prognosis in tuberculosis
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changes in vessel walls, some glial proliferation, andchromatolysis in nerve-cells, all of which he regards aspotentially reversible. He also found, however, evidenceof permanent and irreversible nerve-cell changes-shadowcells and neuronophagia-in a small proportion of cells,mainly in animals given intensive treatment (11-16shocks) as opposed to a lighter course (4 shocks). Sincethe cats all had typical grand-mal seizures, the relevanceof these observations to modern controlled E.c.T. in manis doubtful. They may, however, reflect the type of cellchanges responsible for the memory defects and otherclinical features noted with the older methods of treat-ment. They may also illustrate the possible mechanismof " epileptic deterioration " after repeated grand-malfits in constitutional epilepsy.
1. Crissey, J. T., Shelley, W. B. New Engl. J. Med. 1952, 247,965.
2. Sulzberger, M. B., Baer, R. L., Borota, A. Arch. Derm. Syph.,Chicago. 1952, 65, 639.
X RAYS FOR SKIN DISEASES
THE value of X rays in the treatment of malignantepitheliomata is undisputed ; but there is some differenceof opinion about the worth of fractional X-irradiationin the treatment of benign dermatoses. Crissey andShelley 1 have treated patients with lichen simplexchronicus, lichen planus, psoriasis, nummular eczema,contact dermatitis, and acne vulgaris by X rays insuch a way as to compare the state of treated anduntreated areas. All patients received lOOr weekly(measured in air) for four weeks. Accurately locatedconed areas, 1.9-6 cm. in diameter, were treated. Thecone was placed centrally in groups of lesions, but
eccentrically in solitary lesions in order to avoid con-fusion with spontaneous central involution, which iscommon with some dermatoses. The response of thetreated area was compared with the remainder by amarking system in which 1+ represented perceptibleinvolution, 2+ marked involution, and 3+ a returnto clinical normality except for skin pigmentation.For each disease the plus marks of all patients treatedwere added together and graphically recorded, abscissaerepresenting the weeks of treatment and ordinates theaggregate of marks. A consistently and significantlygreater response was noted in the radiated area thanthe control area in lichen simplex chronicus (16 patients),lichen planus (5 patients), and psoriasis (16 patients) ;but in nummular eczema (16 patients), contact dermatitis(40 patients), and acne vulgaris (25 patients) there wasa steady progress towards healing in both irradiatedand control areas, with a small but discernible differencein favour of the treated areas. For strict control it wouldhave been better if an independent observer had inspectedand assessed the results ; but barring possible errors ofthis sort from any unintentional bias, X-ray treatmentof certain dermatoses seems to have been vindicated.But are X rays harmless in the dosage employed by
dermatologists ? The answer is a firm Yes, accordingto follow-up studies carried out by Sulzberger et al.,2who observed 1000 patients who had received X-raytreatment and 1000 who had not, for various skinconditions, including acne, eczema, psoriasis, skincancer, and neurodermatitis. These workers dividedthe irradiated patients into two groups : those who hadnot received more then 85r units on any one occasion
(763 patients), and those who had received irradiationsof more than 85r (237 patients). The former groupincluded only 2 patients with sequelse ; both had duringtheir lives been exposed to sunlight more than the
average, so it was by no means certain that X-irradiationwas entirely or even mainly responsible for the atrophy,telangiectasia, depigmentation, hyperpigmentation, andkeratosis that were observed. Of the 761 patients whoshowed no sequelae 12 had received a total dosage of37 5-150r, 618 had received 150-1000r, 130 had received
1000-2000r, and 1 had received more than 2000r.
Sulzberger et al conclude that there is no evidenceof harmful sequelae from totals of 1000r or less of X raysapplied superficially in the fractional doses and qualitiesgenerally employed by dermatologists for benigndermatoses ; when total doses of more than 1000rare given it must be expected that 1-5% of patients willexhibit X-ray sequelae that are relatively mild and ofonly cosmetic importance. There is no evidence thatcancer, X-ray ulcer, or any other dangerous ill effectsfollow doses adding up to a maximum of 1400r, whichsome dermatologists today regard as permissible for
benign dermatoses.Of the 237 patients who had received once or on several
occasions more than 85r only 26 showed X-ray sequelae,even though 76 of the 237 had received over 1000rand 5 more than 4000r.
Clearly, sequelae are to be expected in some patientsreceiving large X-ray exposures for malignant diseaseof the skin. Sulzberger and his colleagues conclude thatthe doses necessary for the cure of cancers and other
malignant growths of the skin cause mild sequelae inabout 25% of cases.
