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CARBON MONOXIDE POISONING
154
ning of treatment. The argument in favour of this rate is that it may enable the success or failure of a method to be judged sooner than can be done when the survival-rate is used. For instance, with experience it might be possible from the trend of the symptom-free rate in the three-year period to estimate the survival-rate at the end of five years. At present the volume of material does not suffice for such a purpose, nor indeed to show whether the two rates are in fact more highly correlated than the two survival-rates at the same points of time. In
detailed an inquiry we can and selective reference to the results. It appears that 70 per cent. of the women with carcinoma of the breast who presented themselves for treatment in Stage I of the disease survived three years, and 50 per cent. five years. Of those in Stage III, on the other hand, only 18-8 and 13-6 per cent. were alive, many of these being given only palliative treatment. The 2058 patients with carcinoma of the cervix were divided into four stages : of those in the earliest group 61’1 per cent. survived three years and 49’4 per cent. five years, whereas of those in the latest group only 12-6 per cent. were alive after three years and 7’2 per cent. after five. Figures for carcinoma of the lip show, as might be expected, the great importance of involvement of the glands. Of those in whom the growth was limited to the lip slightly more than three-quarters lived five years ; of those with the regional lymph glands affected less than a third survived as long. Whatever the stage of disease, the outlook with carcinoma of the tongue is depressing, for of the patients most favourably placed only a quarter are alive at the end of five years, while out of 30 advanced cases only 1 remained. The floor of the mouth gives less unsatisfactory results than this-at least when the glands are not involved -for rather more than half the patients lived five years. With each of these sites, as has been shown over and over again, the chances of survival are better, often much better, if local spread or metastasis has not taken place. Yet the report shows that the proportion of patients in whom the disease is still localised to its original site when application for treatment is made, amounts, for all the sites investigated, to only 25 per cent. This figure varied but little between 1930 and 1932, although there was reason to think that the proportion coming for radium treatment at an early stage was increasing slowly among those with carcinoma of the lip, tongue, and cervix uteri. Younger patients with the latter or with carcinoma of the breast to some extent tend to seek treatment at an earlier stage then those who are older. The question of age is also studied in relation to survival, in two groups, under and over fifty years. For carcinoma of the breast there is no significant difference though the figures suggest a slightly more favourable issue in Stages I and II with the older patients. For the cervix this difference is definite and gives statistical support to the belief held by many clinicians that the prognosis is rather worse in young patients. For the remaining sites the data are insufficient for investigation of
reviewing so attempt only brief
between age and survival. For the relative success of different methods of treatment has had to be postponed till more material has accumulated, though those that prevail have been tabulated. One very serious obstacle to such a study is the large number of different combinations of methods of treatment. For instance 86 such combinations were distinguished in treatment for carcinoma of the breast, 66 for the cervix, 56 for the lip, 110 for the tongue, and 53 for the nor of the mouth. Some attempts to cope with this problem have been made for the breast and the cervix. Patients with carcinoma of the breast in Stages II and III show a slightly better three-year survival-rate and a higher symptom-free rate when treated by interstitial irradiation combined with excision than when treated with interstitial irradiation alone, but with the smaller number of patients observed for five years there seems to be no clear advantage of one treatment over the other. For carcinoma of the cervix there is a suggestion that the use of X rays combined with the Stockholm method of treatment gives a greater freedom from recurrence than the Stockholm method alone ; but the survival-rates at three years under the two methods show no material difference. In judging these various and numerous survivalrates it must be remembered, as the report emphasises, that they give a picture of the average results of radium treatment at a very widely scattered group of hospitals, and " must not be compared lightly either with the results of special clinics, or with results based upon a picked series of cases treated by a highly skilled surgeon. On the contrary, the results ... may be said to be those achieved by the medical skill of a large .part of the country working with radium, in conjunction with other methods, upon the average cancer patient seeking treatment." The statistical treatment of the data and their presentation have, we may add, been carried out with obvious care and skill.
