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ANNOTATIONS

PLEURAL AND PULMONARY SEPSIS

IN his Lettsomian lectures to the Medical Societyof London, which have now been published in thetransactions, Mr. J. E. H. Roberts covers the wholefield of the surgery of pleural and pulmonary infec-tions. The general reader will perhaps be mostinterested in the sections which deal with the septicinfections of the lungs and pleura-bronchiectasis,pulmonary abscess, and empyema-for these are

emergencies of medical practice which concern thegeneral practitioner at least as closely as they dothe workers in special departments. The adequatetreatment of bronchiectasis, as Mr. Roberts rightlyinsists, demands the collaboration of physician andsurgeon. The patient depends upon the former fordiagnosis at a stage when surgery can still offer a

hope of cure. It is no longer necessary to wait untilgushes of stinking sputum at stated hours, clubbedfingers, and physical signs of expectoration bringmelancholy proof of incurable disease. The injectionof lipiodol as a preliminary to X ray examinationof the bronchial tree is seldom necessary in such casesand may indeed be undesirable. But in the explora-tion of lungs damaged by pneumonia, in the investiga-tion of obscure cases of chronic cough or haemoptysis,lipiodol will often clarify the clinical picture andpoint the way to relief. In the same field diagnosticbronchoscopy has made notable advances. Earlydiagnosis in this disease as in most diseases impliesthe possibility of cure. Here lobectomy has achievedits most notable triumphs. The experience of Mr.Roberts enables him to support the teaching thatthis hazardous operation is less dangerous in earlylife than it is at a later age. As youthful sufferersfrom infected bronchiectasis, one of the most loath-some of all diseases, have hitherto been condemnedto early death, it seems likely that this operationwill be more frequently undertaken. The operativemortality, estimated at under 10 per cent., is a slightrisk compared with that of the untreated disease.For the relief of patients whom surgery cannot helpthe system of postural drainage, advocated by Mr.H. P. Nelson, based upon the anatomy of the bronchialtree will be found far more efficient than the tradi-tional bedside tipping and the creosote chamber,which was at best a clumsy and relatively ineffectivemethod of inducing cough and expectoration.

In the treatment of empyema a tendency to postponeor to endeavour to avoid operation has been noticedsince the discovery of the heavy death-rate amonginfluenza patients suffering from watery empyemataand submitted to early operation. The finding of

pus in the pleural cavity is no longer regarded as anindication for an emergency operation. Patients arenow sometimes left soaking in their own pus for daysuntil a series of test-tubes indicate that safety hasat last been attained and the pleura may be openedwithout the risk of mediastinal flutter or other

imagined evils. But whether pus in the pleura is ofsyn-pneumonic or meta-pneumonic origin, whetherwe have to deal with an empyema involving the wholepleural space or a pleural abscess limited by adhesions,the principles of treatment remain the same. It isonly their application that must be altered. Pusmust be removed and the sooner it is removed thebetter; the cavity must be obliterated, and anydelay in its closure may result in a chronic empyema ;the function of the underlying lung must be restored,and the earlier it is restored the more complete will

be its restitution. Repeated aspirations are seldomcurative and they are disturbing to the patient;they diminish but do not abolish toxaemia. Mr.Roberts advocates a single aspiration as a preliminarymeasure when the mediastinum is mobile, but forsubsequent drainage he recommends an intercostalcatheter and closed drainage system. There is

general agreement that a closed drainage system,preferably with some form of suction, should be usedwhenever an empyema in the acute or early chronicstage is treated by thoracotomy and rib resection.The considerable number of cases of chronic empyemastill encountered proves that the early treatment ofempyema is often imperfect. Yet the principlesupon which treatment should be founded are easy tounderstand, the technique of their application is

simple, and the results of such treatment entirelysatisfactory. It is neither to the credit of medicinenor surgery that two thousand years after the deathof Hippocrates the treatment of empyema should sooften be undertaken in ignorance and conducted in aperfunctory manner for which the patient has to pay,often in years of suffering and not seldom in permanentinvalidity.

