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WILMS' TUMOUR
824
the specificity must reside in the shape of the D.N.A.histone complex-a shape which, we must conclude, is distinct from that of either of its two separate components. WILMS’ TUMOUR
pleased if we
can recollect that Wilms’ tumour of the kidney found in children: we may 1 even remember that its modern name is and, because it is derived from the immature renal blastema, it may contain not only epithelial elements of tubules and incompletely formed glomeruli as well as connective tissue or sarcomatous elements, but also striated muscle,"cartilage, or even bone. Our pleasure is clouded by the belief that such a tumour is very commonly fatal, only a few fortunate patients being saved by
WE
is
are
a rare tumour
nephroblastoma
operation. The two-year-survival
rate of patients with Wilms’ before 1934 was only 9% 2 ; but Lattimer et al.22 bring the welcome news that, of their 42 cases treated since then, 16 survived for two or more years after operation. In their series females were slightly preponderant (in most series1 males are about twice as numerous as females); the tumours were equally frequent on each side, and in 4 patients there were bilateral growths. Tumours at the lower pole carried a better prognosis, being more easily palpable and surrounded by loose fatty coverings which could absorb some local extension and still be removed successfully with the tumour. The most important finding was that the age of onset was closely linked with the two-year-survival rate; this was 90% in children whose tumours were treated before the age of 1 year, 70% at 0-2 years, but only 18% above that age. The majority of the tumours were in children under 5 years. These figures provide a powerful argument for careful abdominal palpation of all infants not only at birth but also at intervals in the first 2 years, and for immediate investigation and treatment of any intra-abdominal mass or unexplained hxmaturia. This tumour apparently runs contrary to the general experience of tumours-the younger the patient the greater the malignancy. All the patients had a palpable abdominal mass, and 60% had hypertension which was cured by removing the tumour; a high proportion had either gross haematuria or red blood-cells in the urine. As regards differential often simulated Wilms’ diagnosis, sympathicoblastoma but tumour: sympathicoblastoma displaced or distorted in the kidney such a way that it could be distinguished by retrograde pyelography; it gave rise to metastases in bones; or it extended across the midline and became nodular and fixed, whereas the Wilms’ tumours were confined to one side and remained globular and somewhat mobile. Hydronephrosis was the commonest single cause of palpable abdominal masses, and this lesion was diagnosed by transillumination in a dark room or by retrograde pyelography. Cystic disease of the kidneys was also fairly common. The frequency of these simple lesions was the chief reason for not giving preoperative radiotherapy. The standard treatment was nephrectomy followed by radiation, though a few patients who underwent nephrectomy alone also did very well. The great majority of the patients who died postoperatively did so within the first 2 years, and after that time the chance of cure was good. Radiotherapy may cause the disappearance of occasional lung metastases, but Lattimer et al. warn against the ill effects; radiotherapy stunted bone growth on one side in
tumour
1.1. 2.
1948. Willis, R. A. Pathology of Tumours; Tumours ; p. 925. London, 1948 Lattimer, J. K., Melicow, M. M., Uson, A. C. N.Y. St. J. Med. 1959, 59, 415.
several children and caused complete atrophy of an ovary in 1. The radiosensitivity of Wilms’ tumours differs widely, and is quite unpredictable even after histological study. The value of radiotherapy is probably more precautionary than curative, and Lattimer’s good results should be ascribed mainly to prompt diagnosis and operation. Therein lies our cue. FITTING THE JOB TO THE WORKER
job can be fitted to the worker has gradually gained strength from the early days when THE idea that the
balloonists died from lack of oxygen and coalminers were killed by gross environmental abnormalities. The physiologists were first in this field, under the leadership of such eminent men as J. S. Haldane, studying such problems as the decompression of divers and the composition of coalmine atmospheres. In the first week of March this year an international (although mostly Western European) conference was held in Zurich on the subject of fitting the job to the worker. It aimed at presenting to representatives of both employers and workers the methods and results of applying the biological sciences to this general task.
