THE ATTACK ON DISABILITY

76 that the site of origin of the disease should be peripheral rather than hilar, the agent being presumed to pass over the larger bronchi and to lodge at the periphery.

Annotations PATHOLOGY OF BRONCHIAL CARCINOMA FASHIONS change, even in the science of pathology. Before Barnard’s1 classical paper appeared in 1926, tumours of the lung hila and mediastinum were regarded as lymphosarcomas or small round-cell sarcomas arising in intrathoracic lymph-nodes. Thereafter the epithelial nature of these tumours was acknowledged, and the diagnosis of carcinoma of the bronchus replaced that of lymphosarcoma of the mediastinum to such an extent that today the latter condition is hardly believed to arise. American authors, and notably Fried,2 described evidence supporting the view that oat-ceIl cancers of the bronchus are anaplastic squamous-cell growths originating from the stratified respiratory epithelium of main or first subsidiary bronchi near the hilum. But not uncommonly necropsy reveals the curious combination of a solitary, well-defined, peripheral primary bronchial carcinoma with either solitary or multiple secondary deposits in distant organs such as the brain, the primary tumour being of oat-cell type.34 In such cases the site of origin must be a medium or small bronchus, which can in fact sometimes be demonstrated in the centre of the tumour. Raeburn and Spencer5 have tried to throw light on the origin of bronchial carcinoma by looking for the earliest stages of its development in apparently normal lungs. The whole of both lungs, removed from all adults at necropsy, was examined by gross sections ; and all suspicious nodules, particularly scars, were examined microscopically. By this means 13 small early tumours and 2 larger ones were found in a comparatively short time. 4 of these arose as intra-epithelial cancer (analagous to Bowen’s skin cancer) in main lobar bronchi ; but the other 11were in the periphery of the lung, some of them close beneath the pleural surface. These started as bronchiolar proliferation in scar tissue, but, in several, evidence of lymphatic permeation and even metastasis to a rib was found. Raeburn and Spencer rightly point out that lung cancer as usually seen at necropsy is the end-result of the cancer process. Once a mass of invaded hilar glands has, by reason of tumour, become inseparable from a main bronchus, it is too late to know whether the tumour started in the bronchus or spread from the glands. Yet the familiar hilar mass with occlusion of a main bronchus has, not unnaturally, led workers to accept the idea of a’primary origin from main bronchial epithelium. The observations of Raeburn and Spencer, in what must have been a laborious piece of work, may revolutionise thought in the same way that Barnard’s work did nearly ago. There is experimental evidence to support the new findings. From a long series of experiments, Orr6 has shown that the latent period in carcinogenesis is associated with a progressive alteration in the connective tissue surrounding the epithelial cells which ultimately undergo the malignant change. The fact that these minute bronchial tumours were found in association with scars is thus especially significant. Orr and Bielschowsky 7described lung tumours-both adenomas and carcinomas-induced chemically in the rat, and these arose in areas of chronic ’"" collapse and inflammation. If in human lung cancer there is indeed a chemical factor, no experimentalist would be surprised -

thirty years

8etiological

Barnard, W. G. J. Path. Bact. 1926, 29, 241. 2. Fried, B. M. Bronchiogenic Carcinoma and Adenoma. 1.

3. 4. 5. 6. 7.

London, 1948 ; p. 39. Bonser, G. M. J. Path. Bact. 1934, 38, 209. Stewart, M. J., Allison, P. R. Ibid, 1943, 55, 105. Raeburn, C., Spencer, H. Thorax, 1953, 8, 1. See also Raeburn, C. Lancet, 1951, ii, 474. Orr, J. W. Acta Un. int. Cancr. 1948, 6, 52. Orr, J. W., Bielschowsky, F. Brit. J. Cancer, 1947, 1, 396.

