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INNOCENT AND MALIGNANT TUMOURS OF THE INTESTINE.
1268 known. The lesion of the mitral valve is usually not sufficient to give rise to definite physical signs. The second clinical type here described which the infection may take is that in which, following upon a furuncle in the region of the bucco-nasal fold, a phlegmonous inflammation supervenes which involves on the affected side of the face the upper lip, nose, and orbital region. Severe general symptoms appear, blood culture is positive, exophthahnia may occur from involvement of the cavernous sinus, and death takes place within two or three days of the have now been issued1 by the United States Public occurrence of general symptoms. This association of Health Service. The report is reassuring inasmuch as symptoms is termed by the writers the erysipelatoid no decisive clinical indications of lead poisoning due form " of the disease, chiefly on account of the diffuse to ethyl fluid were brought to light, even though the inflammatory infiltration which develops around the
petrol ; hence its sale was voluntarily discontinued May, 1925, awaiting the report of an expert committee. Careful and scientific investigations were undertaken in which car drivers using ordinary petrol were compared with drivers using the ethyl fluid, garage workers only handling ordinary petrol were compared with those handling the ethyl fluid, and all were compared with workers exposed to a known lead risk in factory employment. The text giving details of the inquiry, tables summarising the observations, and the report of the committee,
in
"
men appeared to be absorbing definite small amounts of lead. Possibly these men experience a special exposure from the dust of garages, which was found to contain from 0-8 mg. to 22-3 mg. Pb per gramme of dust. The committee find no good grounds for prohibiting the use of ethyl motor spirit of a composition of 1 part to 1300, so long as its distribution and use are controlled. Immediately upon issue of this report tentative regulations for governing the manufacture, distribution, and use of tetra-ethyl lead have been submitted to the health officers of the various States for consideration, and they may be expected to be finally adopted at an early date. Meanwhile, we may hope that in this country the prevailing type of British motor engines will be maintained and that no need may arise for subjecting the public to a new and somewhat disconcerting health risk.
garage
of infection, but its general resemblance At the same time the seems but slight. authors appear to imply that recognition of this condition as one of the forms which a staphylococcal This is infection may take has been wanting. certainly not the case, for in English surgical writing and teaching, and we can hardly think less so in France, the possible grave effects of a septic focus in the region of veins inosculating with the ophthalmics, and through them septic thrombosis, involving the cavernous sinus in the same process, is well known. The other condition of acute septicaemia associated with endocarditis is not as well known and does not seem to be a common occurrence in this country.
primary site to erysipelas
INNOCENT AND MALIGNANT TUMOURS OF THE INTESTINE.
____
WHETHER or not the parenchyma of innocent tumours is more liable to develop malignant characters IN an interesting paper upon staphylococcal septi- than non-neoplastic cells has long been a subject caemias which appears in a recent issue of the Presse of debate among pathologists and surgeons. There ]I édicale (May 15th), Drs. P. George and H. Giroire, is plenty of evidence to show that a carcinoma may who have observed a number of cases of the condition develop in an adenoma, or a sarcoma in an innocent during the last year, state that in most medical connective tissue tumour, but it is difficult to prove text-books two clinical types of this infection are that the malignant cells are actually derived from " recognised. First, a typhoid " form, without special those of the innocent neoplasm, that they are, as it localisation in any organ, in which the diagnosis were, a later stage in what is essentially a single can only be made by blood culture, and secondly, process. It is common knowledge that innocent and a subacute form with pyeemic features. For their malignant tumours frequently coexist side by side, part the authors have met with two clinical types of but many authorities deny that this is more than a generalised staphylococcal infection, in one of which coincidence. And inasmuch as the vast majority of the main localisation of the organisms