BRITISH MEDICAL JOURNAL
191
22 JANUARY 1977
13 Asamer, H, et al, Schweizerische mnedizinische Wochenschrift, 1974, 104, 1188. 41 Evans, D J, et al, British Medical Journal, 1973, 3, 326. 5Garcia-Fuentes, M, Chantler, C, and Williams, D G, Tenth European Society for Paediatric Nephrology. Barcelona, Sandoz, 1976. 16 Ashton, H, Frenk, E, and Stevenson, C J, British J7ournal of Dermatology, 1971, 85, 199. 17 Sterky, G, and Thilen, A, Acta Paediatrica, 1960, 49, 217. 18 Koskimies, 0, et al, Acta Paediatrica Scandinavica, 1974, 63, 357. 9 Winterborn, M H, personal communication. 211 Medical Research Council Working Party, British Medical Journal, 1971, 2, 239.
Deafness and mental health The deaf or hard of hearing whose impairment arises after normal speech development are a neglected group. Their needs often go unrecognised and their disability may attract social stigma rather than sympathy. ' To a greater or less degree they may be isolated from past pleasures and present social discourse.2 3 Difficulties in communication may result in their being bypassed or ignored even in matters of direct personal concern, so that they are made to feel stupid, inferior, or incompetent. Depression and other neurotic symptomsparticularly preoccupation with tinnitus or other adventitious noises-and various psychosomatic complaints are common sequelae,4 and many authors have drawn attention to the association between deafness and the development of paranoid illness. Kraepelin" observed the occurrence of delusions of persecution in the hard of hearing, and more recent authors have emphasised the increased prevalence of deafness in schizophrenic and paranoid illnesses when compared with affective disorders.7 " Kay et al1° have shown that the presence of social deafness is one of the premorbid characteristics which discriminate between patients with paranoid and with affective psychoses. Roth and McClelland" contrasted patients with affective disorders with schizophrenics, who were found more often to have deafness, visual defects, or skeletal abnormalities such as dwarfism, hunchback, or amputations. They suggested that in predisposed individuals these disabilities might increase sensitivity, impede social communication and relationships, decrease self-esteem, and aggravate tendencies to withdrawal, solitariness, and paranoid distortion of reality. Misunderstanding or misinterpretation of the outside world may lead any of us to flashes of paranoid thinking, but the testing of these ideas against external reality offers constant readjustment. Where there is a failure of such reality testing an edifice of paranoid disorder may be erected upon this foundation of misunderstanding.12 It is not difficult to understand how deafness might facilitate such a process. Indeed, it is now apparent that deafness may contribute to the development of mental disorder through its association with sensory deprivation, communication disorder, perceptual distortion, and attention deficit or as a non-specific stress."1 Regardless of the actual pathogenesis, then, hearing disorders which are severe, of early onset, and of long duration are important causative factors in paranoid psychoses of middle and later life. In contrast, the hearing losses associated with ageing seem to be of less importance. This suggests that the psychopathological process is one of gradual change and offers some prospect of intervention. The commonest cause of the progression from deafness to paranoia is bilateral middle ear disease originating in childhood or early adult life, and here prevention should be the aim. Chronic suppurative otitis
media tends to arise from multiple attacks of acute otitis media and otorrhoea, particularly in socially disadvantaged children.14 Education needs to be directed to early recognition and effective treatment, and more aggressive measures may be required to identify those at risk. Once deafness is established accurate assessment is essential, as is the prescription (where appropriate) of a flexible, effective, inconspicuous, and simple deaf aid. At present such aids are often cumbersome or unreliable, and the deaf tend to avoid wearing them or spend their money in search of more acceptable devices.'5 Equally important are efforts to combat withdrawal or isolation by involvement of the deaf not only in organisations concerned specifically with the deaf, but also in more general social activities. Families and employers may need help and guidance, which can often be provided by social workers with special experience or through voluntary agencies. Assessment facilities, audiology services, and social services do, however, vary from one part of the country to another. The general practitioner has a vital part to play in ensuring that his patient receives the best service available and is enabled to remain in the real world. Barker, R G, Adjustment to Physical Handicap and Illness. New York, Social Science Research Council, 1953. Ashley, J, Journey into Silence. London, Bodley Head, 1973. Disabilities and How to Live With Them, p 10. London, Lancet, 1952. Denmark, J C, Proceedings of the Royal Society of Medicine, 1969, 62, 965. Mahapatra, S B, Acta Psychiatrica Scandinavica, 1974, 50, 596. Kraepelin, E, Lehrbuch der Psychiatrie, 8th edn, vol 4, p 1441. Leipzig, Barth, 1915. 