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42
THE SPECULUM. 43
apomorpboib Apborisms.
ON SURGEONS.
Orpheus, with his lute, of old moved stones and trees ; Sir Surgeon moves our stone—his loot he misnames fees!
ON THE SERPENT IN EDEN.
Poor modern Adam! Eve and Eden's dream, All spoiled by that damned serpent Spironeme !
ON FATE.
The things men do P.V. rewarded are With prostates prodded painfully P.R.!
ON COLIC.
A colic is a bloody thing—God wot, Barb wire—red hot,
Convolving in a terpsichorean frolic, Deep in one's intimate abdominal relations ! Squirmings and squeals—profane vociferations
Thus—colic !
THE CHILD AND PELVIS.
The child in transit to the pelvis saith,
"Now give me Liberty or give me Death!"
The pelvis groans that all death's misery. Is fun compared with a delivery!
16atbos•
The lady called and asked if she might see Good Doctor Punk. I bowed, for that was me.
I smiled her in, and bade her take a seat, Then asked her what she had that I could treat.
Did she feel tender here—or here—or here?
Had she a cough now? Was her water clear?
How were her bowels acting.? Nice and free?
And was she—er—unwell, quite painlessly?
Whether her spouse were navvy, sweep or porter, And would she bring a specimen of water?
"Of what, dear madam, do you most complain?
Is it stra.ngury—tumour on the brain?"
She looked aghast, and dully shook her head,
"I just come for the washing, sir," she said.
Ebe fnis9ion of the fiDebical Man.
• There are three official functions of the Medical Students' Society which everybody who has the interests of the society at heart should strive to attend—
the dinner, the ball and the annual general meeting. Whilst many have no excuse, some may be pardoned for failure to attend the dinner or ball for reasons of diet, finance, etc., but every medical student might be reasonably expected to attend the annual general meeting. Whilst the attendance this year was by no means poor, it was not what it ought to be, and perhaps in this function, as in others, it is ignorance of what is being missed that prevents overcrowding.
After preliminary business had been negotiated in commendable style by the newly-elected president of the society (Prof. R. J. A. Berry), he proceeded with the presidential address—his first appearance with us as Dean of the Faculty.
Sympathy at the continued ill-health of his predecessor was expressed, and then followed a few words of timely warning and advice to medical students—direct from the Faculty, as it were. After referring to the progress of the Medical School, both in personnel and buildings, the president introduced Professor MacCallum, who delivered an inspiring address on The Mission of the Medical Man.
"What are the causal factors in the study of medicine ?" he began. Whilst some had high ideals of service, others badly wanted a career, and a few badly wanted recompense. The fulfilling of the medical curriculum does not neces- sarily convey to a student any notion of his mission in life, and whilst the final examination was the great leveller which gives to the more fortunate a degree of prestige associated with the public valuation of his academic degree, it must be remembered that general training and the developmnt of personality were equally ncessary.
Whilst the existence of disease is the main blot on the medical profession, the hospitals could be regarded as some measure of our failure • and in carrying out one's life work it should be remembered that our education costs the State twice as much as it costs us. The popularity of "quacks" was due to the fact that, whilst some patients get well because they would in any case, a few get well because of treatment, and some die in spite of treatment. We must not allow ourselves to become extensively-traind "quacks."
From the army point of view, a sick man was not only one man less, but also required the assistance of others, and furthermore, disease kills more men than are killed by bullets. In civil life patients are an economic loss to the com- munity, and every patient in hospital should he regarded as an instance of per- sonal failure by members of the profession.
The aims of the medical profession should be, firstly, to ensure the birth of healthy children, and, secondly, to eradicate disease. A corollary to this second aim would be the elimination of pathologists and general practitioners, except for accidents. Thus medicine, alone in the professions, could claim to be altruistic, inasmuch as it works for the elimination of the need for medicine. There are three groups of medical men—those engaged in the treatment of existing disease, those engaged in preventitive and public health work, and that band of workers engaged in the fundamental investigation of disease. Whereas the second of these groups is often departmentally damned, the third group is sustained mainly by enthusiasm, which has, of course, a negligible market value.
However, diagnosis and treatment are becoming more and more dependent on the laboratories, and thus the poor often obtain better treatment for nothing
THE SPECULUM. 45 than the rich. However, most laboratory workers are but glorified general prac- titioners, though, if properly equipped and untrammelled by routine work, they are capable of great research. They should be free to investigate problems rather than cases.
