- Email: [email protected]
A Fresh Start
1213
active, and re-establishment of activity involves a brief pseudocarcinomatosum ". The name has found some burst of downgrowth, or invasion, by the new hair germ. 11 favour, especially on the Continent,6but in effect this has meant that there are now three equal contenders for It is thus not at all difficult to understand that, while in the title of one lesion. We still dislike keratoacanthoma; most tissues invasiveness spells irreversible malignancy, abnormal proliferation of the hair-follicle complex may but, since it has been shown so clearly that the lesion result in a burst of growth that is invasive yet not arises not (as we then supposed) from the epidermis but from the hair follicle and sebaceous glands, the malignant. WHITELEY and GHADIALLY had already shown 12 that objection to molluscum sebaceum is no longer valid. "
"
of the rabbit skin are commoner when This title has priority and should be accepted. in areas of active and this hair growth; painting begun A Fresh Start is not surprising, for in such areas the whole skin is No medical curriculum, however well devised, remains hyperplastic and hyperactive. It is equally believable satisfactory for long, since undergraduate teaching should that mollusca should arise at times of inactivity, for at constantly take account of advances in knowledge and of this time the essential sensitive hair-germ lies near the surface, dormant, awaiting the trigger action of the society’s changing needs. Lately the preclinical course has been much criticised; and most plans for improvenormal cyclic stimulus (unknown, but perhaps ment have centred round reduction in its length and its vascular 13) to set it into sudden violent growth. The carcinogen, it may be supposed, supplies the stimulus in integration with the clinical course. Dr. TANNER, in an address that appears at the beginning of this issue, recomthe rabbit in an abnormal form, and so the growth promends more radical reform. Impressed by the doctor’s duced is abnormal; but it is in the direction of normal " very wide field of operation" in "applied human new growth of follicles and lasts just about as long as the biology ", he calls for reconstitution of the preclinical normal activity of the follicle. In man most mollusca curriculum to cover, in three years, " all the present arise on the exposed skins of elderly people-in just the sites where, judged by the incidence of true tumours, the ground of 1st M.B., 2nd M.B., and general pathology, but reorientated in consecutive courses entitled Cellular effect of external carcinogens such as sunlight is maxiBiology, Organisation of Mammals, and Organisation of mal. In younger men, and at other sites, there is a significantly frequent history of exposure to industrial Man ". These should prove understandable and attraccarcinogens.14 It is thus not at all unreasonable to regard tive to the student who thinks of " medical practice as an carcinogens as implicated in the lesion in man as well as endeavour to understand individual people in relation to in animals. As WHITELEY points out, the areas of their hereditary endowment, their upbringing, their maximal incidence are those where the inactive phase of family, their social position, and their whole culture; and as an endeavour to guide them, so far as may be, from the hair cycle is longest. Inescapably one must suppose childhood to old age through the squalls and doldrums that the molluscum is produced by the action of a mild so that they slip as seldom as possible over that invisible carcinogenic stimulus on a group of resting hair follicles, exciting them to premature and perverted activity. equator which divides health and disease, whether of Perhaps because some minor mutation has been pro- mind or body ". Certainly any student who receives duced in the epithelium, perhaps because some external such a preclinical education will not thereafter happily component of the complex machinery of the hair cycle tolerate a clinical training consisting of instruction is lacking, the growth is irregular and no differentiated by a multitude of specialists each on how to be an products (hairs or sebum cells) result, but only non- elementary specialist in his own particular field". specific keratin. But the growth expands only to the (Even students who have had a more orthodox preanatomical limits of the normal full-grown follicle, and clinical course can find their clinical years difficult and by a process of apprenticeits growth ceases when the normal cycle would return to unsatisfactory. " Training " writes a works student, ship ", only when the master the resting phase. This seems, all told, a most reasonable explanation of a very remarkable lesion. The idea that practises the trade that his students intend to follows) It should be possible, as TANNER says, now that the carcinogenic stimuli may excite intense but self-limiting General Medical Council has given freedom and enbursts of proliferation in tissues normally subject to phasic activity is new, and may have other applications. couragement to experiment in medical schools, to put such a plan into action. There would no doubt be some An odd position, for which we must take some blame, in introducing a preclinical course lasting three has arisen over the nomenclature of these lesions. In 1 1953 we suggested that, since MACCORMAC and years, of which the first replaced the last year of study at SCARFF’S1;; original name of molluscum sebaceum was no school. But the largest obstacle to fulfilling this of adaptalonger tenable (being based on the hypothesis of origin plan-or any other well-constructed scheme that needs-is likelier to be of finding a from a sebaceous cyst, which was disproved) and ROOK tion to current " medical school with the courage, initiative, and determiand WHIMSTER’S 1E’ " keratoacanthoma seemed unduly nation to try it. It seems probable that zeal less than vague in anything except its unwarrantable assumption TANNER’S, combined with the powers of reaction, will of neoplasia, the lesions might best be called " molluscum cause this scheme, like many another, to get no further 11. Chase, H. B. Physiol. Rev. 1954, 34, 113. 12. Whiteley, H. J., Ghadially, F. N. Brit. J. Cancer, 1951, 5, 353. than the curriculum committee, which doubtless will lay 13. Montagna, W., Ellis, R. A. J. nat. Cancer Inst. 1957, 19, 451. 14. Binkley, G. W., Johnson, H. H. Arch. Derm., Chicago, 1955, 71, 66. it aside after comfortably agreeing that it is nebulous and true tumours
is
"
difficulty
15. 16.
