1488 BRITISH ASSOCIATION OF RADIOLOGISTS AT a meeting of this association held at the British Institute of Radiology on June llth and 12th, under the presidency of Prof. J. M. WOODBURN MORISON, the Skinner lecture on the After-care of Patients Suffering from Cancer of the Breast was delivered by Dr. F. HERNAMAN-JOHNSON. After drawing attention to the increase in the death- rate from carcinoma of the breast during the last thirty years, the speaker gave it as his opinion that little advantage was likely to accrue from the adoption of heavy dosage methods of radiation therapy in this field, and that radiation therapy should be employed primarily as a palliative measure following radical surgery. The objects to be attained in palliation were first to free the patient from any external signs of the growth, secondly to relieve pain and discomfort, thirdly to delay the onset of and, if necessary, treat metastases, and lastly to treat the patient from a psychological point of view. In this respect attention was drawn to the value of surgery where the patient was more likely to feel that the growth had in fact been completely removed. Reference was made to Dr. A. T. Todd’s work, but Dr. Hernaman-Johnson did not consider this suitable for hospital patients. Referring to biochemical tests he was of opinion that the differential sedimentation-rate, while not of value in diagnosis, was useful in assessing the response to treatment. Isolated skin recurrences should, he thought, not be regarded as of grave importance ; heavy dosage should be employed locally. Axillary recurrences should be removed surgically, while supraclavicular gland metastases should be dealt with by heavy doses of X ray therapy. Metastatic deposits in bones were worth while treating, and in such cases Todd’s method should be employed. Thoracic invasion rarely responds and the prognosis with liver metastases should be regarded as quite hopeless. Wave-length in Radiotherapy Mr. G. F. STEBBING, opening a discussion on wave-length as a factor in radiotherapy, emphasised the fact that in this form of treatment results were obtained only when the dosage was carried to a level which produced a fairly severe reaction on the skin, and that all factors which might contribute to a lessening of this reaction were worthy of consideration. It was almost universally accepted that the same physical dosage measured in rontgens (r) produces less normal tissue damage when delivered by radiation of short wave-length. Despite this lesser biological response of the normal tissues Mr. Stebbing was of opinion that so far as malignant cells were concerned the reverse was the case and that using short wave-length rays a more lethal effect on the tumour was obtained. This view was based primarily on the belief that the action of the radiation on the tumour cells is direct and not through the tumour bed. In addition to this " selective " action the use of short wave-length rays as produced by higher voltages resulted in greater penetration and so an improved depth dose which, though numerically not of a high order, was in many cases of very great value. Thus an absolute gain of 5 per cent. per field resulted in a total gain of 30 per cent. if six ports of entry were employed as in many cross- fire methods. Dr. DOUGLAS WEBSTER, on the other hand, while admitting that the use of higher voltages enabled a greater depth dose to be obtained, pointed out that a similar result could be obtained by the use of greater treatment distances. He did not consider that there was any selective or specific action in relation to wave-length, and in support of this view he pointed out that from the physical point of view ionisation effects did not run parallel to the wave-length of the radiation and that, from the practical aspect, the measurement of the r a the higher voltages was a matter of some difficulty. On the biological side he quoted a number of experiments in which the employment of radiation generated at widely different voltages had failed to produce any different response on the part of the biological medium. On clinical grounds there was, as yet, no concrete evidence to support the view that better results were obtained by the use of higher voltages and that clinics employ- ing X rays generated at potentials of 600 kv had not produced results superior to those obtained at 200 kv. Dr. RALSTON PATERSON, supporting Dr. Webster, was of opinion that short wave-length rays were, as a rule, to be preferred since their use entailed less skin reaction for the same measured dosage. This advantage, however, he considered to be due not to any specific or selective action on malignant tissue but to some physical factor as yet undetermined and possibly related to a defect in our present measurement methods. Dr. STRUTHERS FULTON did not consider that radiation effects were due to any specific or selective action. Clinically similar and equally satisfactory results were obtained in skin malignancy by the use