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POLYMER-FUME FEVER
27 of mycosis fungoides. On the basis of retrospective information, however, it confirms that the premycotic phase can be very variable, in duration as well as clinically, the range being from 2 months to 48 years. Despite this, the mode of presentation or duration of the premycotic phase do not influence survival once the tumour stage is reached. At the time of diagnosis two characteristics were noted to be of major prognostic significance in the National Cancer Institute series. Patients over sixty years of age had a shorter survival-time, even when deaths from other causes were excluded and corrections were made for the effect of ageing. This age factor is similar to that in Hodgkin’s disease and acute leukæmia. Tumours, ulceration, or enlarged lymph-nodes Half the were associated with shortened survival. patients died within 2!years of developing tumours and ulceration, the prognosis being apparently worse with ulceration; and of patients who had tumours, ulceration, and lymph-node enlargement half died within a year. Lymph-node biopsies were done in 61 patients: where the node showed features of a malignant lymphoma, the median survival was 18 months; and when the histology was reactive the median survival increased to 34 months. In patients with enlargement of liver or spleen the outlook was very grave, median survival being only 3 months. Out of this series 120 had died by January, 1971, and 75 were thought to have died from mycosis fungoides. At necropsy many were found to have involvement of other systems and organs. Apparently death was due to infection in half the cases, Staphylococcus aureus and Pseudomonas being the commonest infective organisms, and pneumonia or septicaemia the usual terminal
episode. The National Cancer Institute series 8 provides strong evidence that mycosis fungoides, in its later stages, becomes a systemic malignant reticulosis, but justifies its retention as a clinical and histological entity. This investigation was not primarily concerned with treatment, but there was no evidence that Xirradiation and chemotherapy influenced survival.
They do, however, produce symptomatic improvement unpleasant skin lesions.
and relieve the very
MAN IN HIS WORLD
A SYMPOSIUM last week at the Royal Society of Medicine evoked a headline in the Daily Telegraph:: "Mice point way to doom in 1984 ". The most fearful of the doomsters have, of course, extracted this gloomy message from the experiments of Dr. J. B. Calhoun, chief of the section of behavioural systems at the National Institutes of Health, Bethesda. His mouse
population certainly provided
some
worrying
evidence about the reaction of animal communities in particular circumstances, and their apparent reluctance to struggle for survival; but the security of translating these results directly to mankind’s situation, terrible though it is in many parts of the world, is arguable. " What about Hong Kong ?" asked Prof. J. Z. Young. " I’ve seen Calcutta and been horrified ", retorted Dr. Calhoun. Doubtless, the Editor of Nature
has already gripped his acid ink-well to attack Dr. Calhoun and his deductions from the fate of those unfortunate mice. Among many other telling contributions to the symposium, Dr. James Birley’s carried more than a little impact. Tackling the nearly impossible task of summarising " the effect of the environment on the individual ", he went for it with a skill which showed why he is dean of the Institute of Psychiatry. He shrewdly took up William James’s comment that habits are the " fly-wheel of society ". With these fly-wheels on the whirl, with institutions which " codify society’s habits" as our steering-wheel, and with a "pair of primate hands and a primate brain to guide us, we are travelling very fast ". By any standard, Dr. Birley argued, we were going through a period of violent cultural change, evolutionary considerations quite apart. Over half the species were hungry or physically ill; and the family atmosphere was highly charged " to say the least of it ". Recognising this as a very dangerous situation, in psychiatric terms, what, Dr. Birley "asked, were our skills for coping with it ? He saw a faint hope ": during the cultural revolution, the human brain had vastly enlarged its range. What reason was there to suppose that its activities could not continue to extend ? Millions of circuits might be yet unused. One of the skills which man might not have grasped-or worked out-was how to communicate with other animals. Yet, provocative as this thought of Dr. Birley’s was, no-one could escape the challenge of one of his closing remarks (though not everyone cheered): " Copernicus put the earth and Darwin put man in a new place. Future discoveries may put us in yet another place, with even greater respect for our environment and, possibly, even for each other as well."