MacCormac, H., Scarff, R. W. Brit. J. Derm. 1936, 48, 624. Rook, A. J , Whimster, I. W. Arch. belges Derm. 1950 6, 137.
17. Lond. Hosp. Gaz.
1958, 61, 42.
1214
is
not a
"
concrete
plan ";
for
only "
concrete
plans
"-
by which, we suspect, is meant detailed timetables-are heavy enough to replace the weight of tradition. And timetables can be made only by a group of department heads and never by the single advocate of a new approach. Hence it seems certain that no established school will undertake an experiment as radical as that advocated by TANNER. But, if all the older schools are tied to their dead past, the same cannot be said of new schools, such as that of the University of Western Australia. To break the mould of the existing curriculum it may be necessary to start in Britain a new medical school. Its staff, drawn from many different traditions, might soon be fused into an enthusiastic team by competition with its orthodox rivals.
Annotations DIAGNOSTIC CENTRE FOR SOUTH LONDON
IN the years just after the war, the Pioneer Health Centre, established at Peckham by the late Dr. Scott Williamson and Dr. Innes Pearse, was one of the medical institutions in which our visitors from abroad showed most interest. But by 1950 financial difficulties prevented its continuation on the original lines A decision was reached to dispose of the property to an authority prepared to use it for purposes related as closely as possible to the aims and objects of the founders, and in 1951 it was bought by the London County Council, under which it has continued as the Queens Road Health Centre. The two departments of the Council with interests akin to those of the founders were those of public health and education. The education department took over facilities including the swimming-pool and the gymnasium, and established a thriving institute for adult education which offered a wide range of classes-in dressmaking, millinery, pottery, and even boat-building. The health department used the centre for a day nursery, for certain other maternity and child-welfare activities, and later for a child-guidance clinic. For various reasons, it did not prove possible to start group practices for medical and dental practitioners, and the setting-up of a research unit consequently remained in abeyance, though the Minister of Health had expressed the hope that research would be undertaken, in which case he would consider assisting it. The Sir Halley Stewart Trust, having been generous subscribers to the Pioneer Health Centre, retained their interest in the new Queens Road centre. In 1956 it became possible to make further progress. General practitioners practising within a mile of the centre were invited to a meeting, with representatives of the Sir Halley Stewart Trust, the College of General Practitioners, the London Local Medical Committee, the South East Metropolitan Regional Hospital Board, and the local health authority; and afterwards 15 of them expressed their interest in the development of the centre. At a subsequent meeting attended by 25 practitioners a subcommittee was formed to discuss details. It was link that a close with the generally agreed College of General Practitioners was essential, and the Sir Halley Stewart Trust agreed to pay the expense of a medical director to organise and direct research at the centre over a period of five years, at a cost to them of over E12.500. Provisional plans have now been drawn up for adapta-
tion of the building so that it will provide a diagnostic medical centre for the use of local doctors. The cost of the internal adaptation will amount to about E16,000, of which the Nuffield Foundation is prepared to give E12.000. The grants from the Sir Halley Stewart Trust and the Nuffield Foundation are subject to the running costs being borne by the London County Council. As a beginning, the intention is to offer, to all general practitioners in the neighbourhood, X-ray and pathologicallaboratory diagnostic facilities, and physiotherapy. It is hoped that these doctors will be able to meet each other, more frequently, in the common-room of the centre; that they will have a closer link with consultants, who will discuss cases with them there; and that some of them will participate directly both in research projects affecting general practice and also in the training of medical students. PHYSICAL CHANGES IN THE PROLAPSED DISC