is upon the carcinomata arise directly from epithelia without any heart valves, and, in the other, the infection is a intermediate adenomatous stage, it is clear that the facial one which they term the " erysipelatoid assumption of malignant properties by the cell may form." The first of the above types of the disease, be quite abrupt. One thing, however, is certainwhich occurs principally in adults, commences with namely, that the malignant process may originate general symptoms and may be thought to be an simultaneously or nearly so in several parts of an influenzal infection, but the condition rapidly worsens epithelial area. It was demonstrated many years and admission to hospital is usually sought in four ago that an apparently single carcinoma of the tongue At this time the patient is seriously ill may in reality consist of a mingling of two or more or five days. Sir Lenthal and though splenic enlargement is present does not independent and distinct tumours. show any definite localising signs. There are, however, Cheatle has demonstrated the same multiple origin certain cutaneous alterations which the writers con- in rodent ulcers, and a similar process has been shown sider highly specific. These are of the nature of to occur in the development of tar carcinomata in analyses the same ecchymotic or petechial spots, which may occur over mice. Now Dr. Cuthbert Dukes as it occurs in the large this time and small red areas of the phenomenon, surface, bright any part of about the size of a lentil situated especially upon intestine. For a long time it has been recognised that the face and upon the extremities, which become simple tumours of the mucosa of the large bowel vesicular and finally pustular and which upon bacterio- are often followed by the development of carcinomata ; logical examination are found to contain staphylococci especially in this prone to occur when the intestine in pure culture. These are embolic lesions and is the seat of multiple papillomata. Dr. Dukes has sections show the capillaries of the underlying skin made an extensive and careful study of these lesions, choked with masses of the organisms, whilst blood and has brought to light some very interesting points. cultures give a pure growth of staphylococcus aureus. In the complete large intestines of 127 persons dying The patient progresses from bad to worse and death, from diseases other than cancer, single or multiple which is often preceded by coma and hyperpyrexia, adenomata were found in 12 cases (rather less than takes place usually within a week of the onset. At 10 per cent.), but in 33 successive intestines affected post mortem, examination shows the presence of an with carcinoma such adenomata occurred in 25, or acute endocarditis usually involving the mitral valve. 75 per cent. Inasmuch as in the malignant cases only alone and a certain number of embolic lesions in the the small portion of intestine removed along with lungs or internal organs. The authors consider that the tumour by operation was examined, the difference the symptomatology and the cutaneous lesions are I is even greater than would appear. Investigating characteristic and enable a definite diagnosis to be these tumours anatomically, Dr. Dukes finds that in made prior to the results of blood culture being the early stages they are usually multiple, though STAPHYLOCOCCAL SEPTICÆMIA.
1
Journal of Industrial Hygiene, May, 1926.
1 British Journal of Surgery, vol. xiii., No. 52.
1269 fusion of neighbouring foci of the later stages give rise to
proliferation may in technical apparently single It should
an
Moreover, at the margin or neck of the .adenoma the adjacent epithelium presents pronounced chronic inflammatory changes. In course of time malignancy supervenes in these irritated cells, as well as in the cells of the adenoma itself. Dr. Dukes suggests that a cancrogenic agent causes a more than usually vigorous growth in many separated spots in a considerable area of mucous membrane. Later, - a crop of adenomata arise from this sensitive field, .and some of these become surrounded by secondary tumours. The mucosa between these primary and secondary tumours becomes irritated, hampered in its growth, and folded inwards. Whether the malignant change develops in these dislocated cells or whether in the cells of the actual adenomata is uncertain, but the cancer makes its appearance when .a crop of simple tumours has arisen in an irritated field and in close association with one of them. The author’s conclusions are supported by excellent figures and diagrams, and his article is as convincing .as’ it is interesting. .growth.
____
RESEARCH IN BREWING.