of long wave-length X rays on the one hand and gamma rays on the other. The fact that with X rays these results were obtained at relatively lower dosage levels as measured physically in rontgens tended to support the view held by Dr. Paterson that our present methods of measurement might, in time, require to be revised. Dr. R. E. ROBERTS, arguing against there being any selective action, pointed out that if long wave- length rays produced a greater effect on the skin it was reasonable to assume that they would also produce a greater effect on tumour tissue. Dr. F. ELLIS cited a number of clinical and bio- logical experiments from the literature, all of which tended to show that no selective action in relation to wave-length did in fact exist. Mr. STEBBING, replying, pointed out that skin tumours were, as a rule, sensitive, and that care must be exercised in drawing deductions from this material. With deep-seated tumours the difficulty was greater and it was in the treatment of such cases that the value of short wave-length rays was most apparent. Low Voltage Near-distance X Ray Therapy Dr. S. B. ADAMS, after outlining the particular merits of this form of treatment, proceeded to describe two special applicators which had been devised at the Royal Cancer Hospital with a view to providing a more homogeneous distribution of energy on the skin surface than that obtainable with the standard applicators. He discussed the question of dosage, illustrating his remarks by slides of clinical subjects successfully treated by this method. Clinical and biological problems in relation to the factors of time and intensity were being investigated, but it was as yet too soon to put forward any definite results.
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1488
BRITISH ASSOCIATION OF
RADIOLOGISTS
AT a meeting of this association held at the BritishInstitute of Radiology on June llth and 12th,under the presidency of Prof. J. M. WOODBURNMORISON, the Skinner lecture on theAfter-care of Patients Suffering from Cancer
of the Breast
was delivered by Dr. F. HERNAMAN-JOHNSON. Afterdrawing attention to the increase in the death-rate from carcinoma of the breast during the lastthirty years, the speaker gave it as his opinion thatlittle advantage was likely to accrue from the adoptionof heavy dosage methods of radiation therapy in thisfield, and that radiation therapy should be employedprimarily as a palliative measure following radicalsurgery. The objects to be attained in palliationwere first to free the patient from any external signsof the growth, secondly to relieve pain and discomfort,thirdly to delay the onset of and, if necessary, treatmetastases, and lastly to treat the patient from apsychological point of view. In this respect attentionwas drawn to the value of surgery where the patientwas more likely to feel that the growth had in factbeen completely removed. Reference was made toDr. A. T. Todd’s work, but Dr. Hernaman-Johnsondid not consider this suitable for hospital patients.Referring to biochemical tests he was of opinion thatthe differential sedimentation-rate, while not ofvalue in diagnosis, was useful in assessing the responseto treatment. Isolated skin recurrences should,he thought, not be regarded as of grave importance ;heavy dosage should be employed locally. Axillaryrecurrences should be removed surgically, whilesupraclavicular gland metastases should be dealtwith by heavy doses of X ray therapy. Metastatic
deposits in bones were worth while treating, and insuch cases Todd’s method should be employed.Thoracic invasion rarely responds and the prognosiswith liver metastases should be regarded as quitehopeless.
Wave-length in RadiotherapyMr. G. F. STEBBING, opening a discussion on
wave-length as a factor in radiotherapy, emphasisedthe fact that in this form of treatment results wereobtained only when the dosage was carried to a
level which produced a fairly severe reaction on theskin, and that all factors which might contributeto a lessening of this reaction were worthy ofconsideration. It was almost universally acceptedthat the same physical dosage measured in rontgens(r) produces less normal tissue damage when deliveredby radiation of short wave-length. Despite thislesser biological response of the normal tissuesMr. Stebbing was of opinion that so far as malignantcells were concerned the reverse was the case andthat using short wave-length rays a more lethaleffect on the tumour was obtained. This view wasbased primarily on the belief that the action of theradiation on the tumour cells is direct and not throughthe tumour bed. In addition to this " selective "action the use of short wave-length rays as producedby higher voltages resulted in greater penetrationand so an improved depth dose which, thoughnumerically not of a high order, was in many casesof very great value. Thus an absolute gain of 5 percent. per field resulted in a total gain of 30 per cent.if six ports of entry were employed as in many cross-fire methods.
