- Email: [email protected]
The Almoner
560 2-4 seconds raised the temperature to an average of 750°C. Thus, there is now substantial agreement on the temperatures reached during habitual smoking. At such temperatures carcinogenic hydrocarbons are formed from organic matter, and in fact several workers have detected benzpyrene in the tar. Some of this compound may be destroyed under the same conditions.9 Other suspected substances include which have been found to be carcinogenic to phenols, mouse skin,10 certain chemicals existing as free radicals according to GREENE,11 and arsenic, which has increased by 300% in American-tobacco cigarettes12 between 1932 and 1951 as a result of the use of arsenic in the control of pests. Another possibility is that cigarette tar acts as a promoter rather than an initiator
in
carcinogenesis.13 Unfortunately,
to detect this
the form of
action,
so
benzpyrene,
in
a
test
designed
much initiator was used, in that no satisfactory answer
obtained. When the tar has been collected under proper conditions, the next step is to try to isolate known carcinogens or to test the crude tar for its carcinogenic properties in animals. Both courses have led to an impasse. Benzpyrene has been detected and measured by several observers. Tumours have been induced in mouse skin by some but not most of those who have tried; and one group have produced tumours in rabbit skin. Are any of these findings relevant to the problem of human lung cancer ? It is not now
was
adequate to describe an agent as a carcinogen without saying to what, to whom, and in what amount. Benzpyrene is not carcinogenic to all tissues of all animals. The only test reported in man was negative, but possibly its duration was inadequate.14 The characteristic hyperplasia induced by benzpyrene in human foetal lung surviving in culture is suggestive but not conclusive evidence of carcinogenic potency in man.15 Positive responses in animal tissues are the best guide we have, but they do no more than
warning. Apart from any possible relationship
serve as a
with
lung
cancer, there is evidence of other harmful actions of cigarette tar. Immediate and late effects at the site of deposition of tobacco smoke and tar are being
An immediate visible effect is the cessation of ciliary action when the toxic substances are in sufficiently high concentration. These substances are then dissolved and absorbed into the mucous membrane,17 and they include carcinogens The late effects include increased for animals.16 thickness and metaplasia of bronchial epithelium.Is We are a long way from deciding just what smoking does to the bronchial mucosa. But that is no reason for being hesitant in putting the known facts before the public and in dissuading young people from starting to smoke. One way of deterring them might be to let them see and smell this malodorous and nauseous
investigated.16
tar, which, if appearance is to prove
the
anything to
go
by,
is
likely
evil-doer.
10. Bontwell, R. K., Rusch. H. P., Booth, B. Proc. Amer. Cancer Res. 1956, 2, 96. 11. Greene, C. R. Science, 1956, 123, 227. New Engl. J. Med. 1956, 254, 1149. 12. Satterlee, H. S. 13. Gellhorn, A., Klausner, C., Hibbert, J. Proc. Amer. Cancer Res. 1956, 2, 109. 14. Cottini, G. B., Mazzone, G. B. Amer. J. Cancer, 1939, 37, J. Path. Bact. 1956, 71, 262. 15. Lasnitzki, I. 16. Kotin, P., Falk, H. Proc. Amer. Ass. Cancer Res. 1956, 2, 17. Hilding. A. C. New Engl. J. Med. 1956, 254, 1155. 18. Chang, S. C. Proc. Amer. Ass. Cancer Res. 1956, 2, 99.
Ass.
Ass.
186. 127.
