625LEADING ARTICLES

Revolting Students

THE LANCETLONDON 23 MARCH 1968

" In their search for a new sense of continuity and sameness,adolescents have to re-fight many of the battles of earlier years, eventhough to do so they must artificially appoint perfectly well-meaningpeople to play the roles of adversaries ..."-E. H. ERiKSON; Child-hood and Society (Pelican Books, 1965).How far does ERIKSON’s observation explain current

student unrest ? One of the most depressing thingsabout adolescent behaviour is its capacity to provokemiddle-aged responses: a touch of stupidity or irre-

sponsibility, especially if evoked in the name of a causerather than sanctified by an association with rugbyfootball or with fund-raising for charity, sends rate-payers rumbling to the correspondence columns of thepapers. And in the news columns, two rude studentsthrowing paint, or twenty radical students sitting down,are reported with more emphasis than a hundredstudents doing voluntary social work, a thousand

engaged in legal and civilised political action, or tenthousand working satisfactorily at their very demandingcourses. If there is a lack of proportion here, it ismutual.There are two possible explanations for student

unrest. One is that there is a need to rebel, as ERIKSONsuggests, which will express itself irrespective of issues.The other is that there are aspects of society generallyor specifically of university society, which provokerebellion. These two explanations are not mutuallyexclusive, for any rebellion will obviously recruit to itsranks individuals with a strong need to revolt. Some ofthese will be re-enacting unresolved childhood conflicts,but it would be naive to try to ascribe revolutionarymovements, or indeed conservative regimes, to the

personality disorders of individuals. The same appliesto student unrest.

Naturally, the adolescent, in so far as he is concernedprimarily with his emergence from a state of dependenceand compliance, is likely to test his strength andchallenge that of others in ways which take incompleteaccount of all aspects of reality. But in making thischallenge he is a necessary counter-balance to the

conservatism, readiness to compromise, and tendencytowards mental closure of the parental generation.Unrest of this sort has always been one of the sources ofsocial change. In our time there is no shortage ofnational or international causes for rebellion, or oflocal university ones. As a ground-swell to the wholemovement one can point to the general mood shift of thenew generation-a shift expressed in the high valuationput on personal experience and relationships, includingsexual relationships, in a questioning of the " official"values of achievement and production, and in a rejectionof a world characterised by massive inequality and

violence. Some of this revulsion with the world takesthe form of a rather pathetic retreat into the magicaldrug world. Compared to this, political action andrebellion seem healthy, but none the less they appearto provoke adult counter-violence. Cannot this moodof the younger generation, provided it evades theextreme position of a Dionysian denial of reason,constitute a civilising correction to many of the valuesand assumptions of both capitalist and Communistsocieties ?As regards the universities’ domestic issues, what can

be done to control violence and rebellion and to preventa waste of energy and the loss of sympathy ? Clearlysome disciplinary machinery must exist in universities,but should the police perhaps be invited to take overmore responsibility ? In the past the student punishedby the university frequently got off more lightly thanthe ordinary man (or " rocker ") in the street punishedby the courts. Today students may be prepared toabandon this privilege. But in those areas in which theuniversities do wield power, it must be applied and beseen to be applied with as much concern for evidenceand the rights of the accused as is shown in the courts.The ultimate sanction—that of depriving the student ofthe right to complete his training-is an extremelygrave one. However, before discipline is applied torebellious students, discussion will often have brokendown. No way exists of avoiding disagreements andconfrontations, if only because the students, besidesbeing adolescents, have genuine grievances about theireconomic position, a genuine desire to play a widerpart in the running of their universities, and a genuineconcern about world issues, especially peace. In

pursuing these ends, they are bound to meet genuineopposition-an opposition itself made up of inter-woven strands of principle, wisdom, and irrational

prejudice. The universities cannot avoid such con-

frontations, but it is to be hoped that they can give anexample to society by the way in which they are handled.A hardening of attitudes, an authoritarian stance, a

willingness to stereotype the students, can only provokemore violent and irrational responses, whereas themaintenance and development of communication, andwillingness to exchange views on the basis of mutualrespect can make the confrontations both productiveand truly educational.

