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TUMOURS OF THE SUPRARENAL MEDULLA
1118 a really great advance in the Local Government Act have been only partially the preventive idea can be attained fulfilled. The outdoor medical service of the pooroutside of a salaried service ; but he is obviously z, law has been little changed. Cooperation between quite aware that no such service can be established voluntary and council hospitals is not much closer. until it is welcome to the medical profession. His Indeed, the heralded reform in local government immediate and practical suggestion is an extension has proved in some places less a break up than a in quality rather than quantity. Against some consolidation of the poor-law, and, where steps of the abuses of insurance he suggests technical have been taken to transfer hospitals out of its safeguards derived from the practice of other atmosphere, there is, here and there, an itching lands, but he sees no final solution of this problem to bring them back in the sacred name of economy. but in a higher moral outlook. He is firmly a But the pendulum swings fast in our time, and believer in the perfectibility of mankind and we can hardly foresee how soon we may be faced quotes with approval in reference to these matters with dangers to medicine of the opposite kind. the saying of Senator ELiHU ROOT that " pessimism Sir ARTHUR NEWSHOLME’S valuable studies will be is criminal weakness." indispensable to those who wish to prepare their All these things appear to be beyond the realm minds for some of the medico-political problems of of practical politics just now. The objects of thethe future.
doubtful whether
application of
ANNOTATIONS The statement that we are all supposed to know the law is not quite accurate. The true legal maxim is that ignorance of the law excuses nobody. A few years ago a witness at the Wandsworth County Court gave yet another version with which many will sympathise. I know," he said, " that ignorance is no excuse for the law." Whichever of these versions we may prefer, we shall all welcome the efforts of the B.B.C. to instruct us. The medical profession, however, must mildly protest against the broadcasting of a suggestion that perjury is part of the professional duty of a doctor.
THE B.B.C. ON MEDICAL PRIVILEGE
By means of lectures and mock trials the B.B.C. is pursuing the laudable object of acquainting us with the law which every citizen is supposed to know. The latest item in the series of trials, broadcast " under the title of Consider your Verdict," consisted of the closing speeches and the judge’s summing-up in imaginary proceedings against a medical practitioner. Listeners were invited to suppose that a doctor had been asked in the witness-box to answer questions in violation of professional confidence and that, instead of refusing to answer, he had given false answers, thereby exposing himself to a prosecution for perjury. In so far as the dramatising of this hypothesis gave publicity to the principle of medical secrecy, and in so far as it explained that the principle exists in the interests of the patients and is therefore for the public benefit, the mock trial was excellent. In so far as it suggested that doctors, instead of keeping their mouths shut, are ready to give false answers upon oath, it was less admirable. The hypothetical doctor was supposed to have been asked two questions before the magistrateshad he treated a patient for drug-taking, and had he supplied the patient with dangerous drugs ? To both these questions he answered " No." When charged with perjury he admitted that the answers were untrue but, pleading that they were made in accordance with professional etiquette, he contended that they were not " wilfully" false within the meaning of the Perjury Act. Actually, of course, in real life no practitioner would have adopted so inept and so mistaken a line of conduct. He might or might not have declined to answer, according to his personal view of his professional duty. Thereupon the magistrates might or might not have taken .serious notice of the refusal. They have not the powers of an assize court to commit a witness for contempt of court. The Summary Jurisdiction Acts enable magistrates to send a witness to gaol for seven days if he refuses to answer proper questions "without offering any just excuse for such refusal." The witness might or might not successfully maintain that medical privilege was a just excuse. But none of these contingencies would give a jury a chance to answer the glib question " should a doctor tell ?" The B.B.C., therefore, to bring the doctor’s dilemma within the range of the " Consider your Verdict " series, had to drag in the exotic and improbable
element of
perjury.