BREWING, like the agriculture of to-day and the medicine of yesterday, is one of those ancient crafts which the patient labour of the scientific investigator is slowly raising from the status of an empirical art to that of a science. It is to the credit of the brewing .trade, at a time when many industries are accepting or seeking help from some outside source, that its own Institute has financed a research scheme by a system of voluntary contributions based on output Results of considerable from nearly 300 firms. technical and scientific value appear in the fifth report of the Institute of Brewing Research Scheme, covering the period April, 1924, to April, 1926, which has just been issued. Beer needs for its -manufacture four main ingredients-water, barley malt, hops, and yeast-and each of these materials .forms the chief subject-matter for investigation by the Until the Institute .four subcommittees of experts. .shall have appointed a director-general of research .the chairman of the Research Fund Committee, Mr. J. S. Ford, F.R.S.E., is acting in that capacity. Field experiments, carried on all over England on the influence of soil, season, and manures on the yield and quality of barley grown for malting, are supervised by Sir John Russell, F.R.S., director of the Rothamstead Experimental Station. After .malting the analytical work is in the hands of Mr. H. Lloyd Hind, whose results promise well for both farmer and brewer. Investigations on hops comprise the systematic breeding and crossing of new varieties at the South-Eastern Agricultural College, Wye, by Prof. E. S. Salmon, and their testing at the East Malling Research Station and at Horsmonden. ’The objects in view are to procure for the grower new and prolific varieties of hop more able to resist disease, while at the same time securing for the brewer the qualities he considers valuable. Chemical investigations on the preservative and antiseptic -properties of hops have engaged the attention of Prof. F. L. Pyman, F.R.S., and Dr. T. K. Walker at Manchester since 1921. It may not be generally known that apart from the agreeable flavour conferred - own beer by hops, they are a valuable ally to the brewer in his fight against the invasion of his beer by the foreign organisms which cause turbidity, fret and acidity. Valuable work is being done on the keeping properties of the yeast used for fermentation and the effect of hydrogen-ion concentration on the character and stability of beer. The - measurement of the true " free acidity " is becoming recognised as an essential procedure in the various stages of brewing. Over and above the actual staff of the Institute a large body of farmers, brewers, -chemists, maltsters, and hop-growers-all busy menvoluntarily give their services on numerous com:mittees supervising the researches, while expert .annual
assistance is engaged where required. not be forgotten that it was on the basis of Pasteur’s researches on the disease organisms of wine and beer that arose the superstructure of modern surgery and preventive medicine.
FLUORINE AS A SLOW POISON. THE toxic effects of long-continued small doses of iodine and bromine and their derivatives are well known. Recently Prof. H. Cristiani has described1 chronic poisoning by another member of the halogen series, fluorine. This element is apparently present in minute quantities in many of our foodstuffs, and was at one time frequently used as a preservative, although its use as such is now prohibited in most countries. In the neighbourhood of certain factories the food of animals may contain toxic quantities of fluorine, and this element may also be present in excess in water into which certain industrial products have been allowed to pass. In some districts in Switzerland where these conditions are present an enclemic disease occurs among animals, characterised by wasting and cachexia, with a special localisation in the regions of the vertebral column and lower limbs, while the bones become softened and frequently show spontaneous fractures. On account of this last symptom the disease has usually been considered by veterinarians as a form of osteomalacia, and farmers and others seeking compensation for their diseased cattle have been met by the statement that there is no evidence that osteomalacia can be caused by the ingestion of poisonous substances. Prof. Cristiani has set himself to disprove this, and he has established that the disease from which these animals suffer can be separated from true osteomalacia and should be " " designated by a separate name such as fluorism or " fluorine cachexia." His experiments consisted in feeding animals on diets which, while maintaining perfect health in control animals, produced the syndrome described above when there was added in small doses (a) hay which was suspected of having produced the disease in cattle ; (b) hay mildly .impregnated with certain salts of fluorine, or (c) grass submitted to the action of fluorine in one of its gaseous forms and used either fresh or as hay. The time of appearance of symptoms was variable and depended to a certain extent on the dose of fluorine employed. The experimental animals wasted and eventually died with symptoms of bulbar paralysis and respiratory failure. At autopsy the bone-marrow was found to be extremely scanty ; the bone-tissue showed much rarefaction, and the bones on analysis showed a high fluorine content. Prof. Cristiani is at present studying the question as to whether chronic fluorine poisoning occurs in man. Its symptoms are so slow in appearing and in progressing that it may possibly be present sometimes among the inhabitants of industrial areas where much fluorine is produced. ____
THE PATHOLOGY OF BURNS. was for a long time a good deal of difficulty in explaining the toxaemia and death which may follow burns, and it is only comparatively recently that our knowledge of the subject has determined to a satisfactory explanation which brings the ill-effects of burns into line with the shock due to tissue injury. The evidence, along with an interesting discussion of burns of all kinds, is well summarised by Dr. G. T. Pack in the Archives of Pathology and Laboratory Medicine (1926, i., 767). In the first place, it is clear that the poisonous substance comes from the burned tissue and is carried in the blood; if the tissue is excised toxemia is prevented, and if burned skin is transplanted from one animal to another the latter has symptoms and dies. If one of a pair of experimental Siamese twins is burned, both have symptoms, and experiments with crossed circulations show that the THERE