1. Hartley, P. H. S., Wingfield, R. C., Burrows, V. A. BromptonHosp. Rep. 1935, 4, 1.
2. Bradford Hill, A. Principles of Medical Statistics. London,1950.
3. Foster-Carter, A. F., Myers, M., Goddard, D. L. M., Young,F. H., Benjamin, B. Brompton Hosp. Rep. 1952, 21, 1.
4. Rafferty, T. N. Artificial Pneumothorax. London, 1944.5. Mitchell, R. S. Amer. Rev. Tuberc. 1951, 64, 1, 21, 27, 127,
PROGNOSIS IN TUBERCULOSISTHE Brompton Hospital Sanatorium at Frimley was
opened in 1905. By 1935 Hartley et al.1- were able to
survey 8766 cases which had been treated there ; andProfessor Bradford Hill has cited their report as anexcellent example of the application of statisticalmethods to this type of clinical research. The analysisby Dr. Foster-Carter and his colleagues,3 which issummarised on p. 486, maintains the standard ; it isan important and timely contribution to the knowledgeof pulmonary tuberculosis.
These workers have wisely concentrated on the
prognosis of treatment by artificial pneumothorax,about which so much has been written to so little effect.They show convincingly that adhesions in a pneumo-thorax are not necessarily dangerous to the patient.Rafferty 4 concluded that closure of cavities and failureto find tubercle bacilli iri the sputum were not suitablecriteria of an adequate pneumothorax ; success was
to be judged by the freedom of the lung from adhesions.This view has been widely accepted, and in a recentextensive study 5 one of the main conclusions was that" free anatomic collapse should be achieved or the
pneumothorax abandoned." The Brompton analysisshows clearly that such a view is not tenable. Itestablishes beyond reasonable doubt that adhesions haveno effect on the prognosis, provided that pulmonarycavities disappear. Foster-Carter and his co-workersclaim that the whole conception of what constitutesa satisfactory pneumothorax should be re-examined,and that " many patients have been, and are being,sacrificed to the fetish of free anatomical collapse."Their conclusions, though based on detailed evidencewhich is presented fully in an appendix, are unlikelyto pass unchallenged.Pneumothorax treatment is now being used much
less commonly in this country. It requires years ofskilled attention by the physician, and if badly carriedout it may be dangerous. Newer methods of treatment,and especially pulmonary resection, may seem to offera more rapid return to normal life for the patient andless constant anxiety for the doctor, yet there is alwaysa danger that the early spectacular results of new methodsmav distract attention from the familiar achievements
of the old. Although survival is not the sole criterionof success, no new method is likely to last if it offers alower survival-rate. In the series described by Foster-Carter and his colleagues, 80% of patients with effectivepneumothoraces (in that the cavities appeared to haveclosed) were alive after 8 years ; many had had extensivedisease, and excluding these the survival-rate was
89%. Of patients with no obvious cavities before thepneumothorax was induced 88% survived 8 years ;while of those without cavitation who had no initial
collapse treatment 89% were still living 8 years after-wards. It is against such figures that new methods willeventually be judged. ,
1. Fosbroke, J. Lancet, 1830-31, i, 533, 645, 740, 777, 823.2. New York Times, Jan. 30, 1953.3. See Lancet, 1952, ii, 967.4. Johnston, C. M. Brit. J. industr. Med. 1953, 10, 41.5. Theilgaard, E. Thesis, Copenhagen, 1951.
NOISE IN INDUSTRY
AMID the increasing din since 1831, when Fosbroke 1described deafness in blacksmiths, many occupationalhazards to hearing have been identified. The latest tobe added to the list is the jet engine. According toLieut.-Colonel J. E. Lett,2 of the United States ArmyAir Force School of Aviation Medicine, the noise of suchan engine is now the loudest industrial noise, measuring120-140 decibels. This noise has little or no effect on the
pilot, who sits ahead of it, but is a serious problem forground staff and for the personnel of aircraft-carriers.Air Vice-Marshal E. D. D. Dickson 3 has remarked thata whisper has an intensity of up to 30 decibels ; normalconversation, or a quiet motor-car, of 35-55 decibels ;the raised voice, or a railway sleeping-car, of 60-75decibels ; and a shout of about 100 decibels. Any noiseof more than 90 decibels’ intensity may cause acoustictrauma ; and at an intensity of 120 decibels the humanear experiences discomfort. The intensity of noise of ajet engine is about 145 decibels.Johnston 4 has investigated the hearing of chippers
and riveters, stampers, platers, headers, welders, wormers,and turners (these occupations are listed in descendingorder of noise-level). He found that hearing-loss is veryprevalent among them ; and in those who had been
exposed for more than twenty years the loss was definitelyrelated to noise-intensity. In addition to the intensityof noises, many factors contribute to acoustictrauma in industry : these factors include the total timeof exposure, the duration of each exposure, the frequencyand volume of the noise, the age of the person exposed,and the presence or absence of previous aural disease.Theilgaard 5 suggested that conductive deafness due tomiddle-ear disease afforded some protection to the organof hearing in noisy surroundings. Johnston found in hisseries of 438 ears in 219 people that 19 ears were the siteof active suppuration and 58 ears showed scarring or adry perforation of the tympanic membrane. In 4 casesof otitis media (active or healed) the hearing-loss was20-40 decibels greater in the unaffected ear than in theaffected one, in two of the frequencies commonly attackedby acoustic trauma (2896 and 5792 cycles per second).Thus otitis media may occasionally give some protectionto the cochlea for these frequencies. Furthermore, hecites a single case of long-standing unilateral meatalocclusion by wax in which the unaffected ear showed ahearing-loss of over 50 decibels in the frequencies 2048,5792, and 4096 cycles per second, whereas the previouslyoccluded ears showed little or no loss.
