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SOCIETY OF RADIOTHERAPISTS OF GREAT BRITAIN AND IRELAND
782 if that failed. when the clinical and radiological information showed that progress was not being made. Dr. F. G. CHANDLER spoke of the comparative of spontaneous healing. Inhalations, especially of menthol steam, were useful. Arsenic by the mouth had the greatest value, and so had sodium benzoate and novarsenobenzol intravenously. Sulphanilamide might be effective in certain cases. There existed a form of suppurative pneumonitis in which there was no cavity or fluid level, and a large area of lung was necrotic. Perhaps lobectomy or even total pneumonectomy was the method of choice, but these were severe measures. He asked how he should treat diffuse lung abscess without a definite
or
with the
use
of external
drainage
The time for external drainage
was
,
frequency
boundary. Mr. A. TuDoR EDWARDS said he had never seen a true pneumococcal abscess follow a true lobar pneumonia. He thought that most lung abscesses were caused by the inhalation of infective material. Oil would run freely into the bronchial tree, and so the larynx did not form an impregnable defence. Needling a lung through a normal chest wall was absolutely unjustifiable, and even when the lung was exposed needling had great dangers. He made a
deliberate incision through the pleura with a knife, and would rather do so even if the pleura were adherent than pass a needle through a free pleura. If the pleura were free he would suture the wound, insert an intercostal tube into the lobe, and aspirate all the air. The abscess could be localised with great accuracy by this method. At least ten days should be allowed between the two stages of operation. was not quite a pulmonary diffuse condition with multiple abscesses. The only effective method of treating it was by coagulation and excision with a diathermy loop. Dr. P. H. MArTsow-BHR, reminded the meeting of the possibility that a lung abscess might be caused by amoeba and therefore at once curable with emetine. He mentioned one case in a woman of 73, whose only contact with the tropics had been ten days in Calcutta as a bride of 20. The PRESIDENT spoke of the danger of being too optimistic and of keeping patients waiting for spontaneous cure so long that the inflammatory process produced irreparable change in the lobe, with chronic invalidism. Neuhoff had published a series of cases in which early operation had been successful in a very high proportion. Operative drainage in an early stage was not very dangerous, and should be undertaken when postural treatment did not produce drainage. The best evidence of failure to drain was the persistence of a fluid level for a fortnight. If a tomogram showed that the bronchus leaving the abscess was in the apex of the cavity, postural drainage was likely to be of value. Dr. W. BuRTON WOOD said that the physician must devise better means of dealing with diffuse pulmonary suppuration. The introduction of Prontosil and allied remedies opened up a new field of therapy. Dr. J. G. SCADDiNG confirmed that suppurations occurred after lobar pneumonia. All writers on the subject had described ring shadows indicating cavities. He had seen many cases without symptoms of pulmonary abscess clear up without particular treatment. It might form a link in a long series of conditions of which the extreme form was a frankly putrid abscess, and explain some of the discrepancies in the response of various patients to treatment. Dr. E. R. BoLnrrD recalled a case in which a young man had begun to recover after a severe fit of cough-
Suppurative pneumonitis abscess, but
a
ing, in which he had evacuated much pus, brought on by the severe tilting of his stretcher on the way up a steep flight of stairs to an operating theatre. Dr. MAXWELL said in reply that he had encountered a case of amoebic lung abscess in a patient who had never been out of the country nor had dysentery. Diffuse suppuration sometimes responded extraordinarily well to ultra-short wave diathermy. Where the suppuration did not resolve completely, a definite abscess might be formed which could be treated in the ordinary way. Mr. BROCK, also in reply, stated that one problem of diffuse suppuration was the possibility of overlooking a large cavity within the " black-out." The possibility of saving the patient’s life might justify the use of the needle in such a case. Lung abscesses often came to treatment too late-perhaps because of mistrust of external drainage. -
---------------
SOCIETY OF RADIOTHERAPISTS OF GREAT BRITAIN AND IRELAND
AT a meeting of this society held on March 18th, with Dr. N. S. FINZI in the chair, Dr. RALSTON PATERSON opened a discussion on Methods of Prescribing and Measuring Dosage in Radiation
Therapy