Dr. DOUGLAS WEBSTER, on the other hand, whileadmitting that the use of higher voltages enableda greater depth dose to be obtained, pointed out that asimilar result could be obtained by the use of greatertreatment distances. He did not consider thatthere was any selective or specific action in relationto wave-length, and in support of this view he pointedout that from the physical point of view ionisationeffects did not run parallel to the wave-length of theradiation and that, from the practical aspect, themeasurement of the r a the higher voltages wasa matter of some difficulty. On the biological sidehe quoted a number of experiments in which theemployment of radiation generated at widely differentvoltages had failed to produce any different responseon the part of the biological medium. On clinicalgrounds there was, as yet, no concrete evidence tosupport the view that better results were obtainedby the use of higher voltages and that clinics employ-ing X rays generated at potentials of 600 kv hadnot produced results superior to those obtained at200 kv.
Dr. RALSTON PATERSON, supporting Dr. Webster,was of opinion that short wave-length rays were,as a rule, to be preferred since their use entailedless skin reaction for the same measured dosage.This advantage, however, he considered to be duenot to any specific or selective action on malignanttissue but to some physical factor as yet undeterminedand possibly related to a defect in our presentmeasurement methods.
Dr. STRUTHERS FULTON did not consider thatradiation effects were due to any specific or selectiveaction. Clinically similar and equally satisfactoryresults were obtained in skin malignancy by the useof long wave-length X rays on the one hand andgamma rays on the other. The fact that withX rays these results were obtained at relativelylower dosage levels as measured physically in rontgenstended to support the view held by Dr. Patersonthat our present methods of measurement might,in time, require to be revised.
Dr. R. E. ROBERTS, arguing against there beingany selective action, pointed out that if long wave-length rays produced a greater effect on the skin itwas reasonable to assume that they would also
produce a greater effect on tumour tissue.Dr. F. ELLIS cited a number of clinical and bio-
logical experiments from the literature, all of whichtended to show that no selective action in relationto wave-length did in fact exist.
Mr. STEBBING, replying, pointed out that skintumours were, as a rule, sensitive, and that care
must be exercised in drawing deductions from thismaterial. With deep-seated tumours the difficultywas greater and it was in the treatment of suchcases that the value of short wave-length rays wasmost apparent.Low Voltage Near-distance X Ray TherapyDr. S. B. ADAMS, after outlining the particular
merits of this form of treatment, proceeded todescribe two special applicators which had beendevised at the Royal Cancer Hospital with a view toproviding a more homogeneous distribution of energyon the skin surface than that obtainable with thestandard applicators. He discussed the questionof dosage, illustrating his remarks by slides of clinicalsubjects successfully treated by this method. Clinicaland biological problems in relation to the factors oftime and intensity were being investigated, but itwas as yet too soon to put forward any definiteresults.
1489Dr. J. F. BROMLEY considered the possibilities of
the method in the treatment of lesions in the mouthand in carcinoma of the rectum. The particularmerit of this method in the treatment of skin
malignancy in the region of the eye was demonstratedby a series of slides showing clinical results.Dr. Bromley also briefly outlined certain biologicalexperiments on which he was engaged.