Long exposure to noise may have other effects.
According to R. M. Woodham 2 administrator of theDaniel and Florence Guggenheim Aviation Safety Centreat Cornell University, it " makes one jittery" and caneven break down body tissue ; the lung is one part of thebody known to be adversely affected by the sound of jetengines.- Johnston investigated several other subjective
effects of noise in industrial workers. Tinnitus was acommon complaint (though rarely present at the time ofexamination), but was always slight and never causedloss of sleep. Vertigo was rare. Poor concentration,headache, and irritability were usually attributable todissatisfaction with the nature of the work.
Individual susceptibility to noise varies widely, andit is important that a method should be devised wherebysusceptibility may be determined before workers are
employed in one of the noisier industries. Dicksonbelieves that some idea of susceptibility could be gainedfrom knowing the rate at which hearing recovers afterexposure ; for if exposure is stopped, hearing-loss maybe reversible in what he calls the " chronic " type ofacoustic trauma, which is caused by long-continuedexposure, particularly to sounds of high frequency (thepeak-frequency of a jet engine is about 2000 cycles persecond). Grove 6 recommended that every workmanengaged in a job where the noise-level exceeds 90 decibelsshould have a pre-employment audiogram and bere-tested after one week and subsequently at intervals.Any workman who complains of tinnitus after workingin a noisy environment should have his hearing re-tested.Johnston observes that the ideal remedy would be toeliminate injurious noise. Improvement in the designof machines and their mountings has already donemuch to help ; and reduction of reflection and reverbera.tion of noise by sound-proofing surfaces and baffle wallshas sometimes been effective. Failing these measures,there remains the " acoustic insulation of the worker’sears " by protective devices. A meatal plug, such ascotton-wool impregnated with yellow soft paraffin, mayattenuate noise by 20-30 decibels ; it of course reduceshearing for conversation, but some ear " muffs " are
designed to allow the hearing of speech while stillprotecting the ear from acoustic trauma. Johnston foundthat of 64 boiler-makers 10 wore protective devices inthe ears, but in no other trades were they worn at all.
6. Grove, W. E. Industr. Med. 1949, 18, 25.7. Cancer of the breast: a review. By D. W. SMITHERS, P. RIGBY-
JONES, D. A. G. GALTON, and P. M. PAYNE. Brit. J. Radiol.1952, suppl. no. 4.
8. Radiotherapy in Cancer of the Breast. By SIGVARD KAAE. Actaradiol., Stockh. 1952, suppl. no. 98.
9. A Report on the Natural Duration of Cancer. By M. GREEITWOOD.Reports on Public Health and medical Subjects, no. 33. Ministryof Health. London, 1926.
TREATMENT OF BREAST CANCER
JusT as the British Journal of Radiology last yeardevoted a supplement to the clinical, pathological, andstatistical aspects of cancer of the breast,7 so the ActaRadiologica has published a volume concerned withradiotherapy in cancer of the breast, with special referenceto the value of preoperative irradiation as a supplementto radical mastectomy.
Cancer of the breast is usually treated by operationcombined with radiotherapy. In most centres there isan enthusiastic team spirit, which guides the form ofthe treatment and encourages a systematic follow-up.Naturally, from time to time treatment is modified indetail; but in general the team pursues some plannedscheme, hoping with the passage of the years to be ableto compare results. So far as length of follow-up isconcerned, comparison is now becoming possible ; butthe difficulties of comparing the results of one centrewith those of another are still very great.
Dr. Sigvard Kaae poses two questions : Do treatedpatients survive longer than untreated, and are the resultsof one form of treatment any better than those of anotherform ? The search for the answer to the first questionbrings us to the main stumbling-block-we do not knowwith any accuracy how long women with untreatedcancer of the breast may be expected to survive. Kaaehas had to use figures compiled by Greenwood 9 before1926, covering 651 untreated cases in which survival was