"
TUMOURS OF THE SUPRARENAL MEDULLA THE tumour of the
I
suprarenal
Mr. F. W. Law elsewhere in
medulla described present issue has
by ’, two important characteristics-namely, its occurrence ’, in early infancy, and the development of metastases in the cranium.
our
Records of such tumours
are now
fairly numerous-J. Klein’- has recently reported a similar case-and so frequently do these characteristics recur, that it may almost be said that multiple tumours of the skull bones and orbits in a child under 2 years indicate either chloroma or malignant There are, it tumour of the suprarenal medulla. must be admitted, cases on record-those of the so-called Pepper type-in which metastases tend to be confined to the abdomen, the liver being their chief site of deposit. Frew found that these were mostly tumours originating in the right suprarenal, and he explained their limitation on the grounds of peculiarities in the lymphatic drainage. A study of the larger number now on record, however, shows that the association of right-sided tumours with limitation to the abdomen does not hold very constantly. Indeed it seems doubtful whether the differentiation of two clinical types, the Pepper type on the one hand, and the Hutchison type with its numerous cranial and other bone metastases on the other hand, is of much value. Quite a number of cases in which liver involvement has predominated, and which might thus pertain to the Pepper group, have shown cranial metastases. It should be remembered that Pepper’s collection of cases was made largely with a view to studying congenital tumours of the liver as well as the suprarenals, so that liver involvement was a somewhat prominent feature of his observations. As a general rule it 1 Amer. Jour. Med. Sci., October, 1932, p. 491.
1119 may be taken that the characteristic feature of malignant suprarenal medullary tumours in infants is the tendency to produce far-flung metastases in Subcutaneous nodules for bone and elsewhere. instance, probably similar to those seen in Law’s 2 case, were found in a case reported by N. B. Capon as well as in three others which he cited. Views on the histogenesis of these tumours have been revolutionised in the last 20 years. The older observers seem usually to have classified them as .sarcomata, and Marchand and Kuster were probably the first to demonstrate their histogenic relationship - to the sympathetic nervous system, although Virchow had already suggested such a possibility. Nowadays this relationship is generally recognised and accordingly such terms as neuroblastoma and ganglioneuroma have been adopted. A study of their microscopic characters seldom fails to make clear the histogenesis. Most of these tumours, especially the more malignant ones, exhibit the peculiar rosette formations which are characteristic of retinal gliomas, and which, as Shaw Dunn3 has demonstrated, can be seen in the neuroblastic cells of the suprarenal
medulla of the foetus. Other less malignant ones show unmistakable ganglion cells and nerve-fibres, and Shaw Dunn has traced in an enlightening manner the true interrelationship of the more highly differentiated ganglio-neuromata with the more primitive neuroblastomata. Doubtless some enthusiastic exponent of the newer doctrines on gliomata will sooner or later relegate the latter type to the class of medulloblastomata, if that term is to survive. These tumours of the suprarenal medulla are interesting because they provide some of the most clearly defined representations of tumours arising from nerve-cells. As Shaw Dunn remarks, they " represent new growths of the most highly specialised cells of the body, cells which apparently never undergo division in normal cases and which are therefore least likely to exhibit neoplastic development." PRESENTATION TO SIR STCLAIR THOMSON
PRIOR to the usual scientific business of the Section Laryngology at the Royal Society of Medicine, on Nov. 4th, a pleasing ceremony was enacted in the form of a presentation, by members of the section, of his portrait in oils to Sir StClair Thomson. It had recently come to the knowledge of certain members of the section that a good portrait was in existence and could be acquired. Mr. Walter Howarth, the retiring president of the section, in making the presentation said that he would not attempt to enumerate the reasons which led to the desire to make the presentation, further than to point out that pre-eminently Sir StClair stood for British laryngology, a specialty which had passed through many vicissitudes before it was recognised as such, and that it must be a source of real gratification to him to realise how great had been his personal share in the efforts for status. Mr. Howarth pointed out that Sir StClair, linguist and traveller, and member of many foreign societies, had secured international friends for the specialty ; he had made his house a centre where all men met ; and his acts of kindness and help to his colleagues were constant, as many members of - the section had experienced. In making the presentation members felt they were doing themselves honour in the act. Sir StClair Thomson’s reply was in characteristic vein. Many of his of