POLYMER-FUME FEVER Harris,1 in 1951, was the first to describe polymerfume fever, and his description has not been improved upon since. In earlier days such observation would have attracted the eponym Harris’s disease. Polymerfume fever is a short, sharp attack of tightness of the chest, difficulty in breathing, sometimes with a dry irritating cough, and fever often with rigors (the shakes). The illness begins several hours after exposure to the heat-degradation products of the plastic, polytetra-
fluorethylene (P.T.F.E.,Fluon’,‘ Teflon’). Recovery relatively rapid and usually complete, so that the patient may think that he has had influenza or a heavy cold and the incident is not reported. Pulmonary damage may be expected but, in fact, such sequelae are is
rare.
Williams and Smith2 have lately described a patient, a woman, who had over forty attacks of polymer-fume fever between December, 1968, and August, 1969, with no serious pulmonary complications. She worked with P.T.F.E., and the cigarette she smoked when finishing work became trace-con-
taminated with 1. Harris, D. K. 2. Williams, N.,
P.T.F.E.
from her unwashed hands.
Lancet, 1951, ii, 1008. Smith, F. K. J. Am. med. Ass. 1972, 219,
1587.
28
contrast, her colleague on the same job did not have the fever; she did not smoke at all. The chemistry of the fumes ofp.T.F.E. heat degradation has been closely studied.3,4 P.T.F.E. is a polymer of tetrafluorethylene (CF2=CF2) and can be represented by the formula [—CF2—CF2—CF2—CF2—]n. Breakdown begins between 250 and 300 °C. Hydrogen fluoride is released, and as the temperature increases above 300 °C a range of aliphatic and cyclic saturated and unsaturated fluorocarbon compounds appear. Some of these compounds are potent pulmonary irritants. In addition, the plastic is given off as a very fine particulate sublimate. The peculiar clinical condition, polymer-fume fever, not found in animal experiment, where pulmonary irritation occurs readily, is thought to be due to the action of the inhaled sublimate; J. H. Foulger, cited by Harris,’1 put forward this explanation. Cavagna et al.,5 Pernis et al.,and others have suggested that the sublimate brings about degranulation of leucocytes with the liberation of endogenous pyrogens as the cause of the fever-a mode of action claimed also where zinc fume precipitates metal-fume fever. Cigarettes burn at 850-900 °C, and smoking P.T.F.E.contaminated cigarettes is a factor common to most reported cases of polymer-fume fever. It is equally common to find that these cases do not develop acute pulmonary irritation and œdema—a non-event that may be explained by an inadequate dosage of the noxious fluorocarbon compounds. A no-smoking rule where P.T.F.E. is processed is a preventive measure of worth, and it is also important that P.T.F.E. should not be heated over 300 °C in industrial manipulation. P.T.F.E. has wide use in industry because of its stability and mechanical and electrical characteristics. It is met most frequently in the home in non-stick cooking-pans. No known case of polymer-fume fever has been reported in a housewife. It seems that the maximum temperatures reached in cooking food in such pans is 195 °C-well below the decomposition range of P.T.F.E.’ The Journal of the American Medical Associationhas stated that should such a pan be neglected on an electric stove, the pyrolysis products released in a " normal sized " kitchen would not reach a harmful concentration. Polymer-fume fever (and metal-fume fever) should be considered in the differential diagnosis of influenza-like symptoms.
By
WHY ANOTHER DIPLOMA?
THE new course at Liverpool for a diploma in tropical child health raises sharply the issue of Britain’s contribution to the education of undergraduate and postgraduate medical students in and from the emergent countries. What should be the criteria ? First, the aim should be to enable every student to take his undergraduate course, if not in the country, at least in the region, where he will later work; and the well3.
Malten, K. E., Zielhuis, R. L. Industrial Toxicology and Dermatology in the Production and Processing of Plastics. Amsterdam, 1964.
Pattison, F. L. M. Toxic Aliphatic Fluorine Compounds. Amsterdam, 1959. 5. Cavagna, G., Finulli, M., Vigliani, E. C. Medna Lav. 1961, 52, 251; Bull. Hyg., Lond. 1962, 37, 144 (abstr.). 6. Pernis, B., Cavagna, G., Finulli, M. Medna Lav. 1961, 52, 649; Bull. Hyg., Lond. 1962, 37, 1130 (abstr.). 4.
