Feb. 15 1M95, vol. 76 GENERAL PRACTICE 317

cost would substantially exceed the amount spent todayon health in Canada.The Chamber does not favour the proposal of the

Federal Government to share with the Provinces thecost of a standard ward level hospital insturance plan.Suich a plan would lead inevitably to compuilsory healthinsurance of a comprehensive nature and to state medi-cine. The Chamber believes that any financial assistanceprovided by the Federal Government should be directedto the areas in which the individual is generally unableto help'himself, to the indigent, the aged, the chronicallyill and to those who suffer catastrophic medical expenses.

GENERAL PRACTICETHE TREATMENT OF THYROIDDISEASE BY RADIOISOTOPES*

C. H. JAIMET, MI.D., F.R.C.P.[C.],F.A.C.P.,t Hamilton, Ont.

IT IS SINGULARLY DIFFICULT for one in generalpractice to learn abotut isotope therapy fromjouirnals or textbooks, but unless you wish tobe an isotopologist there is no need to go aboutit that way. What you require to know is: thelocation of an isotope clinic; the cost to thepatient in time and money; the types of dis-orders amenable to these tests and treatments;the discomforts, hazards and complications ifany, which may occur; and the prognosis forpatients so treated. I will add, with somevehemence, that yotu must have expelled manymyths, misconceptions and grossly stupid im-pressions concerning isotopes foisted upon usthrough the press by inexperienced physiciansand, I am sorry to say, even a few experts inthe field. A few veiled, indefinite and unprovedstatements about the hazards seem to havestuck in many doctors' minds more firmly thancontradictory, optimistic and proved con-cltusions, written, spoken and accepted at medi-cal meetings everywhere in the world.

I will give you a few glamorous truths tobear this out.

1. Sterility. At otur University Clinic, wheresome 2000 goitres have been treated with radio-iodine, the patients themselves frequently referto their drink of radioiodine as the "pregnantcocktail". This because women with hyper-thvroidism are so often sterile, yet many havebecome pregnant within a few months aftertreatment.

2. Effect on offspring. If we say that 10 milli-cturies is an average dose of I'll to cure hyper-thyroidism, it is not uncommon to give 300-600millicuries for a cancer of the thyroid. One suich

*Read at the 89th Annual -Meeting of the CanadianMedical Association, Quebec City, June 14. 1956.,Clinical Director, Departmiient of MIedical Resear ch,McMaster Iuniversity.

girl with cancer of the thyroid, a five-year cureas of now, has three perfect children born sincemassive radioiodinle treatment.

3. Developmieent of puberty,. A girl aged 13,pre-puberty, had over 300 millicuries 1131 forcarcinoma of thyroid and is now, four yearslater, a fully (leveloped, normally functioningyoung lady.

4. Carcinogetnic effect. In August 1955 I heardit reported at the Atomic Energy Conference inGeneva that no case of cancer due to previouslvadministered 1`1 hals yet been diagnosed. Thisin spite of the fact that I1s13 has been given tohumans for over 16 years in the U.S.A. and 6years in Canada.As a member of the Advisory Committee oni

Atomic Energy to the Department of NationalHealth and Welfare, I would not, you can besure, make these statemeints carelesslv or to "sellyou" on this treatinent. They are meant to re-assure and prepare you for the impact nuclearenergy vill have on medicine and research inthe near future of this, the atomic age. The"nuclear" specialist will guard you against anyhazards-it is your job and responsibility toknow when anid wvhat tests and treatment areavailable.

Radioactive iodine, I' ", is the isotope ingeneral use for treatment of the thyroid gland.It is drunk by the patient in a tasteless, colour-less aqueous solution. It does not upset thestomach, depress the bloodforming organs, in-terfere with other endocrine functions, cause orcontribute to sterility, or produce cancer. Thereis no radiation dainger from the patient receivingthe average therapeuitic dose, if the rules of theAtomic Energy Committee are observed. Thereis a danger to the physician and other attendantsrunning a large clinic over a period of years,but this is controlled by not permitting its in-discriminate use in unskilled hands. It is evensaid that radioiodine can be used on the preg-nant woman before the child develops its ownthyroid (about the twelfth week). Most isotop-ologists agree academically that this is true, butfew use it at any time in pregnancy except insmall tracer diaginostic doses in the first eightweeks.Now, what happens to the patient from the