He said that the great need of present-day therapy is so to build up the conception of dosage measurement that information can be accumulated about the actual lethal dose to each particular type of tumour and the tolerance of skin and other normal tissues to similar measured doses. If a system can be used for general statements of doses, quite detached from technique, wave-length, or field size, it is of real value. Dosage must be assessed in terms of is measured in rontgens because which quantity, this measure has gained international acceptance, and the only valid statement of clinical dosage is rontgens in tissue. In the treatment of malignant disease two tissues need practical consideration-the The dosage system must tumour and the skin. allow the determination of the dose actually received at every point in the tumour, usually as a statement of the maximum and minimum doses, while computation of the dose to the skin should also be given in terms of the maximum dose received at any point in the area. In clinical work a statement of quantity alone was inadequate. The duration of exposure had a profound influence on the effect produced and in Dr. Paterson’s view dosage should always be given in relation to time. Although there were physical problems still unsolved, enough accurate information was available about energy absorbed to make it possible to measure in rontgens not only X rays but also gamma rays, but the methods differed. For X radiation the dose could be measured either directly or indirectly-Dr. Paterson on the whole preferred the indirect method. The dose at the surface of the body for the particular applicator or radiation field to be used was determined and the tumour dose was arrived at in terms of percentage depth dose, or for crossed field techniques as the sum of all the contributions received from the various fields. Radium dosage assessment was at once simpler and more complex than X ray dosage assessment because, although the effects of scatter were unimportant, the multiple radio-active foci required and the variety of points at which the dose must be measured added to
783 the difficulties. The speaker, with H. M. Parker, had outlined a system of dosage for radium therapy which he thought quite useful. He suggested that by way of contrast with the methods of X ray and radium dosage outlined, other methods might be examined, such as : (1)R5ntgens in air. This was a measurement of the intensity of an X ray beam, which meant that it measured the output of the X ray tube, not the dose received. (2) Erythema dose. This had real importance at the time when physical measurements had little accuracy, and might be regarded as an experimental assay, now replaced by dosage in rontgens. (3) Summated röntgens to skin fields. This method of reckoning dosage was misleading, especially if multiple fields had been used. It was much more informative to give a dose received at the point being treated, for
example, the cervix. (4) Milligramme hours or millicuries destroyed. Doses in these terms were no longer used by radiologists who now thought of doses to tumour in terms of energy absorbed, and they therefore needed no further discussion. Finally Dr. Paterson put forward a plea for considering, when prescribing radiation treatment, first the dose to the tumour, then the dose to the skin, and only after reaching a decision on these points, the technique to be employed. Mr. B. W. AVINDEYER detailed the international recommendations recently agreed upon in Chicago and pointed out their important features. He did not think that dosage rate in terms of r per minute had much effect on the production of reactions, but he agreed that the over-all time altered the effects and expected an advantage in the form of increased skin tolerance for longer over-all time. In treatment by radium all types of radiation, including the use of radon, must be covered and he used the PatersonParker charts for estimating dosage, except for certain standard applicators for small lesions. Mr. L. H. CLARK discussed the dose received from radium applicators and described his method of obtaining homogeneous radiation. He also used the Paterson-Parker charts, with modifications made necessary by the difficulty of working with radium in unsuitable containers. He measured X ray doses by the indirect method and drew attention to the fact that although charts are drawn for a beam normal at the point of entry, there is, in fact, always some degree of tilting. Mr. T. A. GREENE spoke of the importance of the volume effect, which often made it necessary to restrict the dose delivered, and he described his method of beam direction in relation to tumour
doses. The PRESIDENT pointed out the difficulty of arriving at any decision in international discussions and emphasised the progress that had been made. In this country there was general agreement on the necessity of a statement of tumour dose. MEDICAL SOCIETY OF INDIVIDUAL
PSYCHOLOGY AT
a
meeting
of this
society
held at 11, Chandos-
street, W., on March 10th, with Dr. H. C. SQUIRES in the chair, Prof. JOHN MACMURRAT read a paper on A
Philosopher’s View of Modern Psychology He began by saying that the function of the philosopher was to relate the field of the expert to the more general field in which it was included. Looking