1 La Presse Médicale, April 14th, 1926, p. 469.
petrol ; hence its sale was voluntarily discontinued May, 1925, awaiting the report of an expert committee. Careful and scientific investigations were undertaken in which car drivers using ordinary petrol were compared with drivers using the ethyl fluid, garage workers only handling ordinary petrol were compared with those handling the ethyl fluid, and all were compared with workers exposed to a known lead risk in factory employment. The text giving details of the inquiry, tables summarising the observations, and the report of the committee,
in
"
men appeared to be absorbing definite small amounts of lead. Possibly these men experience a special exposure from the dust of garages, which was found to contain from 0-8 mg. to 22-3 mg. Pb per gramme of dust. The committee find no good grounds for prohibiting the use of ethyl motor spirit of a composition of 1 part to 1300, so long as its distribution and use are controlled. Immediately upon issue of this report tentative regulations for governing the manufacture, distribution, and use of tetra-ethyl lead have been submitted to the health officers of the various States for consideration, and they may be expected to be finally adopted at an early date. Meanwhile, we may hope that in this country the prevailing type of British motor engines will be maintained and that no need may arise for subjecting the public to a new and somewhat disconcerting health risk.
garage
of infection, but its general resemblance At the same time the seems but slight. authors appear to imply that recognition of this condition as one of the forms which a staphylococcal This is infection may take has been wanting. certainly not the case, for in English surgical writing and teaching, and we can hardly think less so in France, the possible grave effects of a septic focus in the region of veins inosculating with the ophthalmics, and through them septic thrombosis, involving the cavernous sinus in the same process, is well known. The other condition of acute septicaemia associated with endocarditis is not as well known and does not seem to be a common occurrence in this country.
primary site to erysipelas
INNOCENT AND MALIGNANT TUMOURS OF THE INTESTINE.
____
WHETHER or not the parenchyma of innocent tumours is more liable to develop malignant characters IN an interesting paper upon staphylococcal septi- than non-neoplastic cells has long been a subject caemias which appears in a recent issue of the Presse of debate among pathologists and surgeons. There ]I édicale (May 15th), Drs. P. George and H. Giroire, is plenty of evidence to show that a carcinoma may who have observed a number of cases of the condition develop in an adenoma, or a sarcoma in an innocent during the last year, state that in most medical connective tissue tumour, but it is difficult to prove text-books two clinical types of this infection are that the malignant cells are actually derived from " recognised. First, a typhoid " form, without special those of the innocent neoplasm, that they are, as it localisation in any organ, in which the diagnosis were, a later stage in what is essentially a single can only be made by blood culture, and secondly, process. It is common knowledge that innocent and a subacute form with pyeemic features. For their malignant tumours frequently coexist side by side, part the authors have met with two clinical types of but many authorities deny that this is more than a generalised staphylococcal infection, in one of which coincidence. And inasmuch as the vast majority of the main localisation of the organisms is upon the carcinomata arise directly from epithelia without any heart valves, and, in the other, the infection is a intermediate adenomatous stage, it is clear that the facial one which they term the " erysipelatoid assumption of malignant properties by the cell may form." The first of the above types of the disease, be quite abrupt. One thing, however, is certainwhich occurs principally in adults, commences with namely, that the malignant process may originate general symptoms and may be thought to be an simultaneously