time you think of radioiodine therapy until heis diagnosed, treated with 1P3", cured, or referredback for other treatment such as surgery? Youfind out where the nearest isotope centre isand make an appointment. You will be told that,regardless of how sure you are that the patienthas hyperthyroidism, diagnostic tracer radio-iodine tests will first be done. The patient isgiven a drink containing a very small amountand told to return 24 hours later. Tests are thendone, usually requiring no specific preparations(ssuch as fasting or resting), and are neitherpainful nor uncomfortable. The treatment doseby mouth may be given that day, or as soonas the results of the tests are calculated. In the

318 GENERAL PRACTICE

majority, the one treatment is sufficient-butrepeat doses may be required, depending on

the technique of the operator, th-e type and sizeof gland and the individual's response to theionizing rays. The radioiodine takes a variableperiod to depress thyroid function-from a fewdays to several months in the minority-butabout 3-6 weeks is the average. During thislatent period the patients' activity is guided bytheir general state of health, type of job, etc.Thyrocardiacs may be better in bed; personswith severe toxic goitre may be better off atwork, with rest about the home; the majoritycarry on their jobs, with increased rest in off-hours. Daily sedatives are good during thisperiod and other medicines for other conditionsare not contraindicated. Of course ordinaryiodine and propylthiouracil, etc., are not to beused unless ordered by the isotopologist. Thepatient retains contact with the family doctoras usual, but the isotopologist should see thepatient at about monthly intervals for 4-6months until satisfied that a maximum responsehas been obtained.

Before radioiodine tests, the isotopologistshould be informed of any antithyroid therapy-and these drugs should then be discontinued, orpreferably not given in the first place to any"thyroid" case until it has been investigated.Ordinary iodine, by saturating the gland, pre-vents diagnosis with I"3' for 1-3 months or

longer after its discontinuance, and similarlyinterferes with treatment (e.g. iodine in Lipiodolor contrast agents for gall-bladder and kidneyradiography). The thiouracil group of blockingagents interferes by preventing binding ofiodine for a period of days to weeks. In a

normal or a hypothyroid case, thyroid extractadministration causes false lowering of thetracer readings and should be discontinued forat least a month before testing.An important question now arises-should all

patients with hyperthyroidism and especiallyall with "goitres" of whatever apparent size andtoxicity have radioiodine tests? In general, theanswer to this is yes and the reasons are three.

(1) The isotopologist is presumably your bestthyroid consultant and it should be for himto say that the tests are or are not necessary..(2) The basal metabolic rate (B.M.R.) is nota reliable test-it is little better than a goodphysician's clinical judgment-and therefore theB.M.R. reading, by itself, if elevated should notbe taken as an indication for surgery, or ifnormal should not rule out hyperthyroidism infavour of its common mimic, anxiety neurosis.(3) Even if the tests are normal for total thyroidfunction, information may still be obtained. Inthis group we may include patients whose lumpsin the neck are not thyroid; or carcinomas andmisplaced goitres picked up by scanning theneck and chest outside the thyroid area witha regional counter or a scintagram. Thyroiditis

Canad. M. A. J.Feb. 15, 1957, vol. 76

must not be forgotten here, for it is often diag-nosed by these tests.Where clinical diagnosis is not certain the

B.M.R. is only about 50% accurate; the non-radioactive protein-bound iodine (P.B.I.) evalua-tion is better but involves a difficult technique;however, radioiodine tests are 95-100% ac-curate. Let me say more about radioiodinetests: I am firmly convinced that, since thereare some eight simple tests either measuringfunction in a different way or measuringdifferent aspects of thyroid function, it is justas inadequate investigation of the borderlinecase to use 1131 pick-up tests alone as it is todepend on the B.M.R. At almost every one ofour weekly clinics we find direct evidence ofthis; we therefore use our battery of five testson all cases, and add one or more where indi-cated. The pick-up measurements only tell youwhat percentage of the dose gets into the gland;the "conversion ratio" blood test' reflects theamount of thyroxine being produced; our salivatest2 reported at the Geneva conferencemeasures another function in a different way,most accurately; and finally, regional countingtells the activity of one part or one small noduleof the gland as compared with the remainderor any small part thereof. This last test willindicate "hot" or "cold" areas-that is, "over-active" or "underactive" nodules, and therebyreveal hyperthyroid tissue where total glandfunction is still normal-or suggest malignancyif a solitary nodule is "cold" or "underactive."Treatment with radioiodine has two distinct