Prof. MORISON emphasised the importance of
considering the dosage at the tumour level. The
profound effect which distance has in modifying thiswas graphically demonstrated as was, also, thecomparatively small gain in depth dose associatedwith the use of higher voltages. An interesting tablewas shown comparing, from the point of view of
energy output and distribution, radiation from a
radium bomb, a radium applicator, an X ray tubeoperating at 200 kv and a short distance X raytube operating at 60 kv. Prof. Morison discussedthe possible difference in biological response to splitdosage, continuous and massive methods of treat-ment. During treatment the tissues graduallychanged in their sensitivity to radiation. Tumourstended to become radio-resistant and he was, there-fore, experimenting with a method whereby the
daily dose was gradually increased throughout the.period of treatment.
Dr. R. MCWHIRTER thought that similar resultscould be obtained by the employment of a tube
operating at the 200 kv level. He had, further,found the single day massive dose method quitesatisfactory for the treatment of skin malignancy.
Dr. FULTON was of opinion that the near-distanceX ray therapy plant provided something whichcould not be duplicated by any other apparatus atpresent available. While approximating in energydistribution to a radium plaque it gave a very muchhigher output. On the other hand, a high voltageX ray tube, while providing a high output, gave amore profound depth dose effect. Two points hadto be borne in mind in using the short distance X raytube. First, the depth dose was small and forthis reason he felt that it should be used with dis-cretion in the treatment of tonsillar lesions, andsecondly, the energy distribution is such that itfalls off rapidly towards the edge of the field. Thisfact must be borne in mind in treating skin malignancyand a correspondingly wider area be subjected toradiation. Short distance X ray therapy had taughtus two important lessons. The first of these was that
permissible dosage is closely associated with the sizeof the field irradiated, and with small fields it was
possible to administer doses measured in r similarto those given by radium. The second point wasthat dosage is also related to volume of tissueirradiated, and here we find that as a result of thesuperficial distribution of energy in the tissues it ispossible to deliver higher doses with the short distanceX ray tube than with an X ray tube generating raysof much shorter wave-length but operating at a
greater distance and so irradiating a larger volume oftissue despite the fact that the ports of entry may besimilar in size.
VentriculographyDr. ERIK LYSHOLM of Stockholm gave an address
before a large audience on radiological experience inventriculography, based upon 806 verified cases
examined by ventriculography and encephalography.The use of the method was, he said, increasing.In Stockholm air was now solely employed as thecontrast agent ; - with refined technique, it wouldshow all the details which could be elicited by opaque
media, the use of which had proved inseparablefrom risk. Arteriography was only employed whena vascular lesion was suspected. For radiographyhe used an apparatus whose constant focal-distanceat all angles enabled him to make a three-dimensionalreconstruction of the ventricular system. Whenthe reconstruction was superimposed upon an
anatomical chart, slight deformities were readilyappreciated, and the lesions could be accuratelylocalised. He demonstrated his new type of grid,constructed entirely of metal, which absorbed itsown secondary and tertiary radiation. The gridlines were so fine as to be almost invisible, and thethickness could be adapted to varying conditionsand objects. The ventriculographic appearance of
supra-tentorial tumours he divided into three groups,each with its characteristic picture :-
(1) Convexity tumour, causing lateral displacement,with tilting of the upper end of the septum pellucidumaway from the tumour and flattening of the upper angleof the lateral ventricle of the same side. The higher thetumour, the greater the amount of tilting of the septum.
(2) Tumour situated laterally, at the level of the Sylvianfissure, causing lateral displacement without tilting ofthe septum or indentation of the outer angle.
(3) Temporal tumours: : the typical picture was a
lateral displacement with a characteristic angulation ofthe septum and third ventricle to one another. This
angle was open towards the side of the tumour; thelateral ventricle on this side was narrowed, drawn outinto a point inferiorly, and showed an indentation on itslower outer side. In this group it was essential to observethe temporal horn. The direction in which it was dis-placed would determine whether the tumour was superficialor deep.
