X RAYS FOR SKIN DISEASES
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479 changes in vessel walls, some glial proliferation, and chromatolysis in nerve-cells, all of which he regards as potentially reversible. He also found, however, evidence of permanent and irreversible nerve-cell changes-shadow cells and neuronophagia-in a small proportion of cells, mainly in animals given intensive treatment (11-16 shocks) as opposed to a lighter course (4 shocks). Since the cats all had typical grand-mal seizures, the relevance of these observations to modern controlled E.c.T. in man is doubtful. They may, however, reflect the type of cell changes responsible for the memory defects and other clinical features noted with the older methods of treat- ment. They may also illustrate the possible mechanism of " epileptic deterioration " after repeated grand-mal fits in constitutional epilepsy. 1. Crissey, J. T., Shelley, W. B. New Engl. J. Med. 1952, 247, 965. 2. Sulzberger, M. B., Baer, R. L., Borota, A. Arch. Derm. Syph., Chicago. 1952, 65, 639. X RAYS FOR SKIN DISEASES THE value of X rays in the treatment of malignant epitheliomata is undisputed ; but there is some difference of opinion about the worth of fractional X-irradiation in the treatment of benign dermatoses. Crissey and Shelley 1 have treated patients with lichen simplex chronicus, lichen planus, psoriasis, nummular eczema, contact dermatitis, and acne vulgaris by X rays in such a way as to compare the state of treated and untreated areas. All patients received lOOr weekly (measured in air) for four weeks. Accurately located coned areas, 1.9-6 cm. in diameter, were treated. The cone was placed centrally in groups of lesions, but eccentrically in solitary lesions in order to avoid con- fusion with spontaneous central involution, which is common with some dermatoses. The response of the treated area was compared with the remainder by a marking system in which 1+ represented perceptible involution, 2+ marked involution, and 3+ a return to clinical normality except for skin pigmentation. For each disease the plus marks of all patients treated were added together and graphically recorded, abscissae representing the weeks of treatment and ordinates the aggregate of marks. A consistently and significantly greater response was noted in the radiated area than the control area in lichen simplex chronicus (16 patients), lichen planus (5 patients), and psoriasis (16 patients) ; but in nummular eczema (16 patients), contact dermatitis (40 patients), and acne vulgaris (25 patients) there was a steady progress towards healing in both irradiated and control areas, with a small but discernible difference in favour of the treated areas. For strict control it would have been better if an independent observer had inspected and assessed the results ; but barring possible errors of this sort from any unintentional bias, X-ray treatment of certain dermatoses seems to have been vindicated. But are X rays harmless in the dosage employed by dermatologists ? The answer is a firm Yes, according to follow-up studies carried out by Sulzberger et al.,2 who observed 1000 patients who had received X-ray treatment and 1000 who had not, for various skin conditions, including acne, eczema, psoriasis, skin cancer, and neurodermatitis. These workers divided the irradiated patients into two groups : those who had not received more then 85r units on any one occasion (763 patients), and those who had received irradiations of more than 85r (237 patients). The former group included only 2 patients with sequelse ; both had during their lives been exposed to sunlight more than the average, so it was by no means certain that X-irradiation was entirely or even mainly responsible for the atrophy, telangiectasia, depigmentation, hyperpigmentation, and keratosis that were observed. Of the 761 patients who showed no sequelae 12 had received a total dosage of 37 5-150r, 618 had received 150-1000r, 130 had received 1000-2000r, and 1 had received more than 2000r. Sulzberger et al conclude that there is no evidence of harmful sequelae from totals of 1000r or less of X rays applied superficially in the fractional doses and qualities generally employed by dermatologists for benign dermatoses ; when total doses of more than 1000r are given it must be expected that 1-5% of patients will exhibit X-ray sequelae that are relatively mild and of only cosmetic importance. There is no evidence that cancer, X-ray ulcer, or any other dangerous ill effects follow doses adding up to a maximum of 1400r, which some dermatologists today regard as permissible for benign dermatoses. Of the 237 patients who had received once or on several occasions more than 85r only 26 showed X-ray sequelae, even though 76 of the 237 had received over 1000r and 5 more than 4000r. Clearly, sequelae are to be expected in some patients receiving large X-ray exposures for malignant disease of the skin. Sulzberger and his colleagues conclude that the doses necessary for the cure of cancers and other malignant growths of the skin cause mild sequelae in about 25% of cases. 1. Hartley, P. H. S., Wingfield, R. C., Burrows, V. A. Brompton Hosp. Rep. 1935, 4, 1. 2. Bradford Hill, A. Principles of Medical Statistics. London, 1950. 3. Foster-Carter, A. F., Myers, M., Goddard, D. L. M., Young, F. H., Benjamin, B. Brompton Hosp. Rep. 1952, 21, 1. 4. Rafferty, T. N. Artificial Pneumothorax. London, 1944. 5. Mitchell, R. S. Amer. Rev. Tuberc. 