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SUBACUTE INCLUSION ENCEPHALITIS
833
The difference was highly significant. (Statistical analysis of the results was performed at the Institute of Mathematics, Department of Biometrics, Hungarian Academy of Sciences.) G. SZEGHY T. Ö. ZOLTÁN University Medical School, M. FÖLDI. Szeged, Hungary. EFFECTS OF DIAGNOSTIC IRRADIATION SIR,-I am very gratified with the replies to my letter of March 16 because both writers have unwittingly lent considerable support to my view. Dr. Sowby (March 30) has confirmed that the largest single upsurge in the death-rate due to birth injury (from 6-0 to 6-3) in the past ten years occurred precisely after the publication of the first Oxford report1 on childhood malignancies, when most X-ray pelvimetries had ceased in 1957. He does, however, seem completely satisfied that a rate of 6 deaths per 1000 births admittedly due to difficulties in labour is a providence-determined rate which is not worth improving. My plea as a radiologist to two maternity hospitals is for the greatest possible reduction of these avoidable deaths, and I still regard a properly carried out and adequately interpreted X-ray pelvimetry as the best possible means towards achieving this. Dr. Stewart (March 30) has now admitted the definite existence of a pre-leukaemic state and its close association with respiratory infection. Is it not obvious that any respiratory disease will be followed in its wake by more than average X-ray examinations ? Has not the time come to exonerate the X-ray exposure entirely and concentrate on the underlying disease as the cause or the trigger to the development of leukxmia-a view which I put forward2 seven years ago and from which I have not deviated. As far
childhood malignancies are concerned, we must discussion whether 20 or 30 children’s deaths from leukaemia could be due to X rays to detract from the major problem of 6384 perinatal deaths from avoidable birth injury. The entire problem of childhood malignancies pales into puny insignificance when compared with the possible benefits which could be obtained by saving hundreds or thousands of children at birth. as
not allow a
London, W.1.
J. RABINOWITCH.
SUBACUTE INCLUSION ENCEPHALITIS
SIR,-Your annotation of Jan. 19 falls a long way short of the standard of this section of your journal. Since the last sentence, referring to subacute inclusion encephalitis and to subacute sclerosing leuco-encephalitis, reads that the consensus of opinion is that the two conditions are variations of the same disease ", there is little justification for discussion of one alone. In fact, the cases reported from Great Britain and North America include both types, as do the much greater numbers reported from Europe and elsewhere, which "
you ignore.
Certainly the disease is uncommon, but you give a
wrong impression of its rarity, and there
can be few E.E.G. of size which do number not one or two departments any cases in their archives: since the paper by Cobb and Hill3 there have been 17 cases in the National Hospital alone. For example, Radermecker and Posermention more than 40 personal cases from Belgium, and Hamoen et al. report 23 cases from Holland-two countries which appear to be centres of distribution of the disease. The number of cases from North America, considering the size of the population and the medical efficiency, is surprisingly small. The paper by Campbell et al.includes postmortem reports 1. Stewart, A., Webb, J. W., Giles, D., Hewitt, D. Lancet, 1956, ii, 447. 2. Rabinowitch, J. ibid. p. 1261. 3 Cobb, W., Hill, D. Brain, 1950, 73, 392. 4 Radermecker, J., Poser, C.M. WldNeurol. 1960, 1, 422. 5 Hamoen, A.M., Herngreen, H., Storm van Leeuwen, W., Magnus, O. Rev. Neurol. 1956, 94, 109. 6.Campbell, A.M. G., Guy, J., Walter, W. C. Arch. Dis. Childh. 1952, 27, 507.
both their cases, which is difficult to reconcile with your that these children recovered. It is true that the disease sometimes appears to pause for long periods in its advance, and one of the National Hospital patients has even returned to work, but the global picture gives little cause for
on
statement
optimism. Your annotation also misses the opportunity of emphasising the number of atypical cases which occur, in which clinical diagnosis is very difficult and greatly depends on the E.E.G. in conjunction with the finding of a paretic type of Lange curve in the cerebrospinal fluid. The National Hospital for Nervous Diseases, W. A. COBB. Queen Square, London, W.C.1. CYTOLOGY OF THE CERVIX one who is convinced that deaths from of the uterine cervix are needless, I am grateful for your leading article of March 2. I should like to comment on Dr. Elliott’s letter (March 9).