2
successes, he
said, had come to him unsought, so that he felt like a man at the end of the Great War who displayed a long row of medals across his chest, and when asked how he got them replied, " The first one I received by mistake, and I got the others because I had the first." One of his ambitions, he said, had been to earn the esteem and regard of his fellows, and in that he must now believe he had not altogether failed. -
SUN-GLARE IN
IRAQ
Squadron-Leader P. C. Livingston has made some interesting observations on the effect of sun-glare on the eyes not only of airmen, but of other Europeans employed in various capacities in Iraq.l Trouble arises mainly, not from atmospheric glare reflected from the sky but from light reflected from the ground, either directly on to the macula or laterally on to the more peripheral parts of the retina. The possible ways in which the visual function may be affected were studied as regards visual acuity, accommodation (spasm or fatigue), alterations in the field of vision and of the senses for form, light, and colour, spasm or fatigue of convergence and alterations in muscle balance, and finally cerebral fatigue involving loss of power to concentrate as well as many of the defects already mentioned. The importance of these observations will be evident in relation to airmen for whom defect in any of these factors is liable to cause accidents. Those examined were divided into five groups according to their occupation, air pilots forming only one of the groups. Over 100 persons were subjected to the various tests, and as far as was found possible all were given a thorough examination once a month during the period from May, 1930, to November, 1931, each being examined from five to ten times. As to visual acuity, 14 of those tested were found to have fallen below their initial visual standard, and in these the general tendency was always towards recovery in the cool weather. In three cases however the loss persisted. Fatigue of accommodation and also of convergence tended to increase during the hot weather. Nearly all those tested suffered to a or less extent in these respects. The power greater of binocular coordination, tested by the Bishop Harman diaphragm test, was affected prejudicially in most of those tested, and this, too, more in the The importance of this summer than the winter. function is great in relation to effecting a safe landing in an aeroplane. A good deal of attention was paid to the light sense-light minimum and light difference -and a new apparatus is described (the Clement Clarke test) by which these senses can be more accurately tested than by other tests in common use. A reduction in both senses was found to be exceedingly common. The visual fields were also found to be contracted concentrically to some extent in certain cases-between one-half and onethird of those examined. In 13 cases ring or arcuate scotomata were demonstrated. On the other hand no fundus changes due to indirect sun-glare were Nor ever demonstrated with the ophthalmoscope. was there any reason to suspect that the colour of the irides had any relation to the effects of glare. There seems to be no way in which we can differentiate between those who are and those who are not susceptible to the deleterious effects of sun-glare. The presence of chronic conjunctivitis naturally tends to increase susceptibility. The outstanding clinical signs of an acute attack are extreme
Jour. Path. and Bact., 3
1928, xxxi., 659. Ibid., 1914-15, xix., 456.
1 Brit. Jour. Ophthalmol., October, 1932, p. 577.
doubtful whether
application of
ANNOTATIONS The statement that we are all supposed to know the law is not quite accurate. The true legal maxim is that ignorance of the law excuses nobody. A few years ago a witness at the Wandsworth County Court gave yet another version with which many will sympathise. I know," he said, " that ignorance is no excuse for the law." Whichever of these versions we may prefer, we shall all welcome the efforts of the B.B.C. to instruct us. The medical profession, however, must mildly protest against the broadcasting of a suggestion that perjury is part of the professional duty of a doctor.