Filling of the third ventricle, of the aqueduct, andof the fourth ventricle was accomplished by specialtechniques. Characteristic filling defects were thenobserved with intrinsic and extrinsic tumours of thethird ventricle. It was sometimes possible todetermine the operability of intraventricular tumoursby observing whether they were completely surroundedby air or attached to the ventricular wall. Hedemonstrated examples of very small cysts at theforamen of Monro-an important type, of whichhe had seen four cases-tumours of the anteriormiddle and posterior parts of the third ventricle, andpineal tumours. Posterior third ventricle tumourscould not always be distinguished from one another.The pinealoma gave a well-defined filling defectwith more or less complete filling of the suprapinealrecess. Calcification in the tumour did not necessarilysignify that it was a pinealoma. Four such tumourshad proved to be gliomata, and one a tuberculoma.Tumours of the lamina quadrigemina were oftenhard to distinguish from posterior tumours of thethird ventricle ; in some cases both regions wereinvaded. If the ventricular defect were small in
comparison with the degree of displacement of theaqueduct, the tumour was likely to be quadrigeminal.Careful observation of the aqueduct gave valuableindications. Quadrigeminal tumours displaced ittowards the clivus, but not laterally. Upper vermistumours caused early compression of the aqueduct,and in the lateral view have a typical picture-namely, an angulation of the supratentorial part ofthe aqueduct, the peak of which was directed back-wards, together with a bowing of its infratentorialpart and of the fourth ventricle downwards andforwards, unaccompanied by any lateral displacement.This deformity did not occur with inflammatorystenosis. Tumours of the cerebellar hemispherescaused bowing of the aqueduct towards the base,with lateral displacement. They rarely obliterated
1490
the cavity of the fourth ventricle. Tumours of thelower vermis pressed upon the lower part of the fourthventricle which, together with the aqueduct, wasdilated. Angulation of the aqueduct was rarelyseen. Intraventricular tumours, if large, mightcompletely obliterate the cavity of the fourth ventricle.If small, they could be outlined : a rough or irregularoutline indicated a papilloma. Ependymomata andmedulloblastomata showed smooth surfaces.
Cerebellopontine angle tumours displaced the
aqueduct dorsally and towards the opposite side, andoften caused a depression of the lateral wall of thefourth ventricle. Pontine tumours also displacedthe aqueduct dorsally, but lateral displacement didnot occur. Dorsal displacement of the aqueduct withflattening of the floor of the fourth ventricle had beenobserved in a few cases of meningioma of the clivus.
Dr. E. W. TWINING, proposing a vote of thanks,stressed the personal element in Dr. Lysholm’sinvestigations. The brilliant results which he haddemonstrated resulted from the concentration of thecases in one centre, and from the concentration of thebest brains upon that material. Routine radio-
graphy could not obtain equivalent results. Everycase involved careful and prolonged personal study.
Short PapersDr. H. W. A. POST outlined the technique and
normal and pathological salpingographic appearancesin the uterus and tubes.
Dr. E. ROHAN WILLIAMS indicated the value ofurography, ascending and intravenous, in demonstrat-ing the physiological dilatation of the renal pelvesand ureters in pregnancy, and the cystographicdiagnosis of placenta prsevia.The use of lipiodol in the localisation of spinal
tumours was described by Dr. H. M. WORTH, whogave details of the technique and showed a numberof cases diagnosed by lipiodol introduced by thelumbar and cistern puncture respectively.
Dr. M. H. JupE read a paper on cases of suprarenaltumour, and described the clinical and radiologicalappearances in the Pepper and the Hutchison typesof neuroblastoma of the adrenal medulla. He drewattention to certain characteristic bone changes inthe latter type.