The Almoner
MEDICAL students are (or should be) continue exhorted to " treat the patient and not the di-This is especially necessary because their main exper ence is of acute general hospitals where each patie comes under observation for a relatively short . and is isolated from his background-his home. famil and work. In these circumstances it is fatally f. to get into the habit of referring to " the calftuberculosis in bed 4," or the Charcot-Marie-T disease in the corner," and to forget that the you mother’s long illness and potential infectiveness m have shattering effects on her family, while the br stiff back means that his career must be replanned. The family doctor, meeting and treati his patients over many years, is in much less dange but he may find himself unable to give such proble the thought and time they need. No good doc who cares about his patients would question that th things are a part of his total clinical responsibilit but to unravel the knots created by an illness U require a number of interviews with the patient b self, his relatives, and even his employers or sch teachers. Not only does this take much time the doctor himself would seldom claim detailed kno ledge of the social agencies and potentialities needed handling the more complex cases. Can he, and sho he, delegate this part of his job to specially trai workers, as he has already delegated other parts nurses, physiotherapists, pharmacists, and the like Those with experience of good medicosocial wo would agree that he can and should. The hospi almoner, the psychiatric social worker, and (i slightly different context) the health visitor are trained for such work and, in varying degree, re to his hand. The psychiatrist has long accepted s help, and his main complaint is that there are enough psychiatric social workers ;he relies on th to supplement his own history-taking, to tell him ab home and working conditions, and to help in patient’s re-establishment and support after tre ment. In many hospitals the almoner occupi similar position, but only too often she still me with hostility from medical staff who fear that may trespass on their territory. It seems strange t there should still be such misunderstanding when profession has been in existence for more than f years and has been so completely accepted by so nu doctors. Sometimes inexperienced or inadequa almoners h e themselves contributed, by excess "
complete
assertion
of their
independence
or
by jealous
guarding their information; but most often med hostility is explained by failure to recognise what’ almoner’s function is-chiefly because the oppon.’. have never had the experience of working with a _ almoner. How common such lack of experience m be is shown by the fact that in 1952 almoner, w employed at only 349 of the 917 general (or rL.: general) hospitals in England and Wales. The book by Miss FLORA BECK which we rw this week is an interesting if not fully succes ot u-’ attempt to further the mutual and almoners ;and certainly this understanding be improved if the patient’s needs are to be ’ without waste of medical time. The almoner’ ’ niques, her habit of helping the patient to solve
understanding
561 rather than telling him how to solve her wide them,and knowledge of social resources are the to valuable all hospital doctor, anxious to treat the whole patient. And what of the general practitioner? One of the defects of Miss BECK’s book, as we see it. is that it does not emphasise the need to consult the patient’s own doctor : indeed the almoner in her stories visits patients’ homes, far from her base, apparently without any communication with the practitioner either from the hospital medical staff or herself—which clearly would not be good practice. Help comparable to what is given to the hospital doctor by the almoner should be given to the family doctor by the health visitor-the third member of the medieosocial team. If the recommendations of the Working Party1 are fulfilled, the health visitor’s relations with the family and with the family doctor should be such that she can give the almoner information and help, and also get information and help from the almoner about patients coming out of hospital. This is additional to her other function, with the medical officer of health and her other colleagues in the health department, of ensuring that necessary personal and environmental assistance is provided. In general practice as in the hospital, there is often need for several kinds of help, and they should not he given in isolation. The whole patient is apt to need the whole team. own
problems
Annotations DEAF OR BACKWARD ? IT has been said that if a child is not speaking by the ane of two it is likely to be either deaf or backward ; and the distinction between deafness and mental defect, in all their degrees, is not always easy. There can be no doubt that some children who are partially deaf have, in the past, been assessed (quite wrongly) as backward children and admitted to schools for the educationally subnormal. The fault lies in the methods of testing and applies mainly to children with deafness for high tones. Since many of these children have good or even normal hearing for low tones, deafness is often unsuspected as the cause of their failure to advance ; and verbal tests of intelligence may therefore be applied. Such verbal tests are always likely to give a low estimate of intelliPeformgence in the child with a high-tone deafness. ance tests, on the other hand, will give a more accurate idea of intelligence, and any wide discrepancy between the results of performance tests and verbal tests should always arouse suspicion of an underlying defect of hearing. Another diagnosis sometimes made in the partially deaf child who is not speaking properly is that f congenital auditory imperception-a form of aphasia <
problems.
Inquiry
into Health Visiting. Report of a Working Party on the Field of Work, Training and Recruitment of Health 1956. Visitors. H.M. Stationery Office. Pp. 183. 6s. 6d. See Lancet. 1956, i, 908.