THE intervertebral disc in man comprises three distinct elements-the nucleus pulposus, the annulus fibrosus, and the cartilage end-plates of the vertebrae. Eckert and Deckert stated that each of these elements degenerates with age. The cartilage plate becomes thinner and its cellularity diminishes, and it may become torn. In the annulus fibrosus swelling of the fibrous lamellae and hyalinisation of the fibres may be seen, while the nucleus pulposus exhibits central fissuring, cavitation, and sometimes fibrosis and calcification. These changes in the nucleus are associated with relative dehydration. The normal nucleus consists of a three-dimensional lattice of collagen fibrils2 in which lies a mucoprotein gel which is responsible for the hydrophilia of the nucleus. With the increase in collagen and diminution of mucoprotein as a result of increasing age, hydrophilia is diminished. The mechanical behaviour of the nucleus pulposus when the spine is removed at necropsy has been analysed by Petterand by Charnley. Its affinity for water may be a major factor in the production of back pain; indeed, its power to swell in the presence of water has been compared to that of laminaria. Hirsch 5 noted that injection of saline solution into the intervertebral disc may produce severe pain in the back. Changes in the fluid content of a disc may account for the attacks of lumbago which sometimes precede true prolapse of the disc. It is now generally conceded that trauma is not a large factor in the production of disc prolapse, and may often be absent. The evidence for this has been summarised by Charnley, who contrasts the clinical picture of the disc lesion with that of spinal injuries. Perhaps the common failure of the pain to subside with rest is the most cogent clinical evidence against the lesion being traumaticapart, of course, from the absence in many cases of a history of injury or even of strain. Prolapsed discs removed at operation have recently been examined by Hendry,6 who has determined their capacity to take up water, comparing this with that of the normal nucleus. By comparing the weight of the removed nucleus after complete hydration in physiological saline solution with that after desiccation, it was possible to estimate the hydration of the prolapsed disc. It is apparent that the deranged disc has a greater affinity for water than its normal fellow; but when the hydration is related to the 1. 2. 3. 4. 5. 6.
Eckert, C., Decker, A. J. Bone Jt Surg. 1947, 29, 447. Sylven, B. Acta orthopœd. scand. 1951, 20, 275. Petter, C. K. J. Bone Jt Surg. 1933, 15, 365. Charnley, J. Lancet, 1952, i, 124. Hirsch, C. Acta orthopœd. scand. 1951, 20, 261. Hendry, N. G. C. J. Bone Jt Surg. 1958, 40B, 132.
’
active, and re-establishment of activity involves a brief pseudocarcinomatosum ". The name has found some burst of downgrowth, or invasion, by the new hair germ. 11 favour, especially on the Continent,6but in effect this has meant that there are now three equal contenders for It is thus not at all difficult to understand that, while in the title of one lesion. We still dislike keratoacanthoma; most tissues invasiveness spells irreversible malignancy, abnormal proliferation of the hair-follicle complex may but, since it has been shown so clearly that the lesion result in a burst of growth that is invasive yet not arises not (as we then supposed) from the epidermis but from the hair follicle and sebaceous glands, the malignant. WHITELEY and GHADIALLY had already shown 12 that objection to molluscum sebaceum is no longer valid. "
"
of the rabbit skin are commoner when This title has priority and should be accepted. in areas of active and this hair growth; painting begun A Fresh Start is not surprising, for in such areas the whole skin is No medical curriculum, however well devised, remains hyperplastic and hyperactive. It is equally believable satisfactory for long, since undergraduate teaching should that mollusca should arise at times of inactivity, for at constantly take account of advances in knowledge and of this time the essential sensitive hair-germ lies near the surface, dormant, awaiting the trigger action of the society’s changing needs. Lately the preclinical course has been much criticised; and most plans for improvenormal cyclic stimulus (unknown, but perhaps ment have centred round reduction in its length and its vascular 13) to set it into sudden violent growth. The carcinogen, it may be supposed, supplies the stimulus in integration with the clinical course. Dr. TANNER, in an address that appears at the beginning of this issue, recomthe rabbit in an abnormal form, and so the growth promends more radical reform. Impressed by the doctor’s duced is abnormal; but it is in the direction of normal " very wide field of operation" in "applied human new growth of follicles and lasts just about as long as the biology ", he calls for reconstitution of the preclinical normal activity of the follicle. In man most mollusca curriculum to cover, in three years, " all the present arise on the exposed skins of elderly people-in just the sites where, judged by the incidence of true tumours, the ground of 1st M.B., 2nd M.B., and general pathology, but reorientated in consecutive courses entitled Cellular effect of external carcinogens such as sunlight is maxiBiology, Organisation