281ANNOTATIONS

fibromatosis.22 23 As more cases have been broughtto light it has become clear that the clinical pictureis not always characteristic. For example, thete maybe persistent hypertension, sometimes of the malignanttype 24-26; and in view of this ROSENHEIM 27 screensall his severe hypertensives for phseochromocytoma.On the other hand, in at least one case no hyper-tension was ever observed. 28 Other symptoms andsigns are caused by some form of vasomotor disturb-ance, fever, and increased basal metabolic rate.

Occasionally there are associated endocrine dis-

orders ; hyperglycaemia and glycosuria are notuncommon. Retention of urine has been reportedin two cases.29 30 Phseochromocytoma has beenfound at necropsy in elderly patients who have diedfrom other causes.

There are laboratory and pharmacological testsfor the presence of the tumour. The laboratory tests,which are generally regarded as the more reliable,consist in estimating the urinary excretion of catecholamines-that is, noradrenaline and adrenaline. Theratio of these substances in the urine roughly parallelsthat in the tumour itself. Unfortunately the methodis elaborate, and is difficult to carry out except wherespecial facilities and skill are available. Recently,however, MOULTON and WILLOUGHBY 31 havedescribed a relatively simple bio-assay techniquewhich can be used as a screening test and which intheir hands has given neither false negative nor

false positive results. EvANS et. al.32 classifiedthe pharmacological tests as

" provocative " and"

adrenolytic. " In the former, paroxysms of

hypertension are induced by histamine, tetraethyl-ammonium bromide, or methacholine ; but false

negative results are not uncommon, and wherethe result is positive the hypertension may be severeand possibly dangerous. Adrenolytic tests involvelowering the blood-pressure by adrenaline antagonists,such as piperoxane, dibenamine, or phentolamine.Piperoxane has the disadvantage that it is toxicand in some cases of essential hypertension mayprovoke serious hypertensive crises.33 34 Nevertheless,RICHARDSON et al. report that piperoxane controlledthe hypertension in their case both before and duringoperation ; and this accords with the experience ofothers.35 .Dibenamine causes long-continued hypo-tension in cases of phaeochromocytoma and mayproduce a fall of blood-pressure in patients withessential hypertension.36 Phentolamine was firstused in this country by HAMILTON et aJ.37; andlater KNOx and SLESSOR 23 found that it modifiedthe symptoms without relieving the hypertensionprovoked by histamine, and that it was extremely22. Glushien, A. S., Mansuy, M. M., Littman, D. S. Amer. J. Med.

1953, 14, 318.23. Knox, J., Slessor, A. Lancet, 1955, i, 790.24. Green, D. M. J. Amer. med. Ass. 1946, 131, 1260.25. Goldenberg, M., Aranow, H., Smith, A. A., Faber, M. Arch.

intern. Med. 1950, 86, 823.26. Swan. H. J. C. Brit. med. J. 1951, i, 440.27. Rosenheim, M. L. Ibid, 1954, ii, 1181.28. Henry, M. U. Ibid, p. 344.29. Barnet, A. J., Blacket, R. B., Depoorter, A. E., Sanderson,

P. H., Wilson, G. M. Clin. Sci. 1950, 9, 151.30. Baird, I. M., Cohen, H. Lancet, 1954, ii, 270.31. Moulton, R., Willoughby, D. A. Ibid, July 2, 1955, p. 16.32. Evans, J. A., Rubitsky, H. J., Bartels, C. C., Bartels, E. C.

Amer. J. Med. 1951, 11, 448.33. Drill, V. A. New Engl. J. Med. 1949, 241, 777.34. Bierman, H. R. J. Amer. med. Ass. 1950, 144, 830.35. Cobb, C. C., Hall, J., Hall, R. A. Lancet, 1953, i, 973.36. Haimovici, H., Medinets, H. E. Proc. Soc. exp. Biol., N.Y.

1948 67, 163.37. Hamilton, M., Litchfield, J. W., Peart, W. S., Sowry, G. S. C.