any
relationship
these, too, any study of
CARBON MONOXIDE POISONING So
long
as
coal gas is used for heat and illumina-
tion, carbon monoxide poisoning will be of great i
interest and importance. Dr. HARVEY G. BECK of Baltimore says that in New York only highway accidents exceed it as a cause of death. We are familiar now with the way in which carbon monoxide, with its high affinity for haemoglobin, displaces oxygen from the blood and produces a fatal anoxaemia without the usual symptoms of asphyxia. Symptoms may be absent altogether, or present only as a kind of mental confusion, according to the concentration of the gas and activity of the victim. This feature is at once the attraction to suicides and the trap to the accidentally exposed. The struggle for air and extreme distress that we associate with suffocation are due to accumulation of carbon dioxide in the alveoli of the lungs, and there is no such accumulation in carbon monoxide poisoning. Indeed the 1 J. Amer. med. Ass. Sept. 26th, 1936, p.
1025.
155
hyperpncea that may accompany this-though almost ineffective and perhaps unnoticed at the time-actually lowers the carbon dioxide content of the blood, leading to a state of affairs which many believe to militate against recovery. Administration of carbon dioxide in treatment is therefore desirable for this reason, as well as for the more important reason that it stimulates the
respiratory centre, thereby causing deep breathing. deep breathing so caused may be as completely effective as possible, oxygen should also be given. Dr. C. K. DRINKER2 of Boston strongly advocates, and points out the advantages That the
mixture of 7 per cent. carbon dioxide and 93 per cent. oxygen. His article is one of the clearest summaries of the physiological and therapeutic aspects of carbon monoxide poisoning that we have seen, and is well worth reading. Chronic carbon monoxide poisoning is a recurring subject of controversy, largely, as the recent advisory committee of the Royal College of Physicians of London on domestic heating by gas suggest,3 because of confusion in terminology. DRINKER points out that acute poisoning followed by recovery may leave residual lesions. The body has been deprived of oxygen, and some parts of it, notably the nervous system, may have suffered irreparable damage. He states, and produces evidence, that this is rarer than one would expect. Acute poisoning is usually followed either by death or complete recovery, but some cases do show sequelae. This, however, is not chronic carbon monoxide poisoning. By chronic is meant the result of continual exposure to concentrations of the gas insufficient to produce acute poisoning, and chronic poisoning in this sense is the entity which is denied existence by some, but in which others believe. The advisory committee of the Royal College of Physicians to which we have just referred hold that " the available evidence is unconvincing as to the occurrence of any definite group of symptoms which would indicate a chronic form of carbon monoxide poisoning." BECK says : " The results establish the fact that slow carbon monoxide asphyxiation (anoxaemia) produces a definite clinicopathologic entity despite views held to the contrary." At first sight these two statements appear irreconcilable, but a perusal of BECK’S paper leaves us with the impression that his patients, whose " intermittent exposure ranged from several months to eighteen years," might have been suffering from repeated attacks of slight acute poisoning. Common sense at least suggests that such a sequence of attacks might well have permanent results, and that the possibility of their occurrence (e.g., in industry) should be minimised. Such an entity, if established, would probably be known as " chronic carbon monoxide poisoning," in spite of definitions excluding it from that title. Chronic poisoning in the sense in which we have defined it, as something gradually appearing in the complete absence of any signs of acute poisoning, probably does not exist. This point is not, as