After Bikini

IN 1954, by one of those miscalculations that maysome day put an end to civilisation, some of the MarshallIslanders in the Pacific were exposed to heavy falloutfrom a 15-megaton thermonuclear test explosion at

Bikini atoll. On Rongelap, 100 miles away, the falloutresembled light snow, and 64 people on the islandreceived, it is estimated, 175 rads of whole-body yradiation, besides heavy skin irradiation from particleson skin and clothing. They suffered acute effects, suchas nausea and burning of the skin, before they wereevacuated two days later. Over the next few months the

626

burns healed; hair fell out and regrew; and the leucocyteand platelet counts fell and recovered (though usuallynot completely). In 1957 the radioactivity of Rongelaphad diminished greatly and the people who had beenevacuated returned to the island, with over 200 otherRongelap people who had not been on the island at thetime of the accident. There was thus a group who hadbeen heavily irradiated, and a second group, mostlyblood relations of the first, who had received little or noradiation and could serve as controls. All these peoplehave been examined periodically ever since; and wereferred 1 to some earlier results. The latest findingswere reported by RoBBiNS et al. to a conference atBethesda, Maryland, in March, 1967, and amplified byCONARD at a meeting of the American Association forthe Advancement of Science in December.3 3

In a thermonuclear explosion, radioactive materialsare produced by fission of heavy elements such as

uranium and plutonium in the bomb itself, and byneutron bombardment of the bomb casing and anythingaround it-which may include 100,000 tons of earth andwater if the bomb is exploded at a low level, as it was atBikini. Any of these radioisotopes can be biologicallyimportant in the short term; others, such as 90Sr, can besignificant later because of their long half-life andconcentration in particular human tissues. Many radio-isotopes of iodine are produced, often in high yield: buttheir half-lives are so short (about 8 days for 1311, a fewhours for the others) that till recently they were notthought to be a serious hazard. The people exposed onRongelap were found to have absorbed several radio-isotopes by inhalation and from contaminated food andwater, and the body burden could be estimated byradiochemical analysis of the urine, though less accu-rately for the short-lived isotopes. Comparison of theheavily exposed and control groups showed an increasein abortions and stillbirths in the exposed group in thefirst four years: but in most respects the health of thetwo groups was similar. Indices of ageing and incidenceof degenerative disease were unchanged. There havebeen 3 cases of cancer in the exposed group (1 of thethyroid and 2 of the female genitalia), and only 1 in theunexposed: the numbers are small and may or may notbe significant. Studies of growth and developmentdisclosed some retardation in children exposed beforethe age of 5 years: and chromosome damage has beendemonstrated.

At first no thyroid abnormalities were detected: butin 1964 a nodule was felt in a 12-year-old girl, and by theend of 1966 nodules had been found in 16 more people(15 in the exposed group and 1 in the control);and there were also 2 cases of hypothyroidism. Of theRongelap children heavily exposed before the age of 10,nodules have developed in 84%. The radiation dose totheir thyroid glands has been estimated at between 700and 1400 rads from radioiodines, plus 175 rads fromexternal y radiation. In people exposed over the age of1. See Lancet, 1966, ii, 580.2. Robbins, J., Rall, J. E., Conard, R. A. Ann. intern. Med. 1967, 66,

1214.3. See Guardian, Dec. 27, 1967.

10, and in children on more distant islands who wereless heavily exposed, the incidence of nodules is muchlower: but on the island of Ailinginae, where the totalthyroid dose from isotopes and external radiation is putat only 123 rads, there is a group of older children withthyroid abnormalities in 12.5%. When these noduleswere found, all the heavily exposed people were put onthyroxine. 10 patients with nodules had a subtotalthyroidectomy; all these nodules were benign and nonehave recurred. Microscopically the picture was that ofadenomatous goitre, resembling iodine-deficiency goitreand not typical of radiation effect, according to severalpathologists. An 11th patient, 1 of the 3 with cancer,was a woman of 41; she had a mixed papillary andfollicular carcinoma treated by total thyroidectomy andradioiodine, and so far has done well. Since thyroxinetreatment was begun, some nodules have regressed; and2 boys with severe growth retardation have improvedgreatly. Thyroid function has been tested in many ofthe Marshallese, with and without nodules. They haveunusually high levels of circulating iodoproteins(thought not to represent thyroxine but giving a highprotein-bound-iodine content) as well as a low rate ofaccumulation of radioiodine in the thyroid gland:the reason for this is unknown. Before the highprotein-bound-iodine level in normal Marshallesewas known, cases of hypothyroidism may have beenmissed. Those whose thyroids were damaged byradiation had partial (in 2 cases complete) loss offunction.