7. J. Am. med. Ass. 1965, 191, 406.
endowed countries can here make a solid contribution by helping to train teachers, and notably teachers of preclinical subjects, for tropical centres. Secondly, of the young medical graduates, only an exceptional few, and those seeking to specialise in subjects that require either elaborate physical resources or teaching which cannot be provided locally, should be encouraged to travel beyond their region. The reasons are threefold : even while under training the young doctor can help in the routine services of his own (usually under-doctored) country; the first graduate years are the time for him to advance his understanding of the circumstances of the area in which he is to settle; and the young doctor who has once experienced the fleshpots of Europe or North America may opt to remain there. This, emphatically, is not to deny that there is a place for visits to (for example) Britain; but these should be made after the doctor has worked for some time in his own country, when, with experience behind him, he will benefit from the stimulus of exchanges in a different setting: the established physician from Accra may be refreshed by a stay in Aberdeen, just as the established physician from Aberdeen may be refreshed by a stay in Alabama. Fourthly, British institutions should disengage themselves from doling out diplomas and certificates to overseas graduates: some of the older colleges have embarked on the final phase of this sorry activity by dispatching posses of professors to far parts where they examine for membership or fellowship. This has nothing to do with education : it is certification. And it does nothing to help the standards in other countries, most of which are well able to offer their own postgraduate qualifications : indeed many already do so. The continuing popularity of the British counterparts derives from the prestige of the bodies concerned; and these bodies could use their prestige more constructively.
Viewed in this light the Liverpool diploma (which is the subject of two Letters to the Editor on p. 40) is not easily defended. In so far as the graduates are established physicians, it may seem largely to escape criticism. But if, as Professor Wolff says, all attending the course had already spent considerable periods working in the child-health services of their countries, why a diploma ? The purpose is given a different complexion by Professor Maegraith and Professor Hay, who hope that " in due course the D.T.c.H. (Liverpool) may come to be regarded " as a yardstick of a graduate’s knowledge or experience of tropical child health. There we have it. If the course succeeds (and the fame of the Liverpool School virtually guarantees that it will), the future tropical paediatrician will not count himself-or be counted-fully qualified without the D.T.c.H. The inception of this diploma course, far from being a stepping-stone to the institution of similar courses in the tropics, will delay this development, in the same way that attachment to the diplomas of the Royal Colleges is delaying acceptance of indigenous qualifications in medicine and surgery. Liverpool might have done better to throw its considerable weight behind the formation of courses in child health in one or more tropical centres. If the Liverpool course is to be retained, the associated diploma should be dropped without further ado.
episode. The National Cancer Institute series 8 provides strong evidence that mycosis fungoides, in its later stages, becomes a systemic malignant reticulosis, but justifies its retention as a clinical and histological entity. This investigation was not primarily concerned with treatment, but there was no evidence that Xirradiation and chemotherapy influenced survival.
They do, however, produce symptomatic improvement unpleasant skin lesions.
