- Email: [email protected]
Preventing the Ultimate Disaster
835
profession. The second congress of I.P.P.N.W.,2,3 which began in Cambridge, England, on April 3, was largely devoted to the possible effects of nuclear war in Europe. It was attended by over 200 doctors from 35 countries. The plenary session began with addresses from Sir DOUGLAS BLACK, President of the Royal College of Physicians of London, and Academician NIKOLAI
BLOKHIN, Chairman of the U.S.S.R. Medical Sciences, both of whom cast of Academy doubt on the sanity of policies in which nuclear weapons were a major force. Prof. H. E. RICHTER, of the Justus Liebig University, Geissen, earned a sympathetic hearing when he spoke of the fears of many young people who were now convinced that the world would end in nuclear war and who protested against their fate. How could peace be threatened, as some politicians declared it was, by an outbreak of a peace-loving attitude? The stockpiling of nuclear weapons could be tolerated by most people only if it was seen as a defence against some absolute enemy, corrupt and aggressive. A collective paranoia had to be replaced by a mutual trust. An American voice, Admiral NOEL GAYLER, identified nuclear weapons as the real enemy. We should get rid of them: they had no military utility. Disarmament and reduction proposals by one side should not be instantly discredited by the opposition. Prof. BERNARD LOWN, professor of cardiology at the Harvard School of Public Health, who shared in the creation of I.P.P.N.W. with Academician EUGENE CHAZOV, Director General of the National Cardiological Research Centre, U.S.S.R. Academy of Medical Sciences, emphasised the need to maintain the momentum of this medical effort to educate and to change public opinion. The objectives of I.P.P.N.W. were to stop the nuclear arms race now, to begin multilateral verifiable nuclear disarmament, and to remove nuclear weapons from the arsenals of nations. Professor CHAZOV had broken his leg and was unable to attend the congress. A statement from him declared that Soviet physicians firmly believed that war was not fatalistically inevitable. They wanted to spare the world another spiral of the arms race and they were convinced that both the Soviet Union and the Western countries had an equal stake in this. To halt the process of sliding towards the ultimate disaster required persistent effort, and the medical contribution should
particularly
Preventing the Ultimate Disaster IN the early days of the suicidal competition in arms between the nations who possess nuclear weapons, President Eisenhower, it is said, was asked to envisage a United States arsenal of 500 nuclear warheads. "Why", he responded, casting a dubious eye on his advisers, "do we not go really crazy and plan for 5000?" The statistics of today’s arsenals and the folly of the accelerating arm$race demonstrate that the President’s eye was not stern enough to restrain those of his fellow statesmen, West and East, who have sought to deter or to dominate by nuclear weaponry. Nor did the Governments foresee too clearly the hazards that could befall when their decisions had led on to a megatonnage of today’s enormity. About 50 000 strategic and tactical nuclear weapons now lie in the hands of the counterpoised powers: equivalent to 3 tons of that simple explosive, trinitrotoluene, for every person on earth. The nuclear accumulation of death lies in the control of political leaders seemingly insensitive to the pleas of their citizens, who yearn to be rid of this threat and who seek to devote their lives and that of their descendants to a happier cause than the present belief in the necessity of preparation for war against an enemy whose common people share a worldwide aspiration towards peace and international cooperation. The paradox-a mounting threat of nuclear war and a universal will for peace-can be resolved only by communication between human beings at all levels and by the imposition of the message for peace on political leaders, swayed, whenever possible, by votes. In this urgent matter an international concord of the medical profession is being heard. Doctors have a strong voice; and it must not be muted because they fear attribution of political motives when they declare that the outbreak of nuclear war will lead to horrors for which they have not the slightest answer. The body created in 1980 and known as International Physicians for the Prevention of Nuclear War’ is the most effective medium for the worldwide transmission of this message from the medical 1. Conference. International i: 790-91.