Brit. Heart. J. 1953, 15, 241.

effective in controlling paroxysms of hypertensionduring surgical removal of the tumour. On p. 267of this issue Dr. HELPS and his colleagues describetheir experience with phentolamine in the diagnosisand management of patients with phaeochromocytoma,and conclude that it is simple and safe to use in

diagnosis ; but false positive results have been

reported,38 especially when the patient is also receivingbarbiturates 39 or during anaesthesia.4OThe symptoms are dispelled by removing the

tumour. Certain anaesthetics, including chloroform,ethyl chloride, and cyclopropane are contra-indi-

cated,41 42 since they may cause ventricular arrhythmiain the presence of excess circulating adrenaline.Medical treatment during and after operation fallsinto two phases : first the administration of adreno-

lytic drugs to control the hypertension which resultsfrom positioning the patient, handling the tumour,and clamping off the blood-supply ; and secondly,the intravenous infusion of noradrenaline to combatthe profound hypotension which results from suddenlycutting off the excess circulating noradrenaline andadrenaline. The hypotensive phase persists for somehours after operation, since noradrenaline and adrena-line depress the transmission of vasotonic impulsesthrough the sympathetic ganglia, and these taketime to recover.

Annotations

COALMINERS’ CALORIES

AFTER a lapse of half a century calories have come intotheir own again. During the ’twenties and ’thirtiesvitamins and minerals held the field, and few nutritionworkers had a thought to spare for the humble calorie.But shortages of food during and after the war of 1939-45forced people to turn their attention to calories, andthe effects of insufficient food were studied experi-mentally and in the field. With the return of plenty anda rise in the standard of living there was an inevitabletendency to eat too much, and during the past five yearsthe problems of overnutrition and obesity and theireffects on health and longevity have occupied manyminds. A Medical Research Council report on the

expenditure of energy and consumption of food byminers and clerks 43 has brought us round in a full circleto the subject in which Atwater was so interested overfifty years ago-the calorie intake and output of normalmen.

Atwater’s only method of measuring energy expendi-ture was his " human calorimeter," inside which thesubject lived and carried out his various activities.

Although much valuable information was obtained withthis machine, its use was obviously limited to activitieswhich were possible inside it, and such exercises as

lumbering,44 playing cricket,45 or hewing coal were out ofthe question. Nevertheless, Atwater made a greatcontribution in establishing that oxygen consumptioncould be used to measure energy expenditure, and

subsequently energy expenditure was measured more or38. Grimson, K. S., Emlet, J. R., Hamblen, E. C. Ann. Surg.

1951, 134, 451.39. Soffer, A. Med. Clin. N. Amer. 1954, 38, 375.40. Gifford, R. W., Roth, G. M., Kvale, W. F. J. Amer. med. Ass.

1952, 149, 1628.41. Papper, E. M., Cahill, G. F. Ibid, 1952, 148, 174.42. Harrison, B. L., Seward, E. H. Brit. med. J. 1954, i, 1077.43. Studies on Expenditure of Energy and Consumption of Food by

Miners and Clerks, Fife, Scotland, 1952. By R. C. GARRY,R. PASSMORE, GRACE M. WARNOCK, and J. V. G. A. DURNIN.Spec. Rep. Ser. med. Res. Coun., Lond. 1955, no. 289. H.M.Stationery Office. Pp. 70. 5s.

44. Lundgren, N. P. V. Acta physiol. scand. 1946, 13, suppl. 41.45. Fletcher, J. G. Lancet, 1955, i, 1165.

282 ANNOTATIONS

less "in the field" by means of the Douglas bag. ADouglas bag, however, is cumbersome to carry aboutin a room, let alone " in the field," and it is filled veryquickly during active work. The recent revival of interestin energy expenditure has been prompted by the intro-duction of the Kofranyi-Michaelis respirometer. Thisinstrument, devised by members of the Max PlanckInstitut fur Arbeitsphysiologie at Dortmund, is a dry-gasmeter which is worn like a haversack. It records thevolume of the expired air and simultaneously ejects asample of this air into a rubber bag. The respirometerweighs less than 7 lb., and almost any kind of muscularwork can be done by a person wearing it.

If an adult is not gaining or losing weight it can beassumed that over a period of weeks or months his energyintake balances his energy expenditure. Thus a person’stotal energy expenditure over such a period can beassessed by measuring his calorie intake, but this gives noindication of how the energy is expended, or of how

closely the intake and expenditure balance from day today. Garry, Passmore, Warnock, and Durnin 43 set out toget some information about all this. Nineteen miners andten clerks employed at a colliery at Buckhaven in theKingdom of Fife were investigated. A continuous recordwas made of the nature and duration of every activityof these men, both at work and at home. From time totime the oxygen consumption at the various activitieswas measured with the Kofranyi-Michaelis respirometer,and all the food the men ate was weighed.