1. An
was to try to assess whether children who had acquired no speech were deaf, mentally defective, emotionally disturbed, or suffering from a combination of these or other conditions. Dawson et al.l have lately given a preliminary report of their observations on 22 such children. They point out " that some children who have never spoken and who are therefore inaccessible and
unit
who may be asocial
or
antisocial in their behaviour
are
diagnosed as being mentally defective and spend their lives in mentally defective institutions." But it has in been shown the Belmont unit that a number already of these children prove, after a period of observation, to be deaf and probably educable. " If facilities were available to continue their education under specialised conditions they could no doubt make useful citizens within their limitations." 19 of the 22 children did not speak at all and superficially all of them seemed to be deaf. Congenital abnormalities were present in 11. When they were admitted, most of the children were emotionally disturbed and gave no indication of their true potentialities. This difficulty had to be at least partly overcome before the child’s disability could be assessed. The child’s reactions to its environment and to its teaching played a large part in determining whether its backwardness was due to deafness or mental defect. When the confidence and cooperation of the child had been gained, tests of hearing and of educational ability started. The ability to assess hearing must, of course, depend upon some positive and objective response to an auditory stimulus and some idea of the child’s hearing could usually be formed by day-to-day observation. The simple conditioned play responses devised by the Ewings were used, but other electrophysiological methods were also applied. These included pure-tone audiometry, electro-encephalography, and psychogalvanometry, but none gave a wholly reliable estimate of the child’s hearing. (It is interesting that 9 of the Ichildren with congenital abnormalities were finally considered to be either totally or partially deaf.) Mental ability was assessed by the Merrill-Palmer preschool scale and the Drever-Collins battery, both of which can be used without the need for the examiner or the examinee to speak. Even more important, however, was the assessment of the educational ability of these children ; for these were children who had been regarded as ineducable. 14 of the 22 children showed improvement in cooperation and awareness over periods ranging from three to twelve months, and 4 of these were judged to be sufficiently stable to take their place in normal schools for the deaf. Dawson et al. hope that even more of these children might ultimately be trained to do some sort of work at which they could earn a living. The earlier these children can be assessed and taught, the better are their chances of responding to teaching. As Dawson et al. put it, " these children present a most difficult problem but certainly not one which can be dismissed. There is yet no means of making a satisfactory diagnosis, but it is already felt that much can be done over a period of time to assess their condition and educability and that where there is any doubt about a child it is entitled to a period of observation." were
NON-EXPLOSIVE ANÆSTHETICS THE need for an all-purpose but non-explosive inhalation anaesthetic is clear,2 and the search goes on.3 The most recent development lies in the clinical investigation of the fluorinated ethers. Fluorination diminishes the inflammability, and also unfortunately the potency, of these anæsthetics; but by treating ethyl vinyl ether in Dawson, M. E., Evans, M. J., Reed, M., Minski, L. J. ment. Sci. 1956, 102, 121. 2. See Lancet, Aug. 18, 1956, p. 352. 3. Ibid, 1956, i, 321. 1.
in
carcinogenesis.13 Unfortunately,
to detect this
the form of
action,
so
benzpyrene,
in
a
test
designed
much initiator was used, in that no satisfactory answer
obtained. When the tar has been collected under proper conditions, the next step is to try to isolate known carcinogens or to test the crude tar for its carcinogenic properties in animals. Both courses have led to an impasse. Benzpyrene has been detected and measured by several observers. Tumours have been induced in mouse skin by some but not most of those who have tried; and one group have produced tumours in rabbit skin. Are any of these findings relevant to the problem of human lung cancer ? It is not now
was
adequate to describe an agent as a carcinogen without saying to what, to whom, and in what amount. Benzpyrene is not carcinogenic to all tissues of all animals. The only test reported in man was negative, but possibly its duration was inadequate.14 The characteristic hyperplasia induced by benzpyrene in human foetal lung surviving in culture is suggestive but not conclusive evidence of carcinogenic potency in man.15 Positive responses in animal tissues are the best guide we have, but they do no more than
warning. Apart from any possible relationship
serve as a
with
lung
cancer, there is evidence of other harmful actions of cigarette tar. Immediate and late effects at the site of deposition of tobacco smoke and tar are being
An immediate visible effect is the cessation of ciliary action when the toxic substances are in sufficiently high concentration. These substances are then dissolved and absorbed into the mucous membrane,17 and they include carcinogens The late effects include increased for animals.16 thickness and metaplasia of bronchial epithelium.Is We are a long way from deciding just what smoking does to the bronchial mucosa. But that is no reason for being hesitant in putting the known facts before the public and in dissuading young people from starting to smoke. One way of deterring them might be to let them see and smell this malodorous and nauseous
investigated.16
tar, which, if appearance is to prove
the
anything to
go
by,
is
likely
evil-doer.
