- Email: [email protected]
CANCER RESEARCH
254 established astrologers who, having themselves only survived at the cost of letting administrative paperwork crowd out all that was most creative in them, belonged firmly in the latter camp. We must not be too hard on them; for their superiors of earlier years, more accustomed to the discipline of the longbowmen and the trenches than to that of the laboratory or the studio, had been of the belief that original, productive men did best when uprooted from time to time and posted willy-nilly to any unit which happened to be under strength. Such an attitude could never have grown up during the Golden Age, when every man-jack had gardening in his bones, poetry in his heart, and curiosity in his very soul. Thus the conclave came to consist of harassed men, racked with psychosomatic disease, old before their time, embittered by the lost opportunities of developing the best ideas of their youth, and unconsciously ripe to use the power now placed in their hands in a negative and dithering manner. Un’Umdrum achieved a kind of recognition at the last, mainly among astrologers too young to realise what they risked, or travellers from other lands; and it is largely thanks to these last when he died-ironically enough, as the result of an operation for the stone, performed by one of his barber-school contemporaries who had attained fame and riches-his unique and disquieting insight into the zodiac did not altogether die with him.
Letters to the Editor
most
*
*
*
Skirting the fringe of the dying typhoid epidemic, as a good new Australian had to do to permit early readmission to her adopted country, my wife found the dictates of hygiene difficult to fulfil. Stopping for coffee in a sundrenched village, she was politely shown the hand basin before being allowed to sit down. Having washed her hands she turned to complete the ritual only to find that there was a single square of damp towelling which had clearly been in use for many days and by every visitor. Half learned lessons carry their own danger. ""
*
*
Your correspondent (July 18) who wrote: " I should like to share my experience with another monoamine-oxidase inhibitor " is clearly a victim of the rare chemical-compound disease (known to Germans as Formelsucht or Komplexkomplex). In a typical case the sufferer believes himself to be a molecule, nearly always of elaborate structure, and feels a need for contact with other identical or similar molecules. Treatment is at best symptomatic; two patients with complementary beliefs, who can persuade themselves that a beneficial chemical change has occurred between them, may be their own best therapists. Let us hope that through your columns this correspondent will find such a friend. *
*
*
We have long been plagued with difficulties over the supply and laundering of gowns for patients in the X-ray department. Particularly for chest X-rays, sheer numbers lead to difficulty. The men do without, of course, but the ladies of one clinic can quite easily exhaust the supply of clean gowns. If only the topless gown would really catch on all our troubles would be over.
difficulty in keeping our radiographers clad reasonably presentable white coats. Each intake of student radiographers receives a form with an inquiry about their vital statistics. The hospital secretary told me yesterday that now they were only required to give two measurements-waist and hips. I walked right into that one, by pointing out that surely We have
a
similar
in
the one measurement which was needed was that of the bust, the waist being taken care of by the standard green belt, the hips being assumed to be near that of the bust, while the length was adjusted by the sewing room. " Ah! " the secretary assured me, We are issuing topless uniforms in future to all your staff." "
*
*
..
Everyone knows that man-made electronic machines perform innumerable complicated tasks and calculations. What is not so well publicised is that pigs are still required to unearth truffles, that essential ingredient of the French delectable delicacy, pâté de foie gras.