Ignorance is the enemy of civilisation, and our knowledge has a money value which interferes with its dissemination. Are we out to fight disease, or to fight it at a price ? Mothers, for instance, know next to nothing about child- bearing, and the rearing of children—the number of rubber comforters hears this out. The guidance of expert medical advice is necessary in all phases of life—home conditions, school conditions, factories, grading of mental types, dis- posal of sewage, supply of food and water, etc. And inasmuch as we shrink from forming opinions and instructing uninformed on such matters, we betray our profession.
In conclusion, lie stated all research on the beginning of disease must be in the hands of the general practitioner, who alone sees early cases. The soul of medicine is the spirit of research, and the medical profession is a powerful factor in the progress of civilisation. After a vote of thanks to Prof. MacCallum, the meeting closed.
Dear, frowsy Parkville ! Those of us who have lived there in our student years will always have of it memories tender and absurd. Those ugly mid-
Victorian houses, those tiny back yards, those stained ceilings, the mud-coloured wallpapers, with white bows and baskets of puce roses, the woodwork painted an irrelevant green, the skeleton wardrobe with its too-narrow red curtain, the chest of drawers with drawers that stick, and a small mirror that obstinately refuses to reflect anything but one's knees. The dining rooms have red wall- paper, and are decorated with jardinieres of that drearily respectable vegetable, the aspidestra, and with enlarged photographs of hydrocephalous children in plush suits, and illuminated certificates to prove that Alf. answered his country's call and that father has joined the Rechabites.
One of the minor excitements of Parkville is wondering who will he one's landlady next week. The current one always wants to sell out and have a pork shop in Brunswick, and she never has any difficulty in doing so, apparently at a profit, to a lady who has just sold a pork shop in Brunswick, and wants to have a boarding house in Parkville. One takes the change philosophically, if one is but a bed and breakfast boarder, who spends the week-ends at home. One sees little of the landladies, who are all much alike—stout, kindly old souls, who don't sweep under one's bed, who apparently sleep in their clothes, and who eat, live, and have their being in a little den of a kitchen, where they sometimes entertain their friends with stewed tea and screams. The rumble of conversation and yells of laughter float up in the evening as one groans over Rose and Carless. One is awakened in the morning by an uproar compounded of Ormond striking seven, the yowls of milkmen, the rattle of cart wheels on the cobbled right-of-ways, the shrill yapping of nasty little woolly dogs, the screech of caged parrots, and the parting comments of the tomcats on the events of the night. Standing at the window—with its half-mast Venetian blind and sash precariously suspended by
one frayed cord—one brushes one's hair, and gazes pensively down at the neigh- bouring yards. Women of uncertain age and amorphous figure, with flannelette jackets, pink felt slippers and fluff in their hair, gossip over the fences. My land- lady's daughter, who is "in the tailoring," emerges fully and well dressed, and goes to the washhouse trough to wash the middle of her face. . . . Your idealist would have a thin time in Parkville of a. morning.
In the late afternoon students converge on the dairy, carrying little jugs, or gather in the good Mr. Mierisch's shop to buy cocoa and biscuits. The park is then charming, with its open, breezy spaces, and the few beautifully placed groups of slender gums. A haze of smoke or mist turns the western suburbs to a grey silhouette, and Mount Macedon stands out blue and clear.
Parkville evenings. Through open windows one can see studious heads bent over tables piled high with books. Screeches of cats puncture a momentary silence, and in every street one can hear popular music played with merciless precision by pianolas. College youths, sweltering in their gowns on the hottest nights, parade the parade with a somewhat over-elaborate unconsciousness of the local fauna. Other youths of an immature and spotty kind hang themselves up by the elbows to the counter of the news agent's shop, and in flat, droning voices discourse on what they put in their chem. papers, for hours and hours, to the piteously bored Misses Douglas. My landlady's daughter plays Nellie Kelly with one finger. A young Scotchman, whom one hears but never sees, yells a song in the bathroom and washes himself in a loud, enthusiastic manner, which probably signifies that he is going to see his young lady. Girls scraping and tapping along in their high-heeled shoes go past, hanging on to the arms of silent young men, and carrying on an endless monologue hissing with "I sez."
and "She sez." The park, whose windswept stretches seem so ingenuous by day, has an intriguing air of mystery by night. It is like a great dark lake, and the street lamps of south and west suburbs, dimly seen, are like the lights on a distant shore. Sounds from the Zoo—the roar of a lion, the strange plaintive cry of some big bird give an exotic air. . . . Dear Parkville, here's my love to you! Shall I ever live again in your shabby houses and dusty streets, where I was so happy ? Could one ever go back ? No, I think not.