THE B.B.C. ON MEDICAL PRIVILEGE
By means of lectures and mock trials the B.B.C. is pursuing the laudable object of acquainting us with the law which every citizen is supposed to know. The latest item in the series of trials, broadcast " under the title of Consider your Verdict," consisted of the closing speeches and the judge’s summing-up in imaginary proceedings against a medical practitioner. Listeners were invited to suppose that a doctor had been asked in the witness-box to answer questions in violation of professional confidence and that, instead of refusing to answer, he had given false answers, thereby exposing himself to a prosecution for perjury. In so far as the dramatising of this hypothesis gave publicity to the principle of medical secrecy, and in so far as it explained that the principle exists in the interests of the patients and is therefore for the public benefit, the mock trial was excellent. In so far as it suggested that doctors, instead of keeping their mouths shut, are ready to give false answers upon oath, it was less admirable. The hypothetical doctor was supposed to have been asked two questions before the magistrateshad he treated a patient for drug-taking, and had he supplied the patient with dangerous drugs ? To both these questions he answered " No." When charged with perjury he admitted that the answers were untrue but, pleading that they were made in accordance with professional etiquette, he contended that they were not " wilfully" false within the meaning of the Perjury Act. Actually, of course, in real life no practitioner would have adopted so inept and so mistaken a line of conduct. He might or might not have declined to answer, according to his personal view of his professional duty. Thereupon the magistrates might or might not have taken .serious notice of the refusal. They have not the powers of an assize court to commit a witness for contempt of court. The Summary Jurisdiction Acts enable magistrates to send a witness to gaol for seven days if he refuses to answer proper questions "without offering any just excuse for such refusal." The witness might or might not successfully maintain that medical privilege was a just excuse. But none of these contingencies would give a jury a chance to answer the glib question " should a doctor tell ?" The B.B.C., therefore, to bring the doctor’s dilemma within the range of the " Consider your Verdict " series, had to drag in the exotic and improbable
element of
perjury.
"
TUMOURS OF THE SUPRARENAL MEDULLA THE tumour of the
I
suprarenal
Mr. F. W. Law elsewhere in
medulla described present issue has
by ’, two important characteristics-namely, its occurrence ’, in early infancy, and the development of metastases in the cranium.
our
Records of such tumours
are now
fairly numerous-J. Klein’- has recently reported a similar case-and so frequently do these characteristics recur, that it may almost be said that multiple tumours of the skull bones and orbits in a child under 2 years indicate either chloroma or malignant There are, it tumour of the suprarenal medulla. must be admitted, cases on record-those of the so-called Pepper type-in which metastases tend to be confined to the abdomen, the liver being their chief site of deposit. Frew found that these were mostly tumours originating in the right suprarenal, and he explained their limitation on the grounds of peculiarities in the lymphatic drainage. A study of the larger number now on record, however, shows that the association of right-sided tumours with limitation to the abdomen does not hold very constantly. Indeed it seems doubtful whether the differentiation of two clinical types, the Pepper type on the one hand, and the Hutchison type with its numerous cranial and other bone metastases on the other hand, is of much value. Quite a number of cases in which liver involvement has predominated, and which might thus pertain to the Pepper group, have shown cranial metastases. It should be remembered that Pepper’s collection of cases was made largely with a view to studying congenital tumours of the liver as well as the suprarenals, so that liver involvement was a somewhat prominent feature of his observations. As a general rule it 1 Amer. Jour. Med. Sci., October, 1932, p. 491.
1119 may be taken that the characteristic feature of malignant suprarenal medullary tumours in infants is the tendency to produce far-flung metastases in Subcutaneous nodules for bone and elsewhere. instance, probably similar to those seen in Law’s 2 case, were found in a case reported by N. B. Capon as well as in three others which he cited. Views on the histogenesis of these tumours have been revolutionised in the last 20 years. The older observers seem usually to have classified them as .sarcomata, and Marchand and Kuster were probably the first to demonstrate their histogenic relationship - to the sympathetic nervous system, although Virchow had already suggested such a possibility. Nowadays this relationship is generally recognised and accordingly such terms as neuroblastoma and ganglioneuroma have been adopted. A study of their microscopic characters seldom fails to make clear the histogenesis. Most of these tumours, especially the more malignant ones, exhibit the peculiar rosette formations which are characteristic of retinal gliomas, and which, as Shaw Dunn3 has demonstrated, can be seen in the neuroblastic cells of the suprarenal