CANCER RESEARCH
SIR,-In your annotation on Cancer Research (July 4) you refer to the work of the British Empire Cancer Cam-
paign, and in particular to the question still posed by the increasing incidence of bladder cancer. You state: " For ten years a bladder cancer hazard has been suspected in the rubber industry " and that " the situation has not been properly investigated because of limited cooperation from the industry and because it was widely believed that bladder carcinogens were no longer used." As medical adviser to the Rubber Manufacturing Employers’ Association during the past seven years, I have been concerned primarily to achieve precisely that cooperation between the industry, the Medical Inspectorate of Factories, and research authorities, which you state to be lacking. Following the lead given by the Association of British Chemical Manufacturers, the rubber industry authorised in 1957 the setting up of its own research unit and laboratory to deal specifically with the problem of occupational tumours of the bladder within the industry. At that time the hazard which had been created by the use in industry of &bgr;-naphthylamine and other suspected bladder carcinogens, including benzidine, was not
merely suspected
but
clearly recognised. Furthermore,
when the manufacture of 3-naphthylamine was discontinued by the chemical industry in 1949, all rubber manufacturers in the Employers’ Association were advised of the potential danger, and they took immediate steps to withdraw this material from production use and destroyed existing stocks. There is no evidence that any of our manufacturers have used this substance since that date. Unhappily, benzidine was not so clearly incriminated as a potential bladder carcinogen for some time afterwards, and it is now known that this substance was in fact used in certain sections of the industry until 1956. I have no information to suggest that its use has been continued in any of our members’ factories since that date. The function of the R.M.E.A. research unit and laboratory since it was established in 1957 has been to keep detailed records of all known cases of papilloma arising in the industry, to obtain information about the usage of suspected carcinogens in the industry, to keep our members constantly aware of the continuing importance of this problem in view of the known long latent period between exposure and onset of disease, and to encourage the fullest possible participation of our members in a service which we provide for the cytological screening, at regular intervals, of urine samples from all those employees who could conceivably have been exposed to bladder carcinogens. The work of this unit has, in fact, achieved in considerable measure the objects for which it was established. In the past six years our cytological service has been responsible for the early diagnosis, subsequently confirmed by cystoscopy, of 28 new cases of bladder papilloma in patients who have thus been afforded the opportunity for early treatment. Furthermore, our system of record-keeping of industry sicknessabsence ensures that all cases of papilloma of the bladder occurring within the industry, whether considered to be of industrial or other origin, are brought to our notice. With our unit based in Birmingham, I have endeavoured to establish the closest possible cooperation with hospital departments, and with the local Medical Inspector of Factories who has free access, as a member of our health advisory committee, to all relevant information. A similar measure of cooperation also exists between this unit, genito-urinary departments in other parts of the country, and the various research bodies interested in this question. For the future, a continuing scrutiny is being applied with the greatest care to all new materials introduced into
the
industry; and this is accepted, I believe, as a joint responsibility by consumer and manufacturing industries. R.M.E.A. Health Research Unit,
134, Edmund Street, Birmingham, 3.
GUY PARKES.
255
*** The
efforts
of
the
Rubber
Manufacturing Employers’ Association, though excellent, do not entirely meet the present need. Firstly, several small users of rubber do not belong to the Association; and, secondly, the Association being constituted and financed as it is, the possibility that its conclusions are biased can hardly be ruled out. Traditionally the employer fears litigation and the economic consequences of divulging trade secrets. If these considerations do not apply in the rubber industry, surely there can be no objection to the situation being examined by an independent and impartial team of investigators. The main obstacle to proper assessment of the incidence of bladder cancer is the unavailability of detailed information on the population of rubber workers risk in the past twenty or more years. Moreover, some knowledge of the industrial processes employed at various times in different branches of the industry is essential. With access to these data the following important questions at
could be answered: 1. What is currently the extent of the extra risk of bladder among rubber workers ? 2. Does the extra risk extend to workers who joined the industry after 1956, when benzidine ceased to be used by members of the R.M.E.A. ? 3. Has the use of known bladder carcinogens really ceased within the industry ? In particular, do any of the firms which are not members of the R.M.E.A. still use such substances ? cancer
Casewas unable to answer these questions from the data he was able to obtain. Such information as he could assemble, based on death certificates and employment tables " with perhaps a little help from the number of new cases of bladder tumour coming to light within the itself ", was " not reassuring ". He concluded: industry " A detailed epidemiological study of the situation, with the full co-operation of the rubber industry and trade unions concerned, would therefore seem eminently desirable." May Dr. Parkes’s letter be taken as a pledge of full cooperation from the members of the R.M.E.A. ? If so, will other rubber users and the trade unions follow suit, and, in any event, will the Minister of Health show any greater interest than in the past ?-ED. L. CYCLOPROPANE HEPATITIS: A DANISH DISEASE ? SIR,-In their reply to Dr. Johnstone concerning hepatic necrosis after halothane anaesthesia. Dr. Chadwick and Dr. Jennings (May 2) ask for retrospective surveys. Since no causal relation has yet been proved, jaundice ansesmight equally follow the administration of other thetics. Thus in previously reported cases of " halothane hepatitis " thiobarbiturates were also given during the anxsthesia-except in one reported from this hospital2 where jaundice followed each of two halothane anaesthesias. In a retrospective survey of liver disturbances after anxsthesia we found three further cases of jaundice-after the administration of cyclopropane by means of a semiclosed to-and-fro system with Waters’ absorber, controlled ventilation, and intubation. Suxamethonium-chloride drip or d-tubocurarine was used for relaxation. In one case anaesthesia was induced with thiopentone. In all three, morphine/scopolamine was used for premedication, and one or more blood-transfusions were given during the operations. All the anaesthesias were uncomplicated. Two patients had penicillin and streptomycin postoperatively. Case 1.-A man, aged 57, previously healthy, was admitted 1.