—BLUE PETER.
EARLY BRITISH SURGERY.—CRANIOTOMY.
THE SPECULUM. 47
1Rabium.
By DR. L. J. CLENDINNEN.
Chemically Radium is a metal, first isolated from its compounds by Madame Curie in 1910. It belongs to the family of alkaline earths with At.Wt. 226.5.
It is used therapeutically in form of one of its salts, generally sulphate, or as emanation.
Radium gives off three kinds of radiation—Alpha, Beta and Gamma rays.
( 1) Alpha rays are neglible in therapeutic work. They are positively charged atoms which will not penetrate a sheet of paper, and so are eliminated by the Radium container.
(2) Beta rays are smaller particles projected with 10 times the velocity, and of varying penetration—soft ones are stopped by one-tenth m.m. of lead, while the hardest will penetrate 2 m.m.
(3) Gamma rays are very penetrating, it requiring 10 inches of soft tissue to absorb half these rays.
The Radium atom is comparatively unstable and disintegrates, giving off an Alpha particle, which is actually a Helium atom, and Radium emanation, which is a gas, and which is soluble in water: Radium emanation decays rapidly in a complex way, but its therapeutic action is similar to that of a Radium salt for a temporary period—it loses half its strength in less than four days. On this account Radium emanation is collected in tiny capillary tubes sealed off, and these are placed in areas to be treated, and left there.
On the other hand, unless a very large amount of Radium running into tens of thousands of pounds' worth is available for a source of supply, one is not able to collect sufficient emanation for cancer therapy.
Another advantage is that if emanation tubes are accidentally lost, no great loss is sustained.
When Radium emanation is not used, the Radium salt is placed in a con- tainer. At first this was distributed over a surface which was then coated with varnish. This varnish did not last, and leakage and loss of Radium occurred.
These flat applicators (plaques) are now encased by a very thin layer of a secret metal alloy which is durable, and allows a large percentage of Beta rays through, which are utilised in Dermatology.
It was found in the treating of new growths of any size, although the visible growth diminished and apparently disappeared, that it often recurred from the deeper parts being not sufficiently dosed.
The Radium was then placed in glass tubes, which were then placed in metal tubes, and these were introduced into the growth itself, and so a more homo- geneous dose could be given. These have been further improved in the last few years, and now Radium used for burying is obtained in fine metal needles with walls of less than z m.m., the hollow centres of which contain Radium Sul- phate, and the points of which are reinforced with steel. These produce much less trauma, and are often buried deeply in a growth and are recovered by drawing on a fine wire threaded to the eye of each.
Radiation varies as do light rays, diminishing with the square of the distance.
In actual practice with needles containing 10 milligrams of Radium element, about 1 c.m. apart is found to give the best results.
In regard to referring to an amount of Radium, it is more accurate to refer to weight of Radium element present rather than weight of the salt. Ten milli- grams of Radium Bromide contains a little over five milligrams of element.
The intensity of flat applicators naturally varies with amount of Radium salt ' per unit of surface, and a full strength applicator is one containing five milli- grams of Radium element per square c.m. A square plaque, 2 x 2 c.m., contain- ing five milligrams, is known as a quarter strength applicator.
Biologic Effect.—Small doses of Radium will stimulate cells to grow and multiply, which same cells, with a larger dose, are inhibited in growth and rendered sterile, and which are destroyed with a still bigger dose.
The sensitive part of the cell is the nucleus, and all cells vary in the sensitive- ness of their nuclei. Of the normal cells of the body those of the testis and ovary are many times more sensitive than connective tissue cells, which again are less resistant than nerve cells. As a general rule pathological cells are more sensitive than normal cells, while rapidly growing cells of an embryonic type are the most susceptible of all. Again in the same growth the individual sensitiveness of the cell varies, those cells in the resting stage being as much as six times more resistant than those undergoing mitosis.
It can therefore be understood that the necessary lethal dose for neoplasms varies considerably. A certain dose given to a rapidly growing and therefore vascular grOwth, with cells undergoing rapid division and of a highly embryonic type, will produce a rapid dimunition and perhaps local disappearance of the growth, without any signs of inflammation to parts around. This is the selective action of Radium. The same dose applied to a slow growing and so lowly vascular growth with cells of a more adult type would produce no result, except perhaps to stimulate this growth, and a considerably larger dose which would produce a marked inflammatory reaction is then necessary. Even in some cases the normal tissues must be partially sacrificed. This is the destructive dose.