of,
a
2 J. Industr. Hyg. November, 1936, p. 637. 3 See Lancet, 1936. 2, 1531.
may at first appear, merely academic. Dr. J. S. OwENS,4 for instance, in the course of a paper on carbon monoxide poisoning from motor-car fumes, mentioned in 1933 " the possibility that low concentrations of CO may be injurious when breathed for long periods," while M. LoEPER 5 and his colleagues in Paris have just published a paper on occupational CO poisoning in which they attribute various quite severe symptoms to minute but abnormal blood-CO values, only measurable by a certain chemical method more delicate than spectroscopy. In this group of patients long exposure to small concentrations of CO was established. The argument, convincing at first, is not helped by the paper immediately following, in which they describe " l’oxycarbonémie endogene." This deals with a group of patients with various clinical syndromes in which similar concentrations of CO in the blood are attributed to the effects of the malady itself and not to exposure to CO. Fortunately it is now generally admitted that carbon monoxide is chemically non-toxic, and can be injurious only in so far as it produces anoxaemia. There is no evidence that exposure which does not result in anoxaemia has the slightest effect, and even BECK’S contention that repeated anoxaemia is injurious is by no means generally accepted. Dr. ESTHER KILLICK’s recent work11 is also reassuring, for it shows that the body, on repeated exposure to carbon monoxide, develops a resistance to it so that the blood takes up less and less on successive occasions. Though it may be an insidious enemy, carbon monoxide has no hidden resources, and can be fought very successfully if we make full use of our ordinary weapons. Dr. A. Hugh Thompson, consulting surgeon to the Western Ophthalmic Hospital and a valued contributor to THE LANCET, died on Jan. llth at his home in Ellerdale-road, Hampstead, in his 78th year. 4 Ibid, 1933, 1, 154.
5 Bull. Soc. méd. Hôp. Paris, Dec. 21st, 1936, pp. 1671 and 1676. 6 See Lancet, 1936, 2, 143.
THE DUBLIN FEVER HospiTAL.-On Jan. 1st the new
constitution of Cork-street Fever
Hospital
became
effective, and the institution will in future be known as the Dublin Fever Hospital. Hitherto, the hospital, which has been in existence for more than a hundred years, has been a voluntary institution controlled by It was founded a board of voluntary governors. originally mainly by members of the Society of Friends, and there has always been a strong element of that philanthropic society interested in its management; the same family names recur again and again in the roll of governors. From the beginning of this year the voluntary character of the institution disappears and the hospital becomes a public one, the cost of maintenance being a joint charge on the corporation of Dublin and on the Dublin board of assistance. The control will be in the hands of representatives of these two bodies and of the existing board of governors of the hospital, who are constituted a perpetual college of electors for the election of such representatives. The medical officers of health for the city and the county of Dublin will have certain advisory duties in regard to the hospital. The present site is not sufficient for the enlargement required, and it is understood that search is being made for a commodious and convenient site.
ning of treatment. The argument in favour of this rate is that it may enable the success or failure of a method to be judged sooner than can be done when the survival-rate is used. For instance, with experience it might be possible from the trend of the symptom-free rate in the three-year period to estimate the survival-rate at the end of five years. At present the volume of material does not suffice for such a purpose, nor indeed to show whether the two rates are in fact more highly correlated than the two survival-rates at the same points of time. In
detailed an inquiry we can and selective reference to the results. It appears that 70 per cent. of the women with carcinoma of the breast who presented themselves for treatment in Stage I of the disease survived three years, and 50 per cent. five years. Of those in Stage III, on the other hand, only 18-8 and 13-6 per cent. were alive, many of these being given only palliative treatment. The 2058 patients with carcinoma of the cervix were divided into four stages : of those in the earliest group 61’1 per cent. survived three years and 49’4 per cent. five years, whereas of those in the latest group only 12-6 per cent. were alive after three years and 7’2 per cent. after five. Figures for carcinoma of the lip show, as might be expected, the great importance of involvement of the glands. Of those in whom the growth was limited to the lip slightly more than three-quarters lived five years ; of those with the regional lymph glands affected less than a third survived as long. Whatever the stage of disease, the outlook with carcinoma of the tongue is depressing, for of the patients most favourably placed only a quarter are alive at the end of five years, while out of 30 advanced cases only 1 remained. The floor of the mouth gives less unsatisfactory results than this-at least when the glands are not involved -for rather more than half the patients lived five years. With each of these sites, as