Case,
R. A. M.
British
Empire
p. 134. London, 1964. 2. Tygstrup, N. Lancet, 1963, ii, 466.
Cancer
Campaign:
report for
1963;
on account of duodenal ulcer. Preoperative serum alkalinephosphatase, transaminase, and bilirubin readings were normal. Vagotomy and pyloroplasty was performed. Postoperatively the patient showed signs of lung infarction, and anticoagulative treatment was begun with dicoumarol. 5 days postoperatively, the transaminase and bilirubin levels rose above normal (5-7 mM per hour per litre and 2-2 mg. per 100 ml.). In the following days jaundice increased, and the alkaline-phosphatase level was slightly raised (15-4 King-Armstrong units per 100 ml.); 3 weeks after operation it had risen to 48-2 units, the serumglutamic-oxaloacetic-transaminase (S.G.O.T.) level was 8-9 units; the serum-glutamic-pyruvate-transaminase (S.G.P.T.) level was
5-2
units; and the serum-bilirubin was 8-5 mg. per 100 ml. The test showed 33 °o retention. In the next 2 months these readings gradually returned to normal, and the patient recovered. The anticoagulant treatment was stopped,
bromsulphalein
and liver biopsy now shows normal liver tissue. Case 2.-A woman, aged 75, was admitted on account of a gastric ulcer. She had previously been healthy. Her serum alkaline-phosphatase, transaminase, and bilirubin readings were normal. Gastric resection and pyloroplasty was performed. 5 days later she was jaundiced. The serum-bilirubin was now 6-0 mg. per 100 ml. and S.G.O.T. was 1-8 units. On the 8th postoperative day the patient suddenly died from pulmonary embolism. Post mortem the liver showed subacute hepatitis with some fatty degeneration (the preoperative liver biopsy specimen had been normal). Case 3.-A woman, aged 74, was admitted on account of cancer of the colon. There had been no previous liver disease. Preoperatively the liver was found to be normal, and a hemicolectomy was performed. From the 2nd postoperative day the patient had slight fever, and nausea and vomiting. Her condition deterioriated, and she died 3 weeks after the operation. Postmortem liver findings were interstitial subacute hepatitis and parenchymatous liver degeneration.
The causal relationship between cyclopropane and in these 3 cases is at any rate as valid as in most of the reported cases of halothane hepatitis ". Because of its apparent predilection for the United States " halothane hepatitis " has been called an American disease ".3 All these cases occurred in Denmark.
hepatitis
"
"
Department of Anesthetics Surgical Department A, Bispebjerg Hospital,
and
Copenhagen.
K.-Å. BENNIKE J. O. HAGELSTEN.
RUPTURE OF THE UNSCARRED UTERUS
SIR,-The letter of Dr. Philpott and Professor Crichton4 prompts me to record the following case: A 28-year-old Muganda woman, at term, was admitted having been woken from sleep some 4 hours previously by severe abdominal pain. Since the onset of the pain she had not felt foetal movements. She was gravida-6, having had four normal deliveries and an abortion at 6 months. She was moderately shocked and in pain. The abdomen was very tender all over, and rebound pain was present. The foetal head was felt just above the pelvic brim, but the foetal heart could not be heard. The cervix was two fingers dilated, with intact membranes which were not tense. There was slight oedema of the legs, but a catheter specimen of urine was free of albumin. Rupture of the uterus was diagnosed. On opening the abdomen a large quantity of slightly bloodstained fluid welled up out of the wound, but the uterus appeared intact. A hand was passed up towards the fundus, and a hole some 5 cm. in diameter was felt near the attachment of the left tube. Foetal limbs were felt, but were not projecting. The front of the uterus from the anterior margin of the defect was incised, and a living female infant was delivered. The subsequent progress of mother and infant was satisfactory.
this site seems to be uncommon, as is foetal survival. Later questioning of the patient revealed that
Rupture
3. 4.
at
Heidenberg, W. S., Torio, I. S., Cebula, I ibid. 1963, i, Philpott, R. H., Crichton, D. ibid. 1964, i, 883.