parts-the giving of a therapeutic dose to thepatient to drink from a waxed cup, and thefollow-up including a repeat dose if necessary,symptomatic supportive therapy, and earlyrecognition and treatment of hypothyroidismshould this occur.We prefer to give a somewhat smaller initial

dose and repeat it, than to produce more hypo-thyroidism. Our incidence of unplanned hypo-thyroidism is much less than 5%, as comparedwith 12-13% reported in the U.S.A. It is veryimportant for you to know however that, ifhypothyroidism develops, and this is usuallyafter about 3-4 months, the, early administrationof thyroid extract by mouth will often rest thegland enough to allow recovery from this statein a few months. If the patient fails to returnfor follow-up, and the family doctor doesnothing about it, then, after a few more weeksthe hypothyroidism will more likely be per-manent. Since recognizing the urgency fortreating the hypothyroid state at the earliestdate, we have further reduced the number ofour cases of chronic hypothyroidism.Many doctors feel that only a diffuse toxic

goitre can be treated with I"3'. You must distin-guish between "can' and "should". Here arethe facts. Diffuse toxic goitre is best treatedwith I131; this results in 100% cure. However,

Canad. M. A. J. GENERAL PRACTICE 319Feb. 15, 1957, vol. 76GERArICTE

the toxicity of a nodular goitre is just asamenable to this treatment, though the dose isgreatqr and you cannot usually shrink the goitredown to normal size. Therefore, since you cancure hyperthyroidism due to nodular goitre, thequestion is whether you should so treat allnodular toxic goitres. The answer is neither "yes"nor "no". If the patient is not old and is a goodsurgical risk, then surgery is the treatment ofchoice. If the gland is very large or causingpressure symptoms, surgery is preferable. If thepatient is older, has complications, particularlycardiac, or is resistant to pre-surgical antithyroidtherapy, then J131 is the choice. Furthermore,I131 administration is excellent pre-surgical treat-ment for any toxic goitre and does not causeany scarring to interfere with subsequent re-moval of the gland. I would like to inject atthis point my opinion that antithyroid drugslike propylthiouracil or tapazole have no placein the long-term treatment of hyperthyroidism(pregnancy excepted). I should also state thatI131 gives the best results on the exophthalmosassociated with toxic goitres, and pituitary x-radiation is still a valuable adjunct to antithyroidtreatment when the eye condition is severe.You may ask whether 1131 has anything to

offer the patient with a large non-toxi& nodulargoitre with pressure who is a very poor surgicalrisk. The answer is yes; in 25-40%v, improvementis noted. You may also ask about this "under-or-over 40 years of age" statement which sooften comes up. It is our opinion that, generallyspeaking, age by itself does not rule out treat-ment with I131. We are all still pioneers in thefield of nuclear medicine, so one can readilyunderstand why some people say that you shouldnever treat children or uncomplicated cases inadults under age 40. Personally I cannot findany valid objection to doing either, but I willadmit to not treating children for the time being.We treat young adults and our justification is(1) their statement re the "pregnant cocktail",and (2) lack of any cases of carcinoma of thy-roid as yet after I131 treatment.

Following I131 treatment of a toxic goitre, mildto moderate gland tenderness may developbut is never serious. Occasionally, a temporaryexacerbation of hyperthyroidism may appearabout the 4th to 10th day. This is never danger-ous, but we avoid it in the thyrocardiac by givingsmaller, repeated doses rather than a full initialone. Patients may sometimes complain after I131treatment that they are not improving quicklyenough. It took us a while to realize that thepathological change in the gland is correctedlong before reversal of the effects of its toxicityon other organs. The nervous, muscular andcardiovascular systems may require considerableconvalescence, and this, though shorter thanwith types of treatment other than 1131, justseems longer because the patient has not hadto leave his job, stay in bed, or undergo opera-tion. We should therefore say to the patient at

the outset that the more rest he has in the firstsix weeks the sooner he will feel well. In otherwords, euthyroidism, usually obtained in 4-6-8weeks, is not always synonymous with sympto-matic recovery.