has been shown over and over again, the chances of survival are better, often much better, if local spread or metastasis has not taken place. Yet the report shows that the proportion of patients in whom the disease is still localised to its original site when application for treatment is made, amounts, for all the sites investigated, to only 25 per cent. This figure varied but little between 1930 and 1932, although there was reason to think that the proportion coming for radium treatment at an early stage was increasing slowly among those with carcinoma of the lip, tongue, and cervix uteri. Younger patients with the latter or with carcinoma of the breast to some extent tend to seek treatment at an earlier stage then those who are older. The question of age is also studied in relation to survival, in two groups, under and over fifty years. For carcinoma of the breast there is no significant difference though the figures suggest a slightly more favourable issue in Stages I and II with the older patients. For the cervix this difference is definite and gives statistical support to the belief held by many clinicians that the prognosis is rather worse in young patients. For the remaining sites the data are insufficient for investigation of
reviewing so attempt only brief
between age and survival. For the relative success of different methods of treatment has had to be postponed till more material has accumulated, though those that prevail have been tabulated. One very serious obstacle to such a study is the large number of different combinations of methods of treatment. For instance 86 such combinations were distinguished in treatment for carcinoma of the breast, 66 for the cervix, 56 for the lip, 110 for the tongue, and 53 for the nor of the mouth. Some attempts to cope with this problem have been made for the breast and the cervix. Patients with carcinoma of the breast in Stages II and III show a slightly better three-year survival-rate and a higher symptom-free rate when treated by interstitial irradiation combined with excision than when treated with interstitial irradiation alone, but with the smaller number of patients observed for five years there seems to be no clear advantage of one treatment over the other. For carcinoma of the cervix there is a suggestion that the use of X rays combined with the Stockholm method of treatment gives a greater freedom from recurrence than the Stockholm method alone ; but the survival-rates at three years under the two methods show no material difference. In judging these various and numerous survivalrates it must be remembered, as the report emphasises, that they give a picture of the average results of radium treatment at a very widely scattered group of hospitals, and " must not be compared lightly either with the results of special clinics, or with results based upon a picked series of cases treated by a highly skilled surgeon. On the contrary, the results ... may be said to be those achieved by the medical skill of a large .part of the country working with radium, in conjunction with other methods, upon the average cancer patient seeking treatment." The statistical treatment of the data and their presentation have, we may add, been carried out with obvious care and skill.
any
relationship
these, too, any study of
CARBON MONOXIDE POISONING So
long
as
coal gas is used for heat and illumina-
tion, carbon monoxide poisoning will be of great i
interest and importance. Dr. HARVEY G. BECK of Baltimore says that in New York only highway accidents exceed it as a cause of death. We are familiar now with the way in which carbon monoxide, with its high affinity for haemoglobin, displaces oxygen from the blood and produces a fatal anoxaemia without the usual symptoms of asphyxia. Symptoms may be absent altogether, or present only as a kind of mental confusion, according to the concentration of the gas and activity of the victim. This feature is at once the attraction to suicides and the trap to the accidentally exposed. The struggle for air and extreme distress that we associate with suffocation are due to accumulation of carbon dioxide in the alveoli of the lungs, and there is no such accumulation in carbon monoxide poisoning. Indeed the 1 J. Amer. med. Ass. Sept. 26th, 1936, p.
1025.
155
hyperpncea that may accompany this-though almost ineffective and perhaps unnoticed at the time-actually lowers the carbon dioxide content of the blood, leading to a state of affairs which many believe to militate against recovery. Administration of carbon dioxide in treatment is therefore desirable for this reason, as well as for the more important reason that it stimulates the
respiratory centre, thereby causing deep breathing. deep breathing so caused may be as completely effective as possible, oxygen should also be given. Dr. C. K. DRINKER2 of Boston strongly advocates, and points out the advantages That the