and relieve the very
MAN IN HIS WORLD
A SYMPOSIUM last week at the Royal Society of Medicine evoked a headline in the Daily Telegraph:: "Mice point way to doom in 1984 ". The most fearful of the doomsters have, of course, extracted this gloomy message from the experiments of Dr. J. B. Calhoun, chief of the section of behavioural systems at the National Institutes of Health, Bethesda. His mouse
population certainly provided
some
worrying
evidence about the reaction of animal communities in particular circumstances, and their apparent reluctance to struggle for survival; but the security of translating these results directly to mankind’s situation, terrible though it is in many parts of the world, is arguable. " What about Hong Kong ?" asked Prof. J. Z. Young. " I’ve seen Calcutta and been horrified ", retorted Dr. Calhoun. Doubtless, the Editor of Nature
has already gripped his acid ink-well to attack Dr. Calhoun and his deductions from the fate of those unfortunate mice. Among many other telling contributions to the symposium, Dr. James Birley’s carried more than a little impact. Tackling the nearly impossible task of summarising " the effect of the environment on the individual ", he went for it with a skill which showed why he is dean of the Institute of Psychiatry. He shrewdly took up William James’s comment that habits are the " fly-wheel of society ". With these fly-wheels on the whirl, with institutions which " codify society’s habits" as our steering-wheel, and with a "pair of primate hands and a primate brain to guide us, we are travelling very fast ". By any standard, Dr. Birley argued, we were going through a period of violent cultural change, evolutionary considerations quite apart. Over half the species were hungry or physically ill; and the family atmosphere was highly charged " to say the least of it ". Recognising this as a very dangerous situation, in psychiatric terms, what, Dr. Birley "asked, were our skills for coping with it ? He saw a faint hope ": during the cultural revolution, the human brain had vastly enlarged its range. What reason was there to suppose that its activities could not continue to extend ? Millions of circuits might be yet unused. One of the skills which man might not have grasped-or worked out-was how to communicate with other animals. Yet, provocative as this thought of Dr. Birley’s was, no-one could escape the challenge of one of his closing remarks (though not everyone cheered): " Copernicus put the earth and Darwin put man in a new place. Future discoveries may put us in yet another place, with even greater respect for our environment and, possibly, even for each other as well."
POLYMER-FUME FEVER Harris,1 in 1951, was the first to describe polymerfume fever, and his description has not been improved upon since. In earlier days such observation would have attracted the eponym Harris’s disease. Polymerfume fever is a short, sharp attack of tightness of the chest, difficulty in breathing, sometimes with a dry irritating cough, and fever often with rigors (the shakes). The illness begins several hours after exposure to the heat-degradation products of the plastic, polytetra-
fluorethylene (P.T.F.E.,Fluon’,‘ Teflon’). Recovery relatively rapid and usually complete, so that the patient may think that he has had influenza or a heavy cold and the incident is not reported. Pulmonary damage may be expected but, in fact, such sequelae are is
rare.
Williams and Smith2 have lately described a patient, a woman, who had over forty attacks of polymer-fume fever between December, 1968, and August, 1969, with no serious pulmonary complications. She worked with P.T.F.E., and the cigarette she smoked when finishing work became trace-con-
taminated with 1. Harris, D. K. 2. Williams, N.,
P.T.F.E.
from her unwashed hands.
Lancet, 1951, ii, 1008. Smith, F. K. J. Am. med. Ass. 1972, 219,
1587.
28
contrast, her colleague on the same job did not have the fever; she did not smoke at all. The chemistry of the fumes ofp.T.F.E. heat degradation has been closely studied.3,4 P.T.F.E. is a polymer of tetrafluorethylene (CF2=CF2) and can be represented by the formula [—CF2—CF2—CF2—CF2—]n. Breakdown begins between 250 and 300 °C. Hydrogen fluoride is released, and as the temperature increases above 300 °C a range of aliphatic and cyclic saturated and unsaturated fluorocarbon compounds appear. Some of these compounds are potent pulmonary irritants. In addition, the plastic is given off as a very fine particulate sublimate. The peculiar clinical condition, polymer-fume fever, not found in animal experiment, where pulmonary irritation occurs readily, is thought to be due to the action of the inhaled sublimate; J. H. Foulger, cited by Harris,’1 put forward this explanation. Cavagna et al.,5 Pernis et al.,and others have suggested that the sublimate brings about degranulation of leucocytes with the liberation of endogenous pyrogens as the cause of the fever-a mode of action claimed also where zinc fume precipitates metal-fume fever. Cigarettes burn at 850-900 °C, and smoking P.T.F.E.contaminated cigarettes is a factor common to most reported cases of polymer-fume fever. It is equally common to find that these cases do not develop acute pulmonary irritation and œdema—a non-event that may be explained by an inadequate dosage of the noxious fluorocarbon compounds. A no-smoking rule where P.T.F.E. is processed is a preventive measure of worth, and it is also important that P.T.F.E. should not be heated over 300 °C in industrial manipulation. P.T.F.E. has wide use in industry because of its stability and mechanical and electrical characteristics. It is met most frequently in the home in non-stick cooking-pans. No known case of polymer-fume fever has been reported in a housewife. It seems that the maximum temperatures reached in cooking food in such pans is 195 °C-well below the decomposition range of P.T.F.E.’ The Journal of the American Medical Associationhas stated that should such a pan be neglected on an electric stove, the pyrolysis products released in a " normal sized " kitchen would not reach a harmful concentration. Polymer-fume fever (and metal-fume fever) should be considered in the differential diagnosis of influenza-like symptoms.