or nearly so in several parts of an influenzal infection, but the condition rapidly worsens epithelial area. It was demonstrated many years and admission to hospital is usually sought in four ago that an apparently single carcinoma of the tongue At this time the patient is seriously ill may in reality consist of a mingling of two or more or five days. Sir Lenthal and though splenic enlargement is present does not independent and distinct tumours. show any definite localising signs. There are, however, Cheatle has demonstrated the same multiple origin certain cutaneous alterations which the writers con- in rodent ulcers, and a similar process has been shown sider highly specific. These are of the nature of to occur in the development of tar carcinomata in analyses the same ecchymotic or petechial spots, which may occur over mice. Now Dr. Cuthbert Dukes as it occurs in the large this time and small red areas of the phenomenon, surface, bright any part of about the size of a lentil situated especially upon intestine. For a long time it has been recognised that the face and upon the extremities, which become simple tumours of the mucosa of the large bowel vesicular and finally pustular and which upon bacterio- are often followed by the development of carcinomata ; logical examination are found to contain staphylococci especially in this prone to occur when the intestine in pure culture. These are embolic lesions and is the seat of multiple papillomata. Dr. Dukes has sections show the capillaries of the underlying skin made an extensive and careful study of these lesions, choked with masses of the organisms, whilst blood and has brought to light some very interesting points. cultures give a pure growth of staphylococcus aureus. In the complete large intestines of 127 persons dying The patient progresses from bad to worse and death, from diseases other than cancer, single or multiple which is often preceded by coma and hyperpyrexia, adenomata were found in 12 cases (rather less than takes place usually within a week of the onset. At 10 per cent.), but in 33 successive intestines affected post mortem, examination shows the presence of an with carcinoma such adenomata occurred in 25, or acute endocarditis usually involving the mitral valve. 75 per cent. Inasmuch as in the malignant cases only alone and a certain number of embolic lesions in the the small portion of intestine removed along with lungs or internal organs. The authors consider that the tumour by operation was examined, the difference the symptomatology and the cutaneous lesions are I is even greater than would appear. Investigating characteristic and enable a definite diagnosis to be these tumours anatomically, Dr. Dukes finds that in made prior to the results of blood culture being the early stages they are usually multiple, though STAPHYLOCOCCAL SEPTICÆMIA.
1
Journal of Industrial Hygiene, May, 1926.
1 British Journal of Surgery, vol. xiii., No. 52.
1269 fusion of neighbouring foci of the later stages give rise to
proliferation may in technical apparently single It should
an
Moreover, at the margin or neck of the .adenoma the adjacent epithelium presents pronounced chronic inflammatory changes. In course of time malignancy supervenes in these irritated cells, as well as in the cells of the adenoma itself. Dr. Dukes suggests that a cancrogenic agent causes a more than usually vigorous growth in many separated spots in a considerable area of mucous membrane. Later, - a crop of adenomata arise from this sensitive field, .and some of these become surrounded by secondary tumours. The mucosa between these primary and secondary tumours becomes irritated, hampered in its growth, and folded inwards. Whether the malignant change develops in these dislocated cells or whether in the cells of the actual adenomata is uncertain, but the cancer makes its appearance when .a crop of simple tumours has arisen in an irritated field and in close association with one of them. The author’s conclusions are supported by excellent figures and diagrams, and his article is as convincing .as’ it is interesting. .growth.
____
RESEARCH IN BREWING.
