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ALCOHOL AND INSANITY.
769 -
the alteration in the effect of the doses as usually administered that it was not until I had tried everv kind of antitoxin on the market that I realised that the poor results of our usual doses were not due to inactive serum but to an alteration in the type of the The case-mortality in this hospital has disease. undergone three alterations since 1900 : 1902-07, 6.4 per cent. 1908-16, 4-8 per cent. : rising in 1922 to 8.2 per cent. In this area the medical officer of health circulates all practitioners from time to time, advising the dosage which is based on the type of disease prevalent at the time. This is a far wiser plan than attempting The to set standards for the whole country. Memorandum of the Ministry of Health advocates too low dosage to arrest the type of disease still prevalent in this area, but happily now becoming less virulent. I consider that the great differences in dosage suggested by various authorities in various countries are accounted for by wide variations in virulence which may occur in this disease and has occurred during my own period of observation of the disease during the last 14 years. As regards Dr. Ker’s statement that 2000 to 3000 units given in the first couple of days would produce a phenomenal fall in
I
disprove
B. A. PETERS, Hospital, Bristol.
Chief Medical Officer, Ham Green
BURIED RADIUM EMANATION TUBES.
---
think
that these
obvious
pros
and
cons
are
readily granted by those who have practical experience in the subject. There are, however, some debatable points which it might be useful to mention briefly. (a) The Uniform Irradiation of a Tumour by the Surgical Introduction of Radio-active Tubes.-I presuppose that it is desired to give each part the same dose, presumably the lethal dose. The question is,
our own cases here utterly it for our present type of disease. Of the last 80 fatal cases in this hospital. 19 received doses of from 2000 to 10,000 units within the first 48 hours while awaiting bacteriological confirmation before admission, but these amounts were insufficient to prevent death. It is very unfortunate that an authority of Dr. Ker’s eminence should be found suggesting small doses while many of us have been trying to persuade our medical brethren to givee large doses. No doubt the doses suggested by him would arrest the type of disease now prevalent in Edinburgh and prevalent in Bristol from 1908 to 1921, but his doctrine would be utterly misleading if applied ’, to the type of disease we have had here during the last two years, in which death frequently occurred within two or three days of the onset of the disease from an overwhelming toxaemia. I am, Sir, yours faithfully,
diphtheria mortality,
-
What are the best sources to use for this purpose ? We must avoid point sources and sources giving easily absorbed radiation ; here are two objections to the emanation capillaries. If platinum tubes of thickness 0’5 mm. are used, the bulk of the radiation is of a very penetrating character, and some approach to uniformity of irradiation is got by using a number of them suitably placed ; purely geometrical requirements must, however, giveway to what is possible surgically. The lack of uniformity of irradiation can be compensated to some extent by the external application of gamma rays, but it appears hardly possible to avoid the overdosing of the tissues in those zones which are in immediate contact with the tubes. (b) The Avoidance of Tissue Reactions of an Undesirable Nature.—Dominici held that it was a good thing to avoid the actual destruction of the tissues irradiated, and he aimed at producing a reaction in the normal tissues of the host which would bring about the desired results ; he was a strong advocate of gamma radiation. Lately Dr. Laborde has maintained that the rather violent changes induced in the tissues by the beta rays from the emanation capillaries is an argument against their use. (c) The Advantages of Using Sources of Constant Intensity.—Advances in radium therapy depend not only upon a recognition of the forms of disease for which it is a suitable agent, but upon the quantitative way in which it is applied ; the quantitative technique is perhaps just as difficult as that involved in the deep X ray therapy of the present day, and it might serve a useful purpose in radium therapy if there were some agreement among those interested in the surgical use of radium to use tubes graded in size and content, according to a definite scale. The quantities at different centres in ordinary use range roughly from 1 to 100 mg. of radium bromide, and if arbitrary quantities. say,1, 10, 25. 50, and 100 mgm. were decided upon and placed in tubes appropriate in size to these contents, comparisons between the results of treatment at different centres would become