With regard to this, it is proved that a very different result is produced by 103 milligrams acting for 10 hours to 10 milligrams acting for 100 hours, and there- fore the history that a patient has had a 1000 milligram hour dose of Radium does not give all the facts. In all doses the coverings of the Radium (the amount of filtration), and in surface applications, the distance from the skin and strength of application, are very necessary. With regard to filters in derma- tological work, the soft Beta rays are utilised and the plaque is used with no further filtering than its capsule, and if of varnish type, rubber or aluminium,
1 m m of which cuts off 50 per cent. of Beta rays. Where a larger dose is required at a depth, these softer rays are absorbed by thicker filters to protect the skin, and so allow the more penetrating rays longer to act. Brass, silver or lead are the most frequently used, and they vary in their density, 1 m.m. of leads cuts out over 99 per cent. of Beta rays. The exposure in these cases accordingly lengthened to numbers of hours, whilst lightly screened applications are measured in minutes with a full strength applicator.
Radium radiation compared with that of X-rays is more intense, but more localised, and so in malignancies in nearly all cases, excepting Rodent Ulcer, best results are obtained by a combination of these two.
As a general rule Radium is applied to the primary growth whilst X-rays are given to the gland areas for the action on these and the closing of the lym- phatics. There is a decided risk in treating a Carcinoma of the lip or cervix uteri with Radium without treating the glandular areas with X-rays, as a deposit in these may be actually stimulated.
THE SPECULUM. 49
%o[vo[.
(V. Speculum, November, 1924.)
[Editorial Note.—The following solution being not only the only one to reach this office, but also of such obvious intrinsic worth, we have deemed it only fair to those of our readers who attempted the solution of the commentary and gave it up in despair, to give them the benefit of the ripe learning and re- markable reasoning powers of our distinguished contributor. As he is personally unknown to any member of the staff, and gave no address with his communica- tion, we feel that we must seize on this, the only opportunity we have, of express- ing to him our thanks and those of our readers for his masterly solution of an insoluble problem.]
As its title suggests, this case presents features both of psychological and of a gynaecological interest. Let us deal with the psychological manifestations first.
The patient is a male, a medical student, and aged 24. These facts, taken in conjunction with the mention of a clinic, lead us to suppose that he is ap- proaching the end-point of a definite stage in his life history, but not necessarily that he is yet within measurable distance of that end-point. So much for general considerations. Let us now consider his psychological symptoms in what light they throw on the position. The chief symptom noticed by the patient is that his brain—or what is left of it--is becoming increasingly more difficult to gal- vanise into its former wonted activity. Added to this is bodily weakness of no mean order, which we may safely assume to be of cerebral origin ; in fact, a great part of the left cerebral hemisphere seems to be completely functionless.
Having got so far, let us try to find some cause for this grave state of affairs. This may be found by careful and intelligent perusal of the rest of the history. There we find a startling revelation of the cause of the condition. We find that this patient has been a medical student for many years, several of which were spent in the dissecting room. That this atmosphere created a profound im- pression on an over-sensitive nature cannot be doubted, as we read that it was then, and then only, that he yielded himself body and soul, especially the former, to the drug nicotine. The importance of this fact cannot be over-estimated.
Till this time he had been pure, but now began that slow process, that drugging of his higher faculties, which has brought him to his present pass. And this was not all. Doubtless, in the course of his studies, he dissected a brain, possibly many brains. Brains, it will be remembered, are hardened and preserved in formalin. Now, at least, the position is obvious. This unhappy young man is suffering from a formalin-complex. Day after day as he toiled, with weary limbs and failing sight, searching for the medulla oblongata or the cerebellum, he came to connect "brain" with something that was hard and cold and dead. This con- stant suggestion, acting on a system undermined by years of strenuous toil, and poisoned by the most deadly of the alkaloids, had its full and terrible effect. He came to believe actually that his own brain was like that upon which he had spent so many fruitless hours. On inquiry, it will almost certainly be found that it was a left half on which he worked. And from belief, it is but a step to action, or in this case, inaction. Fully believing that the left half of his cerebrum was even as the dread thing that lured his shrinking body on tottering limbs, day after day, from dawn till dark, within the gloomy portals of the Anatomy School, so , he found himself forced to act as if the thing he had come to believe were the reality. As we see him now he is the hapless victim of cigarettes, formalin, and auto-suggestion.