7 Kay, D W K, and Roth, M,3rournal of Mental Science, 1961, 107, 649. 8 Post, F, Persistent Persecutory States of the Elderly. London, Pergamon, 1966. 9 McClelland, H A, et al, Proceedings of the Fourth World Congress of Psychiatry, vol 4, p 2955. London, Excerpta Medica, 1966. '0 Kay, D W K, et al, British3Journal of Psychiatry, 1976, 129, 207. 11 Roth, M, and McClelland, H A, Vestnik Academicheskikh Nauk SSSR, Meditsina, 1971, no 5, 77. 12 Cameron, N, American Journal of Sociology, 1943, 49, 32. 13 Cooper, A F, British J7ournal of Psychiatry, 1976, 129, 216. 14 Miller, F J W, et al, Grozing up in Newcastle upon Tyne. London, Nuffield Foundation, Oxford University Press, 1960. '5 British Medical Journal, 1973, 2, 569. 2 3 4
Radiation-induced breast cancer There is no way in which a naturally occurring breast cancer can be distinguished histologically from one induced by ionising radiation. That radiation does induce breast cancer can, indeed, be suggested only by epidemiological data showing an increase in the observed incidence of the tumour in women at risk compared with that expected. In 1965 MacKenzie' reported an increase of breast cancer in women who had had repeated fluoroscopic examinations during treatment by artificial pneumothorax for pulmonary tuberculosis. Myrden and Hiltz2 continued this investigation among tuberculous women .in Nova Scotia. Of 300. women fluoroscoped, 22 developed cancer of the breast compared with 4 of the 483 who had not undergone fluoroscopy. The average age of the women at the time of irradiation was 26, and the cancers developed about 17 years later. Some of the patients had had more than 500 fluoroscopies; the total dose of radiation to the breast varied from 50 rads to 6000 rads delivered over some weeks to years. In a separate type of study Wanebo et a13 noted an excess of breast cancer in women who had survived an
192
atomic bomb explosion who had been exposed to doses of over 10 rads when compared with those whose dose was 9 rads or less. The average age of the women at the time of irradiation was 34 years-a single large exposure received in a very short space of time. Jablon and Kato4 found that between 1965 and 1970 19 deaths occurred from breast cancer in those exposed to more than 10 rads compared with an expected number of 4 9. This 15-20 year latent period correlates well with the 17 year delay found in the women with tuberculosis who had had repeated fluoroscopic examination. Mettler et a15 reported on 606 women treated with x-rays for acute postpartum mastitis. The maximum follow-up was 25 years, and they found 13 cases of breast cancer, compared with 5-86 expected. The average age at the time of treatment was 27 years and the average dose to each breast was 200 rads given over a time varying from a few minutes to several weeks. Only if cystic mastitis is seen as a precursor of malignancy (and that is very much a matter of opinion) could it be argued that some of these cancers were due to progression of underlying disease. The circumstances in which these groups of unfortunate women were exposed to radiation might be considered extreme. More recently, however, Simon and Silverstone6 have voiced concern that the mortality rate from breast cancer may increase in America owing to radiation-induced cancer as a consequence of mammography, if this is carried out in women with a life expectancy greater than 20 years. The practical problems in trying to estimate the risk from low-level radiation were discussed at length by Mole7 in the Silvanus Thompson Memorial Lecture given two years ago at the British Institute of Radiology. These included our sparse knowledge of the process of carcinogenesis; the different conditions ofirradiation and the varying doses; and the vastly different fractionation times. He concluded, however, that we must assume that there is no threshold for carcinogenesis: the occurrence of cancer is simply a matter of probability increasing with increasing dose. This view seems to be becoming increasingly accepted as a valid hypothesis. In mammography the radiation dose to the breast varies considerably, depending on the technique and the film used