To the Editor of THE LANCET. simplified to some extent. In the radium clinical investigation which is at SIR,-It is not likely that the claim of Dr. Walter Stevenson (THE LANCET, April 7th) that the use of present being conducted at different centres in Great small radium emanation tubes for medical purposes Britain and Ireland under the aegis of the Medical originated in Dublin will be seriously questioned. Research Council the attempt has been made to do I am. Sir. -vours faithfullv. This idea has been adopted at various radium centres this. and the technique developed in such a way that the RUSS. emanation may be concentrated in minute glass The Middlesex Hospital, London, April 9th, 1923. capillaries measuring no more than about 3 mm. long and 0’5 mm. diameter. Dr. Failla, of the Memorial Hospital in New- York, has devised a piece of ALCOHOL AND INSANITY. apparatus for this purpose which is little short of a To the Editor of THE LANCET. triumph of experimental skill. By the use of emanation in this way, the risk of loss of radium is probably SIR,—Dr. Sullivan refuses to differentiate between minimised, although accidents have happened in the a concrete instance and an abstract principle. It is past to glass vessels containing radium in solution. not of the smallest importance from the present A further apparent advantage is that tubes of any point of view whether or not mental stress is a cause desired strength or dimensions may be filled to meet of insanity. Dr. Sullivan will not, I suppose, deny clinical requirements. This is not possible if the that there is some cause of insanity. Let us call it and I will grant him that mental stress has no available supply of radium is sealed into a number of "x causal connexion with insanity. Then " x " stands platinum tubes arbitrarily graded in strength. A few disadvantages of the method may be men- for any and every cause of insanity except alcoholism, tioned. The cost of the apparatus, its upkeep, and and the point at issue remains unchanged. In order to the personnel for its efficient working is considerable : provethat alcoholism is not a cause of insanity, it is the emanation tubes slowly decline in strength, and necessary to show (in addition to the facts originally this makes the calculation of the dose a little tire- adduced in your leading article) that ‘‘ x has not some. Dr. Regaud has thought it more useful to increased in proportion to the diminution in alcoholism. measure the quantity which he calls 1’emanation This neither Dr. Sullivan nor your leading article détruite " instead of the average strength of the has made any attempt to do. I am. Sir. yours faithfully, emanation, though the latter appears more directly useful. STANLEY WYARD. STANLEY Wimpole-street, W., April 9th.
SIDNEY
"
"
"
the alteration in the effect of the doses as usually administered that it was not until I had tried everv kind of antitoxin on the market that I realised that the poor results of our usual doses were not due to inactive serum but to an alteration in the type of the The case-mortality in this hospital has disease. undergone three alterations since 1900 : 1902-07, 6.4 per cent. 1908-16, 4-8 per cent. : rising in 1922 to 8.2 per cent. In this area the medical officer of health circulates all practitioners from time to time, advising the dosage which is based on the type of disease prevalent at the time. This is a far wiser plan than attempting The to set standards for the whole country. Memorandum of the Ministry of Health advocates too low dosage to arrest the type of disease still prevalent in this area, but happily now becoming less virulent. I consider that the great differences in dosage suggested by various authorities in various countries are accounted for by wide variations in virulence which may occur in this disease and has occurred during my own period of observation of the disease during the last 14 years. As regards Dr. Ker’s statement that 2000 to 3000 units given in the first couple of days would produce a phenomenal fall in
I
disprove
B. A. PETERS, Hospital, Bristol.
Chief Medical Officer, Ham Green
BURIED RADIUM EMANATION TUBES.