of Mammals, and Organisation of mal. In younger men, and at other sites, there is a significantly frequent history of exposure to industrial Man ". These should prove understandable and attraccarcinogens.14 It is thus not at all unreasonable to regard tive to the student who thinks of " medical practice as an carcinogens as implicated in the lesion in man as well as endeavour to understand individual people in relation to in animals. As WHITELEY points out, the areas of their hereditary endowment, their upbringing, their maximal incidence are those where the inactive phase of family, their social position, and their whole culture; and as an endeavour to guide them, so far as may be, from the hair cycle is longest. Inescapably one must suppose childhood to old age through the squalls and doldrums that the molluscum is produced by the action of a mild so that they slip as seldom as possible over that invisible carcinogenic stimulus on a group of resting hair follicles, exciting them to premature and perverted activity. equator which divides health and disease, whether of Perhaps because some minor mutation has been pro- mind or body ". Certainly any student who receives duced in the epithelium, perhaps because some external such a preclinical education will not thereafter happily component of the complex machinery of the hair cycle tolerate a clinical training consisting of instruction is lacking, the growth is irregular and no differentiated by a multitude of specialists each on how to be an products (hairs or sebum cells) result, but only non- elementary specialist in his own particular field". specific keratin. But the growth expands only to the (Even students who have had a more orthodox preanatomical limits of the normal full-grown follicle, and clinical course can find their clinical years difficult and by a process of apprenticeits growth ceases when the normal cycle would return to unsatisfactory. " Training " writes a works student, ship ", only when the master the resting phase. This seems, all told, a most reasonable explanation of a very remarkable lesion. The idea that practises the trade that his students intend to follows) It should be possible, as TANNER says, now that the carcinogenic stimuli may excite intense but self-limiting General Medical Council has given freedom and enbursts of proliferation in tissues normally subject to phasic activity is new, and may have other applications. couragement to experiment in medical schools, to put such a plan into action. There would no doubt be some An odd position, for which we must take some blame, in introducing a preclinical course lasting three has arisen over the nomenclature of these lesions. In 1 1953 we suggested that, since MACCORMAC and years, of which the first replaced the last year of study at SCARFF’S1;; original name of molluscum sebaceum was no school. But the largest obstacle to fulfilling this of adaptalonger tenable (being based on the hypothesis of origin plan-or any other well-constructed scheme that needs-is likelier to be of finding a from a sebaceous cyst, which was disproved) and ROOK tion to current " medical school with the courage, initiative, and determiand WHIMSTER’S 1E’ " keratoacanthoma seemed unduly nation to try it. It seems probable that zeal less than vague in anything except its unwarrantable assumption TANNER’S, combined with the powers of reaction, will of neoplasia, the lesions might best be called " molluscum cause this scheme, like many another, to get no further 11. Chase, H. B. Physiol. Rev. 1954, 34, 113. 12. Whiteley, H. J., Ghadially, F. N. Brit. J. Cancer, 1951, 5, 353. than the curriculum committee, which doubtless will lay 13. Montagna, W., Ellis, R. A. J. nat. Cancer Inst. 1957, 19, 451. 14. Binkley, G. W., Johnson, H. H. Arch. Derm., Chicago, 1955, 71, 66. it aside after comfortably agreeing that it is nebulous and true tumours
is
"
difficulty
15. 16.
MacCormac, H., Scarff, R. W. Brit. J. Derm. 1936, 48, 624. Rook, A. J , Whimster, I. W. Arch. belges Derm. 1950 6, 137.
17. Lond. Hosp. Gaz.
1958, 61, 42.
1214
is
not a
"
concrete
plan ";
for
only "
concrete
plans
"-
by which, we suspect, is meant detailed timetables-are heavy enough to replace the weight of tradition. And timetables can be made only by a group of department heads and never by the single advocate of a new approach. Hence it seems certain that no established school will undertake an experiment as radical as that advocated by TANNER. But, if all the older schools are tied to their dead past, the same cannot be said of new schools, such as that of the University of Western Australia. To break the mould of the existing curriculum it may be necessary to start in Britain a new medical school. Its staff, drawn from many different traditions, might soon be fused into an enthusiastic team by competition with its orthodox rivals.