at medical science he noticed that the relation of doctor and patient, from which medical science and practice arise, was a particular type of relation between persons. It conditioned everything within the field of medicine and was itself conditioned by the nature of human relations in general. The patient is a person who is anxious about himself, who asks another person to help him. The fact that the doctor-patient relation is a relation of persons provides certain principles in itself. Just as a teacher who teaches his subject and not his pupils is a bad teacher, so a doctor who sets out to heal diseases instead of healing people will not be a good doctor. The patient as a person requiring help is the focus of all problems in medicine. If medicine treats diseases, then a classification of diseases into bodily and mental will arise in which the unity of the person is lost sight of. Physicians and psychotherapists will have different objects to treat, and the necessity of coöperation in treating a patient who is always suffering in mind, whether or not he is suffering organically, will be lost sight of. Every case which a doctor deals with arises because of the patient’s anxiety about himself. His anxiety, which brings him to the doctor, is his sense that something is the matter with him. The task of the physician is to discover what is the matter. If some malfunctioning of the organism can be discovered, then it can be correlated with the anxiety of the patient about himself. If this is correct then the restoration of proper bodily functioning will remove this anxiety and bring the relation of doctor and patient to an end. But if the doctor can assure himself that there is no organic failure sufficient to account for the anxiety of the patient, what is to be done ? The physician may feel inclined to say that there is nothing the matter with him. But there must be something the matter with a man who comes to a doctor when there is nothing the matter with him. The anxiety must have a As it is an anxiety about himself the cause cause. must lie in himself. If it has no observable bodily correlate the anxiety itself is a disease, and expresses the patient’s sense that something is the matter with his functioning as a human being. The task of finding what is the matter and curing it is then the task of the psychotherapist. Prof. Macmurray devoted the rest of his address to a determination of some of the general characteristics of fear as exhibited in human behaviour. He emphasised the need for distinguishing fear and its
derivatives as negative motives with an inhibitory effect, from the positive motives which determine the positive life processes. He distinguished human fear from " animal" fear by the presence of anticipatory phantasy. He pointed out that in all the development of consciousness and especially in all rational reflection fear was always present. Reflection itself involved the inhibition of action. In action fear expressed itself as caution : the recognition of the possibility of mistaken behaviour and so in the distinction between right and wrong. Thus it was a mistake to maintain that fear was neurotic in itself. Nevertheless anxiety, as a pervasive fear which determined an egocentric and selfdefensive attitude to life, was an expression of human malfunctioning. The rhythm of human life involved both fear to provide the motive for withdrawal into reflection and the triumph over fear to provide the return to positive activity enriched by reflection. This general diagnosis of human malfunctioning, he added, could not be complete without reference to love in relation to fear, because of the inherent mutuality or reciprocity between persons which is
or
with the
use
of external
drainage
The time for external drainage
was
,
frequency
boundary. Mr. A. TuDoR EDWARDS said he had never seen a true pneumococcal abscess follow a true lobar pneumonia. He thought that most lung abscesses were caused by the inhalation of infective material. Oil would run freely into the bronchial tree, and so the larynx did not form an impregnable defence. Needling a lung through a normal chest wall was absolutely unjustifiable, and even when the lung was exposed needling had great dangers. He made a
deliberate incision through the pleura with a knife, and would rather do so even if the pleura were adherent than pass a needle through a free pleura. If the pleura were free he would suture the wound, insert an intercostal tube into the lobe, and aspirate all the air. The abscess could be localised with great accuracy by this method. At least ten days should be allowed between the two stages of operation. was not quite a pulmonary diffuse condition with multiple abscesses. The only effective method of treating it was by coagulation and excision with a diathermy loop. Dr. P. H. MArTsow-BHR, reminded the meeting of the possibility that a lung abscess might be caused by amoeba and therefore at once curable with emetine. He mentioned one case in a woman of 73, whose only contact with the tropics had been ten days in Calcutta as a bride of 20. The PRESIDENT spoke of the danger of being too optimistic and of keeping patients waiting for spontaneous cure so long that the inflammatory process produced irreparable change in the lobe, with chronic invalidism. Neuhoff had published a series of cases in which early operation had been successful in a very high proportion. Operative drainage in an early stage was not very dangerous, and should be undertaken when postural treatment did not produce drainage. The best evidence of failure to drain was the persistence of a fluid level for a fortnight. If a tomogram showed that the bronchus leaving the abscess was in the apex of the cavity, postural drainage was likely to be of value. Dr. W. BuRTON WOOD said that the physician must devise better means of dealing with diffuse pulmonary suppuration. The introduction of Prontosil and allied remedies opened up a new field of therapy. Dr. J. G. SCADDiNG confirmed that suppurations occurred after lobar pneumonia. All writers on the subject had described ring shadows indicating cavities. He had seen many cases without symptoms of pulmonary abscess clear up without particular treatment. It might form a link in a long series of conditions of which the extreme form was a frankly putrid abscess, and explain some of the discrepancies in the response of various patients to treatment. Dr. E. R. BoLnrrD recalled a case in which a young man had begun to recover after a severe fit of cough-