BREWING, like the agriculture of to-day and the medicine of yesterday, is one of those ancient crafts which the patient labour of the scientific investigator is slowly raising from the status of an empirical art to that of a science. It is to the credit of the brewing .trade, at a time when many industries are accepting or seeking help from some outside source, that its own Institute has financed a research scheme by a system of voluntary contributions based on output Results of considerable from nearly 300 firms. technical and scientific value appear in the fifth report of the Institute of Brewing Research Scheme, covering the period April, 1924, to April, 1926, which has just been issued. Beer needs for its -manufacture four main ingredients-water, barley malt, hops, and yeast-and each of these materials .forms the chief subject-matter for investigation by the Until the Institute .four subcommittees of experts. .shall have appointed a director-general of research .the chairman of the Research Fund Committee, Mr. J. S. Ford, F.R.S.E., is acting in that capacity. Field experiments, carried on all over England on the influence of soil, season, and manures on the yield and quality of barley grown for malting, are supervised by Sir John Russell, F.R.S., director of the Rothamstead Experimental Station. After .malting the analytical work is in the hands of Mr. H. Lloyd Hind, whose results promise well for both farmer and brewer. Investigations on hops comprise the systematic breeding and crossing of new varieties at the South-Eastern Agricultural College, Wye, by Prof. E. S. Salmon, and their testing at the East Malling Research Station and at Horsmonden. ’The objects in view are to procure for the grower new and prolific varieties of hop more able to resist disease, while at the same time securing for the brewer the qualities he considers valuable. Chemical investigations on the preservative and antiseptic -properties of hops have engaged the attention of Prof. F. L. Pyman, F.R.S., and Dr. T. K. Walker at Manchester since 1921. It may not be generally known that apart from the agreeable flavour conferred - own beer by hops, they are a valuable ally to the brewer in his fight against the invasion of his beer by the foreign organisms which cause turbidity, fret and acidity. Valuable work is being done on the keeping properties of the yeast used for fermentation and the effect of hydrogen-ion concentration on the character and stability of beer. The - measurement of the true " free acidity " is becoming recognised as an essential procedure in the various stages of brewing. Over and above the actual staff of the Institute a large body of farmers, brewers, -chemists, maltsters, and hop-growers-all busy menvoluntarily give their services on numerous com:mittees supervising the researches, while expert .annual
assistance is engaged where required. not be forgotten that it was on the basis of Pasteur’s researches on the disease organisms of wine and beer that arose the superstructure of modern surgery and preventive medicine.
FLUORINE AS A SLOW POISON. THE toxic effects of long-continued small doses of iodine and bromine and their derivatives are well known. Recently Prof. H. Cristiani has described1 chronic poisoning by another member of the halogen series, fluorine. This element is apparently present in minute quantities in many of our foodstuffs, and was at one time frequently used as a preservative, although its use as such is now prohibited in most countries. In the neighbourhood of certain factories the food of animals may contain toxic quantities of fluorine, and this element may also be present in excess in water into which certain industrial products have been allowed to pass. In some districts in Switzerland where these conditions are present an enclemic disease occurs among animals, characterised by wasting and cachexia, with a special localisation in the regions of the vertebral column and lower limbs, while the bones become softened and frequently show spontaneous fractures. On account of this last symptom the disease has usually been considered by veterinarians as a form of osteomalacia, and farmers and others seeking compensation for their diseased cattle have been met by the statement that there is no evidence that osteomalacia can be caused by the ingestion of poisonous substances. Prof. Cristiani has set himself to disprove this, and he has established that the disease from which these animals suffer can be separated from true osteomalacia and should be " " designated by a separate name such as fluorism or " fluorine cachexia." His experiments consisted in feeding animals on diets which, while maintaining perfect health in control animals, produced the syndrome described above when there was added in small doses (a) hay which was suspected of having produced the disease in cattle ; (b) hay mildly .impregnated with certain salts of fluorine, or (c) grass submitted to the action of fluorine in one of its gaseous forms and used either fresh or as hay. The time of appearance of symptoms was variable and depended to a certain extent on the dose of fluorine employed. The experimental animals wasted and eventually died with symptoms of bulbar paralysis and respiratory failure. At autopsy the bone-marrow was found to be extremely scanty ; the bone-tissue showed much rarefaction, and the bones on analysis showed a high fluorine content. Prof. Cristiani is at present studying the question as to whether chronic fluorine poisoning occurs in man. Its symptoms are so slow in appearing and in progressing that it may possibly be present sometimes among the inhabitants of industrial areas where much fluorine is produced. ____
THE PATHOLOGY OF BURNS. was for a long time a good deal of difficulty in explaining the toxaemia and death which may follow burns, and it is only comparatively recently that our knowledge of the subject has determined to a satisfactory explanation which brings the ill-effects of burns into line with the shock due to tissue injury. The evidence, along with an interesting discussion of burns of all kinds, is well summarised by Dr. G. T. Pack in the Archives of Pathology and Laboratory Medicine (1926, i., 767). In the first place, it is clear that the poisonous substance comes from the burned tissue and is carried in the blood; if the tissue is excised toxemia is prevented, and if burned skin is transplanted from one animal to another the latter has symptoms and dies. If one of a pair of experimental Siamese twins is burned, both have symptoms, and experiments with crossed circulations show that the THERE
1 La Presse Médicale, April 14th, 1926, p. 469.