I have had to touch lightly on many pointsin this brief presentation, and I have left cancerof the thyroid to the end in order to stress twopoints. Firstly: initially surgery, i.e., radical re-moval, is the treatment. Secondly: subsequently,radioiodine should always be considered. Thereare not many carcinomas of the thyroid, it istrue, and of these only about 15% will benefitfrom 1131 treatment. However, out of some fourdozen of these, six women with invasion oftrachea and adjacent structures are living andapparently cured five years after 1131 treatmentalone. WNe feel that one cure or prevention outof even 50 justifies all our work.To close, may I refer you to our Geneva

Conference paper3 for the details of our researchand tests with which I have not dealt in thisdiscussion.

REFERENCES

1. SHELINE, G. E. AND CLARK, D. E.: J. Lab. & Clin.Med., 36: 450, 1950.

2. THODE, H. G., JAIMET, C. H. AND KIRKWOOD, S.: NewEngland J. Med., 251: 129, 1954.

3. JAIMET, C. H. AND THODE, H. G.: Canad. M. A. J.,74: 845, 1956.

THE MANAGEMENT OFADVANCED MALIGNANCY*

G. A. COPPING, M.D., C.M., F.R.C.P.[C.],M.R.C.P.( Lond. ),t Montreal

IT WOULD SEEM impertinent to stress the im-portance of early diagnosis in neoplastic diseasein addressing an audience of experienced phy-sicians and surgeons. And yet our errors con-tinue, errors of omission most of them, dueperhaps to fatigue, to preoccupation, to pressureof work-sometimes to carelessness-rarely toactual ignorance. Reflex alarm signals in our-selves are needed to act as an inescapable check,and such reflexes come only with repetition.The management of advanced malignancy is

a doleful business. It calls for the exercise ofthose faculties of sympathy and the desire tohelp one's fellow man in distress which in richendowment set apart the saints and the world'sgreat benefactors, but which in most of us existonly in smaller amounts. The long months whenone must sustain, comfort and encourage thewretched victims of this miserable afflictionoften find one running short of those resourcesof the soul which bring one recurrently to the

*Paper presented to the Thunder Bay Medical Societyof the Ont.rio Medical Association. September 14, 1956.tkssistant Professor of Medicine, McGill University.

320 GENERAL PRACTICE

bedside cheerful and interested. While researchin cancer has not yielded much in definite thera-peutic results, it has opened up a number offields of great significance whose study mightstrengthen and refocus the flagging interest ofthe tired physician.

SOME ASPECTS OF RESEARCHCarcinoma research divides itself into two

parts: the study of the phenomena having to dowith "carcinogenesis" or the original appearanceof the neoplasm, and of those concerned with its'persistence and spread. The present view ofcarcinogenesis is that when susceptible tissuesare repeatedly exposed to the effect of certainchemical compounds, viruses, certain forms ofradiation energy and trauma, a change occursin the nuclear metabolism of the, affected cells,bringing about alterations in their chromosomeswhich breed true and lead to a failure of normalcell maturation. Repeated exposure is requiredto bring this about and it appears to go throughtwo stages, one in which the specific carcinogenis required, the other, consequent to it, requir-ing only the non-specific irritation of heat orother trauma. For a long time cells so alteredseem incapable of maintaining themselves andthey disappear from the affected tissue but, withrepeated exposure the new entity finallyestablishes itself and a clinical neoplasm results.By what means the earlier abortive attemptsare destroyed is, unfortunately, not yet knownbut it has been suggested that an antibodymechanism is involved, and there appears to besome supporting evidence to support the guess.It is of interest that the cellular responsetowards neoplasia is usually multicentric in thesusceptible tissue; one thinks of the not infre-quent clinical occurrence of multiple primarytumours, especially in the liver.The concept of carcinogenesis concerns a

carcinogenic agent and its receiving targettissue. The chemical carcinogenic agents arearomatic hydrocarbons and such compoundssometimes occur in nature. There is also a wholehost of closely related substances, widely spreadthroughout our external and even our internalbodily, environments, which, with very littlechemical change, may become carcinogenic.Encompassed about as we are with such lethalor potentially lethal entities, it is strange thatwe all do not succumb to neoplastic disease.When one realizes that no less than 19 knowncoal tar carcinogenic agents are permitted bythe Government of the United States for use inclothing, food and cosmetic industries-some ofthem, such as butter yellow, being classicalproducers of laboratory carcinoma-the extentof the danger is apparent. International surveyssuggest that those countries most advanced inaniline dye production and consumption alreadyshow significant increases in their national inci-dence of neoplasia.