PUBLIC HEALTH
Refresher Courses
THE life of a medical officer in any branch of thepublic health service is increasingly hard. The
enlarging scope of the public health department iscalling for a very high type of medical officer whorequires, in addition to medical knowledge, personaland social qualities to which Sir Kingsley Woodalluded at the last annual dinner of the Society ofM.O.H.’s. The imagination of the advertising agent,the zeal of the missionary, the patience of Job,the hide of the hippopotamus were among the
qualifications, " coupled," he added, " I suppose,with medical knowledge." On the same occasionDr. Ernest Ward spoke of the initiative taken by theSociety in promoting higher education, and its hopefor the advice and cooperation of the Ministry ofHealth in arranging for it. The organisation of shortpost-graduate courses for the various classes ofmedical officers employed by local authorities wasthe first step suggested. No time has been lost anda circular now issued by the executive secretary ofthe Society to local authorities tells of provisionalarrangements for a series of refresher courses. Threesuch courses are announced :
(1) Sept. 28th to Oct. lst, at Cardiff, for medical officersof health, limited to 40.
(2) Week beginning Nov. 8th, at Manchester, for schoolmedical officers, limited to 30.
(3) Early in 1938, a course in infectious diseases, inLondon, limited to 20.
No sanction, it seems, is required for expenditureincurred on these courses by local authorities whichhave the conviction that they will get an adequatereturn for their money in the maintenance of efficiencyon the part of their staff. The Board of Educationhas also expressed general agreement with the
principle and a syllabus of a school medical courseis now being drawn up. An attendance fee of two
guineas will cover the central organising expensesand local fees for each course, and prompt applicationis desirable in view of the strict limitation of numbers.No other commendation of the scheme is necessarythan a mild expression of surprise that it has not beenput into execution before. All honour to the presentinitiative.
INFECTIOUS DISEASE
IN ENGLAND AND WALES DURING THE WEEK ENDED
JUNE 5TH, 1937Notifications.-The following cases of infectious
disease were notified during the week : Small-pox, 0 ;scarlet-fever, 1517 ; diphtheria, 925 ; enteric fever,39 ; pneumonia (primary or influenzal), 652 ; puer-peral fever, 33 ; puerperal pyrexia, 124 ; cerebro-spinal fever, 17 ; acute poliomyelitis, 3 ; acutepolio-encephalitis, 1 ; encephalitis lethargica, 5 ;relapsing fever, 2 (Leatherhead, Wharfedale R.D.);continued fever, 1 (Stockport) ; dysentery, 33;ophthalmia neonatorum, 115. No case of cholera,plague, or typhus fever was notified during theweek.The number of cases in the Infectious Hospitals of the London’
County Council on June 1 Ith was 2902, which included : Scarletfever, 736 ; diphtheria, 830 ; measles, 91 ; whooping-cough,446 ; puerperal fever, 22 mothers (plus 13 babies) ; encephalitislethargica, 2 82 ; poliomyelitis, 2. At St. Margaret’s Hospitalthere were 24 babies (plus 13 mothers) with ophthalmianeonatorum.
Deaths.-In 123 great towns, including London,there was no death from small-pox, 1 (0) from entericfever, 7 (0) from measles, 0 (0) from scarlet fever,16 (6) from whooping-cough, 29 (4) from diphtheria,46 (13) from diarrhoea and enteritis under two years,and 17 (4) from influenza. The figures in parenthesesare those for London itself.Four persons died at Birmingham of diphtheria and 2 each
at Darlington and Worcester. There were 7 fatal cases ofdiarrhoea at Willesden and 4 at Leeds.
The number of stillbirths notified during the week was313 (corresponding to a rate of 41 per 1000 totalbirths), including 52 in London.
NEw HOSPITAL AT IvER.-The new Iver, Denham,and Langley Cottage Hospital will be opened on July 2ndby the Duke of Kent.ROYAL EYE HOSPITAL, SouTHWABE.—This hospital
is setting up a special committee to carry out researchwith a view to preventing injuries to the eyes. Amuseum of various devices intended to protect the
eyes of industrial workers is being prepared and thecommittee is asking employers in South London to helpin the campaign. Plans are being prepared for two addi-tional wards and accommodation for extra nursing staffis to be provided. The cost of this, which is the first partof the rebuilding scheme, will be about 1:50,000.