SIR,-As
cancer
The control of cervical cancer certainly does imply much than early cytological detection. Although there is no universal agreement on the precise method of eradication of these early lesions as yet, this should not deter efforts to achieve early detection. If, in the past in some centres, the treatment of in-situ carcinoma has been more drastic than for established (invasive) carcinoma, as has been alleged, this is probably not the case today. Simple hysterectomy with a generous vaginal cuff is the operation of choice now in the United States. A small proportion of carcinoma-in-situ may involve the portio vaginalis and even the upper vagina. Recurrence or residual carcinoma also seems to be less frequent if a vaginal cuff is included, In young women who want to have children, lesser procedures that do not cause permanent sterility are often effective. Our experience indicates that the diagnostic cold conisation removed the lesion completely in about two-thirds of the cases. Cytology has allowed us to follow up all treated patients very carefully. Conservative treatment, followed by persistent negative cell-examinations, has permitted normal pregnancies in young women. If the lesion is not successfully eradicated by conservative measures one can always resort to hysterectomy: the long natural history of cervical cancer fortunately allows individual treatment to fit the circumstances. All those involved in the detection, diagnosis, treatment, and follow-up of patients should work closely together as a team. We do this, and can thus assure Dr. Elliott that our surgical colleagues do not needlessly mutilate women. The incidence of invasive carcinoma and, therefore, of carcinoma-in-situ varies with socioeconomic status. The rates differ in various parts of the world, even in different areas of a given city. Prevalence-rates represent the number of cases existing at a particular time. Thus they are always higher than incidence-rates, which represent the number of new cases per year. This difference must be kept in mind when comparing figures. The data on incidence are most meaningful when applied to a community, since they will vary considerably because of various factors. In Jefferson County, Kentucky, the incidence-rate of in-situ carcinoma in a sample population is about 50 per 100,000 women. This happens to be almost identical with the rate of invasive squamous carcinoma of the cervix in the years before cytological investigations were undertaken in the same community. Dysplasia of the cervix, on the other hand, has an incidence three times as great, which could imply that for one reason or another only one in three The cases of dysplasia progresses to carcinoma-in-situ. is to which are bioloseparate epithelial atypias, problem, then, gically progressive, from those which have less likelihood of
more
progression. Moreover, by treating dysplasia conservatively we may actually be preventing in-situ carcinoma, and, thus, invasive cancer. I am at a complete loss to understand why Dr. Elliott thinks the Jefferson County, Kentucky, study showed signs of defeating its own object. The preliminary study lasting
The difference was highly significant. (Statistical analysis of the results was performed at the Institute of Mathematics, Department of Biometrics, Hungarian Academy of Sciences.) G. SZEGHY T. Ö. ZOLTÁN University Medical School, M. FÖLDI. Szeged, Hungary. EFFECTS OF DIAGNOSTIC IRRADIATION SIR,-I am very gratified with the replies to my letter of March 16 because both writers have unwittingly lent considerable support to my view. Dr. Sowby (March 30) has confirmed that the largest single upsurge in the death-rate due to birth injury (from 6-0 to 6-3) in the past ten years occurred precisely after the publication of the first Oxford report1 on childhood malignancies, when most X-ray pelvimetries had ceased in 1957. He does, however, seem completely satisfied that a rate of 6 deaths per 1000 births admittedly due to difficulties in labour is a providence-determined rate which is not worth improving. My plea as a radiologist to two maternity hospitals is for the greatest possible reduction of these avoidable deaths, and I still regard a properly carried out and adequately interpreted X-ray pelvimetry as the best possible means towards achieving this. Dr. Stewart (March 30) has now admitted the definite existence of a pre-leukaemic state and its close association with respiratory infection. Is it not obvious that any respiratory disease will be followed in its wake by more than average X-ray examinations ? Has not the time come to exonerate the X-ray exposure entirely and concentrate on the underlying disease as the cause or the trigger to the development of leukxmia-a view which I put forward2 seven years ago and from which I have not deviated. As far
childhood malignancies are concerned, we must discussion whether 20 or 30 children’s deaths from leukaemia could be due to X rays to detract from the major problem of 6384 perinatal deaths from avoidable birth injury. The entire problem of childhood malignancies pales into puny insignificance when compared with the possible benefits which could be obtained by saving hundreds or thousands of children at birth. as
not allow a
London, W.1.
J. RABINOWITCH.
SUBACUTE INCLUSION ENCEPHALITIS
SIR,-Your annotation of Jan. 19 falls a long way short of the standard of this section of your journal. Since the last sentence, referring to subacute inclusion encephalitis and to subacute sclerosing leuco-encephalitis, reads that the consensus of opinion is that the two conditions are variations of the same disease ", there is little justification for discussion of one alone. In fact, the cases reported from Great Britain and North America include both types, as do the much greater numbers reported from Europe and elsewhere, which "
you ignore.