Annotations DIAGNOSTIC CENTRE FOR SOUTH LONDON
IN the years just after the war, the Pioneer Health Centre, established at Peckham by the late Dr. Scott Williamson and Dr. Innes Pearse, was one of the medical institutions in which our visitors from abroad showed most interest. But by 1950 financial difficulties prevented its continuation on the original lines A decision was reached to dispose of the property to an authority prepared to use it for purposes related as closely as possible to the aims and objects of the founders, and in 1951 it was bought by the London County Council, under which it has continued as the Queens Road Health Centre. The two departments of the Council with interests akin to those of the founders were those of public health and education. The education department took over facilities including the swimming-pool and the gymnasium, and established a thriving institute for adult education which offered a wide range of classes-in dressmaking, millinery, pottery, and even boat-building. The health department used the centre for a day nursery, for certain other maternity and child-welfare activities, and later for a child-guidance clinic. For various reasons, it did not prove possible to start group practices for medical and dental practitioners, and the setting-up of a research unit consequently remained in abeyance, though the Minister of Health had expressed the hope that research would be undertaken, in which case he would consider assisting it. The Sir Halley Stewart Trust, having been generous subscribers to the Pioneer Health Centre, retained their interest in the new Queens Road centre. In 1956 it became possible to make further progress. General practitioners practising within a mile of the centre were invited to a meeting, with representatives of the Sir Halley Stewart Trust, the College of General Practitioners, the London Local Medical Committee, the South East Metropolitan Regional Hospital Board, and the local health authority; and afterwards 15 of them expressed their interest in the development of the centre. At a subsequent meeting attended by 25 practitioners a subcommittee was formed to discuss details. It was link that a close with the generally agreed College of General Practitioners was essential, and the Sir Halley Stewart Trust agreed to pay the expense of a medical director to organise and direct research at the centre over a period of five years, at a cost to them of over E12.500. Provisional plans have now been drawn up for adapta-
tion of the building so that it will provide a diagnostic medical centre for the use of local doctors. The cost of the internal adaptation will amount to about E16,000, of which the Nuffield Foundation is prepared to give E12.000. The grants from the Sir Halley Stewart Trust and the Nuffield Foundation are subject to the running costs being borne by the London County Council. As a beginning, the intention is to offer, to all general practitioners in the neighbourhood, X-ray and pathologicallaboratory diagnostic facilities, and physiotherapy. It is hoped that these doctors will be able to meet each other, more frequently, in the common-room of the centre; that they will have a closer link with consultants, who will discuss cases with them there; and that some of them will participate directly both in research projects affecting general practice and also in the training of medical students. PHYSICAL CHANGES IN THE PROLAPSED DISC
THE intervertebral disc in man comprises three distinct elements-the nucleus pulposus, the annulus fibrosus, and the cartilage end-plates of the vertebrae. Eckert and Deckert stated that each of these elements degenerates with age. The cartilage plate becomes thinner and its cellularity diminishes, and it may become torn. In the annulus fibrosus swelling of the fibrous lamellae and hyalinisation of the fibres may be seen, while the nucleus pulposus exhibits central fissuring, cavitation, and sometimes fibrosis and calcification. These changes in the nucleus are associated with relative dehydration. The normal nucleus consists of a three-dimensional lattice of collagen fibrils2 in which lies a mucoprotein gel which is responsible for the hydrophilia of the nucleus. With the increase in collagen and diminution of mucoprotein as a result of increasing age, hydrophilia is diminished. The mechanical behaviour of the nucleus pulposus when the spine is removed at necropsy has been analysed by Petterand by Charnley. Its affinity for water may be a major factor in the production of back pain; indeed, its power to swell in the presence of water has been compared to that of laminaria. Hirsch 5 noted that injection of saline solution into the intervertebral disc may produce severe pain in the back. Changes in the fluid content of a disc may account for the attacks of lumbago which sometimes precede true prolapse of the disc. It is now generally conceded that trauma is not a large factor in the production of disc prolapse, and may often be absent. The evidence for this has been summarised by Charnley, who contrasts the clinical picture of the disc lesion with that of spinal injuries. Perhaps the common failure of the pain to subside with rest is the most cogent clinical evidence against the lesion being traumaticapart, of course, from the absence in many cases of a history of injury or even of strain. Prolapsed discs removed at operation have recently been examined by Hendry,6 who has determined their capacity to take up water, comparing this with that of the normal nucleus. By comparing the weight of the removed nucleus after complete hydration in physiological saline solution with that after desiccation, it was possible to estimate the hydration of the prolapsed disc. It is apparent that the deranged disc has a greater affinity for water than its normal fellow; but when the hydration is related to the 1. 2. 3. 4. 5. 6.
Eckert, C., Decker, A. J. Bone Jt Surg. 1947, 29, 447. Sylven, B. Acta orthopœd. scand. 1951, 20, 275. Petter, C. K. J. Bone Jt Surg. 1933, 15, 365. Charnley, J. Lancet, 1952, i, 124. Hirsch, C. Acta orthopœd. scand. 1951, 20, 261. Hendry, N. G. C. J. Bone Jt Surg. 1958, 40B, 132.
’