Canad. M. A. J.Feb. 15, 1957, vol. 76

In considering the factor in carcinogenesis ofthe receptivity or otherwise of the target or hosttissue, one is on equally interesting but some-what less factual ground. The immurtity ofcertain animal strains, the variation in indi-vidual immunity within the susceptible groupsand the differences in immunity between organsare all most intriguing features of this aspect ofthe problem. An interesting finding in the studyof host receptivity is the observation that incertain primary experimental liver neoplasiasthe blood supply to each induced nodule can betraced to the hepatic artery, suggesting specificoxygen or other needs.The metabolism of neoplastic tissue at once

resembles and yet differs from that of the hostcells about it, and the hope is that following theline of enzyme competition which has been soproductive in the sulfonamide and antibioticfields a lead towards tumour cell enzyme block-age may be fouind. So far the similarity betweenthe metabolism of the normal and neoplasticcell has not allowed this to be done but it maybe that the exploitation of existing differencesmay yet present medicine with a therapeuticor preventive agent. A number of interestingobservations have been made which it is hopedmay finally throw some light on this problem.For instance, the protein metabolism of tumourcells is of the "one-way" type and protein usedby suclh cells is, therefore, not available forlater use elsewhere in the body. It follows thatthe ebb and flow of protein which accompanyvarious bodily stresses must be borne by thenormal tissues alone, an explanation at least ofthe remarkable host tissue wasting.

In studying the metabolism of tumours, avery interesting observation has been made ondata from insurance surveys correlating bodyweight with neoplasm incidence. There issignificantly more carcinoma in the overweightgroup. This agrees with experimental studiesshowing greater resistance against carcinogenicagents when there is reduced caloric intake, afeature which appears capable of analysis intocontributory reduction by either fat or proteinrestriction, as well as with lowered total calorielevels. That it is body build and not just caloricintake alone, however, is suggested by workshowing that resistance to carcinogenesis is in-creased by lowering the body weight of experi-mental animals with thyroid extract, nothwith-standing the greater food intake resulting. Aswell, a great deal of work has been done onthe relative vitamin needs of normal and neo-plastic tissues. This work makes very compli-cated and confusing reading and one comesaway from it with the suspicion that importantassistance in this field will probably not beforthcoming. As yet there does not seem to bemuch available on the electrolyte metabolismof the neoplastic cell.

Canad. M. A. J.Feb. 15, 1957, vol. 76 GENERAL PRACTICE 321

TfHE CLINICAL MANAGEMENTOF ADVANCED MALIGNANCYFaced with a case of advanced disease, the

first decision to be made is whether there isstill a chance of effecting a cure. If one bearsin mind that in the great majority of neoplasmsthe only hope of cure lies in total extirpation,this decision is not usually difficult. The secondproblem is whether one can prolong life andreduce suffering.Three main means of therapeutic approach

are available-surgery, radiation, and chemicalor hormone administration. It is impossible todeal with any one of these in detail.* However,a few generalizations may be made. Radiationtherapy in its present highly technical stagemust be left to the experts-it can often be usedto relieve pain or reduce pressure by causingtumour masses to shrink and, as in the case ofcervical carcinoma of the uterus, it may evenbring about permanent cure, but for the dosageand mode of administration one must rely onthe local expert and the local equipment.There are two groups of chemical agents,