Suppurative pneumonitis abscess, but
a
ing, in which he had evacuated much pus, brought on by the severe tilting of his stretcher on the way up a steep flight of stairs to an operating theatre. Dr. MAXWELL said in reply that he had encountered a case of amoebic lung abscess in a patient who had never been out of the country nor had dysentery. Diffuse suppuration sometimes responded extraordinarily well to ultra-short wave diathermy. Where the suppuration did not resolve completely, a definite abscess might be formed which could be treated in the ordinary way. Mr. BROCK, also in reply, stated that one problem of diffuse suppuration was the possibility of overlooking a large cavity within the " black-out." The possibility of saving the patient’s life might justify the use of the needle in such a case. Lung abscesses often came to treatment too late-perhaps because of mistrust of external drainage. -
---------------
SOCIETY OF RADIOTHERAPISTS OF GREAT BRITAIN AND IRELAND
AT a meeting of this society held on March 18th, with Dr. N. S. FINZI in the chair, Dr. RALSTON PATERSON opened a discussion on Methods of Prescribing and Measuring Dosage in Radiation
Therapy
He said that the great need of present-day therapy is so to build up the conception of dosage measurement that information can be accumulated about the actual lethal dose to each particular type of tumour and the tolerance of skin and other normal tissues to similar measured doses. If a system can be used for general statements of doses, quite detached from technique, wave-length, or field size, it is of real value. Dosage must be assessed in terms of is measured in rontgens because which quantity, this measure has gained international acceptance, and the only valid statement of clinical dosage is rontgens in tissue. In the treatment of malignant disease two tissues need practical consideration-the The dosage system must tumour and the skin. allow the determination of the dose actually received at every point in the tumour, usually as a statement of the maximum and minimum doses, while computation of the dose to the skin should also be given in terms of the maximum dose received at any point in the area. In clinical work a statement of quantity alone was inadequate. The duration of exposure had a profound influence on the effect produced and in Dr. Paterson’s view dosage should always be given in relation to time. Although there were physical problems still unsolved, enough accurate information was available about energy absorbed to make it possible to measure in rontgens not only X rays but also gamma rays, but the methods differed. For X radiation the dose could be measured either directly or indirectly-Dr. Paterson on the whole preferred the indirect method. The dose at the surface of the body for the particular applicator or radiation field to be used was determined and the tumour dose was arrived at in terms of percentage depth dose, or for crossed field techniques as the sum of all the contributions received from the various fields. Radium dosage assessment was at once simpler and more complex than X ray dosage assessment because, although the effects of scatter were unimportant, the multiple radio-active foci required and the variety of points at which the dose must be measured added to
783 the difficulties. The speaker, with H. M. Parker, had outlined a system of dosage for radium therapy which he thought quite useful. He suggested that by way of contrast with the methods of X ray and radium dosage outlined, other methods might be examined, such as : (1)R5ntgens in air. This was a measurement of the intensity of an X ray beam, which meant that it measured the output of the X ray tube, not the dose received. (2) Erythema dose. This had real importance at the time when physical measurements had little accuracy, and might be regarded as an experimental assay, now replaced by dosage in rontgens. (3) Summated röntgens to skin fields. This method of reckoning dosage was misleading, especially if multiple fields had been used. It was much more informative to give a dose received at the point being treated, for