1951, 64, 1, 21, 27, 127, 141, 151. PROGNOSIS IN TUBERCULOSIS THE Brompton Hospital Sanatorium at Frimley was opened in 1905. By 1935 Hartley et al.1- were able to survey 8766 cases which had been treated there ; and Professor Bradford Hill has cited their report as an excellent example of the application of statistical methods to this type of clinical research. The analysis by Dr. Foster-Carter and his colleagues,3 which is summarised on p. 486, maintains the standard ; it is an important and timely contribution to the knowledge of pulmonary tuberculosis. These workers have wisely concentrated on the prognosis of treatment by artificial pneumothorax, about which so much has been written to so little effect. They show convincingly that adhesions in a pneumo- thorax are not necessarily dangerous to the patient. Rafferty 4 concluded that closure of cavities and failure to find tubercle bacilli iri the sputum were not suitable criteria of an adequate pneumothorax ; success was to be judged by the freedom of the lung from adhesions. This view has been widely accepted, and in a recent extensive study 5 one of the main conclusions was that " free anatomic collapse should be achieved or the pneumothorax abandoned." The Brompton analysis shows clearly that such a view is not tenable. It establishes beyond reasonable doubt that adhesions have no effect on the prognosis, provided that pulmonary cavities disappear. Foster-Carter and his co-workers claim that the whole conception of what constitutes a satisfactory pneumothorax should be re-examined, and that " many patients have been, and are being, sacrificed to the fetish of free anatomical collapse." Their conclusions, though based on detailed evidence which is presented fully in an appendix, are unlikely to pass unchallenged. Pneumothorax treatment is now being used much less commonly in this country. It requires years of skilled attention by the physician, and if badly carried out it may be dangerous. Newer methods of treatment, and especially pulmonary resection, may seem to offer a more rapid return to normal life for the patient and less constant anxiety for the doctor, yet there is always a danger that the early spectacular results of new methods mav distract attention from the familiar achievements
Transcript of X RAYS FOR SKIN DISEASES
479
changes in vessel walls, some glial proliferation, andchromatolysis in nerve-cells, all of which he regards aspotentially reversible. He also found, however, evidenceof permanent and irreversible nerve-cell changes-shadowcells and neuronophagia-in a small proportion of cells,mainly in animals given intensive treatment (11-16shocks) as opposed to a lighter course (4 shocks). Sincethe cats all had typical grand-mal seizures, the relevanceof these observations to modern controlled E.c.T. in manis doubtful. They may, however, reflect the type of cellchanges responsible for the memory defects and otherclinical features noted with the older methods of treat-ment. They may also illustrate the possible mechanismof " epileptic deterioration " after repeated grand-malfits in constitutional epilepsy.
1. Crissey, J. T., Shelley, W. B. New Engl. J. Med. 1952, 247,965.
2. Sulzberger, M. B., Baer, R. L., Borota, A. Arch. Derm. Syph.,Chicago. 1952, 65, 639.
X RAYS FOR SKIN DISEASES
THE value of X rays in the treatment of malignantepitheliomata is undisputed ; but there is some differenceof opinion about the worth of fractional X-irradiationin the treatment of benign dermatoses. Crissey andShelley 1 have treated patients with lichen simplexchronicus, lichen planus, psoriasis, nummular eczema,contact dermatitis, and acne vulgaris by X rays insuch a way as to compare the state of treated anduntreated areas. All patients received lOOr weekly(measured in air) for four weeks. Accurately locatedconed areas, 1.9-6 cm. in diameter, were treated. Thecone was placed centrally in groups of lesions, but
eccentrically in solitary lesions in order to avoid con-fusion with spontaneous central involution, which iscommon with some dermatoses. The response of thetreated area was compared with the remainder by amarking system in which 1+ represented perceptibleinvolution, 2+ marked involution, and 3+ a returnto clinical normality except for skin pigmentation.For each disease the plus marks of all patients treatedwere added together and graphically recorded, abscissaerepresenting the weeks of treatment and ordinates theaggregate of marks. A consistently and significantlygreater response was noted in the radiated area thanthe control area in lichen simplex chronicus (16 patients),lichen planus (5 patients), and psoriasis (16 patients) ;but in nummular eczema (16 patients), contact dermatitis(40 patients), and acne vulgaris (25 patients) there wasa steady progress towards healing in both irradiatedand control areas, with a small but discernible differencein favour of the treated areas. For strict control it wouldhave been better if an independent observer had inspectedand assessed the results ; but barring possible errors ofthis sort from any unintentional bias, X-ray treatmentof certain dermatoses seems to have been vindicated.But are X rays harmless in the dosage employed by
dermatologists ? The answer is a firm Yes, accordingto follow-up studies carried out by Sulzberger et al.,2who observed 1000 patients who had received X-raytreatment and 1000 who had not, for various skinconditions, including acne, eczema, psoriasis, skincancer, and neurodermatitis. These workers dividedthe irradiated patients into two groups : those who hadnot received more then 85r units on any one occasion
(763 patients), and those who had received irradiationsof more than 85r (237 patients). The former groupincluded only 2 patients with sequelse ; both had duringtheir lives been exposed to sunlight more than the
average, so it was by no means certain that X-irradiationwas entirely or even mainly responsible for the atrophy,telangiectasia, depigmentation, hyperpigmentation, andkeratosis that were observed. Of the 761 patients whoshowed no sequelae 12 had received a total dosage of37 5-150r, 618 had received 150-1000r, 130 had received
1000-2000r, and 1 had received more than 2000r.