antimitotic and antimetabolic, according towhether their effect seems to be upon thenucleus alone or upon the chemistry of the cellas a whole. There are at present nine sub-stances receiving most attention, five of themantimitotic agents, namely nitrogen mustard,triethylene melamine (TEM), thio-triethylenephosphoramide (THIOTEPA), Myleian (1:4-dimethanesulfoxybutane), and Fowler's solution;four are antimetabolic agents, namely two folicacid antagonists (aminopterins) and two purineantagonists (mercaptopurin and urethane). Mostof the chemicals are almost as toxic to normalas to neoplastic tissues and, in time, sensitivetumour tissues not infrequently become re-fractory to their therapeutic action. However,allowance being made for these shortcomings,they may sometimes aid greatly in reducing painand the size of the tumour masses. The lymph-omas and the diseases of bone marrow, theleukemias and polycythiemia are sometimesmuch improved, and in the case of chronicmyelogenous leukamia Myleran seems to holdout hope of actual lengthening of life. Thesupplementary use of cortisone or ACTH toreduce undesirable drug reactions is often ofmuch value, quite apart from their possiblespecific effects on the tumour cells directly.A standard type of program for the use of

radiation in the treatment of malignancy isillustrated by that followed for the therapy ofcarcinoma of the breast. Surgery alone is usedfor the early tumour when it is small and with-out local or distant spread. Advanced disease

*There is available on application to the Montreal Officeof the Canadian Cancef Society at 1390 SherbrookeStreet West, a booklet "The Offlce Diagnosis of Cancer"with detailed instructions as to the proper choice oftherapy, its dosage and toxic reactions, as indicated inthe various cancers of the body.

locally is treated by irradiation of the lymphdrainage area and of the breast itself withoutsurgery being employed. The occurrence ofbone pain with x-ray findings of metastases callsfor radiation; if such findings are absent thearea is closely watched with frequent use ofradiographs; if suspicion is high, the area istreated even though there is no apparent bonechange. It is a common observation that themetastases to bone are sensitive to x-rays, oftenmore so than the original lesion; their earlytreatment both reduces pain and lessens thepossibility of spontaneous fracture. The breastwith its tumour is removed ten or twelve weeksafter irradiation; the earlier practice of opera-tion first and irradiation later has beenabandoned because of the effect upon the scar.The breast is removed to preclude the possi-bility of areas of neoplasm surviving the ir-radiation. It is an interesting observation that atumour once well irradiated is unlikely tometastasize thereafter.One or two points concerning the irradiation

of metastases are of interest. As mentionedalready, the transplanted cells are often un-usually sensitive, responding well and requiringonly small doses. Microscopic examination mayfail to demonstrate residual malignant cells inthe tissues of the treated area, and bone lesionsmay heal. In the case of widespread riddlingthe weight-bearing bones are treated. Metastasesto the liver are not amenable to radiation ther-apy. With the possible exception of solitarypulmonary metastases from the thyroid orkidney, which can sometimes be satisfactorilyremhoved surgically, there is small hope forthose of other origin, and radiation is probablybest. This is often particularly indicated inthose lesions towards the hilum, where localpressure may cause atelectasis, etc. Pleuraleffusion due to neoplasm usually means deathin four months and should be aspirated to thestage of comfort, but colloidal radioactive goldmay sometimes be instilled. Cerebral metastases,if single, may respond; brain tissue is fairlytolerant to x-ray; its blood vessels are not.Neoplasms of the gastro-intestinal tract and ofthe prostate are resistant to x-ray. Their bonymetastases, following the general rule, may besomewhat more sensitive and bone pain fromthese can sometimes be helped. Of greatinterest, although it is still in the stage ofanimal experimentation, is the discovery thattumour sensitivity is increased by chilling, andthe possibility of combining radiation withartificial hibernation suggests itself.There are one or two points to be raised in

comparing the usefulness of radiation and ofthe chemotherapeutic agents. Neoplasms whensensitive to one are generally sensitive to theother. The therapeutic results seem comparable,perhaps more interest being shown in thechemicals for therapy of the lymphomas. How-

322 GENERAL PRAcrCE Canad. M. A. J.Feb. 15, 1957, vol. 76

ever, enthusiasm for each varies from centre tocentre and one suspects that, with a few excep-tions such as the use of Myleran for the treat-ment of chronic myelogenous leukhemia andp32 for the treatment of polycythaemia, theultimate decision depends upon one s ownexperience.

