- Email: [email protected]
RADIOTHERAPY OF CANCER IN THE MOUTH
179 further
investigated the relation between water and salt reabsorption. Urea and mannitol were used as osmotic diuretics so that the urinary volume was increased some 60%, but there was only a trivial increase in NaCl and iVaHC03 excretion. Thus in the rat sodium and water reabsorption are largely independent. The contents of the proximal tubules and loops of Henle are isosmotic ; so water is presumably passively reabsorbed preserving isotonicity as the solids of the glomerular filtrate pass through the tubular cells. This finding outmoded Marshall’s theory that the loops of Henle were the main sites of osmotic work for water reabsorption. In fact they seem to play the part more of osmotic dialysers, so that their contents reach the distal tubules isotonic with plasma. The maximum reabsorptive capacity (Tdm) of the distal tubules for both water and salt may be limited by critical constants. If this is true and the reabsorption of sodium in the proximal tubules is constant, sodium loss in the urine will depend on the glomerular filtration-rate. Such an assumption is supported by Merill’s theory, which is now fairly generally accepted, that the sodium retention of chronic congestive failure is due to reduced glomerular filtration-rate, but new research techniques are needed to study Tdm before this point can be settled. Dr. Homer Smith ended his narrative on a more homely and reassuring note by stating his belief that urea and creatinine clearances are still very useful clinically, even if they lack the refinements of research methods, and though the creatinine clearance in particular is hard to interpret in the presence of heart-failure. HOPEFUL SIGNS IN
MENTAL NURSING
field in which the best be nullified by poor nursing; but the most conscientious nurses cannot fail to give poor service if they are pushed beyond reasonable limits. The reports of the Board of Control, and more recently, of the Minister of Health, have been depressing in their repetition of complaints that treatment of mental illness is being held up by a desperate shortage of nurses. There is now some evidence that the vicious circle of wastage-longer hours-increased wastage is being broken. In the years 1937-43 the average wastage of student nurses from mental hospitals was higher than in any other type of hospital,1 It stood at the distressing figure of 82%, while the tuberculosis sanatoria lost 65% and the general hospitals lost 37%. Over the past twelve years there has been a dramatic fall in the intake of female mental nurses. In 1938 it was 9600 but in 1945 it had fallen to 2400. Since the inception of the National Health Service this trend seems to have been reversed. It is difficult to compare figures, because they are now collected and arranged differently, but some conclusions can be drawn from the fact that there was an increase of 5000 nurses in training (all types of hospitals) between July, 1948, and December, 1949, and an increase of nearly 1000 in the total nursing staff in mental hospitals. The mental-deficiency institutions, on the other hand, lost 63 nurses in the same period. It is difficult to assess requirements, because not only are most mental hospitals understaffed for their present commitments, but most of them ought to increase their beds. Even if nurses were available to staff these beds it is by no means certain that the money to maintain them would also be forthcoming : the recent cuts in estimates may force mental hospitals to close some of the beds they already offer. The present shortage of nurses might then even be eased for a time. Bearing all these variables in mind it is possible to estimate the present need at roughly 8000 (2000 of them PSYCHIATRY is
pre-eminently
a
medical attention and treatment
can
males). 1.
Report of the Working Party of Nurses. 1947.
on
In recruitment the mental hospitals have to fight a public opinion which still thinks in terms of asylums where all hope is lost. At the Schoolgirls’ Exhibition, held in London last month, a mental hospital was for the first time represented in the nursing section. The Claybury Hospital stand attempted " to enlighten the public as to conditions in mental hospitals and to recruit girls into the profession of mental nursing." In accordance with this double purpose, the stand showed modern instruments of treatment-such as apparatus for electricconvulsive therapy, and leucotomes-besides instruments used at Hanwell in the last century for mechanical restraint. Occupational-therapy work, and photographs of the hospital departments and wards gave an impression of cheerfulness and hope. The exhibit which attracted most attention was one of intensely dramatic freeexpression painting by a schizophrenic girl, the series showing unmistakable improvement to the most unpractised eye. Opinions vary on the exact value of this type of exhibition. It seems probable that, as far as immediate recruitment is concerned, it preaches only to the converted. But better understanding of the increasing hope in psychiatric treatment must surely bring a response in the future. The medical and nursing professions are largely to blame for public ignorance, and there is a good deal of ignorance among doctors and nurses themselves. The Ministry of Health is hoping to produce a short documentary film which will emphasise that insanity is merely a form of illness, and that much can be done for it. It will be some time before this can be made, but in the meantime there is plenty of room for other types of educational propaganda such as that offered by the National Association for Mental Health.