Physicians for the Prevention of
Nuclear War. Lancet 1981;
consist in speaking honestly to people all over the world about what mankind would face if a thermonuclear war broke out. Why should doctors deserve a special hearing, when most are ignorant of arms control and innocent of atomic physics? Their area of knowledge lies in the medical consequence of nuclear war; the possibilities of medical care after a nuclear attack; and-among those with more psychological interests-the "denial" strategies of populations at risk and the abberrations of 2. Note. Prevention of nuclear war. Lancet 1982; i: 753. 3. Editorial. An appeal for peace. Lancet 1982; i: 321.
836
which might trigger an exchange. Those who had entrusted doctors with their health and lives should be made aware of the reality of the danger.
personality
The conclusions of the congress will be summarised in week’s Lancet.
next
’
Parotid Tumours: Enucleation or Excision PAROTID tumours were described under the name scirrhous tumours by SIEBOLD in 1793. BILLROTH gave a detailed account in 1859 and they were termed mixed tumours by MINSENN in 1874.’ The first operation for what was probably a mixed parotid tumour was done by BECLARD in 1824,2and for the next hundred years the routine operation was enucleation. This was felt to be the best operation for a supposedly benign tumour because it carried the lowest risk to the facial nerve. The shortcomings of this procedure began to be exposed in the 1930s by MCFARLAND, who called for prolonged observation of the behaviour of these tumours. Of 297 mixed tumours of the parotid, submaxillary, and sublingual glands, almost one in four recurred during a long follow-up and about 507o ultimately killed the patient.3 From about 1940 two modifications were advised to reduce local recurrence-excision rather than enucleation, and postoperative irradiation. Excision of the parotid gland was popularised in the 1940s by HAMILTON BAILEY in the U.K. and by REDON in France. BAILEY insisted that the capsule should be removed with a cuff of normal tissue,4 but in such operations the facial nerve is greatly at risk. Of 9 patients reported by KIDD5 in 1950, 3 had a facial paralysis; his method of finding the facial nerve was first to expose the cervical branch, a procedure now thought to be dangerous. The incidence of facial paralysis has been reduced by refinements of technique including hypotensive anaesthesia and stimulation of the facial nerve. In addition it is now recognised that the easiest and safest way to find the facial nerve is to look for it where it is thickest and most constant in position-that is, where the trunk emerges from the stylomastoid foramen. In 1940, PATEY, later one of the champions of parotidectomy, stated that enucleation followed by irradiation was the best active treatment.A more recent advocate of this policy is MCEVEDY who in 1976 reported 73 patients who received postoperative radiotherapy (radium needle implant or teletherapy). 18% had a transient facial palsy, 5% had permanent paralysis. On follow-up at a minimum of 5 years, 3% of the tumours had recurred. MCEVEDY favours this 1. Eneroth CM. Classification of parotid tumours. Proc Roy Soc Med 1966; 59: 429-35. 2. Béclard PA. Extirpation de la parotide. Arch Gén Méd 1824; 4: 60-66. 3. McFarland J. Three hundred mixed tumours of the salivary glands, of which sixty-nine recurred. Surg Gynecol Obstet 1936; 63: 457-68. 4. Bailey H. The treatment of tumours of the parotid gland with special reference to total parotidectomy. Br J Surg 1941; 28: 337-46. 5. Kidd HA. Complete excision ofthe parotid gland with preservation of the facial nerve. Br Med J 1950; i: 989-91. 6. Patey DH. The treatment of mixed tumours of the parotid gland. Br J Surg 1940; 28:
29-38
approach because parotidectomy is more hazardous to the facial nerve.’ The other major complication of parotid surgery is Frey’s syndrome-that is, sweating and discomfort on one side of the face during eating. This syndrome is virtually untreatable. In HAW’s series it arose only after parotidectomy, not after enucleation.8 There are thus two opposing camps: those who advocate enucleation plus radiotherapy because they think that the operation carries less risk to the facial nerve and less risk of complications (notably Frey’s syndrome); and those who advise excision because, with good exposure, the facial nerve is not greatly at risk, recurrence is less likely, and the patient is not exposed to the carcinogenic hazard of radiation. STEVENS and HOBSLEY9 have now illuminated the with a report on 