1185.
Letters to the Editor
most
*
*
*
Skirting the fringe of the dying typhoid epidemic, as a good new Australian had to do to permit early readmission to her adopted country, my wife found the dictates of hygiene difficult to fulfil. Stopping for coffee in a sundrenched village, she was politely shown the hand basin before being allowed to sit down. Having washed her hands she turned to complete the ritual only to find that there was a single square of damp towelling which had clearly been in use for many days and by every visitor. Half learned lessons carry their own danger. ""
*
*
Your correspondent (July 18) who wrote: " I should like to share my experience with another monoamine-oxidase inhibitor " is clearly a victim of the rare chemical-compound disease (known to Germans as Formelsucht or Komplexkomplex). In a typical case the sufferer believes himself to be a molecule, nearly always of elaborate structure, and feels a need for contact with other identical or similar molecules. Treatment is at best symptomatic; two patients with complementary beliefs, who can persuade themselves that a beneficial chemical change has occurred between them, may be their own best therapists. Let us hope that through your columns this correspondent will find such a friend. *
*
*
We have long been plagued with difficulties over the supply and laundering of gowns for patients in the X-ray department. Particularly for chest X-rays, sheer numbers lead to difficulty. The men do without, of course, but the ladies of one clinic can quite easily exhaust the supply of clean gowns. If only the topless gown would really catch on all our troubles would be over.
difficulty in keeping our radiographers clad reasonably presentable white coats. Each intake of student radiographers receives a form with an inquiry about their vital statistics. The hospital secretary told me yesterday that now they were only required to give two measurements-waist and hips. I walked right into that one, by pointing out that surely We have
a
similar
in
the one measurement which was needed was that of the bust, the waist being taken care of by the standard green belt, the hips being assumed to be near that of the bust, while the length was adjusted by the sewing room. " Ah! " the secretary assured me, We are issuing topless uniforms in future to all your staff." "
*
*
..
Everyone knows that man-made electronic machines perform innumerable complicated tasks and calculations. What is not so well publicised is that pigs are still required to unearth truffles, that essential ingredient of the French delectable delicacy, pâté de foie gras.
CANCER RESEARCH
SIR,-In your annotation on Cancer Research (July 4) you refer to the work of the British Empire Cancer Cam-
paign, and in particular to the question still posed by the increasing incidence of bladder cancer. You state: " For ten years a bladder cancer hazard has been suspected in the rubber industry " and that " the situation has not been properly investigated because of limited cooperation from the industry and because it was widely believed that bladder carcinogens were no longer used." As medical adviser to the Rubber Manufacturing Employers’ Association during the past seven years, I have been concerned primarily to achieve precisely that cooperation between the industry, the Medical Inspectorate of Factories, and research authorities, which you state to be lacking. Following the lead given by the Association of British Chemical Manufacturers, the rubber industry authorised in 1957 the setting up of its own research unit and laboratory to deal specifically with the problem of occupational tumours of the bladder within the industry. At that time the hazard which had been created by the use in industry of &bgr;-naphthylamine and other suspected bladder carcinogens, including benzidine, was not
merely suspected
but
clearly recognised. Furthermore,
when the manufacture of 3-naphthylamine was discontinued by the chemical industry in 1949, all rubber manufacturers in the Employers’ Association were advised of the potential danger, and they took immediate steps to withdraw this material from production use and destroyed existing stocks. There is no evidence that any of our manufacturers have used this substance since that date. Unhappily, benzidine was not so clearly incriminated as a potential bladder carcinogen for some time afterwards, and it is now known that this substance was in fact used in certain sections of the industry until 1956. I have no information to suggest that its use has been continued in any of our members’ factories since that date. The function of the R.M.E.A. research unit and laboratory since it was established in 1957 has been to keep detailed records of all known cases of papilloma arising in the industry, to obtain information about the usage of suspected carcinogens in the industry, to keep our members constantly aware of the continuing importance of this problem in view of the known long latent period between exposure and onset of