. O n the o t h e r h a n d there is some statistical evidence t h a t lung c a n c e r is m o r e p r e v a l e n t in the fog and petrol laden air of o u r industrial cities t h a n in the country. T h e r e is no evidence that people smoke dlore in towns, but there is evidence that the air o f industrial cities contains B e n z p h y n e n e , a substance which in animals will p r o d u c e cancer. HALLIDAY SUTtlERLAND, M.D.
Combined Meeting of the Metropolitan Tuberculosis Societies A combined meeting of the Tuberculosis Societies of the North-East, North-'~Vest and South-East Metropolitan Regions was held on Saturday, February I3, to discuss the place of resection in the treatment of pulmonary tuberculosis. The opening speaker, M r Ronald Edwards, began by admitting that because of the relatively short time for which resection had been practised it was not yet possible to make a real comparison of its results with those of the various forms of collapse therapy. Resection may be undertaken in the following five varieties of disease: (a) Tim Caseous Nodule, (b) Destroyed Lung, (c) Bronchiectatie Areas, (d) Fibrocaseous Disease, and (e) Empyema Associated with Underlying Pulmonary Disease. M r Edwards said he had not entirely given uP thoracoplasty, and felt that if a patient was to be treated b y resection it should be possible to remove all the major areas of disease. In the elderly, also, h lr Edwards preferred thoracoplasty to resection. With regard to puhnonary function, resection had no marked difference from thoracoplasty and, in fact, it is often advisable to do a small tlmracoplasty as well as resection to prevent over-expansion of the residual lung. Referring to post-operative complications, ik'Ir Edwards admitted that a bronchial fistula was a worse disaster than any of the complications of thoracoplasty, but apart from this the complications of resection were less troublesome. Patients treated by resection were usually
back to active life in six to nine months after operation and M r Edwards emphasized the close co-operation with the chest physicians in both preliminary and post-operative care. So far as total figures were concerned, he and his colleagues had operated on r,o23 patients with post-operative mortality of 1-95 per cent. M r Holmes Sellors followed and while accepting resection as an essential part of modern t/'eatment of pulmonary tuberculosis, he wished to take the more conservative view. He wondered whether pulmonary tuberculosis could be safely regarded as a purely local phenomenon rather than as part of a general disease. He questioned the need to remove all small caseous nodules because little was known of the fate of these lesions. He also stressed the social background of the patients has often an important bearing as to whether they should be treated surgically. Lesions which might well be best excised from a patient who needed to return to vigorous manual labour could often be left alone in a patient who followed some quiet sedentary occupation. Mr Holmes Sellors felt that the complications of resection were considerable and could not be ignored. He had Carried out thoracoplasties on I,I7I patients compared with 538 resections for the years i946-I952, and he regarded resection as being indicated in the following cases: (a) large solid loci, (b) thick-walled unclosed cavities under artificial pneumothoraces, (c) cavities in the apical segments of lower lobes,