100 patients who underwent formal parotidectomy. Of 72 who had a primary operation, none had a permanent facial paralysis and none had a recurrence after median follow-up of 4 years. Of 28 patients who had the operation for recurrent disease, 11 had a permanent facial paralysis and in 4 there was malignant degeneration. Recurrences, after enucleation often multicentric and invading the skin, are very difficult to deal with surgically. A further point raised by HOBSLEY is the consequence of attempted enucleation when the diagnosis proves to be wrong. Inadvertent enucleation of a malignant lump such as an adenoid cystic or mucoepidermoid carcinoma is a disaster. At least seven different operations have been used in treatment of these mixed tumours of the scene
parotid-intracapsular
enucleation,
extracapsular
enucleation, removal of the tumour with a cuff of normal tissue, removal of the lower pole of the gland (with and without identification of the nerve), superficial parotidectomy, and total parotidectomy. Few would now advocate total parotidectomy, as BAILEY did; and even complete superficial conservative parotidectomy (with preservation of all named branches of facial nerve) is almost certainly excessive: the tumour never involves the superior part of the gland, so that removal of that part of the gland overlying the upper division of the facial nerve puts the nerve in unnecessary danger. Enucleation is certainly not an adequate treatment. Even enucleation plus radiotherapy ought now to be abandoned in favour of some form of conservative parotidectomy-that is, removal of the lower part of the gland with identification of the facial nerve. No better justification is needed than BAILEY’s statement made 40 years ago. "It is my belief that by instituting some radical alternatives in teaching and practice, all but a very few parotid tumours can be placed in a category where our conception of surgical pathology tells us they
belong-absolute curability." McEvedy BV, Ross WM. The treatment of mixed parotid tumours by enucleation and radiotherapy. Br J Surg 1976; 63: 341-42. 8. Haw CS. Pleomorphic adenoma of the parotid gland. J Roy Coll Surg Edin 1975; 20: 7.
25-29. 9. Stevens
KL, Hobsley M. The treatment parotidectomy. Br J Surg 1982; 69: 1-3.
of
pleomorphic
adenomas
by formal
profession. The second congress of I.P.P.N.W.,2,3 which began in Cambridge, England, on April 3, was largely devoted to the possible effects of nuclear war in Europe. It was attended by over 200 doctors from 35 countries. The plenary session began with addresses from Sir DOUGLAS BLACK, President of the Royal College of Physicians of London, and Academician NIKOLAI
BLOKHIN, Chairman of the U.S.S.R. Medical Sciences, both of whom cast of Academy doubt on the sanity of policies in which nuclear weapons were a major force. Prof. H. E. RICHTER, of the Justus Liebig University, Geissen, earned a sympathetic hearing when he spoke of the fears of many young people who were now convinced that the world would end in nuclear war and who protested against their fate. How could peace be threatened, as some politicians declared it was, by an outbreak of a peace-loving attitude? The stockpiling of nuclear weapons could be tolerated by most people only if it was seen as a defence against some absolute enemy, corrupt and aggressive. A collective paranoia had to be replaced by a mutual trust. An American voice, Admiral NOEL GAYLER, identified nuclear weapons as the real enemy. We should get rid of them: they had no military utility. Disarmament and reduction proposals by one side should not be instantly discredited by the opposition. Prof. BERNARD LOWN, professor of cardiology at the Harvard School of Public Health, who shared in the creation of I.P.P.N.W. with Academician EUGENE CHAZOV, Director General of the National Cardiological Research Centre, U.S.S.R. Academy of Medical Sciences, emphasised the need to maintain the momentum of this medical effort to educate and to change public opinion. The objectives of I.P.P.N.W. were to stop the nuclear arms race now, to begin multilateral verifiable nuclear disarmament, and to remove nuclear weapons from the arsenals of nations. Professor CHAZOV had broken his leg and was unable to attend the congress. A statement from him declared that Soviet physicians firmly believed that war was not fatalistically inevitable. They wanted to spare the world another spiral of the arms race and they were convinced that both the Soviet Union and the Western countries had an equal stake in this. To halt the process of sliding towards the ultimate disaster required persistent effort, and the medical contribution should