disease, and to encourage the fullest possible participation of our members in a service which we provide for the cytological screening, at regular intervals, of urine samples from all those employees who could conceivably have been exposed to bladder carcinogens. The work of this unit has, in fact, achieved in considerable measure the objects for which it was established. In the past six years our cytological service has been responsible for the early diagnosis, subsequently confirmed by cystoscopy, of 28 new cases of bladder papilloma in patients who have thus been afforded the opportunity for early treatment. Furthermore, our system of record-keeping of industry sicknessabsence ensures that all cases of papilloma of the bladder occurring within the industry, whether considered to be of industrial or other origin, are brought to our notice. With our unit based in Birmingham, I have endeavoured to establish the closest possible cooperation with hospital departments, and with the local Medical Inspector of Factories who has free access, as a member of our health advisory committee, to all relevant information. A similar measure of cooperation also exists between this unit, genito-urinary departments in other parts of the country, and the various research bodies interested in this question. For the future, a continuing scrutiny is being applied with the greatest care to all new materials introduced into
the
industry; and this is accepted, I believe, as a joint responsibility by consumer and manufacturing industries. R.M.E.A. Health Research Unit,
134, Edmund Street, Birmingham, 3.
GUY PARKES.
255
*** The
efforts
of
the
Rubber
Manufacturing Employers’ Association, though excellent, do not entirely meet the present need. Firstly, several small users of rubber do not belong to the Association; and, secondly, the Association being constituted and financed as it is, the possibility that its conclusions are biased can hardly be ruled out. Traditionally the employer fears litigation and the economic consequences of divulging trade secrets. If these considerations do not apply in the rubber industry, surely there can be no objection to the situation being examined by an independent and impartial team of investigators. The main obstacle to proper assessment of the incidence of bladder cancer is the unavailability of detailed information on the population of rubber workers risk in the past twenty or more years. Moreover, some knowledge of the industrial processes employed at various times in different branches of the industry is essential. With access to these data the following important questions at
could be answered: 1. What is currently the extent of the extra risk of bladder among rubber workers ? 2. Does the extra risk extend to workers who joined the industry after 1956, when benzidine ceased to be used by members of the R.M.E.A. ? 3. Has the use of known bladder carcinogens really ceased within the industry ? In particular, do any of the firms which are not members of the R.M.E.A. still use such substances ? cancer
Casewas unable to answer these questions from the data he was able to obtain. Such information as he could assemble, based on death certificates and employment tables " with perhaps a little help from the number of new cases of bladder tumour coming to light within the itself ", was " not reassuring ". He concluded: industry " A detailed epidemiological study of the situation, with the full co-operation of the rubber industry and trade unions concerned, would therefore seem eminently desirable." May Dr. Parkes’s letter be taken as a pledge of full cooperation from the members of the R.M.E.A. ? If so, will other rubber users and the trade unions follow suit, and, in any event, will the Minister of Health show any greater interest than in the past ?-ED. L. CYCLOPROPANE HEPATITIS: A DANISH DISEASE ? SIR,-In their reply to Dr. Johnstone concerning hepatic necrosis after halothane anaesthesia. Dr. Chadwick and Dr. Jennings (May 2) ask for retrospective surveys. Since no causal relation has yet been proved, jaundice ansesmight equally follow the administration of other thetics. Thus in previously reported cases of " halothane hepatitis " thiobarbiturates were also given during the anxsthesia-except in one reported from this hospital2 where jaundice followed each of two halothane anaesthesias. In a retrospective survey of liver disturbances after anxsthesia we found three further cases of jaundice-after the administration of cyclopropane by means of a semiclosed to-and-fro system with Waters’ absorber, controlled ventilation, and intubation. Suxamethonium-chloride drip or d-tubocurarine was used for relaxation. In one case anaesthesia was induced with thiopentone. In all three, morphine/scopolamine was used for premedication, and one or more blood-transfusions were given during the operations. All the anaesthesias were uncomplicated. Two patients had penicillin and streptomycin postoperatively. Case 1.-A man, aged 57, previously healthy, was admitted 1.