Heavy muscular work, the anatomical factors in work design, the presentation and use of information, the shaping and layout of controls, the lighting, noise, and climate of the workplace and its arrangement, were all discussed. It was hoped by the European Productivity Agency of the Organisation for European Economic Cooperation, which convened the conference, that in this way industry could be made aware of the resources which can be put at its disposal for improving workplaces. The United Kingdom sent a strong delegation, most of them members of the Ergonomics Research Society. Anatomists from Oxford, very much interested in the live body, joined with physiologists from London and the Medical Research Council’s staff concerned with the practical control of the environment and with equipment design. The Universities of Cambridge and Reading, together with the British boot and shoe industry, contributed the applied psychologists, and the University of Durham sent the medical head of its department of industrial health in Newcastle. There were similar, but rather smaller, delegations from Scandinavia, Western Germany, Holland, Belgium, France, Switzerland, and Italy. Thus the pattern changes. The human biologist is now
right outside his laboratory, suggesting to both sides of industry how the environment might be improved.Industry, however, is managed by engineers, chemists, lawyers, and accountants, with physicists quickly coming up, and none of them has had a training in the human limitations of the environment which they control. Doctors are the only sizable group employed in factories who come near to understanding this; but even they may be restricted by their own or their management’s conception of their role, or by the load of purely clinical work. The Ergonomics Research Society has returned this month to Oxford, the place of its birth, to celebrate its tenth anniversary, and to review the past and gaze into the future. Notwithstanding its queer title, this society has flourished, and it now has an international reputation. The time may be approaching for it to consider bringing its subject to the notice of three groups of people in authority in British industry-doctors, management and men, and those in charge of technical education. Perhaps a series of small, separate conferences, on the Zurich model, for each of these groups, with carefully selected participants, should be arranged. Such meetings can only do good in so far as they bring together the points of view of human biologist, industrial manager, and technical teacher.
the specificity must reside in the shape of the D.N.A.histone complex-a shape which, we must conclude, is distinct from that of either of its two separate components. WILMS’ TUMOUR
pleased if we
can recollect that Wilms’ tumour of the kidney found in children: we may 1 even remember that its modern name is and, because it is derived from the immature renal blastema, it may contain not only epithelial elements of tubules and incompletely formed glomeruli as well as connective tissue or sarcomatous elements, but also striated muscle,"cartilage, or even bone. Our pleasure is clouded by the belief that such a tumour is very commonly fatal, only a few fortunate patients being saved by
WE
is
are
a rare tumour
nephroblastoma
operation. The two-year-survival
rate of patients with Wilms’ before 1934 was only 9% 2 ; but Lattimer et al.22 bring the welcome news that, of their 42 cases treated since then, 16 survived for two or more years after operation. In their series females were slightly preponderant (in most series1 males are about twice as numerous as females); the tumours were equally frequent on each side, and in 4 patients there were bilateral growths. Tumours at the lower pole carried a better prognosis, being more easily palpable and surrounded by loose fatty coverings which could absorb some local extension and still be removed successfully with the tumour. The most important finding was that the age of onset was closely linked with the two-year-survival rate; this was 90% in children whose tumours were treated before the age of 1 year, 70% at 0-2 years, but only 18% above that age. The majority of the tumours were in children under 5 years. These figures provide a powerful argument for careful abdominal palpation of all infants not only at birth but also at intervals in the first 2 years, and for immediate investigation and treatment of any intra-abdominal mass or unexplained hxmaturia. This tumour apparently runs contrary to the general experience of tumours-the younger the patient the greater the malignancy. All the patients had a palpable abdominal mass, and 60% had hypertension which was cured by removing the tumour; a high proportion had either gross haematuria or red blood-cells in the urine. As regards differential often simulated Wilms’ diagnosis, sympathicoblastoma but tumour: sympathicoblastoma displaced or distorted in the kidney such a way that it could be distinguished by retrograde pyelography; it gave rise to metastases in bones; or it extended across the midline and became nodular and fixed, whereas the Wilms’ tumours were confined to one side and remained globular and somewhat mobile. Hydronephrosis was the commonest single cause of palpable abdominal masses, and this lesion was diagnosed by transillumination in a dark room or by retrograde pyelography. Cystic disease of the kidneys was also fairly common. The frequency of these simple lesions was the chief reason for not giving preoperative radiotherapy. The standard treatment was nephrectomy followed by radiation, though a few patients who underwent nephrectomy alone also did very well. The great majority of the patients who died postoperatively did so within the first 2 years, and after that time the chance of cure was good. Radiotherapy may cause the disappearance of occasional lung metastases, but Lattimer et al. warn against the ill effects; radiotherapy stunted bone growth on one side in
tumour
1.1. 2.