and the number or frequency of repeat examinations. Most screening centres have tried to cut down the dose to the breast: in Manchester George et al8 succeeded in lowering the radiation dose to the upper inner quadrant of the breast from 71 +3-7 rads to 0418+0-5 rads, while Ellis9 has suggested that the maximum dose per individual examination should not exceed 2 rads. The report of the trial conducted by the Health Insurance Plan in New York'0 showed that mammography conferred no benefit on women who were well and under the age of 50. In these women only 19% of cancers would not have been detected without mammography, and 61% would not have been detected without clinical examination. In women aged over 50 clinical and mammographic examinations made similar contributions to cancer detection. From the results of this report, and taking into account the fact that the latent period before breast cancer appears is about 20 years, Simon and Silverstone6 have suggested that fit women under 50 should not be screened by mammography. This is already the practice in some centres,8 where mammography is confined to women over 50 years of age unless there are clinical indications for the procedure. Similarly Stark and Way1" have restricted mammography to "high-risk women over 35 years of age." The risk of a single examination by mammography in a
BRITISH MEDICAL JOURNAL
22 JANUARY 1977
woman under 50 may be very small, but the optimum frequency of repeat examinations is still not clearly defined-and neither is the risk. In any individual the risk has to be balanced against the ultimate benefit from the examination. It is worth quoting again from Mole,7 who states that "a truly negligible level of risk as far as the individual is concerned may mean a large number of casualties if every member of a large population is exposed to it." IMacKenzie, I, British Journal of Cancer, 1965, 19, 1. 2 Myrden, J A, and Hiltz, J E, Canadian Medical Association Journal, 1969, 100, 1032. 3Wanebo, C K, et al, New England J'ournal of Medicine, 1968, 279, 667. 4Jablon, S, and Kato, H, Radiation Research, 1972, 50, 649. 5 Mettler, F A, et al,,Journal of the National Cancer Institute, 1969, 43, 803. 6 Simon, N, and Silverstone, S M, Bulletin of the New York Academy of Medicine, 1976, 52,. 741. 7Mole, R H, British Journal of Radiology, 1975, 48, 157. 8 George, W D, et al, British Medical3Journal, 1976, 2, 858. 9 Ellis, R E, British Journal of Radiology, 1972, 45, 795. 0 Strax, P, Venet, L, and Shapiro, S, American J7ournal of Roentgenology, 1973, 117, 686. " Stark, A M, and Way, S, Cancer, 1974, 33, 1671.
Progress at last for consultants? By the time Barbara Castle lost her job as Secretary of State last April doctors' confidence in the DHSS was probably at its lowest ebb ever. Nowhere in the NHS had she wreaked more havoc than among consultants. The protracted and abortive negotiations on a new contract for them' and her persistent attack on private medicine left a legacy of bitter resentment among senior hospital staff. Their discontent was worsened by a Government incomes policy that has hit consultants especially hard. Sadly, though perhaps not surprisingly, these travails exacerbated internal differences among this group of doctors. So consultants' leaders deserve credit for pressing ahead with their efforts to obtain a new contract despite the discouraging background. In June 1976 Mr David Bolt, chairman of the CCHMS's Negotiating Subcommittee, wrote to consultants inviting their views about a new contract.2 In September the Negotiating Subcommittee published a discussion paper,3 which has since been widely debated, with reactions to it generally favourable. This is an achievement. For too long agreement has been hampered not only by Government obduracy but also by the differences between the various specialties and between part-time and full-time consultants as well as the misgivings of some doctors that a precisely defined contract would mean less professional freedom. Now that the CCHMS has reached the final stages in preparing its proposals4 doctors will be pleased to learn (p 252) that Mr Ennals is willing to start discussing them. While his letter is hedged around with the "ifs and buts" that are today an inevitable prologue to any serious negotiations affecting pay this is a step forward. The Chairman of Council has welcomed the Secretary of State's initiative. All doctors will echo Dr Cameron's hope that "we will soon be able to demonstrate to the consultant body evidence of real progress... ." Even "soon" will not be soon enough for most consultants. British Medical Journal, British British Medical_Journal, 4British Medical Journal,
2
3
1975, 1, 45.
1, 1548. Medical_Journal, 1976, 1976, 2, 655.