particularly
Preventing the Ultimate Disaster IN the early days of the suicidal competition in arms between the nations who possess nuclear weapons, President Eisenhower, it is said, was asked to envisage a United States arsenal of 500 nuclear warheads. "Why", he responded, casting a dubious eye on his advisers, "do we not go really crazy and plan for 5000?" The statistics of today’s arsenals and the folly of the accelerating arm$race demonstrate that the President’s eye was not stern enough to restrain those of his fellow statesmen, West and East, who have sought to deter or to dominate by nuclear weaponry. Nor did the Governments foresee too clearly the hazards that could befall when their decisions had led on to a megatonnage of today’s enormity. About 50 000 strategic and tactical nuclear weapons now lie in the hands of the counterpoised powers: equivalent to 3 tons of that simple explosive, trinitrotoluene, for every person on earth. The nuclear accumulation of death lies in the control of political leaders seemingly insensitive to the pleas of their citizens, who yearn to be rid of this threat and who seek to devote their lives and that of their descendants to a happier cause than the present belief in the necessity of preparation for war against an enemy whose common people share a worldwide aspiration towards peace and international cooperation. The paradox-a mounting threat of nuclear war and a universal will for peace-can be resolved only by communication between human beings at all levels and by the imposition of the message for peace on political leaders, swayed, whenever possible, by votes. In this urgent matter an international concord of the medical profession is being heard. Doctors have a strong voice; and it must not be muted because they fear attribution of political motives when they declare that the outbreak of nuclear war will lead to horrors for which they have not the slightest answer. The body created in 1980 and known as International Physicians for the Prevention of Nuclear War’ is the most effective medium for the worldwide transmission of this message from the medical 1. Conference. International i: 790-91.
Physicians for the Prevention of
Nuclear War. Lancet 1981;
consist in speaking honestly to people all over the world about what mankind would face if a thermonuclear war broke out. Why should doctors deserve a special hearing, when most are ignorant of arms control and innocent of atomic physics? Their area of knowledge lies in the medical consequence of nuclear war; the possibilities of medical care after a nuclear attack; and-among those with more psychological interests-the "denial" strategies of populations at risk and the abberrations of 2. Note. Prevention of nuclear war. Lancet 1982; i: 753. 3. Editorial. An appeal for peace. Lancet 1982; i: 321.
836
which might trigger an exchange. Those who had entrusted doctors with their health and lives should be made aware of the reality of the danger.
personality
The conclusions of the congress will be summarised in week’s Lancet.
next
’
Parotid Tumours: Enucleation or Excision PAROTID tumours were described under the name scirrhous tumours by SIEBOLD in 1793. BILLROTH gave a detailed account in 1859 and they were termed mixed tumours by MINSENN in 1874.’ The first operation for what was probably a mixed parotid tumour was done by BECLARD in 1824,2and for the next hundred years the routine operation was enucleation. This was felt to be the best operation for a supposedly benign tumour because it carried the lowest risk to the facial nerve. The shortcomings of this procedure began to be exposed in the 1930s by MCFARLAND, who called for prolonged observation of the behaviour of these tumours. Of 297 mixed tumours of the parotid, submaxillary, and sublingual glands, almost one in four recurred during a long follow-up and about 507o ultimately killed the patient.3 From about 1940 two modifications were advised to reduce local recurrence-excision rather than enucleation, and postoperative irradiation. Excision of the parotid gland was popularised in the 1940s by HAMILTON BAILEY in the U.K. and by REDON in France. BAILEY insisted that the capsule should be removed with a cuff of normal tissue,4 but in such operations the facial nerve is greatly at risk. Of 9 patients reported by KIDD5 in 1950, 3 had a facial paralysis; his method of finding the facial nerve was first to expose the cervical branch, a procedure now thought to be dangerous. The incidence of facial paralysis has been reduced by refinements of technique including hypotensive anaesthesia and stimulation of the facial nerve. In addition it is now recognised that the easiest and safest way to find the facial nerve is to look for it where it is thickest and most constant in position-that is, where the trunk emerges from the stylomastoid foramen. In 1940, PATEY, later one of the champions of parotidectomy, stated that enucleation followed by irradiation was the best active treatment.A more recent advocate of this policy is MCEVEDY who in 1976 reported 73 patients who received postoperative radiotherapy (radium needle implant or teletherapy). 