---
think
that these
obvious
pros
and
cons
are
readily granted by those who have practical experience in the subject. There are, however, some debatable points which it might be useful to mention briefly. (a) The Uniform Irradiation of a Tumour by the Surgical Introduction of Radio-active Tubes.-I presuppose that it is desired to give each part the same dose, presumably the lethal dose. The question is,
our own cases here utterly it for our present type of disease. Of the last 80 fatal cases in this hospital. 19 received doses of from 2000 to 10,000 units within the first 48 hours while awaiting bacteriological confirmation before admission, but these amounts were insufficient to prevent death. It is very unfortunate that an authority of Dr. Ker’s eminence should be found suggesting small doses while many of us have been trying to persuade our medical brethren to givee large doses. No doubt the doses suggested by him would arrest the type of disease now prevalent in Edinburgh and prevalent in Bristol from 1908 to 1921, but his doctrine would be utterly misleading if applied ’, to the type of disease we have had here during the last two years, in which death frequently occurred within two or three days of the onset of the disease from an overwhelming toxaemia. I am, Sir, yours faithfully,
diphtheria mortality,
-
What are the best sources to use for this purpose ? We must avoid point sources and sources giving easily absorbed radiation ; here are two objections to the emanation capillaries. If platinum tubes of thickness 0’5 mm. are used, the bulk of the radiation is of a very penetrating character, and some approach to uniformity of irradiation is got by using a number of them suitably placed ; purely geometrical requirements must, however, giveway to what is possible surgically. The lack of uniformity of irradiation can be compensated to some extent by the external application of gamma rays, but it appears hardly possible to avoid the overdosing of the tissues in those zones which are in immediate contact with the tubes. (b) The Avoidance of Tissue Reactions of an Undesirable Nature.—Dominici held that it was a good thing to avoid the actual destruction of the tissues irradiated, and he aimed at producing a reaction in the normal tissues of the host which would bring about the desired results ; he was a strong advocate of gamma radiation. Lately Dr. Laborde has maintained that the rather violent changes induced in the tissues by the beta rays from the emanation capillaries is an argument against their use. (c) The Advantages of Using Sources of Constant Intensity.—Advances in radium therapy depend not only upon a recognition of the forms of disease for which it is a suitable agent, but upon the quantitative way in which it is applied ; the quantitative technique is perhaps just as difficult as that involved in the deep X ray therapy of the present day, and it might serve a useful purpose in radium therapy if there were some agreement among those interested in the surgical use of radium to use tubes graded in size and content, according to a definite scale. The quantities at different centres in ordinary use range roughly from 1 to 100 mg. of radium bromide, and if arbitrary quantities. say,1, 10, 25. 50, and 100 mgm. were decided upon and placed in tubes appropriate in size to these contents, comparisons between the results of treatment at different centres would become
To the Editor of THE LANCET. simplified to some extent. In the radium clinical investigation which is at SIR,-It is not likely that the claim of Dr. Walter Stevenson (THE LANCET, April 7th) that the use of present being conducted at different centres in Great small radium emanation tubes for medical purposes Britain and Ireland under the aegis of the Medical originated in Dublin will be seriously questioned. Research Council the attempt has been made to do I am. Sir. -vours faithfullv. This idea has been adopted at various radium centres this. and the technique developed in such a way that the RUSS. emanation may be concentrated in minute glass The Middlesex Hospital, London, April 9th, 1923. capillaries measuring no more than about 3 mm. long and 0’5 mm. diameter. Dr. Failla, of the Memorial Hospital in New- York, has devised a piece of ALCOHOL AND INSANITY. apparatus for this purpose which is little short of a To the Editor of THE LANCET. triumph of experimental skill. By the use of emanation in this way, the risk of loss of radium is probably SIR,—Dr. Sullivan refuses to differentiate between minimised, although accidents have happened in the a concrete instance and an abstract principle. It is past to glass vessels containing radium in solution. not of the smallest importance from the present A further apparent advantage is that tubes of any point of view whether or not mental stress is a cause desired strength or dimensions may be filled to meet of insanity. Dr. Sullivan will not, I suppose, deny clinical requirements. This is not possible if the that there is some cause of insanity. Let us call it and I will grant him that mental stress has no available supply of radium is sealed into a number of "x causal connexion with insanity. Then " x " stands platinum tubes arbitrarily graded in strength. A few disadvantages of the method may be men- for any and every cause of insanity except alcoholism, tioned. The cost of the apparatus, its upkeep, and and the point at issue remains unchanged. In order to the personnel for its efficient working is considerable : provethat alcoholism is not a cause of insanity, it is the emanation tubes slowly decline in strength, and necessary to show (in addition to the facts originally this makes the calculation of the dose a little tire- adduced in your leading article) that ‘‘ x has not some. Dr. Regaud has thought it more useful to increased in proportion to the diminution in alcoholism. measure the quantity which he calls 1’emanation This neither Dr. Sullivan nor your leading article détruite " instead of the average strength of the has made any attempt to do. I am. Sir. yours faithfully, emanation, though the latter appears more directly useful. STANLEY WYARD. STANLEY Wimpole-street, W., April 9th.
SIDNEY
"
"
"