example, the cervix. (4) Milligramme hours or millicuries destroyed. Doses in these terms were no longer used by radiologists who now thought of doses to tumour in terms of energy absorbed, and they therefore needed no further discussion. Finally Dr. Paterson put forward a plea for considering, when prescribing radiation treatment, first the dose to the tumour, then the dose to the skin, and only after reaching a decision on these points, the technique to be employed. Mr. B. W. AVINDEYER detailed the international recommendations recently agreed upon in Chicago and pointed out their important features. He did not think that dosage rate in terms of r per minute had much effect on the production of reactions, but he agreed that the over-all time altered the effects and expected an advantage in the form of increased skin tolerance for longer over-all time. In treatment by radium all types of radiation, including the use of radon, must be covered and he used the PatersonParker charts for estimating dosage, except for certain standard applicators for small lesions. Mr. L. H. CLARK discussed the dose received from radium applicators and described his method of obtaining homogeneous radiation. He also used the Paterson-Parker charts, with modifications made necessary by the difficulty of working with radium in unsuitable containers. He measured X ray doses by the indirect method and drew attention to the fact that although charts are drawn for a beam normal at the point of entry, there is, in fact, always some degree of tilting. Mr. T. A. GREENE spoke of the importance of the volume effect, which often made it necessary to restrict the dose delivered, and he described his method of beam direction in relation to tumour
doses. The PRESIDENT pointed out the difficulty of arriving at any decision in international discussions and emphasised the progress that had been made. In this country there was general agreement on the necessity of a statement of tumour dose. MEDICAL SOCIETY OF INDIVIDUAL
PSYCHOLOGY AT
a
meeting
of this
society
held at 11, Chandos-
street, W., on March 10th, with Dr. H. C. SQUIRES in the chair, Prof. JOHN MACMURRAT read a paper on A
Philosopher’s View of Modern Psychology He began by saying that the function of the philosopher was to relate the field of the expert to the more general field in which it was included. Looking
at medical science he noticed that the relation of doctor and patient, from which medical science and practice arise, was a particular type of relation between persons. It conditioned everything within the field of medicine and was itself conditioned by the nature of human relations in general. The patient is a person who is anxious about himself, who asks another person to help him. The fact that the doctor-patient relation is a relation of persons provides certain principles in itself. Just as a teacher who teaches his subject and not his pupils is a bad teacher, so a doctor who sets out to heal diseases instead of healing people will not be a good doctor. The patient as a person requiring help is the focus of all problems in medicine. If medicine treats diseases, then a classification of diseases into bodily and mental will arise in which the unity of the person is lost sight of. Physicians and psychotherapists will have different objects to treat, and the necessity of coöperation in treating a patient who is always suffering in mind, whether or not he is suffering organically, will be lost sight of. Every case which a doctor deals with arises because of the patient’s anxiety about himself. His anxiety, which brings him to the doctor, is his sense that something is the matter with him. The task of the physician is to discover what is the matter. If some malfunctioning of the organism can be discovered, then it can be correlated with the anxiety of the patient about himself. If this is correct then the restoration of proper bodily functioning will remove this anxiety and bring the relation of doctor and patient to an end. But if the doctor can assure himself that there is no organic failure sufficient to account for the anxiety of the patient, what is to be done ? The physician may feel inclined to say that there is nothing the matter with him. But there must be something the matter with a man who comes to a doctor when there is nothing the matter with him. The anxiety must have a As it is an anxiety about himself the cause cause. must lie in himself. If it has no observable bodily correlate the anxiety itself is a disease, and expresses the patient’s sense that something is the matter with his functioning as a human being. The task of finding what is the matter and curing it is then the task of the psychotherapist. Prof. Macmurray devoted the rest of his address to a determination of some of the general characteristics of fear as exhibited in human behaviour. He emphasised the need for distinguishing fear and its
derivatives as negative motives with an inhibitory effect, from the positive motives which determine the positive life processes. He distinguished human fear from " animal" fear by the presence of anticipatory phantasy. He pointed out that in all the development of consciousness and especially in all rational reflection fear was always present. Reflection itself involved the inhibition of action. In action fear expressed itself as caution : the recognition of the possibility of mistaken behaviour and so in the distinction between right and wrong. Thus it was a mistake to maintain that fear was neurotic in itself. Nevertheless anxiety, as a pervasive fear which determined an egocentric and selfdefensive attitude to life, was an expression of human malfunctioning. The rhythm of human life involved both fear to provide the motive for withdrawal into reflection and the triumph over fear to provide the return to positive activity enriched by reflection. This general diagnosis of human malfunctioning, he added, could not be complete without reference to love in relation to fear, because of the inherent mutuality or reciprocity between persons which is