ACCIDENTS AND THE MORTALITY OF

YOUNG ADULTS

A cuRious feature has been observed in Germanand French life tables which is absent from the

corresponding English tables : the probability of

dying in early adult male life (between ages 20 and 30)does not rise steadily with age but for a few yearsof life shows a slight decline. For instance, in Ger-many, in 1924-26, the mortality figure at age 22was 457 per 100,000, while at age 29 it was only404; the corresponding figures for England andWales, in 1920-22, were 374 and 418. In the Englishfigures there is an unbroken rise with advancingage, in the German ones a temporary improvementin the mortality experience, an improvement whichis also absent in Germany and France from thefemale experience. This improvement amongst themales was attributed by Otto von Schjerning, inhis book, " Sanitatsstatistische Betrachtungen uberVolk und Heer" (1910), to the favourable influenceof compulsory military service, an advantage whichyoung adult Englishmen do not enjoy. The validityof this explanation is somewhat shaken by theresults of an excellent statistical study published byW. J. Martin in the current number of the Journalof Hygiene. In life tables constructed on the census

population of England and Wales in 1931 and thedeaths registered in 1930-32, he finds that a similarcourse of mortality has now appeared in this country.As conscription cannot be invoked as an explana-tion he turns to the different causes of death in searchof the responsible factor. The only two found toexhibit a decline in the mortality-rates between theages of 24 and 27 are tuberculosis and accidents.The greater decline with age is shown by accidents,which have become proportionately much more

important as a cause of death between 1920 and1932 ; tuberculosis, on the other hand, has becomeproportionately less important. The new indentationin the English mortality curve for males is clearlyderived from accidents, and excluding them the

mortality curves rises steadily with age. The mor-tality of females from accidents follows much thesame course, but with them such causes of deathform in young adult life only about 5 per cent. of

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the deaths from all causes, whereas for males theyaccounted in 1930-32 for 20 per cent. of the totalmortality at ages 19-23. With females, therefore,the contribution of accidents is not sufficient to

change the general trend of mortality with age ;with males it is amply sufficient. Subdivision ofaccidents into type shows that the mortality fromevery type except road transport is, at ages 20-25,at a lower level in 1930-32 than in 1920-22. Roadaccidents have increased at these ages by 450 percent. in ten years, and accounted for more deaths in1930-32 than did all forms of accidents in 1920-22.

THE RADIUM BEAM

ON another page Mr. Stanford Cade and Mr. F. M.Allchin describe the combined treatment of hypo-pharyngeal cancer with X rays and radium, suggestingthat such combined treatment of extrinsic laryngealcancer by irradiation with different wave-lengthsmay increase the radio-sensitivity of the tumourand so lead to retrogression of the disease. Thistreatment they claim is safe as compared with moreintensive methods. The quantity of radium usedwas two grammes at a distance of 6-7 cm. from theskin, each patient receiving two treatments of 50minutes each in the twenty-four hours, five days aweek for six or seven weeks. The authors think thattwo grammes of radium may not be the best possiblequantity for this purpose and state their intentionof increasing the quantity as opportunity arises. Itis announced that a new " bomb " containing fourgrammes of radium is to be assembled and tested inthe workshop of the Westminster Hospital radiumannexe at Hampstead. In this bomb the hollowglobe will probably consist of a new tungsten alloyone and a half times the density of lead, with a goldor platinum collar at the outlet, by means of whichthe gamma rays will be more effectively preventedfrom spreading, the size of the bomb remainingunchanged. With the new apparatus radium beamtreatment will be applied at a greater skin distancewith the result that a more effective dose can be givenat a greater depth below the surface. Minor improve-ments in the suspension of the bomb will avoid thenecessity of adjusting the distance of the radium fromthe patient by raising or lowering the radium container.The present two-gramme bomb is at present con-

tinuously in use at the annexe for five days a week withthree shifts of operators, two days of the week-endbeing reserved for experimental work. It will be asatisfaction to all concerned when the new buildingin Horseferry-road, with its ample allotment of spacefor radium and cancer work, will bring this work

again into close relation with the clinical activitiesof Westminster Hospital.