medulla of the foetus. Other less malignant ones show unmistakable ganglion cells and nerve-fibres, and Shaw Dunn has traced in an enlightening manner the true interrelationship of the more highly differentiated ganglio-neuromata with the more primitive neuroblastomata. Doubtless some enthusiastic exponent of the newer doctrines on gliomata will sooner or later relegate the latter type to the class of medulloblastomata, if that term is to survive. These tumours of the suprarenal medulla are interesting because they provide some of the most clearly defined representations of tumours arising from nerve-cells. As Shaw Dunn remarks, they " represent new growths of the most highly specialised cells of the body, cells which apparently never undergo division in normal cases and which are therefore least likely to exhibit neoplastic development." PRESENTATION TO SIR STCLAIR THOMSON
PRIOR to the usual scientific business of the Section Laryngology at the Royal Society of Medicine, on Nov. 4th, a pleasing ceremony was enacted in the form of a presentation, by members of the section, of his portrait in oils to Sir StClair Thomson. It had recently come to the knowledge of certain members of the section that a good portrait was in existence and could be acquired. Mr. Walter Howarth, the retiring president of the section, in making the presentation said that he would not attempt to enumerate the reasons which led to the desire to make the presentation, further than to point out that pre-eminently Sir StClair stood for British laryngology, a specialty which had passed through many vicissitudes before it was recognised as such, and that it must be a source of real gratification to him to realise how great had been his personal share in the efforts for status. Mr. Howarth pointed out that Sir StClair, linguist and traveller, and member of many foreign societies, had secured international friends for the specialty ; he had made his house a centre where all men met ; and his acts of kindness and help to his colleagues were constant, as many members of - the section had experienced. In making the presentation members felt they were doing themselves honour in the act. Sir StClair Thomson’s reply was in characteristic vein. Many of his of
2
successes, he
said, had come to him unsought, so that he felt like a man at the end of the Great War who displayed a long row of medals across his chest, and when asked how he got them replied, " The first one I received by mistake, and I got the others because I had the first." One of his ambitions, he said, had been to earn the esteem and regard of his fellows, and in that he must now believe he had not altogether failed. -
SUN-GLARE IN
IRAQ
Squadron-Leader P. C. Livingston has made some interesting observations on the effect of sun-glare on the eyes not only of airmen, but of other Europeans employed in various capacities in Iraq.l Trouble arises mainly, not from atmospheric glare reflected from the sky but from light reflected from the ground, either directly on to the macula or laterally on to the more peripheral parts of the retina. The possible ways in which the visual function may be affected were studied as regards visual acuity, accommodation (spasm or fatigue), alterations in the field of vision and of the senses for form, light, and colour, spasm or fatigue of convergence and alterations in muscle balance, and finally cerebral fatigue involving loss of power to concentrate as well as many of the defects already mentioned. The importance of these observations will be evident in relation to airmen for whom defect in any of these factors is liable to cause accidents. Those examined were divided into five groups according to their occupation, air pilots forming only one of the groups. Over 100 persons were subjected to the various tests, and as far as was found possible all were given a thorough examination once a month during the period from May, 1930, to November, 1931, each being examined from five to ten times. As to visual acuity, 14 of those tested were found to have fallen below their initial visual standard, and in these the general tendency was always towards recovery in the cool weather. In three cases however the loss persisted. Fatigue of accommodation and also of convergence tended to increase during the hot weather. Nearly all those tested suffered to a or less extent in these respects. The power greater of binocular coordination, tested by the Bishop Harman diaphragm test, was affected prejudicially in most of those tested, and this, too, more in the The importance of this summer than the winter. function is great in relation to effecting a safe landing in an aeroplane. A good deal of attention was paid to the light sense-light minimum and light difference -and a new apparatus is described (the Clement Clarke test) by which these senses can be more accurately tested than by other tests in common use. A reduction in both senses was found to be exceedingly common. The visual fields were also found to be contracted concentrically to some extent in certain cases-between one-half and onethird of those examined. In 13 cases ring or arcuate scotomata were demonstrated. On the other hand no fundus changes due to indirect sun-glare were Nor ever demonstrated with the ophthalmoscope. was there any reason to suspect that the colour of the irides had any relation to the effects of glare. There seems to be no way in which we can differentiate between those who are and those who are not susceptible to the deleterious effects of sun-glare. The presence of chronic conjunctivitis naturally tends to increase susceptibility. The outstanding clinical signs of an acute attack are extreme
Jour. Path. and Bact., 3
1928, xxxi., 659. Ibid., 1914-15, xix., 456.
1 Brit. Jour. Ophthalmol., October, 1932, p. 577.