18% had a transient facial palsy, 5% had permanent paralysis. On follow-up at a minimum of 5 years, 3% of the tumours had recurred. MCEVEDY favours this 1. Eneroth CM. Classification of parotid tumours. Proc Roy Soc Med 1966; 59: 429-35. 2. Béclard PA. Extirpation de la parotide. Arch Gén Méd 1824; 4: 60-66. 3. McFarland J. Three hundred mixed tumours of the salivary glands, of which sixty-nine recurred. Surg Gynecol Obstet 1936; 63: 457-68. 4. Bailey H. The treatment of tumours of the parotid gland with special reference to total parotidectomy. Br J Surg 1941; 28: 337-46. 5. Kidd HA. Complete excision ofthe parotid gland with preservation of the facial nerve. Br Med J 1950; i: 989-91. 6. Patey DH. The treatment of mixed tumours of the parotid gland. Br J Surg 1940; 28:
29-38
approach because parotidectomy is more hazardous to the facial nerve.’ The other major complication of parotid surgery is Frey’s syndrome-that is, sweating and discomfort on one side of the face during eating. This syndrome is virtually untreatable. In HAW’s series it arose only after parotidectomy, not after enucleation.8 There are thus two opposing camps: those who advocate enucleation plus radiotherapy because they think that the operation carries less risk to the facial nerve and less risk of complications (notably Frey’s syndrome); and those who advise excision because, with good exposure, the facial nerve is not greatly at risk, recurrence is less likely, and the patient is not exposed to the carcinogenic hazard of radiation. STEVENS and HOBSLEY9 have now illuminated the with a report on 100 patients who underwent formal parotidectomy. Of 72 who had a primary operation, none had a permanent facial paralysis and none had a recurrence after median follow-up of 4 years. Of 28 patients who had the operation for recurrent disease, 11 had a permanent facial paralysis and in 4 there was malignant degeneration. Recurrences, after enucleation often multicentric and invading the skin, are very difficult to deal with surgically. A further point raised by HOBSLEY is the consequence of attempted enucleation when the diagnosis proves to be wrong. Inadvertent enucleation of a malignant lump such as an adenoid cystic or mucoepidermoid carcinoma is a disaster. At least seven different operations have been used in treatment of these mixed tumours of the scene
parotid-intracapsular
enucleation,
extracapsular
enucleation, removal of the tumour with a cuff of normal tissue, removal of the lower pole of the gland (with and without identification of the nerve), superficial parotidectomy, and total parotidectomy. Few would now advocate total parotidectomy, as BAILEY did; and even complete superficial conservative parotidectomy (with preservation of all named branches of facial nerve) is almost certainly excessive: the tumour never involves the superior part of the gland, so that removal of that part of the gland overlying the upper division of the facial nerve puts the nerve in unnecessary danger. Enucleation is certainly not an adequate treatment. Even enucleation plus radiotherapy ought now to be abandoned in favour of some form of conservative parotidectomy-that is, removal of the lower part of the gland with identification of the facial nerve. No better justification is needed than BAILEY’s statement made 40 years ago. "It is my belief that by instituting some radical alternatives in teaching and practice, all but a very few parotid tumours can be placed in a category where our conception of surgical pathology tells us they
belong-absolute curability." McEvedy BV, Ross WM. The treatment of mixed parotid tumours by enucleation and radiotherapy. Br J Surg 1976; 63: 341-42. 8. Haw CS. Pleomorphic adenoma of the parotid gland. J Roy Coll Surg Edin 1975; 20: 7.
25-29. 9. Stevens
KL, Hobsley M. The treatment parotidectomy. Br J Surg 1982; 69: 1-3.
of
pleomorphic
adenomas
by formal