10. Bontwell, R. K., Rusch. H. P., Booth, B. Proc. Amer. Cancer Res. 1956, 2, 96. 11. Greene, C. R. Science, 1956, 123, 227. New Engl. J. Med. 1956, 254, 1149. 12. Satterlee, H. S. 13. Gellhorn, A., Klausner, C., Hibbert, J. Proc. Amer. Cancer Res. 1956, 2, 109. 14. Cottini, G. B., Mazzone, G. B. Amer. J. Cancer, 1939, 37, J. Path. Bact. 1956, 71, 262. 15. Lasnitzki, I. 16. Kotin, P., Falk, H. Proc. Amer. Ass. Cancer Res. 1956, 2, 17. Hilding. A. C. New Engl. J. Med. 1956, 254, 1155. 18. Chang, S. C. Proc. Amer. Ass. Cancer Res. 1956, 2, 99.
Ass.
Ass.
186. 127.
The Almoner
MEDICAL students are (or should be) continue exhorted to " treat the patient and not the di-This is especially necessary because their main exper ence is of acute general hospitals where each patie comes under observation for a relatively short . and is isolated from his background-his home. famil and work. In these circumstances it is fatally f. to get into the habit of referring to " the calftuberculosis in bed 4," or the Charcot-Marie-T disease in the corner," and to forget that the you mother’s long illness and potential infectiveness m have shattering effects on her family, while the br stiff back means that his career must be replanned. The family doctor, meeting and treati his patients over many years, is in much less dange but he may find himself unable to give such proble the thought and time they need. No good doc who cares about his patients would question that th things are a part of his total clinical responsibilit but to unravel the knots created by an illness U require a number of interviews with the patient b self, his relatives, and even his employers or sch teachers. Not only does this take much time the doctor himself would seldom claim detailed kno ledge of the social agencies and potentialities needed handling the more complex cases. Can he, and sho he, delegate this part of his job to specially trai workers, as he has already delegated other parts nurses, physiotherapists, pharmacists, and the like Those with experience of good medicosocial wo would agree that he can and should. The hospi almoner, the psychiatric social worker, and (i slightly different context) the health visitor are trained for such work and, in varying degree, re to his hand. The psychiatrist has long accepted s help, and his main complaint is that there are enough psychiatric social workers ;he relies on th to supplement his own history-taking, to tell him ab home and working conditions, and to help in patient’s re-establishment and support after tre ment. In many hospitals the almoner occupi similar position, but only too often she still me with hostility from medical staff who fear that may trespass on their territory. It seems strange t there should still be such misunderstanding when profession has been in existence for more than f years and has been so completely accepted by so nu doctors. Sometimes inexperienced or inadequa almoners h e themselves contributed, by excess "
complete
assertion
of their
independence
or
by jealous
guarding their information; but most often med hostility is explained by failure to recognise what’ almoner’s function is-chiefly because the oppon.’. have never had the experience of working with a _ almoner. How common such lack of experience m be is shown by the fact that in 1952 almoner, w employed at only 349 of the 917 general (or rL.: general) hospitals in England and Wales. The book by Miss FLORA BECK which we rw this week is an interesting if not fully succes ot u-’ attempt to further the mutual and almoners ;and certainly this understanding be improved if the patient’s needs are to be ’ without waste of medical time. The almoner’ ’ niques, her habit of helping the patient to solve
understanding
561 rather than telling him how to solve her wide them,and knowledge of social resources are the to valuable all hospital doctor, anxious to treat the whole patient. And what of the general practitioner? One of the defects of Miss BECK’s book, as we see it. is that it does not emphasise the need to consult the patient’s own doctor : indeed the almoner in her stories visits patients’ homes, far from her base, apparently without any communication with the practitioner either from the hospital medical staff or herself—which clearly would not be good practice. Help comparable to what is given to the hospital doctor by the almoner should be given to the family doctor by the health visitor-the third member of the medieosocial team. If the recommendations of the Working Party1 are fulfilled, the health visitor’s relations with the family and with the family doctor should be such that she can give the almoner information and help, and also get information and help from the almoner about patients coming out of hospital. This is additional to her other function, with the medical officer of health and her other colleagues in the health department, of ensuring that necessary personal and environmental assistance is provided. In general practice as in the hospital, there is often need for several kinds of help, and they should not he given in isolation. The whole patient is apt to need the whole team. own
problems
Annotations DEAF OR BACKWARD ? IT has been said that if a child is not speaking by the ane of two it is likely to be either deaf or backward ; and the distinction between deafness and mental defect, in all their degrees, is not always easy. There can be no doubt that some children who are partially deaf have, in the past, been assessed (quite wrongly) as backward children and admitted to schools for the educationally subnormal. The fault lies in the methods of testing and applies mainly to children with deafness for high tones. Since many of these children have good or even normal hearing for low tones, deafness is often unsuspected as the cause of their failure to advance ; and verbal tests of intelligence may therefore be applied. Such verbal tests are always likely to give a low estimate of intelliPeformgence in the child with a high-tone deafness. ance tests, on the other hand, will give a more accurate idea of intelligence, and any wide discrepancy between the results of performance tests and verbal tests should always arouse suspicion of an underlying defect of hearing. Another diagnosis sometimes made in the partially deaf child who is not speaking properly is that f congenital auditory imperception-a form of aphasia <
problems.