the Training and Recruitment
RADIOTHERAPY OF CANCER IN THE MOUTH
A Medical Research Council team, headed by Dr. Constance Wood and Mr. J. W. Boag, B.sc., and drawn from the council’s Radiotherapeutic Research Unit, has been comparing the efficacy of gamma rays and X rays in the treatment of cancer in the mouth. Their report,l now published, was eagerly awaited because of the urgent need to decide whether money would be better spent on the development of radium-beam units in all major centres or on other forms of apparatus. Human therapeutic experiments that will satisfy the statisticians are always difficult to devise and to carry out, but in these trials careful planning, with strict standards of comparison and physical control, ensured complete accuracy within the limits set. The comparison made was between the gamma beam from 10 grammes of radium and an X-ray beam at 180 kV, arranged that the isodose curves of the two types of radiation were almost perfectly matched. Beam direction was obtained by using treatment callipers, and tumour dose was calculated with measuring callipers or with the contour-finder devised for the purpose and described in the’report. Statistical analysis, with special methods of estimating survival-rates, has given the following results. The estimated cure-rate at 5 years for patients treated with the radium beam is 31 % (the actual survival-rate at 41/2 years, which was not known until after the report was written, is 28%), and with the X-ray beam 19.2% (actual survival-rate at 4B/z years, 20%). The difference between the 5-year rates is 118%, which is less than 1-62 times its standard error and therefore not significant. The final conclusion reached in the report-" This investigation does not show that the wavelength of the radiation per se, within the limits of the experiment, has any significant effects on the clinical results."so
1. Researches on the Radiotherapy of Oral Cancer. Spec. Rep. Ser. med. Res. Coun., Lond. no. 267. 1950. H. M. Stationery Office. Pp. 148. 12s. 6d.
180
generally accepted. But it is not the complete to the question whether the radium beam has special advantages as a therapeutic instrument. Before forming an opinion on this question several striking findings in the report should be considered.
will be
answer
The detailed statistical tables show that at least eighteen patients with palpable lymph-glands, seven of whom were treated with the X-ray beam, were symptomfree for 3 years or longer. Cure of malignant glands by radiotherapy is rare enough to make this a considerable achievement, and the report points out that the usual view that secondary cancer in glands is more resistant and responds more slowly to radiation than the primary tumour was not borne out in this series, in which the glands often disappeared first. This suggests a special place for the radium beam, or even for an X-ray beam of this type, in the treatment of cases where cancer in a difficult site, accompanied by palpable lymph-glands, makes block-dissection of the neck almost impossible. The effect of the two types of radiation on the skin is also important. It was found that the cases treated with X rays developed skin reactions earlier and more severely ; so a further comparison was arranged between fields on the two sides of the neck of patients with suitable lesions, the fields on one side being treated with gamma rays and those on the other with X rays. This experiment showed that the average ratio of gammaray dose to X-ray dose for the same visible skin reaction was 134 :1. Thus gamma radiation has a definite advantage, even if this is due to differences in penetration and absorption and not to any specific wave-length effect. There is thus some evidence that beam therapy has special uses and that, even if the experimental X-ray beam was a practical instrument, beam therapy should be given by means of gamma rays. In the radium beam we have a source of radiation with which the block of tissue which contains the tumour can be raised to the required dosage, and which, if the tumour is superficial enough, gives a rapid fall in dosage outside this block, thus increasing the tolerance of the normal tissues. Analysis of the results of treatment by site indicates the sites in which conditions are favourable for radium-beam treatment. Unfortunately, however, in some sites, particularly the pharynx, this method, in common with all others, results in so few survivals that no conclusions can be drawn from the figures. For lesions at the back of the mouth, and for some laryngeal lesions, more particularly when the lymph-glands are involved, provisions for radiumbeam therapy should certainly be made. The report " Such apparatus" [the 10 gramme bomb] says : may continue to be used in routine treatment for some time to come " ; it might have gone further and expressed the belief that some form of beam therapy, with either radium or radioactive cobalt, will continue to be used so long as irradiation is chosen for the treatment of oral
symmetrical
"
cancer.