Case,
R. A. M.
British
Empire
p. 134. London, 1964. 2. Tygstrup, N. Lancet, 1963, ii, 466.
Cancer
Campaign:
report for
1963;
on account of duodenal ulcer. Preoperative serum alkalinephosphatase, transaminase, and bilirubin readings were normal. Vagotomy and pyloroplasty was performed. Postoperatively the patient showed signs of lung infarction, and anticoagulative treatment was begun with dicoumarol. 5 days postoperatively, the transaminase and bilirubin levels rose above normal (5-7 mM per hour per litre and 2-2 mg. per 100 ml.). In the following days jaundice increased, and the alkaline-phosphatase level was slightly raised (15-4 King-Armstrong units per 100 ml.); 3 weeks after operation it had risen to 48-2 units, the serumglutamic-oxaloacetic-transaminase (S.G.O.T.) level was 8-9 units; the serum-glutamic-pyruvate-transaminase (S.G.P.T.) level was
5-2
units; and the serum-bilirubin was 8-5 mg. per 100 ml. The test showed 33 °o retention. In the next 2 months these readings gradually returned to normal, and the patient recovered. The anticoagulant treatment was stopped,
bromsulphalein
and liver biopsy now shows normal liver tissue. Case 2.-A woman, aged 75, was admitted on account of a gastric ulcer. She had previously been healthy. Her serum alkaline-phosphatase, transaminase, and bilirubin readings were normal. Gastric resection and pyloroplasty was performed. 5 days later she was jaundiced. The serum-bilirubin was now 6-0 mg. per 100 ml. and S.G.O.T. was 1-8 units. On the 8th postoperative day the patient suddenly died from pulmonary embolism. Post mortem the liver showed subacute hepatitis with some fatty degeneration (the preoperative liver biopsy specimen had been normal). Case 3.-A woman, aged 74, was admitted on account of cancer of the colon. There had been no previous liver disease. Preoperatively the liver was found to be normal, and a hemicolectomy was performed. From the 2nd postoperative day the patient had slight fever, and nausea and vomiting. Her condition deterioriated, and she died 3 weeks after the operation. Postmortem liver findings were interstitial subacute hepatitis and parenchymatous liver degeneration.
The causal relationship between cyclopropane and in these 3 cases is at any rate as valid as in most of the reported cases of halothane hepatitis ". Because of its apparent predilection for the United States " halothane hepatitis " has been called an American disease ".3 All these cases occurred in Denmark.
hepatitis
"
"
Department of Anesthetics Surgical Department A, Bispebjerg Hospital,
and
Copenhagen.
K.-Å. BENNIKE J. O. HAGELSTEN.
RUPTURE OF THE UNSCARRED UTERUS
SIR,-The letter of Dr. Philpott and Professor Crichton4 prompts me to record the following case: A 28-year-old Muganda woman, at term, was admitted having been woken from sleep some 4 hours previously by severe abdominal pain. Since the onset of the pain she had not felt foetal movements. She was gravida-6, having had four normal deliveries and an abortion at 6 months. She was moderately shocked and in pain. The abdomen was very tender all over, and rebound pain was present. The foetal head was felt just above the pelvic brim, but the foetal heart could not be heard. The cervix was two fingers dilated, with intact membranes which were not tense. There was slight oedema of the legs, but a catheter specimen of urine was free of albumin. Rupture of the uterus was diagnosed. On opening the abdomen a large quantity of slightly bloodstained fluid welled up out of the wound, but the uterus appeared intact. A hand was passed up towards the fundus, and a hole some 5 cm. in diameter was felt near the attachment of the left tube. Foetal limbs were felt, but were not projecting. The front of the uterus from the anterior margin of the defect was incised, and a living female infant was delivered. The subsequent progress of mother and infant was satisfactory.
this site seems to be uncommon, as is foetal survival. Later questioning of the patient revealed that
Rupture
3. 4.
at
Heidenberg, W. S., Torio, I. S., Cebula, I ibid. 1963, i, Philpott, R. H., Crichton, D. ibid. 1964, i, 883.
1185.