Certain tumours, more especially those aris-ing from endocrine tissues, are inhibited byhormones having actions opposite to those pro-duced by the parent tissues or opposite to theeffect of the hormones known to act upon them.Thus cestrogenic substances are used to treatcarcinoma of the prostate and testosterone forthat of the breast. The widespread physiologicalactions of cortisone suggest interesting possi-bilities in this respect.

In considering surgery in the advanced caseof malignancy, one must disabuse one's mindof the prejudices of an earlier era before thepresent safer surgical management with anti-biotics, better anesthesia. and electrolyte con-trol. It is now possible with hemiglossectomy,hemimandibulectomy and radical neck dissec-tion which still allow good function in speech,swallowing and breathing, to avoid the previousnecrotizing and sloughing ulcerative erosion ofadvanced neoplasm of the floor of the mouth;similar results with one to three years of lifeare possible in cases of antral carcinoma. Theremoval of liver metastases when found atoperation for bowel carcinoma has provedworth while; solitary metastases of the lung,especially if from thyroid or kidney origin,may be removed satisfactorily and the opera-tion may confer several pain-free and usefulyears of life. The so-called "second look" opera-tion for removal of possible recurrent meta-stases six months after operation for colon orstomach carcinoma is arousing much interest.Rhizotomy, chordotomy and leukotomy for in-tractable pain are attempted, sometimes suc-cessfully, as are bilateral adrenalectomy orhypophysectomy.

In spite of the possibilities raised by theserecent advances, most cases finally become yourproblem and mine, the care of a fatal, wastingdisease. An early problem is what to tell thepatient. Should you tell him the truth? Shouldyou evade the issue? Should you lie to him?Your decision may have a great deal to do withhis morale throughout the rest of his illness andit should be arrived at thoughtfully. My ownpractice-and I have seen no reason to changeit-is always to. tell the truth, but I follow mymother's dictum who taught me that, whileI must always tell the truth, I did not have totell everything I knew. Originally meant as afamily precaution against likely loquacity, ithas a ready application here. The patient whomust know, for reasons of his own soul or be-cause he has certain arrangements to make inthe face of an early death, will make it im-

possible for you to answer him truthfully with-out giving the diagnosis. Most patients, how-ever, make it pitifully easy to evade the issue;they may have declared that they want thetruth but when the time comes they do notlook you straight in the eye and demand it.Incidentally, an additional reason for beingtruthful has arisen out of the newer therapiesfor carcinoma; they are so prolonged that onlya patient who is aware of the severity of hiscondition will follow them.

In medication it is desirable to avoid theroutine use of opiates until they may be re-quired for pain, and they should then be givenin dosage and manner only as indicated. Re-calling the parasitic nature of tumours, thenecessity for as good a state of nutrition aspossible is evident, Unnecessarily heavy sedationwill interfere with this and deprive the patientof a degree of wellbeing and strength whichmight be his. The diet should be broad and asfull as possible for as long as possible. It ispossible to starve a tumour and reduce its sizebut not without starving the patient too.These patients are among the greatest

burdens which we as doctors sustain; all ourresources will be needed, all our qualities ofmedical skill and human kindness. With theirworld closing -in about them, hopes slippingaway, these patients depend upon you. Yourvisits, the little things you say, your interestin the day's complaints and your obviousattempts to find a way to relieve them-theseare the stuff of which doctors are made. Manypeople can be clever but only a good physiciancan steady the hand of a dying man as hecreeps downward, alone and afraid with per-haps only you to help him. The bustle of anti-biotics and reduced morbidities is much moreexciting, but do not forget that some day youwill go down that trail; and you will be verygrateful for a face to look into and for a handto hold.

THE COLLEGE OF GENERALPRACTITIONERS OF THE UNITEDKINGDOM

The fourth annual report (1956) of the Collegeof General Practitioners of the United Kingdomhas recently been published. It is noted that thetotal membership of the College at the end ofSeptember 1956 had reached 3743, an increaseof 456 during the year. Some of the membersare overseas, for example in Australia or NewZealand. Interim councils have been formedin Australia and New Zealand within the lastyear. Work of the faculties (correspondingroughly to chapters in Canada) is recorded.Friendly co-operation has been maintained withthe deans of nearly all medical schools, and