A most skilful and intelligent manipulator, he some. times succeeded where qualified practitioners had failed, and a number of doctors encouraged their patients to go to him-or went to him themselves. On the other hand the profession, as such, can never agree that people who have not had a basic medical training can properly be entrusted with the full care of a patient ab initio; the ultimate responsibility must rest on someone trained in comprehensive diagnosis rather than in a therapeutic technique. Professional opposition, carried rather too far, prevented any official use of Barker’s services in the treatment of injuries during the 1914-18 war, and obliged the General Medical Council to remove the name of his anaesthetist, Dr. F. W. Axham, from the Medical Register, for the offence of covering " an unregistered practitioner. The case of Dr. Axham was long and bitterly debated: the public thought it a monstrous example of professional obscurantism, and a sense of discomfort within the profession would have led to the restoration of Dr. Axham’s name had he not died first, in 1926. Meanwhile the knighthood conferred on Barker in 1922, and the demand that he should receive a Lambeth M.D., had reflected the public respect for his abilities ; and more and more doctors were prepared to believe that a man with so much practical experience, and art, might have knowledge, or at least dodges, which could usefully be embodied in orthodox practice. In 1936 the British Orthopaedic Association accepted his offer of a demonstra. tion, and a report by Mr. W. Rowley Bristow, published in our columns2 describes how Sir Herbert Barker treated 18 patients at St. Thomas’s, where films were later made of his techniques. " He taught," Mr. Bristow wrote, " the value of "
repeated manipulation; the value of traction; the personal supervision and attention to exercising the joint in all directions afterwards ; and above all, I think, the splendid optimism which is essentially a part of treatment, and a necessary part, in helping those with long-standing disabilities, whose confidence has been rudely shaken by failures of the earlier efforts at cure. It is due to Barker to say that but for his pioneer work the manipulative field of orthop2edic surgery would not occupy the position it does today, and that had his offer to demonstrate his technique been accepted twenty-five years ago the general utilisation of this branch of therapeutics would not have been so long delayed." But though Barker did not quite realise it (Mr. Bristow Orthopedic thought) the battle was already won. surgeons now practise manipulative surgery as an "
essential part of their specialty." INTERNATIONAL CONGRESSES LAST Monday the sixth International Congress of Radiology, which is being held in London under the presidency of Dr. Ralston Paterson, was rung in by six strokes on a silver bell presented by British radiologists to mark the silver jubilee of these international meetings. Afterwards the Earl of Athlone formally opened the proceedings, and Sir Henry Dale welcomed 2700 delegates from 54 countries on behalf of British science and medicine and on behalf of the Government. At the dinner held at Guildhall on Monday evening the toast of the congress was proposed by Lord Mountbatten. The exhibition of apparatus which is being held in connection with the congress shows the outstanding advances made since the last exhibition in 1937. Meanwhile at Oxford, Lord Addison, himself a former professor of anatomy, welcomed 550 delegates from 36 countries to the international anatomical congress, which is meeting there this week under the presidency of Prof. W. E. Le Gros Clark, F.R.s.
BARKER FEW unqualified practitioners in medicine reach the eminence attained by Sir Herbert Barker. His death at the age of 81 ends a career that roused strong feeling in the medical profession and brought controversy to a focus. The son of a solicitor, he became, at 19, assistant to his cousin, John Atkinson, who derived his knowledge of bonesetting, by a sort of apostolic succession, from the Hutton family, yeoman farmers of the North. Starting for himself in practice in Manchester, lie found many patients among footballers and athletes, and won the confidence of Walter Whitehead, professor of clinical surgery in Manchester rniversity.1 A first attempt to start a practice in London was abortive, but after a ON July 22 Prof. HiLDA LLOYD was re-elected president period in Glasgow he returned and had great success. of the Royal College of Obstetricians and Gynaecologists. SIR
HERBERT
.