Inquiry
into Health Visiting. Report of a Working Party on the Field of Work, Training and Recruitment of Health 1956. Visitors. H.M. Stationery Office. Pp. 183. 6s. 6d. See Lancet. 1956, i, 908.
1. An
was to try to assess whether children who had acquired no speech were deaf, mentally defective, emotionally disturbed, or suffering from a combination of these or other conditions. Dawson et al.l have lately given a preliminary report of their observations on 22 such children. They point out " that some children who have never spoken and who are therefore inaccessible and
unit
who may be asocial
or
antisocial in their behaviour
are
diagnosed as being mentally defective and spend their lives in mentally defective institutions." But it has in been shown the Belmont unit that a number already of these children prove, after a period of observation, to be deaf and probably educable. " If facilities were available to continue their education under specialised conditions they could no doubt make useful citizens within their limitations." 19 of the 22 children did not speak at all and superficially all of them seemed to be deaf. Congenital abnormalities were present in 11. When they were admitted, most of the children were emotionally disturbed and gave no indication of their true potentialities. This difficulty had to be at least partly overcome before the child’s disability could be assessed. The child’s reactions to its environment and to its teaching played a large part in determining whether its backwardness was due to deafness or mental defect. When the confidence and cooperation of the child had been gained, tests of hearing and of educational ability started. The ability to assess hearing must, of course, depend upon some positive and objective response to an auditory stimulus and some idea of the child’s hearing could usually be formed by day-to-day observation. The simple conditioned play responses devised by the Ewings were used, but other electrophysiological methods were also applied. These included pure-tone audiometry, electro-encephalography, and psychogalvanometry, but none gave a wholly reliable estimate of the child’s hearing. (It is interesting that 9 of the Ichildren with congenital abnormalities were finally considered to be either totally or partially deaf.) Mental ability was assessed by the Merrill-Palmer preschool scale and the Drever-Collins battery, both of which can be used without the need for the examiner or the examinee to speak. Even more important, however, was the assessment of the educational ability of these children ; for these were children who had been regarded as ineducable. 14 of the 22 children showed improvement in cooperation and awareness over periods ranging from three to twelve months, and 4 of these were judged to be sufficiently stable to take their place in normal schools for the deaf. Dawson et al. hope that even more of these children might ultimately be trained to do some sort of work at which they could earn a living. The earlier these children can be assessed and taught, the better are their chances of responding to teaching. As Dawson et al. put it, " these children present a most difficult problem but certainly not one which can be dismissed. There is yet no means of making a satisfactory diagnosis, but it is already felt that much can be done over a period of time to assess their condition and educability and that where there is any doubt about a child it is entitled to a period of observation." were
NON-EXPLOSIVE ANÆSTHETICS THE need for an all-purpose but non-explosive inhalation anaesthetic is clear,2 and the search goes on.3 The most recent development lies in the clinical investigation of the fluorinated ethers. Fluorination diminishes the inflammability, and also unfortunately the potency, of these anæsthetics; but by treating ethyl vinyl ether in Dawson, M. E., Evans, M. J., Reed, M., Minski, L. J. ment. Sci. 1956, 102, 121. 2. See Lancet, Aug. 18, 1956, p. 352. 3. Ibid, 1956, i, 321. 1.