Thyroid abnormalities have been recorded before inpeople exposed to radiation, especially in childhood.PIFER and HEMPELMANN 4 found 9 carcinomas and 21adenomas of the thyroid among 2809 children who hadreceived radiotherapy to the neck; and they refer toother large series in most of which the findings are

similar. WINSHIP and ROSVOLL 5 collected 562 cases of

thyroid cancer in children and estimated that 80% ofthe patients had received radiation therapy. The inci-dence of thyroid cancer in irradiated children has beenestimated at about 1 case per million children per radto the thyroid per year,6 or at 1-7% per 500 rads.7DELAWTER and WINSHIP 8 investigated 222 adultstreated with X irradiation, 146 of them for thyrotoxi-cosis. The doses ranged from 300 to 7975r, with anaverage of 2100r. They found no cancer, though 10cases would have been expected if these adults had beenas susceptible as children. HANFORD et al. followed 458patients who had received X-ray treatment to the neckin doses of 100-1600r more than 10 years previously.There were 7 cases of carcinoma of the thyroid in the162 treated for tuberculous adenitis (5 of them in the 38treated before the age of 20) and 1 in the 62 treated forhyperthyroidism, all in patients who had received over4. Pifer, J. W., Hempelmann, L. H. Ann. N.Y. Acad. Sci. 1964, 114,

838.5. Winship, T., Rosvoll, R. V. Cancer, N.Y. 1961, 14, 734.6. International Commission on Radiological Protection Task Group.

Hlth Physics, 1966, 12, 239.7. Beach, S. A., Dolphin, G. W. Physics Med. Biol. 1963, 6, 583.8. Delawter, D. S., Winship, T. Cancer, N.Y. 1963, 16, 1028.9. Hanford, J. H., Quimby, E. H., Franz, V. K. J. Am. med. Ass. 1962,

181, 404.

627

lOOOr. SOCOLOW at el.1o made routine examinations ofsome 15,000 people from Hiroshima and Nagasaki in1958-61. They found 175 diffusely enlarged thyroids,117 single nodules, and 63 multinodular goitres: but theincidence was similar in each of four groups with

differing exposure, except for a significant increase insingle nodules in the most heavily exposed group. 70

biopsies were done, including 45% of those with singlenodules, and 17 carcinomas were found, plus 4 morediagnosed elsewhere. The thyroid doses in the patientswith carcinoma were estimated to lie between 0 and 2620

rads; and 14 of the 21 patients were in the heavilyirradiated group.Unlike the children of Rongelap, where most of the

radiation was due to radioiodines, all these patients wereexposed to external neutron, y, or X radiation (inJapan fallout was negligible since " small " kilotonbombs were used and the explosion took place high inthe atmosphere, so there was no neutron-irradiateddebris 11). In all the series, however, the radiation doseswere comparable. In patients treated with radioiodinefor thyrotoxicosis the dose administered is much larger-about 10,000 rads-but cancer of the thyroid aftersuch treatment is extremely rare: POCHIN 12 found thatthe incidence was actually less than would be expectedin untreated people. SHELINE et al.,13 however, reported8 cases of thyroid nodules in 256 patients from 5 to 14years after radioiodine treatment for thyrotoxicosis.124 of the 8 were under the age of 10 when treated; and ofthe 18 patients treated before the age of 20, 6 developednodules. There were no frank carcinomas, though in 1patient the nodule appeared invasive, and none of thepatients had hypothyroidism. The nodules were mostlyfollicular adenomas which seemed to begin in hyper-plastic areas of regenerating thyroid epithelium.Why are adenomas and carcinomas of the thyroid