1. Manchester Guardian, July 24, p. 8.
2. Lancet, 1937. i, 546.
investigated the relation between water and salt reabsorption. Urea and mannitol were used as osmotic diuretics so that the urinary volume was increased some 60%, but there was only a trivial increase in NaCl and iVaHC03 excretion. Thus in the rat sodium and water reabsorption are largely independent. The contents of the proximal tubules and loops of Henle are isosmotic ; so water is presumably passively reabsorbed preserving isotonicity as the solids of the glomerular filtrate pass through the tubular cells. This finding outmoded Marshall’s theory that the loops of Henle were the main sites of osmotic work for water reabsorption. In fact they seem to play the part more of osmotic dialysers, so that their contents reach the distal tubules isotonic with plasma. The maximum reabsorptive capacity (Tdm) of the distal tubules for both water and salt may be limited by critical constants. If this is true and the reabsorption of sodium in the proximal tubules is constant, sodium loss in the urine will depend on the glomerular filtration-rate. Such an assumption is supported by Merill’s theory, which is now fairly generally accepted, that the sodium retention of chronic congestive failure is due to reduced glomerular filtration-rate, but new research techniques are needed to study Tdm before this point can be settled. Dr. Homer Smith ended his narrative on a more homely and reassuring note by stating his belief that urea and creatinine clearances are still very useful clinically, even if they lack the refinements of research methods, and though the creatinine clearance in particular is hard to interpret in the presence of heart-failure. HOPEFUL SIGNS IN
MENTAL NURSING
field in which the best be nullified by poor nursing; but the most conscientious nurses cannot fail to give poor service if they are pushed beyond reasonable limits. The reports of the Board of Control, and more recently, of the Minister of Health, have been depressing in their repetition of complaints that treatment of mental illness is being held up by a desperate shortage of nurses. There is now some evidence that the vicious circle of wastage-longer hours-increased wastage is being broken. In the years 1937-43 the average wastage of student nurses from mental hospitals was higher than in any other type of hospital,1 It stood at the distressing figure of 82%, while the tuberculosis sanatoria lost 65% and the general hospitals lost 37%. Over the past twelve years there has been a dramatic fall in the intake of female mental nurses. In 1938 it was 9600 but in 1945 it had fallen to 2400. Since the inception of the National Health Service this trend seems to have been reversed. It is difficult to compare figures, because they are now collected and arranged differently, but some conclusions can be drawn from the fact that there was an increase of 5000 nurses in training (all types of hospitals) between July, 1948, and December, 1949, and an increase of nearly 1000 in the total nursing staff in mental hospitals. The mental-deficiency institutions, on the other hand, lost 63 nurses in the same period. It is difficult to assess requirements, because not only are most mental hospitals understaffed for their present commitments, but most of them ought to increase their beds. Even if nurses were available to staff these beds it is by no means certain that the money to maintain them would also be forthcoming : the recent cuts in estimates may force mental hospitals to close some of the beds they already offer. The present shortage of nurses might then even be eased for a time. Bearing all these variables in mind it is possible to estimate the present need at roughly 8000 (2000 of them PSYCHIATRY is
pre-eminently
a
medical attention and treatment
can
males). 1.
Report of the Working Party of Nurses. 1947.
on
In recruitment the mental hospitals have to fight a public opinion which still thinks in terms of asylums where all hope is lost. At the Schoolgirls’ Exhibition, held in London last month, a mental hospital was for the first time represented in the nursing section. The Claybury Hospital stand attempted " to enlighten the public as to conditions in mental hospitals and to recruit girls into the profession of mental nursing." In accordance with this double purpose, the stand showed modern instruments of treatment-such as apparatus for electricconvulsive therapy, and leucotomes-besides instruments used at Hanwell in the last century for mechanical restraint. Occupational-therapy work, and photographs of the hospital departments and wards gave an impression of cheerfulness and hope. The exhibit which attracted most attention was one of intensely dramatic freeexpression painting by a schizophrenic girl, the series showing unmistakable improvement to the most unpractised eye. Opinions vary on the exact value of this type of exhibition. It seems probable that, as far as immediate recruitment is concerned, it preaches only to the converted. But better understanding of the increasing hope in psychiatric treatment must surely bring a response in the future. The medical and nursing professions are largely to blame for public ignorance, and there is a good deal of ignorance among doctors and nurses themselves. The Ministry of Health is hoping to produce a short documentary film which will emphasise that insanity is merely a form of illness, and that much can be done for it. It will be some time before this can be made, but in the meantime there is plenty of room for other types of educational propaganda such as that offered by the National Association for Mental Health.