TOXIC ACTION OF VOLATILE SOLVENTS

IN recent years the industrial use of volatile solventshas increased, especially in the processes involvedin cellulose spraying, in the rubber and artificial silkindustries, and in the dry cleaning of clothes. It has

long been known that inhalation of the vapour ofmany of these may have serious toxic effects. Thuschronic benzol poisoning is characterised by pro-gressive anaemia with leueopenia and hmmorrhagesmany of the chlorinated hydrocarbons of the aliphaticseries produce severe and often fatal hepatic andrenal damage. Inhaled in high concentration thesevapours produce general anaesthesia, often withconvulsions and other toxic effects on the highercentres. Dr. L. Dautrebande 1 has directed his

1 Presse med., July 6th, 1935, p. 1081.

attention to a different type of action, namely, thaton the blood-vessels, the solvents investigated beingbenzol, petroleum ether (the lower boiling fractionspresent in petrol), and amyl acetate. After oneminute’s inhalation by dogs of air loaded with eitherbenzol or petroleum ether there is not only a fall inblood pressure, but the occlusion of the carotid sinuseswhich normally gives a large rise in pressure is nowwithout effect. Amyl acetate has no such action atordinary temperatures, but if the inspired air iswarmed to above 28° C. the same phenomena areobserved. The normal response to carotid sinusocclusion returns about two minutes after withdrawalof the vapour. By studying the effect of inhalationof these substances before and after the administra-tion of a number of drugs acting on different pointsof the vasomotor system, it is concluded that theiraction is due to a direct effect on the walls of theblood-vessels. This view is confirmed by the factthat all three solvents have a direct paralysing effecton isolated smooth muscle. Thus it is shown thatsaturated solutions inhibit the contractions of the

frog’s heart, the rabbit’s intestine, the pig’s ureter,and the virgin rabbit’s uterus. Evidence is alsoadduced to show that benzol and petroleum etherwhen inhaled have a direct toxic effect on the heart ;in fact, if benzol and adrenaline are administered

simultaneously, death often results from ventricularfibrillation, benzol in this respect resembling chloro-form. Dautrebande considers his results of signifi-cance for industrial toxicology, and it will certainlybe of interest to see if similar phenomena can bedetected in man now that attention has been drawnto them. The vasomotor paralysis may well explainthe syncope which occurs in acute poisoning withthese substances. It is unlikely, however, that theseeffects are related in any way to the serious damageto the haemopoietic system which occurs in chronicbenzol and petroleum poisoning.

PRACTICAL LESSONS FROM IRRADIATION OFBODO CAUDATUS

THE effect of gamma ray irradiation upon the

growth of the protozoon Bodo caudatus has been thesubject of prolonged and careful study over a con-siderable period by Miss Muriel Robertson, D.Sc.,and her collaborators at the Lister Institute, and intwo recent publications the results obtained havebeen summarised.1 2 It is the non-necrotic effects of

gamma rays in restraining growth that have beenstudied. The organisms were not killed by theamount of radium used; their food-supply was

unaffected by the irradiation and the reactions in

regard to rates of growth of the successive genera-tions of cells, their size and physiological reactionscould be studied in comparison with those of controlsunder normal conditions.

It was found that the cells of less than a certain

age at the moment of exposure were greatly delayedin entering into division, so that the increase innumbers could be restrained till it equalled only20 to 30 per cent. of the normal growth. Thisextreme restraint of the multiplication was an expres-sion of the reaction of sensitive cells exposed for thefirst time in their cycle of growth from their emergenceat division of the parent to their maturity or momentof ripeness for division. TJpon further prolongationof the irradiation the growing cultures showed arecovery in rate of multiplication and the subsequent

1 Lawrie, N. R., and Robertson, M.: Biochem. Jour., 1935,xxix., 1017.2 Robertson, M.: Brit. Jour. Radiol., 1935, viii., 502 and 570.