1948. Willis, R. A. Pathology of Tumours; Tumours ; p. 925. London, 1948 Lattimer, J. K., Melicow, M. M., Uson, A. C. N.Y. St. J. Med. 1959, 59, 415.
several children and caused complete atrophy of an ovary in 1. The radiosensitivity of Wilms’ tumours differs widely, and is quite unpredictable even after histological study. The value of radiotherapy is probably more precautionary than curative, and Lattimer’s good results should be ascribed mainly to prompt diagnosis and operation. Therein lies our cue. FITTING THE JOB TO THE WORKER
job can be fitted to the worker has gradually gained strength from the early days when THE idea that the
balloonists died from lack of oxygen and coalminers were killed by gross environmental abnormalities. The physiologists were first in this field, under the leadership of such eminent men as J. S. Haldane, studying such problems as the decompression of divers and the composition of coalmine atmospheres. In the first week of March this year an international (although mostly Western European) conference was held in Zurich on the subject of fitting the job to the worker. It aimed at presenting to representatives of both employers and workers the methods and results of applying the biological sciences to this general task.
Heavy muscular work, the anatomical factors in work design, the presentation and use of information, the shaping and layout of controls, the lighting, noise, and climate of the workplace and its arrangement, were all discussed. It was hoped by the European Productivity Agency of the Organisation for European Economic Cooperation, which convened the conference, that in this way industry could be made aware of the resources which can be put at its disposal for improving workplaces. The United Kingdom sent a strong delegation, most of them members of the Ergonomics Research Society. Anatomists from Oxford, very much interested in the live body, joined with physiologists from London and the Medical Research Council’s staff concerned with the practical control of the environment and with equipment design. The Universities of Cambridge and Reading, together with the British boot and shoe industry, contributed the applied psychologists, and the University of Durham sent the medical head of its department of industrial health in Newcastle. There were similar, but rather smaller, delegations from Scandinavia, Western Germany, Holland, Belgium, France, Switzerland, and Italy. Thus the pattern changes. The human biologist is now
right outside his laboratory, suggesting to both sides of industry how the environment might be improved.Industry, however, is managed by engineers, chemists, lawyers, and accountants, with physicists quickly coming up, and none of them has had a training in the human limitations of the environment which they control. Doctors are the only sizable group employed in factories who come near to understanding this; but even they may be restricted by their own or their management’s conception of their role, or by the load of purely clinical work. The Ergonomics Research Society has returned this month to Oxford, the place of its birth, to celebrate its tenth anniversary, and to review the past and gaze into the future. Notwithstanding its queer title, this society has flourished, and it now has an international reputation. The time may be approaching for it to consider bringing its subject to the notice of three groups of people in authority in British industry-doctors, management and men, and those in charge of technical education. Perhaps a series of small, separate conferences, on the Zurich model, for each of these groups, with carefully selected participants, should be arranged. Such meetings can only do good in so far as they bring together the points of view of human biologist, industrial manager, and technical teacher.