OCCUPATIONAL HEALTH

120 series of charts of patients whose oedema and weight had materially lessened when they were strictly dieted. Even a diet of milk alone had succeeded. In some resistant

cases

thyroid deprivation by surgical operation

thiouracil had greatly reduced the fluid retention of obstinate left heart-failure and had even relieved anginal pain. Good results had followed, too, in congestive failure associated with auricular fibrillation or flutter not controlled by digitalis. or

methyl

ORTHOPÆDICS President : Mr. R. BROOMHEAD Closed Fractures of the Shafts of Radius and Ulna This discussion dealt with fractures in adults of both bones with important displacements, which present special problems of reduction and maintenance. The key to correction of rotation, much neglected in the past, is the orientation of the proximal radial fragment ; and Mr. E. MERVYN EvANS demonstrated a method of It was agreed that determining this radiologically. closed reduction and plaster-of-paris fixation were desirable but that trapped muscle often necessitated open reduction ; if stability could not be secured by interlocking, the fragments should be plated, in spite of dangers of infection and delayed union. Low fractures of the radius alone, with radio-ulnar dislocation, should be plated, continuous thumb-traction being frowned on. No external fixation was advocated after plating. Pain from Lesions of the Thoracic Outlet Prof. LAMBERT ROGERS associated the absence of similar pain in the lower limb with man’s upright posture, in which the structures leaving the thoracic outlet are kinked and those leaving the pelvis are straightened. The pain might be neural or vascular. Neural pain was caused by pressure on the lower trunk of the brachial plexus by a cervical rib, a corresponding fibrous band, the sharp tendinous margin of scalenus medius, or an abnormal scalenus anticus. The importance of scalenus medius prompted the omission of anticus " from the " scalenus-anticus syndrome." Vascular pain was caused by subclavian compression between the clavicle and a cervical or abnormal first rib (costoclavicula-r syndrome). The distribution of pain and the relief on elevation assisted distinction from ruptured intervertebral disc, radiological evidence of which might Failing relief by appropriate prove a " red herring." exercises, the source of pressure might be relieved

Upper-limb

appraisal of the working environment. be corrected if the doctor is in close only personal contact with his management and workpeople. This is almost impossible, he said, when one man is attending a big group of industrial units. He considers that the larger factories certainly need whole-time doctors, but believes that the employment of generalpractitioners in the smaller firms will help to stem the tide of over-specialisation which is to the ultimate detriment of the patient. Dr. DONALD STEWART suggested that the expansion of today’s occupational health services-which are patently inadequate-should be based on facts gleaned from regional surveys of the needs of different areas. One central authority, he considers, should be responsible for this survey and for the coordination of the developing service with the National Health Service. The Ministry of Health, he feels, is the appropriate body to undertake this task. If a single Government department is made responsible for national health, duplication and misdirection of effort should be avoidable. The medical profession and the Ministries of Labour and National Insurance, he said, await with interest the findings of a committee recently appointed by the Government to examine the relationship between the preventive and curative health services inside and outside industry. He thinks it would be foolhardy to plan without facts. Dr. STUART LAIDLAW described an experiment undertaken by Glasgow’s public-health department. With the assistance of two medical officers trained in industrial medicine, surveys were made of a weaving mill and of the city’s cleansing department. It was concluded that the facilities for the practice of preventive medicine provided by some of the major health authorities, used in combination with a part-time practitioner service, would be more practicable, and more economical in medical man-power, than a whole-time occupational to make

Faults

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hurried

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health service.

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exploration.

A discussion, with the section of rheumatology, on the Structure and Functions of the Synovial J.1I ernbrane was reviewed last week (p. 77).