1977, 1, 122.
191
22 JANUARY 1977
13 Asamer, H, et al, Schweizerische mnedizinische Wochenschrift, 1974, 104, 1188. 41 Evans, D J, et al, British Medical Journal, 1973, 3, 326. 5Garcia-Fuentes, M, Chantler, C, and Williams, D G, Tenth European Society for Paediatric Nephrology. Barcelona, Sandoz, 1976. 16 Ashton, H, Frenk, E, and Stevenson, C J, British J7ournal of Dermatology, 1971, 85, 199. 17 Sterky, G, and Thilen, A, Acta Paediatrica, 1960, 49, 217. 18 Koskimies, 0, et al, Acta Paediatrica Scandinavica, 1974, 63, 357. 9 Winterborn, M H, personal communication. 211 Medical Research Council Working Party, British Medical Journal, 1971, 2, 239.
Deafness and mental health The deaf or hard of hearing whose impairment arises after normal speech development are a neglected group. Their needs often go unrecognised and their disability may attract social stigma rather than sympathy. ' To a greater or less degree they may be isolated from past pleasures and present social discourse.2 3 Difficulties in communication may result in their being bypassed or ignored even in matters of direct personal concern, so that they are made to feel stupid, inferior, or incompetent. Depression and other neurotic symptomsparticularly preoccupation with tinnitus or other adventitious noises-and various psychosomatic complaints are common sequelae,4 and many authors have drawn attention to the association between deafness and the development of paranoid illness. Kraepelin" observed the occurrence of delusions of persecution in the hard of hearing, and more recent authors have emphasised the increased prevalence of deafness in schizophrenic and paranoid illnesses when compared with affective disorders.7 " Kay et al1° have shown that the presence of social deafness is one of the premorbid characteristics which discriminate between patients with paranoid and with affective psychoses. Roth and McClelland" contrasted patients with affective disorders with schizophrenics, who were found more often to have deafness, visual defects, or skeletal abnormalities such as dwarfism, hunchback, or amputations. They suggested that in predisposed individuals these disabilities might increase sensitivity, impede social communication and relationships, decrease self-esteem, and aggravate tendencies to withdrawal, solitariness, and paranoid distortion of reality. Misunderstanding or misinterpretation of the outside world may lead any of us to flashes of paranoid thinking, but the testing of these ideas against external reality offers constant readjustment. Where there is a failure of such reality testing an edifice of paranoid disorder may be erected upon this foundation of misunderstanding.12 It is not difficult to understand how deafness might facilitate such a process. Indeed, it is now apparent that deafness may contribute to the development of mental disorder through its association with sensory deprivation, communication disorder, perceptual distortion, and attention deficit or as a non-specific stress."1 Regardless of the actual pathogenesis, then, hearing disorders which are severe, of early onset, and of long duration are important causative factors in paranoid psychoses of middle and later life. In contrast, the hearing losses associated with ageing seem to be of less importance. This suggests that the psychopathological process is one of gradual change and offers some prospect of intervention. The commonest cause of the progression from deafness to paranoia is bilateral middle ear disease originating in childhood or early adult life, and here prevention should be the aim. Chronic suppurative otitis
media tends to arise from multiple attacks of acute otitis media and otorrhoea, particularly in socially disadvantaged children.14 Education needs to be directed to early recognition and effective treatment, and more aggressive measures may be required to identify those at risk. Once deafness is established accurate assessment is essential, as is the prescription (where appropriate) of a flexible, effective, inconspicuous, and simple deaf aid. At present such aids are often cumbersome or unreliable, and the deaf tend to avoid wearing them or spend their money in search of more acceptable devices.'5 Equally important are efforts to combat withdrawal or isolation by involvement of the deaf not only in organisations concerned specifically with the deaf, but also in more general social activities. Families and employers may need help and guidance, which can often be provided by social workers with special experience or through voluntary agencies. Assessment facilities, audiology services, and social services do, however, vary from one part of the country to another. The general practitioner has a vital part to play in ensuring that his patient receives the best service available and is enabled to remain in the real world. Barker, R G, Adjustment to Physical Handicap and Illness. New York, Social Science Research Council, 1953. Ashley, J, Journey into Silence. London, Bodley Head, 1973. Disabilities and How to Live With Them, p 10. London, Lancet, 1952. Denmark, J C, Proceedings of the Royal Society of Medicine, 1969, 62, 965. Mahapatra, S B, Acta Psychiatrica Scandinavica, 1974, 50, 596. Kraepelin, E, Lehrbuch der Psychiatrie, 8th edn, vol 4, p 1441. Leipzig, Barth, 1915. 