mixture of 7 per cent. carbon dioxide and 93 per cent. oxygen. His article is one of the clearest summaries of the physiological and therapeutic aspects of carbon monoxide poisoning that we have seen, and is well worth reading. Chronic carbon monoxide poisoning is a recurring subject of controversy, largely, as the recent advisory committee of the Royal College of Physicians of London on domestic heating by gas suggest,3 because of confusion in terminology. DRINKER points out that acute poisoning followed by recovery may leave residual lesions. The body has been deprived of oxygen, and some parts of it, notably the nervous system, may have suffered irreparable damage. He states, and produces evidence, that this is rarer than one would expect. Acute poisoning is usually followed either by death or complete recovery, but some cases do show sequelae. This, however, is not chronic carbon monoxide poisoning. By chronic is meant the result of continual exposure to concentrations of the gas insufficient to produce acute poisoning, and chronic poisoning in this sense is the entity which is denied existence by some, but in which others believe. The advisory committee of the Royal College of Physicians to which we have just referred hold that " the available evidence is unconvincing as to the occurrence of any definite group of symptoms which would indicate a chronic form of carbon monoxide poisoning." BECK says : " The results establish the fact that slow carbon monoxide asphyxiation (anoxaemia) produces a definite clinicopathologic entity despite views held to the contrary." At first sight these two statements appear irreconcilable, but a perusal of BECK’S paper leaves us with the impression that his patients, whose " intermittent exposure ranged from several months to eighteen years," might have been suffering from repeated attacks of slight acute poisoning. Common sense at least suggests that such a sequence of attacks might well have permanent results, and that the possibility of their occurrence (e.g., in industry) should be minimised. Such an entity, if established, would probably be known as " chronic carbon monoxide poisoning," in spite of definitions excluding it from that title. Chronic poisoning in the sense in which we have defined it, as something gradually appearing in the complete absence of any signs of acute poisoning, probably does not exist. This point is not, as
of,
a
2 J. Industr. Hyg. November, 1936, p. 637. 3 See Lancet, 1936. 2, 1531.
may at first appear, merely academic. Dr. J. S. OwENS,4 for instance, in the course of a paper on carbon monoxide poisoning from motor-car fumes, mentioned in 1933 " the possibility that low concentrations of CO may be injurious when breathed for long periods," while M. LoEPER 5 and his colleagues in Paris have just published a paper on occupational CO poisoning in which they attribute various quite severe symptoms to minute but abnormal blood-CO values, only measurable by a certain chemical method more delicate than spectroscopy. In this group of patients long exposure to small concentrations of CO was established. The argument, convincing at first, is not helped by the paper immediately following, in which they describe " l’oxycarbonémie endogene." This deals with a group of patients with various clinical syndromes in which similar concentrations of CO in the blood are attributed to the effects of the malady itself and not to exposure to CO. Fortunately it is now generally admitted that carbon monoxide is chemically non-toxic, and can be injurious only in so far as it produces anoxaemia. There is no evidence that exposure which does not result in anoxaemia has the slightest effect, and even BECK’S contention that repeated anoxaemia is injurious is by no means generally accepted. Dr. ESTHER KILLICK’s recent work11 is also reassuring, for it shows that the body, on repeated exposure to carbon monoxide, develops a resistance to it so that the blood takes up less and less on successive occasions. Though it may be an insidious enemy, carbon monoxide has no hidden resources, and can be fought very successfully if we make full use of our ordinary weapons. Dr. A. Hugh Thompson, consulting surgeon to the Western Ophthalmic Hospital and a valued contributor to THE LANCET, died on Jan. llth at his home in Ellerdale-road, Hampstead, in his 78th year. 4 Ibid, 1933, 1, 154.
5 Bull. Soc. méd. Hôp. Paris, Dec. 21st, 1936, pp. 1671 and 1676. 6 See Lancet, 1936, 2, 143.
THE DUBLIN FEVER HospiTAL.-On Jan. 1st the new
constitution of Cork-street Fever
Hospital
became
effective, and the institution will in future be known as the Dublin Fever Hospital. Hitherto, the hospital, which has been in existence for more than a hundred years, has been a voluntary institution controlled by It was founded a board of voluntary governors. originally mainly by members of the Society of Friends, and there has always been a strong element of that philanthropic society interested in its management; the same family names recur again and again in the roll of governors. From the beginning of this year the voluntary character of the institution disappears and the hospital becomes a public one, the cost of maintenance being a joint charge on the corporation of Dublin and on the Dublin board of assistance. The control will be in the hands of representatives of these two bodies and of the existing board of governors of the hospital, who are constituted a perpetual college of electors for the election of such representatives. The medical officers of health for the city and the county of Dublin will have certain advisory duties in regard to the hospital. The present site is not sufficient for the enlargement required, and it is understood that search is being made for a commodious and convenient site.