the Training and Recruitment
RADIOTHERAPY OF CANCER IN THE MOUTH
A Medical Research Council team, headed by Dr. Constance Wood and Mr. J. W. Boag, B.sc., and drawn from the council’s Radiotherapeutic Research Unit, has been comparing the efficacy of gamma rays and X rays in the treatment of cancer in the mouth. Their report,l now published, was eagerly awaited because of the urgent need to decide whether money would be better spent on the development of radium-beam units in all major centres or on other forms of apparatus. Human therapeutic experiments that will satisfy the statisticians are always difficult to devise and to carry out, but in these trials careful planning, with strict standards of comparison and physical control, ensured complete accuracy within the limits set. The comparison made was between the gamma beam from 10 grammes of radium and an X-ray beam at 180 kV, arranged that the isodose curves of the two types of radiation were almost perfectly matched. Beam direction was obtained by using treatment callipers, and tumour dose was calculated with measuring callipers or with the contour-finder devised for the purpose and described in the’report. Statistical analysis, with special methods of estimating survival-rates, has given the following results. The estimated cure-rate at 5 years for patients treated with the radium beam is 31 % (the actual survival-rate at 41/2 years, which was not known until after the report was written, is 28%), and with the X-ray beam 19.2% (actual survival-rate at 4B/z years, 20%). The difference between the 5-year rates is 118%, which is less than 1-62 times its standard error and therefore not significant. The final conclusion reached in the report-" This investigation does not show that the wavelength of the radiation per se, within the limits of the experiment, has any significant effects on the clinical results."so
1. Researches on the Radiotherapy of Oral Cancer. Spec. Rep. Ser. med. Res. Coun., Lond. no. 267. 1950. H. M. Stationery Office. Pp. 148. 12s. 6d.
180
generally accepted. But it is not the complete to the question whether the radium beam has special advantages as a therapeutic instrument. Before forming an opinion on this question several striking findings in the report should be considered.
will be
answer
The detailed statistical tables show that at least eighteen patients with palpable lymph-glands, seven of whom were treated with the X-ray beam, were symptomfree for 3 years or longer. Cure of malignant glands by radiotherapy is rare enough to make this a considerable achievement, and the report points out that the usual view that secondary cancer in glands is more resistant and responds more slowly to radiation than the primary tumour was not borne out in this series, in which the glands often disappeared first. This suggests a special place for the radium beam, or even for an X-ray beam of this type, in the treatment of cases where cancer in a difficult site, accompanied by palpable lymph-glands, makes block-dissection of the neck almost impossible. The effect of the two types of radiation on the skin is also important. It was found that the cases treated with X rays developed skin reactions earlier and more severely ; so a further comparison was arranged between fields on the two sides of the neck of patients with suitable lesions, the fields on one side being treated with gamma rays and those on the other with X rays. This experiment showed that the average ratio of gammaray dose to X-ray dose for the same visible skin reaction was 134 :1. Thus gamma radiation has a definite advantage, even if this is due to differences in penetration and absorption and not to any specific wave-length effect. There is thus some evidence that beam therapy has special uses and that, even if the experimental X-ray beam was a practical instrument, beam therapy should be given by means of gamma rays. In the radium beam we have a source of radiation with which the block of tissue which contains the tumour can be raised to the required dosage, and which, if the tumour is superficial enough, gives a rapid fall in dosage outside this block, thus increasing the tolerance of the normal tissues. Analysis of the results of treatment by site indicates the sites in which conditions are favourable for radium-beam treatment. Unfortunately, however, in some sites, particularly the pharynx, this method, in common with all others, results in so few survivals that no conclusions can be drawn from the figures. For lesions at the back of the mouth, and for some laryngeal lesions, more particularly when the lymph-glands are involved, provisions for radiumbeam therapy should certainly be made. The report " Such apparatus" [the 10 gramme bomb] says : may continue to be used in routine treatment for some time to come " ; it might have gone further and expressed the belief that some form of beam therapy, with either radium or radioactive cobalt, will continue to be used so long as irradiation is chosen for the treatment of oral
symmetrical
"
cancer.