7 Kay, D W K, and Roth, M,3rournal of Mental Science, 1961, 107, 649. 8 Post, F, Persistent Persecutory States of the Elderly. London, Pergamon, 1966. 9 McClelland, H A, et al, Proceedings of the Fourth World Congress of Psychiatry, vol 4, p 2955. London, Excerpta Medica, 1966. '0 Kay, D W K, et al, British3Journal of Psychiatry, 1976, 129, 207. 11 Roth, M, and McClelland, H A, Vestnik Academicheskikh Nauk SSSR, Meditsina, 1971, no 5, 77. 12 Cameron, N, American Journal of Sociology, 1943, 49, 32. 13 Cooper, A F, British J7ournal of Psychiatry, 1976, 129, 216. 14 Miller, F J W, et al, Grozing up in Newcastle upon Tyne. London, Nuffield Foundation, Oxford University Press, 1960. '5 British Medical Journal, 1973, 2, 569. 2 3 4
Radiation-induced breast cancer There is no way in which a naturally occurring breast cancer can be distinguished histologically from one induced by ionising radiation. That radiation does induce breast cancer can, indeed, be suggested only by epidemiological data showing an increase in the observed incidence of the tumour in women at risk compared with that expected. In 1965 MacKenzie' reported an increase of breast cancer in women who had had repeated fluoroscopic examinations during treatment by artificial pneumothorax for pulmonary tuberculosis. Myrden and Hiltz2 continued this investigation among tuberculous women .in Nova Scotia. Of 300. women fluoroscoped, 22 developed cancer of the breast compared with 4 of the 483 who had not undergone fluoroscopy. The average age of the women at the time of irradiation was 26, and the cancers developed about 17 years later. Some of the patients had had more than 500 fluoroscopies; the total dose of radiation to the breast varied from 50 rads to 6000 rads delivered over some weeks to years. In a separate type of study Wanebo et a13 noted an excess of breast cancer in women who had survived an
192
atomic bomb explosion who had been exposed to doses of over 10 rads when compared with those whose dose was 9 rads or less. The average age of the women at the time of irradiation was 34 years-a single large exposure received in a very short space of time. Jablon and Kato4 found that between 1965 and 1970 19 deaths occurred from breast cancer in those exposed to more than 10 rads compared with an expected number of 4 9. This 15-20 year latent period correlates well with the 17 year delay found in the women with tuberculosis who had had repeated fluoroscopic examination. Mettler et a15 reported on 606 women treated with x-rays for acute postpartum mastitis. The maximum follow-up was 25 years, and they found 13 cases of breast cancer, compared with 5-86 expected. The average age at the time of treatment was 27 years and the average dose to each breast was 200 rads given over a time varying from a few minutes to several weeks. Only if cystic mastitis is seen as a precursor of malignancy (and that is very much a matter of opinion) could it be argued that some of these cancers were due to progression of underlying disease. The circumstances in which these groups of unfortunate women were exposed to radiation might be considered extreme. More recently, however, Simon and Silverstone6 have voiced concern that the mortality rate from breast cancer may increase in America owing to radiation-induced cancer as a consequence of mammography, if this is carried out in women with a life expectancy greater than 20 years. The practical problems in trying to estimate the risk from low-level radiation were discussed at length by Mole7 in the Silvanus Thompson Memorial Lecture given two years ago at the British Institute of Radiology. These included our sparse knowledge of the process of carcinogenesis; the different conditions ofirradiation and the varying doses; and the vastly different fractionation times. He concluded, however, that we must assume that there is no threshold for carcinogenesis: the occurrence of cancer is simply a matter of probability increasing with increasing dose. This view seems to be becoming increasingly accepted as a valid hypothesis. In mammography the radiation dose to the breast varies considerably, depending on the technique and the film used and the