By
WHY ANOTHER DIPLOMA?
THE new course at Liverpool for a diploma in tropical child health raises sharply the issue of Britain’s contribution to the education of undergraduate and postgraduate medical students in and from the emergent countries. What should be the criteria ? First, the aim should be to enable every student to take his undergraduate course, if not in the country, at least in the region, where he will later work; and the well3.
Malten, K. E., Zielhuis, R. L. Industrial Toxicology and Dermatology in the Production and Processing of Plastics. Amsterdam, 1964.
Pattison, F. L. M. Toxic Aliphatic Fluorine Compounds. Amsterdam, 1959. 5. Cavagna, G., Finulli, M., Vigliani, E. C. Medna Lav. 1961, 52, 251; Bull. Hyg., Lond. 1962, 37, 144 (abstr.). 6. Pernis, B., Cavagna, G., Finulli, M. Medna Lav. 1961, 52, 649; Bull. Hyg., Lond. 1962, 37, 1130 (abstr.). 4.
7. J. Am. med. Ass. 1965, 191, 406.
endowed countries can here make a solid contribution by helping to train teachers, and notably teachers of preclinical subjects, for tropical centres. Secondly, of the young medical graduates, only an exceptional few, and those seeking to specialise in subjects that require either elaborate physical resources or teaching which cannot be provided locally, should be encouraged to travel beyond their region. The reasons are threefold : even while under training the young doctor can help in the routine services of his own (usually under-doctored) country; the first graduate years are the time for him to advance his understanding of the circumstances of the area in which he is to settle; and the young doctor who has once experienced the fleshpots of Europe or North America may opt to remain there. This, emphatically, is not to deny that there is a place for visits to (for example) Britain; but these should be made after the doctor has worked for some time in his own country, when, with experience behind him, he will benefit from the stimulus of exchanges in a different setting: the established physician from Accra may be refreshed by a stay in Aberdeen, just as the established physician from Aberdeen may be refreshed by a stay in Alabama. Fourthly, British institutions should disengage themselves from doling out diplomas and certificates to overseas graduates: some of the older colleges have embarked on the final phase of this sorry activity by dispatching posses of professors to far parts where they examine for membership or fellowship. This has nothing to do with education : it is certification. And it does nothing to help the standards in other countries, most of which are well able to offer their own postgraduate qualifications : indeed many already do so. The continuing popularity of the British counterparts derives from the prestige of the bodies concerned; and these bodies could use their prestige more constructively.
Viewed in this light the Liverpool diploma (which is the subject of two Letters to the Editor on p. 40) is not easily defended. In so far as the graduates are established physicians, it may seem largely to escape criticism. But if, as Professor Wolff says, all attending the course had already spent considerable periods working in the child-health services of their countries, why a diploma ? The purpose is given a different complexion by Professor Maegraith and Professor Hay, who hope that " in due course the D.T.c.H. (Liverpool) may come to be regarded " as a yardstick of a graduate’s knowledge or experience of tropical child health. There we have it. If the course succeeds (and the fame of the Liverpool School virtually guarantees that it will), the future tropical paediatrician will not count himself-or be counted-fully qualified without the D.T.c.H. The inception of this diploma course, far from being a stepping-stone to the institution of similar courses in the tropics, will delay this development, in the same way that attachment to the diplomas of the Royal Colleges is delaying acceptance of indigenous qualifications in medicine and surgery. Liverpool might have done better to throw its considerable weight behind the formation of courses in child health in one or more tropical centres. If the Liverpool course is to be retained, the associated diploma should be dropped without further ado.