commoner after small doses of radiation than after largedoses of 131I? The figures would probably be higher ifall treated patients were systematically examined: thefatality-rate of thyroid carcinoma is low and cases maybe missed if not systematically sought.7 It seems certainthat children are more sensitive than adults, rad for rad,or at least that their induction period for tumours isshorter; and most of the patients given radioiodinetreatment have been adults. It is possible that 1311 isless carcinogenic, rad for rad, than external radiation:the dose-rate is very different. Possibly thyrotoxicosisconfers some protection against the development oftumours: the two diseases seldom coexist. There maybe an optimum radiation dose for production of tumours-that is, a moderate dose may be more hazardous thana large dose: but SHELINE et al.’s patients received largedoses. BEACH and DOLPHIN found an increased cancer-rate as doses rose up to 500 rads; after this the incidencedeclined slightly, but numbers were small.

10. Socolow, E. L., Hashizuma, A., Neriishi, S., Niitani, R. New Engl. J.Med. 1963, 268, 406.

11. Arakawa, E. T. ibid. 1960, 263, 488.12. Pochin, E. E. Proc. R. Soc. Med. 1964, 57, 564.13. Sheline, G. E., Lindsay, S., McCormack, K. R., Galante, M. J. clin.

Endocr. Metab. 1962, 22, 8.

When a thyroid gland is damaged and loses part ofits function, euthyroidism may be maintained by con-tinued overstimulation by thyroid-stimulating hormone,and RoBBINs et al. believe that this stimulation accountsfor the nodules in their patients. The 2 boys withdefinite hypothyroidism did not have nodules, possiblybecause their thyroids were too badly damaged to beable to respond. The same may be true of people giventherapeutic doses of radioiodine, though paradoxicallythey may not show evidence of hypothyroidism, perhapsbecause the reproductive capability of thyroid cells isknocked out before their function is completely lost.That this may be so is indicated by the increasingincidence of hypothyroidism in treated patients as theyears pass, reaching 40% in 10 years.14 RoBBINs et al.believe that the 1 carcinoma in their series is a chanceevent, not due to radiation. Whether malignancy willdevelop in the children with nodules remains to be seen:it is to be hoped that the thyroxine they are having willprevent this.

Annotations

BIGGER AND BETTER?

THE success of mergers in the world of business is

usually judged by such criteria as return on capitalinvested, running costs, or exports. The board ofmanagement of a new group of companies sets targetsof this kind, and soon finds out whether or not the mergeris successful. More and more hospital groups are beingmerged. Is there always a clear purpose in the regroup-ing ? Is the idea to reduce hospital costs, or administrativecosts, or the time of committee-men, or is it to achievebetter clinical integration, a more inclusive service to thelocal community ? If so, has this purpose ever beenrealised ? Has anyone ever assessed the results of a

regrouping, or its effects on the men and women whowork in those hospitals, which, perforce, come under newmanagement ? There is a strong suspicion that regionalboards have assumed that, so far as hospital groups go,bigger must be better.

Although the Act of 1946 was designed to end theisolationism and petty competitiveness of individual

hospitals, there was also a desire to avoid an over-

centralised hospital service. Thus there were to be

groups of hospitals which would work together as a singleclinical and administrative entity. Yet many of the new

hospital-management-committee groups failed to catchthe new spirit of the Act, and we saw, instead, groupsdominated by one hospital, psychiatric hospitals separatedfrom hospitals for the mentally subnormal, and bothseparated from general hospital groups. We saw specialgroups for tuberculosis sanatoria, for children’s hospitals,for cancer hospitals; and in England we saw separateundergraduate-teaching-hospital groups and numbers ofpostgraduate teaching hospitals each separated from oneanother. These faults were not universal-there were

shining exceptions. But in many parts of England andWales these false divisions, once made, were deepenedby the appointment of large committees, interested

14. Greig, W. R. ibid. 1965, 25, 1411.