number or frequency of repeat examinations. Most screening centres have tried to cut down the dose to the breast: in Manchester George et al8 succeeded in lowering the radiation dose to the upper inner quadrant of the breast from 71 +3-7 rads to 0418+0-5 rads, while Ellis9 has suggested that the maximum dose per individual examination should not exceed 2 rads. The report of the trial conducted by the Health Insurance Plan in New York'0 showed that mammography conferred no benefit on women who were well and under the age of 50. In these women only 19% of cancers would not have been detected without mammography, and 61% would not have been detected without clinical examination. In women aged over 50 clinical and mammographic examinations made similar contributions to cancer detection. From the results of this report, and taking into account the fact that the latent period before breast cancer appears is about 20 years, Simon and Silverstone6 have suggested that fit women under 50 should not be screened by mammography. This is already the practice in some centres,8 where mammography is confined to women over 50 years of age unless there are clinical indications for the procedure. Similarly Stark and Way1" have restricted mammography to "high-risk women over 35 years of age." The risk of a single examination by mammography in a
BRITISH MEDICAL JOURNAL
22 JANUARY 1977
woman under 50 may be very small, but the optimum frequency of repeat examinations is still not clearly defined-and neither is the risk. In any individual the risk has to be balanced against the ultimate benefit from the examination. It is worth quoting again from Mole,7 who states that "a truly negligible level of risk as far as the individual is concerned may mean a large number of casualties if every member of a large population is exposed to it." IMacKenzie, I, British Journal of Cancer, 1965, 19, 1. 2 Myrden, J A, and Hiltz, J E, Canadian Medical Association Journal, 1969, 100, 1032. 3Wanebo, C K, et al, New England J'ournal of Medicine, 1968, 279, 667. 4Jablon, S, and Kato, H, Radiation Research, 1972, 50, 649. 5 Mettler, F A, et al,,Journal of the National Cancer Institute, 1969, 43, 803. 6 Simon, N, and Silverstone, S M, Bulletin of the New York Academy of Medicine, 1976, 52,. 741. 7Mole, R H, British Journal of Radiology, 1975, 48, 157. 8 George, W D, et al, British Medical3Journal, 1976, 2, 858. 9 Ellis, R E, British Journal of Radiology, 1972, 45, 795. 0 Strax, P, Venet, L, and Shapiro, S, American J7ournal of Roentgenology, 1973, 117, 686. " Stark, A M, and Way, S, Cancer, 1974, 33, 1671.
Progress at last for consultants? By the time Barbara Castle lost her job as Secretary of State last April doctors' confidence in the DHSS was probably at its lowest ebb ever. Nowhere in the NHS had she wreaked more havoc than among consultants. The protracted and abortive negotiations on a new contract for them' and her persistent attack on private medicine left a legacy of bitter resentment among senior hospital staff. Their discontent was worsened by a Government incomes policy that has hit consultants especially hard. Sadly, though perhaps not surprisingly, these travails exacerbated internal differences among this group of doctors. So consultants' leaders deserve credit for pressing ahead with their efforts to obtain a new contract despite the discouraging background. In June 1976 Mr David Bolt, chairman of the CCHMS's Negotiating Subcommittee, wrote to consultants inviting their views about a new contract.2 In September the Negotiating Subcommittee published a discussion paper,3 which has since been widely debated, with reactions to it generally favourable. This is an achievement. For too long agreement has been hampered not only by Government obduracy but also by the differences between the various specialties and between part-time and full-time consultants as well as the misgivings of some doctors that a precisely defined contract would mean less professional freedom. Now that the CCHMS has reached the final stages in preparing its proposals4 doctors will be pleased to learn (p 252) that Mr Ennals is willing to start discussing them. While his letter is hedged around with the "ifs and buts" that are today an inevitable prologue to any serious negotiations affecting pay this is a step forward. The Chairman of Council has welcomed the Secretary of State's initiative. All doctors will echo Dr Cameron's hope that "we will soon be able to demonstrate to the consultant body evidence of real progress... ." Even "soon" will not be soon enough for most consultants. British Medical Journal, British British Medical_Journal, 4British Medical Journal,
2
3
1975, 1, 45.
1, 1548. Medical_Journal, 1976, 1976, 2, 655.
1977, 1, 122.