Certainly the disease is uncommon, but you give a
wrong impression of its rarity, and there
can be few E.E.G. of size which do number not one or two departments any cases in their archives: since the paper by Cobb and Hill3 there have been 17 cases in the National Hospital alone. For example, Radermecker and Posermention more than 40 personal cases from Belgium, and Hamoen et al. report 23 cases from Holland-two countries which appear to be centres of distribution of the disease. The number of cases from North America, considering the size of the population and the medical efficiency, is surprisingly small. The paper by Campbell et al.includes postmortem reports 1. Stewart, A., Webb, J. W., Giles, D., Hewitt, D. Lancet, 1956, ii, 447. 2. Rabinowitch, J. ibid. p. 1261. 3 Cobb, W., Hill, D. Brain, 1950, 73, 392. 4 Radermecker, J., Poser, C.M. WldNeurol. 1960, 1, 422. 5 Hamoen, A.M., Herngreen, H., Storm van Leeuwen, W., Magnus, O. Rev. Neurol. 1956, 94, 109. 6.Campbell, A.M. G., Guy, J., Walter, W. C. Arch. Dis. Childh. 1952, 27, 507.
both their cases, which is difficult to reconcile with your that these children recovered. It is true that the disease sometimes appears to pause for long periods in its advance, and one of the National Hospital patients has even returned to work, but the global picture gives little cause for
on
statement
optimism. Your annotation also misses the opportunity of emphasising the number of atypical cases which occur, in which clinical diagnosis is very difficult and greatly depends on the E.E.G. in conjunction with the finding of a paretic type of Lange curve in the cerebrospinal fluid. The National Hospital for Nervous Diseases, W. A. COBB. Queen Square, London, W.C.1. CYTOLOGY OF THE CERVIX one who is convinced that deaths from of the uterine cervix are needless, I am grateful for your leading article of March 2. I should like to comment on Dr. Elliott’s letter (March 9).
SIR,-As
cancer
The control of cervical cancer certainly does imply much than early cytological detection. Although there is no universal agreement on the precise method of eradication of these early lesions as yet, this should not deter efforts to achieve early detection. If, in the past in some centres, the treatment of in-situ carcinoma has been more drastic than for established (invasive) carcinoma, as has been alleged, this is probably not the case today. Simple hysterectomy with a generous vaginal cuff is the operation of choice now in the United States. A small proportion of carcinoma-in-situ may involve the portio vaginalis and even the upper vagina. Recurrence or residual carcinoma also seems to be less frequent if a vaginal cuff is included, In young women who want to have children, lesser procedures that do not cause permanent sterility are often effective. Our experience indicates that the diagnostic cold conisation removed the lesion completely in about two-thirds of the cases. Cytology has allowed us to follow up all treated patients very carefully. Conservative treatment, followed by persistent negative cell-examinations, has permitted normal pregnancies in young women. If the lesion is not successfully eradicated by conservative measures one can always resort to hysterectomy: the long natural history of cervical cancer fortunately allows individual treatment to fit the circumstances. All those involved in the detection, diagnosis, treatment, and follow-up of patients should work closely together as a team. We do this, and can thus assure Dr. Elliott that our surgical colleagues do not needlessly mutilate women. The incidence of invasive carcinoma and, therefore, of carcinoma-in-situ varies with socioeconomic status. The rates differ in various parts of the world, even in different areas of a given city. Prevalence-rates represent the number of cases existing at a particular time. Thus they are always higher than incidence-rates, which represent the number of new cases per year. This difference must be kept in mind when comparing figures. The data on incidence are most meaningful when applied to a community, since they will vary considerably because of various factors. In Jefferson County, Kentucky, the incidence-rate of in-situ carcinoma in a sample population is about 50 per 100,000 women. This happens to be almost identical with the rate of invasive squamous carcinoma of the cervix in the years before cytological investigations were undertaken in the same community. Dysplasia of the cervix, on the other hand, has an incidence three times as great, which could imply that for one reason or another only one in three The cases of dysplasia progresses to carcinoma-in-situ. is to which are bioloseparate epithelial atypias, problem, then, gically progressive, from those which have less likelihood of
more
progression. Moreover, by treating dysplasia conservatively we may actually be preventing in-situ carcinoma, and, thus, invasive cancer. I am at a complete loss to understand why Dr. Elliott thinks the Jefferson County, Kentucky, study showed signs of defeating its own object. The preliminary study lasting