OCCUPATIONAL HEALTH President : Prof. R. E. LANE

Comprehensive J.1fedical Service for Industry Controversy added a little spice to both sessions of the occupational health section. The future of occupational health services interests the general practitioner no less A

than the whole-time industrial medical officer. Several speakers, including some with no personal interest in this field, put forward cogent arguments against a service of whole-time industrial medical officers. Dr. N. J. CocH,n said that many believe that general practitioners have no place in industrial medicine because they have not been trained for it ; but neither, he pointed have most of their whole-time colleagues in industry. He that this cannot afford to divert several argued country thousand doctors into whole-time industrial medical practice. The idea of one whole-time doctor looking after several small firms is impracticable where industries are widely scattered. The practice of industrial medicine demands more than cursory visits to see the sick, and

out,

Tuberculosis and Occupatioit A plea was made by Dr. BRIAN DAVY that X-ray results should be used for epidemiological studies, and not only as a public-health weapon for detecting and treating individual cases. The value of analysing group results was well illustrated by Dr. ALICE STEWART in relation to operaives in the boot and shoe industry who for many years have been known to have a high mortality-rate from phthisis. Although workers with poor physique and chronic tuberculosis are found throughout this industry, the incidence of active tuberculosis is not uniformly distributed. Workers employed in factories with large workshops contract the disease more often than those in small workshops. The correlation between the phthisis-rate, and the size of working unit, she said, is very striking. It seems as though exogenous reinfection and superinfection in the workshop play an important part in the incidence of this disease. Dr. F. R. G. HEAF thought that inherent resistance, or the lack of it, was the most important factor in the infectivity of pulmonary tuberculosis, and that the tuberculous and non-tuberculous could be employed together provided the latter had overcome their primary infections, were well nourished, and had good home and- working conditions. Replying, Dr. STEWART asked whether it is easier to stop infection or to raise the resistance to infection of the whole community. She suggested that the former is the more practicable. Dr. PETER EDWARDS held that exogenous infection could in many instances be controlled by constant medical supervision, and by educating the public, though he admitted that 10% of the population are ineducable. He mentioned the many children and adults who have lived in Papworth for years without.

121

being infected. Idleness, he said, is the worst treatment for the tuberculous. Dr. HEAF, discussing reablement and resettlement, showed by illustrative case-histories that incurables It is never certain, he said, can be gainfully employed. that a tuberculous person has recovered from his disability; and it is never possible to assess his capacity for work except by trial and error. Inherent resistance is important, but he believes that the disease, when active, is infectious. Many industrial medical officers at this meeting must have reconsidered their views on ways and in industry. means of employing the tuberculous Individual results of mass radiography are not usually made known to them, so they are unable either to confirm or disprove the theory that carriers in large workshops have caused local epidemics, or to be sure that active cases are under control. RADIOLOGY President : Dr. J. L. A. GROUT

Scope and Limitation of Radiotherapy

Dr. J. S. FuLTON reviewed a wide variety of clinical conditions in which the value of radiotherapy may not be widely appreciated. He pointed out that the biological action of X or y rays is damaging or destructive and that any apparent stimulation is in reality a bio-

.

Dr. F. E. CHESTER-WILLIAMS dealt with those sites where radiotherapy has the greatest value-the skin, the mouth and throat, the breast, and the cervix uteri. In the treatment of skin lesions by irradiation, increased experience brings increased conservatism. He does not apply this treatment to lesions of the palm of the hand or the sole of the foot, and he warned against this therapy for recurring conditions. Pruritis ani is a particular menace, since the perineum does not tolerate heavy or cumulative dosage. The patients tend to come back or to seek a further dose from another practitioner as X-ray therapy commonly affords the greatest measure of relief. There have been disasters with extensive necrosis and even fatalities. In the mouth the most difficult problem is to differentiate recurrence and postradiation necrosis. He advocated radiotherapy for the primary lesion under almost all circumstances, but in operable cases block dissection of metastatic cervical lymph-nodes should be undertaken. In the treatment of carcinoma of the breast he favours simple mastectomy ’

associated with X-ray therapy. There was a lively discussion in which the wisdom of the radiotherapy of plantar verrucse was debated The value of the treatment of cavernous angiomata in children was also discussed. It was pointed out that on the one hand these usually disappear eventually, while on the other hand it is necessary to treat promptly lesions in the napkin area, which are liable to ulcerate and become infected, and other lesions which interfere with vision or with feeding.