THE ATTACK ON DISABILITY LAST year the United Nations organised a group training course on Modern Methods of Rehabilitation of the Adult Disabled, which was held in various cities and training centres in Scandinavia. The report of this course has now been published,1 and it gives a very clear picture of the modern approach to the problem of physical disability. We often think of rehabilitation mainly in terms of the treatment and training of those who were disabled during the war. Those at the U.N. course emphasised that the chief causes of disability were not war injuries but tuberculosis, heart-disease, congenital deformities, and orthopaedic conditions, as well as the results of accidents at work and elsewhere. For example, among the people of the United States alone, whereas 250;000 persons were permanently disabled during the late war, more than 1,250,000 were similarly disabled during the same period by industrial and other accidents, for which inadequate factory regulations may be partly to blame. And these figures take no account of the large numbers permanently or temporarily disabled by the effects of disease and

congenital deformity. a disabled person is not worker. If he is given suitable work he is as willing and competent as his But too often those who are uninjured colleague. for responsible guiding and " placing " him have no detailed knowledge of the employment that is really suitable. A social worker is not always in a position to give the best advice, which often requires personal experience of the work, the workroom conditions, and possibly the equipment or machinery involved. In the words of Mr. K. Jansson, director of rehabilitation of the World Veterans’ Federation, speaking during the course, " to find the right place for the right man, the vocational counsellor must know the applicant and the job." Those actually doing the job should be consulted more often, for they can judge best whether the disabled person is physically and temperamentally suited to the task, and they may be able to suggest useful modifications in tools or machinery. Such good advice may enable a severely disabled person to do a full-time job without the slightest suggestion of charity or " being tolerated." Special factories or groups for the disabled workers are not always the right solution, for open competition fosters good work and companionship. In the matter of prostheses, Jansson observed " that the purpose of the prosthetic centres is to provide the most adequate prosthesis at the cheapest possible price." But cheap prostheses mean mass production, and that It is easy to change one’s may be false economy. clothes and wear a cheaper suit for work ; but a prosthesis, which must be worn all the time, requires expert individual fitting if it is to be satisfactory. By all means let us consider economy in the production of prostheses, but we should remember that each prosthesis ought to be individually fitted and adapted, and if economy is pursued too far it will hamper the wearer and his work. A well-designed prosthesis, which can be worn all day in comfort, will help the patient to forget his disability while he is at congenial work and will help him to do good work that will justify the expenditure. The late Dr. Harold Balme, who made many important contributions to the discussions during the course, was convinced of the need for proper supervision of the first prosthesis and of all subsequent alterations, as specified by the

All the evidence shows that

necessarily handicapped

1. Modern

Methods

of

as

a

Rehabilitation

of

the

Adult

Disabled.

Group-training Course Organised by the United Nations. Geneva, 1952. Pp. 108. 9s. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1. Report of

a

77 wearer and his work. He suggested that the workshops where prostheses are made should cooperate more closely with the limb-fitting centres, again under expert supervision. He might have added that visits by the surgeon to see the patient at his work or in his home may also be helpful on occasion. Another speaker, Mr. Karl Montan, secretary of the Swedish Committee for the Care of Cripples, described some of the work of the committee, which is composed of physicians, surgeons, and a number of disabled people, whose views are a great help. They discuss the problems of housing (including furniture and kitchen utensils), machines, tools, and transport as they affect the disabled. In the past too little time has been given to the design of furniture and utensils for the disabled, and much more could be done, particularly for the housewife, along the lines which are being followed, for example, at King’s College Hospital.2 Only by patient attention to detail can we gain the great advantages that skilful rehabilitation can bring to people at all ages, in all walks of life, and in all countries.

surgeon to meet the needs of the

ENDOCRINE TREATMENT OF MAMMARY CANCER IN the treatment of mammary cancer, adrenalectomy is a last resort; but it is surely justified if it gives the patient two or more extra years of tolerable life. This was the thesis of Dr. Charles Huggins (Chicago) when he opened a discussion on the Endocrinology of Mammary Cancer, at the Ciba Foundation on June 23. Dr. Huggins admitted that the knowledge of breast cancer was confused. He was struck by the many indications of an endocrine factor in its origin and continuance, but was perplexed by the apparant paradox that oestrogens, progesterone, and testosterone might promote development of the breast in certain circumstances and combinations but inhibit breast cancer in others. Cancer of the breast was common in female dogs-it was, in fact, their only common tumour-and examination of a couple of hundred animals would always yield two or three cases, almost invariably associated with milk production in the normal (but not the cancerous) segments of the breast. No less than 7 out of 8 of these dogs with mammary cancer had adrenal adenomata. Dr. Huggins traced the growth of knowledge of the ovarian factor in breast cancer from Sir George Beatson’s observation in 1896 that the condition regressed after ovariectomy. Sir Hugh Lett and otherBritish workers had shown that 20% of breast cancers were improved by removal of the ovaries, but this promising line of progress was checked in 1905 when the radiotherapists claimed (wrongly in Dr. Huggins’s view) that irradiation was equivalent to excision. The issue was not raised until 1943 when Haddow showed that breast again <