A most skilful and intelligent manipulator, he some. times succeeded where qualified practitioners had failed, and a number of doctors encouraged their patients to go to him-or went to him themselves. On the other hand the profession, as such, can never agree that people who have not had a basic medical training can properly be entrusted with the full care of a patient ab initio; the ultimate responsibility must rest on someone trained in comprehensive diagnosis rather than in a therapeutic technique. Professional opposition, carried rather too far, prevented any official use of Barker’s services in the treatment of injuries during the 1914-18 war, and obliged the General Medical Council to remove the name of his anaesthetist, Dr. F. W. Axham, from the Medical Register, for the offence of covering " an unregistered practitioner. The case of Dr. Axham was long and bitterly debated: the public thought it a monstrous example of professional obscurantism, and a sense of discomfort within the profession would have led to the restoration of Dr. Axham’s name had he not died first, in 1926. Meanwhile the knighthood conferred on Barker in 1922, and the demand that he should receive a Lambeth M.D., had reflected the public respect for his abilities ; and more and more doctors were prepared to believe that a man with so much practical experience, and art, might have knowledge, or at least dodges, which could usefully be embodied in orthodox practice. In 1936 the British Orthopaedic Association accepted his offer of a demonstra. tion, and a report by Mr. W. Rowley Bristow, published in our columns2 describes how Sir Herbert Barker treated 18 patients at St. Thomas’s, where films were later made of his techniques. " He taught," Mr. Bristow wrote, " the value of "
repeated manipulation; the value of traction; the personal supervision and attention to exercising the joint in all directions afterwards ; and above all, I think, the splendid optimism which is essentially a part of treatment, and a necessary part, in helping those with long-standing disabilities, whose confidence has been rudely shaken by failures of the earlier efforts at cure. It is due to Barker to say that but for his pioneer work the manipulative field of orthop2edic surgery would not occupy the position it does today, and that had his offer to demonstrate his technique been accepted twenty-five years ago the general utilisation of this branch of therapeutics would not have been so long delayed." But though Barker did not quite realise it (Mr. Bristow Orthopedic thought) the battle was already won. surgeons now practise manipulative surgery as an "
essential part of their specialty." INTERNATIONAL CONGRESSES LAST Monday the sixth International Congress of Radiology, which is being held in London under the presidency of Dr. Ralston Paterson, was rung in by six strokes on a silver bell presented by British radiologists to mark the silver jubilee of these international meetings. Afterwards the Earl of Athlone formally opened the proceedings, and Sir Henry Dale welcomed 2700 delegates from 54 countries on behalf of British science and medicine and on behalf of the Government. At the dinner held at Guildhall on Monday evening the toast of the congress was proposed by Lord Mountbatten. The exhibition of apparatus which is being held in connection with the congress shows the outstanding advances made since the last exhibition in 1937. Meanwhile at Oxford, Lord Addison, himself a former professor of anatomy, welcomed 550 delegates from 36 countries to the international anatomical congress, which is meeting there this week under the presidency of Prof. W. E. Le Gros Clark, F.R.s.
BARKER FEW unqualified practitioners in medicine reach the eminence attained by Sir Herbert Barker. His death at the age of 81 ends a career that roused strong feeling in the medical profession and brought controversy to a focus. The son of a solicitor, he became, at 19, assistant to his cousin, John Atkinson, who derived his knowledge of bonesetting, by a sort of apostolic succession, from the Hutton family, yeoman farmers of the North. Starting for himself in practice in Manchester, lie found many patients among footballers and athletes, and won the confidence of Walter Whitehead, professor of clinical surgery in Manchester rniversity.1 A first attempt to start a practice in London was abortive, but after a ON July 22 Prof. HiLDA LLOYD was re-elected president period in Glasgow he returned and had great success. of the Royal College of Obstetricians and Gynaecologists. SIR
HERBERT
.
1. Manchester Guardian, July 24, p. 8.
2. Lancet, 1937. i, 546.