Canad. M. A. J. MEDicALECONomics 823Feb. 15, 1957, vol. 76

schemes for preceptorships for students are pro-gressing. In many medical schools members ofthe College of General Practitioners are givinglectures to students on such subjects as tech-niques in general practice, a general practi-tioner's bag, medical ethics, and the art oftherapeutics in general practice. A memoran-dum has been prepared on the continuingeducation of general practitioners, and the workof a postgraduate education committee of afaculty board. Research activities are reviewed;these include a morbidity survey whose resultsare ready for publication and an investigationinto acute chest infection in general practice,whose results have already been published. Itis noted that an anonymous donor has givenconsiderable financial help with the College'spermanent and temporary premises and alsowith secretarial expenses. A number of leadingdrug firms have also contributed to the workof the College.

MEDICAL ECONOMICSEXCESSIVE MEDICAL SERVICESAND THE QUESTION OFCONTROLS

In an era of increasing prepayment for medircal care on a fee-for-service basis, administra-tors of such plans will increasingly be facedwith the problem of what appears to be exces-sive utilization.As a general proposition, the amount of medi-

cal care required by a community is determinedby the prevalence of disease, disability anddeath in that community. It is further influencedby the ability of a community to pay for suchservices. When prepayment for comprehensivecare comes into play, the financial bar to serviceis removed. Medical care is then influenced notonly by need, but by social pressures andcustoms, and the emotional and cultural atti-tudes of the physician. There can be no doubtthat widespread health education, through thepress, radio and television, must influence pa-tients to demand more services in the form ofroutine health examinations, unnecessary labora-tory or radiological procedures, and the treat-ment of very minor ailments. On the other hand,the physician can more readily influence thepatient to receive treatments or services, and thepatient will more readily accept such services,under prepayment.There are physicians who will render exces-

sive services purely for reasons of gain. In othersthe motives will be mixed. Let us readily admitthat certain physicians, like certain patients, arefusspots who tend to exaggerate ailments andit might well be that apprehensive physicianswill, by some subtle alchemy of affinity, attract

apprehensive patients. The result will then beoverservice, with financial advantage to thephysician as a result of the situation, but withmoney not being a prime motivation on his part.On the other hand, certain physicians do not

provide adequate service for their patients. AsStephen Taylor3 points out from his study ongeneral practice in the United Kingdom, thepoint at which proper solicitude changes intoundesirable fussing, or firm discipline degener-ates into selfishness, is not necessarily clear-cut.

In regard to utilization, we know that suchrates have increased and are increasing in medi-cally sponsored prepayment plans in Canada.These services are on a fee-for-service basis andit could be easy to say that services have in-creased because physicians make more moneythat way. This is the superficial view. In theUnited Kingdom, general practitioners are paida fixed sum per annum for each patient, sick orwell. The physician there has no financial ad-vantage in providing services. But there also,utilization rates appear to be on the increase.It is rather too much to accept that physiciansare applying all the pressure in Canada, andthat patients are providing all the pressure inBritain. As general social and environmentalconditions have not deteriorated either inCanada or in Britain, since the last war, and asdeath rates have not increased, this increase inutilization might be ascribed to factors otherthan essential medical need.We have the impression that certain diseases

are more common in the United Kingdom, thusneeding more services than in most parts ofCanada. Here we may mention chronic bron-chitis, especially in the smog-bound industrialareas, possibly certain types of arthritis, meta-bolic diseases of old age, and, to a lesser extent,infectious diseases of childhood, especially inovercrowded areas (Logan'). This differentialpicture of disease must not be forgotten whencomparisons of services are made betweenCanada and Britain.The Health Insurance Plan of Greater New

York has recently provided information oncertain services in 29 of its constituent groups.These groups are paid on a capitation basis.They operate a comprehensive clinical, curative,and preventive service for their subscribers. Inthese groups there is no financial incentive forphysicians to provide services, but in spite ofthis there is marked variation in services. Forinstance, the number of services per infant peryear, in the different groups, varied from-8.7 to19.7 services, while surgical rates for proceduresin hospitals varied from 22.3 to 64.7. TheDivision of Research and Statistics of H.I.P. isat present trying to discover the reasons forthis variation (Stevenson2). In the United King-dom there is also marked variation in the num-ber of annual services rendered to patients bydifferent general practitioners (Logan1).