improved by cestrogens. Dr.- Huggins pointed out that adrenalectomy or ovariectomy reduced the incidence of breast cancer in mice, and adrenalectomy reduced the growth of Walker tumours. It was on the strength of these observations that he first did adrenalectomy for breast cancer ; this was in 1945, when substitution therapy was very difficult. Now, with cortisone, maintenance presented no problem, and the following regime had been found satisfactory :

were calmer than normal " burst of adrenal activity "), and they remained in good health on about 37.5 mg. cortisone daily. Skin pigmentation did not develop unless cortisone was omitted for at least two weeks ; but white hair regained some colour, and this Dr. Huggins attributed to a lesser degree of addisonian pigmentation. Dr. Huggins showed some slides illustrating regression of advanced breast cancer in certain cases after adrenalectomy, always combined with ovariectomy when this had not already been done. Bones riddled with secondary deposits were seen to recalcify ; fractures united ; local ulcers healed ; pleural effusions subsided. No statistical evaluation was attempted, but Dr. Huggins reported that certain patients were still alive and apparently well twenty-six months after their operation. Many, however, had not responded at all, and it seemed that some tumours depended on steroids while others did not. The 40% of breast cancers which responded to adrenalectomy were all adenocarcinomas : ductal and undifferentiated carcinomas did not respond. Furthermore, response was best in patients who were still excreting oestrogen in the urine-an excretion that was suppressed

Adrenalectomised patients

people (with

no

by adrenalectomy. Prof. S. Zuckerman, F.R.S., strongly questioned the suggestion that skilful irradiation was less effective than surgery in abolishing ovarian hormonal function ; but Dr. held to his point and reported that by chromatography he had found some oestrogen in the ovaries of women previously subjected to irradiation of the pelvis. Mr. S. J. Folley, D.sc., F.R.S., took up a remark of Dr. Huggins that " anything that would stop lactation would inhibit breast cancer," and pointed out that hypophysectomy would suppress lactation ; to which Dr. Huggins replied that Prof. H. Olivecrona, of Stockholm, had recently performed hypophysectomy in some cases of breast cancer with apparently good results. Dr. Leslie Foulds thought that the dependence of tumours on hormones was not conditioned by their other known characteristics, and he suggested that sooner or later tumours became unresponsive to all outside influences-including hormones. This suggestion was echoed by several other speakers. Dr. 0. Miihlbock (Amsterdam) cited his work on parabiotic rats which suggested that small amounts of cestrogen might inhibit the formation of adrenal adenoma. In his concluding remarks, Dr. Huggins reported that breast cancer responded to his operation equally well in men and women. He was congratulated by Mr. L. R. Broster for weathering the onslaughts of an audience of biochemists, and was thanked by Prof. Alexander Haddow for giving his listeners a memorable evening.

Huggins

DRUG ADDICTION

cancer was

Preoperative day.—Cortisone

200 mg.,

deoxycortone

acetate

Operation day.-150 mg. cortisone preoperatively, four-hourly thereafter, 5 mg. deoxycortone Second day.-Cortisone six-hourly, deoxycortone

5 mg., salt 3 g. Third day.-Cortisone twelve-hourly, as needed, salt 3 g. 2. See

deoxycortone

Lancet, 1953, i, 386.

prevalence prompted

50 mg. acetate. acetate

acetate

of

symposium on drug addiction, Eddy3 states that the problem in the United States is probably now beginning to decline ; but by a recent estimate addicts number one in three thousand of the population. In this symposium Bobbitt4 describes new measures Introducing

5 mg., salt 5 g.

cortisone

drug addiction in the United the Council on Pharmacy and Chemistry of the American Medical Association to describe a scheme for dealing with addicts.2 The doctor is advised never to attempt treatment at home or in a general hospital ; and while awaiting the patient’s admission to a suitable institution he should not give the patient drugs for self-administration : the symptoms of abstinence can almost always be controlled by injecting ¼-1gr. of morphine. THE high States1 has

a

1. See Lancet, 1952, i, 654. 2. J. Amer. med. Ass. 1952, 149, 1220. 3. Eddy, N. B. Amer. J. Med. 1953, 14, 537. 4. Bobbitt, J. M. Ibid, p. 538.