Sulzberger et al conclude that there is no evidenceof harmful sequelae from totals of 1000r or less of X raysapplied superficially in the fractional doses and qualitiesgenerally employed by dermatologists for benigndermatoses ; when total doses of more than 1000rare given it must be expected that 1-5% of patients willexhibit X-ray sequelae that are relatively mild and ofonly cosmetic importance. There is no evidence thatcancer, X-ray ulcer, or any other dangerous ill effectsfollow doses adding up to a maximum of 1400r, whichsome dermatologists today regard as permissible for
benign dermatoses.Of the 237 patients who had received once or on several
occasions more than 85r only 26 showed X-ray sequelae,even though 76 of the 237 had received over 1000rand 5 more than 4000r.
Clearly, sequelae are to be expected in some patientsreceiving large X-ray exposures for malignant diseaseof the skin. Sulzberger and his colleagues conclude thatthe doses necessary for the cure of cancers and other
malignant growths of the skin cause mild sequelae inabout 25% of cases.
1. Hartley, P. H. S., Wingfield, R. C., Burrows, V. A. BromptonHosp. Rep. 1935, 4, 1.
2. Bradford Hill, A. Principles of Medical Statistics. London,1950.
3. Foster-Carter, A. F., Myers, M., Goddard, D. L. M., Young,F. H., Benjamin, B. Brompton Hosp. Rep. 1952, 21, 1.
4. Rafferty, T. N. Artificial Pneumothorax. London, 1944.5. Mitchell, R. S. Amer. Rev. Tuberc. 1951, 64, 1, 21, 27, 127,
141, 151.
PROGNOSIS IN TUBERCULOSISTHE Brompton Hospital Sanatorium at Frimley was
opened in 1905. By 1935 Hartley et al.1- were able to
survey 8766 cases which had been treated there ; andProfessor Bradford Hill has cited their report as anexcellent example of the application of statisticalmethods to this type of clinical research. The analysisby Dr. Foster-Carter and his colleagues,3 which issummarised on p. 486, maintains the standard ; it isan important and timely contribution to the knowledgeof pulmonary tuberculosis.
These workers have wisely concentrated on the
prognosis of treatment by artificial pneumothorax,about which so much has been written to so little effect.They show convincingly that adhesions in a pneumo-thorax are not necessarily dangerous to the patient.Rafferty 4 concluded that closure of cavities and failureto find tubercle bacilli iri the sputum were not suitablecriteria of an adequate pneumothorax ; success was
to be judged by the freedom of the lung from adhesions.This view has been widely accepted, and in a recentextensive study 5 one of the main conclusions was that" free anatomic collapse should be achieved or the
pneumothorax abandoned." The Brompton analysisshows clearly that such a view is not tenable. Itestablishes beyond reasonable doubt that adhesions haveno effect on the prognosis, provided that pulmonarycavities disappear. Foster-Carter and his co-workersclaim that the whole conception of what constitutesa satisfactory pneumothorax should be re-examined,and that " many patients have been, and are being,sacrificed to the fetish of free anatomical collapse."Their conclusions, though based on detailed evidencewhich is presented fully in an appendix, are unlikelyto pass unchallenged.Pneumothorax treatment is now being used much
less commonly in this country. It requires years ofskilled attention by the physician, and if badly carriedout it may be dangerous. Newer methods of treatment,and especially pulmonary resection, may seem to offera more rapid return to normal life for the patient andless constant anxiety for the doctor, yet there is alwaysa danger that the early spectacular results of new methodsmav distract attention from the familiar achievements