logical reaction to tissue damage. Cancer of the lung is apparently becoming more common ; it represents 10% of all cases of malignant disease recorded in the Liverpool area. The proportion of cases in which Radiotherapy in Spoodylitis Ankylopoietica and Osteosurgical removal can be carried out is small, and for the arthritis remainder radiotherapy is the best method of procuring Dr. GWENDOLEN HILTON described her experiences palliation ; life is not much prolonged, but it is made in treating a large series of cases of ankylosing spondylitis. In more comfortable by relief of pain and dyspnoea. X-ray treatment relieves pain in the areas treated ; carcinoma of the oesophagus X-ray therapy is also of at the same time muscle-spasm is relieved and movement great value as a palliative ; in almost all cases obstruction in the affected joints greatly increased. This chronic of the gullet can be relieved -and normal swallowing disease is subject to spontaneous remissions and relapses ; regained, if only for a few months-a respite of the there is evidence that some cases spontaneously become greatest importance. The sudden onset of oesophageal quiescent without advancing beyond the stage where obstruction in a man who is otherwise well and has only the sacro-iliac joints are involved. It is therefore a normal appetite is a particularly distressing feature not possible without prolonged observation-perhaps for of this form of malignant disease. In Wilm’s tumour twenty years-to state whether X-ray therapy has a of the kidney and even in some cases of hypernephroma, permanent effect. With regard to technique, areas size value is of the irradiation to reduce preoperative covering the whole spine and sacro-iliac joints are treated of a bulky fixed tumour and bring it within the scope in rotation to a dose of 1600-lSOOr in three weeks ; of surgical excision. In testicular tumours the associaother areas-e.g., ischial tuberosities-are treated if there tion of radiotherapy with local removal has resulted in is clinical evidence of involvement. After treatment freedom recurrence. from 50% five-year Secondary exercises are given to restore movement. Dr. MARGARET SNELLING described the results of involvement of bone by malignant growths is often believed not to respond to radiotherapy, but here also treatment in 277 cases of ankylosing spondylitis ; the such therapy has a definite field of usefulness. Involvement of bone by direct extension of a primary lesion, as in the mouth, undoubtedly causes increased radioresistance and increased liability to necrosis ; there are, however, many such cases in which healing is obtained by radium or by X rays when surgery has been abandoned. Radiotherapy may be the only method by which the severe pain of skeletal metastases can be relieved. Osteolytic metastases can frequently be made to consolidate, and after the treatment of apparently solita,ry metastases, life may be prolonged in comfort even for many years. In the treatment of the reticuloses radiotherapy is still the sheet anchor. Chemotherapy has not so far afforded any permanent response, and remissions which have been induced by it appear to be of shorter duration than those from irradiation. Turning to non-malignant conditions, Dr. Fulton stressed the value in ankylosing spondylitis of X-ray therapy associated with early mobilisation. For plantar verruca he advocates a single-treatment method with X rays in cases where no previous radiotherapy has been given ; radiotherapy to this area should not be repeated.

of treatment was similar to that described by Dr. Hilton. Of early cases 74% were restored to normal and have had no sign of relapse for periods of five to ten years. More advanced cases had some residual disability due to pre-existing ankylosis and calcification of ligaments. Dr. JANET MALLENDER discussed the value of X-ray therapy in osteo-arthritis. She showed that relief of pain can be obtained in a worth-while percentage of patients ; there seems to be some advantage in spreading the dose over a period of 2-3 weeks. In the subsequent discussion the management of X-ray therapy of the young woman with ankylosing spondylitis was debated. It was pointed out that the sacro-iliac joints can be irradiated obliquely with dosage of the order previously described, without producing any sign of menstrual disorder. The view was expressed that although there might be no ovarian changes great enough to produce menstrual abnormalities, sumcient dose would probably be received by the ovaries to cause subsequent genetic changes ; and the question was raised whether any youngwomen undergoing X-ray treatment to

technique