It is no new discovery that manual labourers need morefood than sedentary workers. Cato knew this in 200 B.C." Rations for the hands : 4 modii of wheat in winter,and in summer 41/2 for the field hands. The overseer,the housekeeper, the foreman and the shepherd shouldhave 3." 46 The miners expended energy equivalent toan average of 3660 calories a day, and the clerks 2800calories. This difference was entirely due to the energyexpenditure at work (1750 and 890 calories a day respec-tively). The two groups spent exactly the same number ofcalories on their spare-time activities. The calorie intakesdiffered by approximately the same amount, but theproportions of the calories derived from protein, fat, andcarbohydrate were about the same in the two groups.There was no suggestion that the miners obtained theadditional energy they required from carbohydratefoods ; they ate one and a half times as much bread asthe clerks, but the clerks ate more buns, cakes, andbiscuits. Both miners and clerks had far more alcoholon Saturday than on- any other day of the week.

It was found that the miners spent 38% of their timeunderground sitting about. This was generally becauseof a breakdown in the mechanical haulage system, andif the mechanisation had been more reliable the menwould have had the opportunity of using their musclesmore. The metabolic cost of the various miningactivities-hewing, loading, and timbering-was about7 calories a minute, but the mean rate of energy expendi-ture during the entire underground shift was only 4.3calories a minute.None of the miners taking part in this investigation

had energetic recreations. They spent their spare timeeating, dozing, reading, and playing with their children.Taking the week as a whole, both at work and at home,the miners spent two-thirds of their total time and morethan one-third of their total energy lying or sitting. Thisis very reminiscent of the findings of Widdowson,Edholm, and :McCance,47 who made a similar investigationon Army cadets. These young men, who were alleged tobe spending lives of tremendous activity, were found tospend 91/4 hours a day sitting and 81/2 hours in bed.Their energy expenditure at these two activities amountedto nearly half of the total. Hewing coal and learning to46. Cato, M. De agri cultura. Chap. 56. c. 200 B.C. London, 1934.47. Widdowson, E. M., Edholm, O. G., McCance, R. A. Brit. J.

Nutr. 1954, 8, 147.

be a soldier are very hard work, but the hard work doesnot last as many hours each day as many people havesupposed.

Coal-mining is clearly a more profitable way in whichto expend one’s calories than some. A stripper atBuckhaven produced about 6 tons of coal a day, whichpresumably provides a good deal more heat than 1750calories. Hutchinson,48 who, during the war, was

interested in rearing rabbits for food, wore a Douglas bagevery day while he was collecting the weeds on whichthe rabbits were fed. After seven weeks he killed therabbits and analysed them, and he found that on theaverage each rabbit provided 550 calories. The energyhe had expended in collecting the weeds to feed thisrabbit amounted to 1022 calories.

AMENITIES IN THE MENTAL HOSPITAL

IN 1948, when the distinction between voluntary andmunicipal’ hospitals melted overnight, King Edward’sHospital Fund for London possibly felt like a goodSamaritan balked of his patient. But not for long.There were still many things a voluntary body couldgive which the Exchequer could never afford, and manyhospitals to help which had never enjoyed the comfortof a wealthy and liberal friend. Since 1949, the Metro-politan mental and mental-deficiency hospitals, and thoseoutside which take a substantial number of their patientsfrom London, have come under the Fund’s wing-a littlematter of 27 mental and 9 mental-deficiency hospitals,containing some 60,000 beds. By the end of last year,nearly :E134,900 had been given to 31 of these 36 hospitals,and the Fund then set up a subcommittee, presided overby Sir Ernest Pooley, 49 to consider their existing situationand needs, and advise on the most effective ways of

giving them help.The subcommittee have now reported 50 that two

factors are prominent in the situation of the hospitals:(1) the legacy of old and often gloomy buildings, and(2) in contrast, the fundamental changes taking place inthe whole attitude towards the mentally ill, and in theirtreatment-social as well as medical. The average age ofour mental hospitals is well over fifty years, and theiroriginal custodial intention appears in the prison-likedesign, the vast and overcrowded wards, and the absenceof any lockers or other receptacles for patients’ posses-sions or clothing. " In some hospitals," the report says," the patients’ clothes are still rolled into bundles andtied to their beds at night, since no storage space is

provided for them." Overcrowding is of a degreeunknown in other hospitals. The original washing,bathing, and toilet facilities were considered primitiveand inadequate even by last-century standards : in some

hospitals they are still unchanged today. Kitchens and

catering, despite grants amounting to some 29,700 fromthe Fund, still need attention.51The average cost of provisions in mental hospitals is

16s.-18s. 2d., and in mental-deficiency hospitals 15a. 9d.-17s.per patient per week, as against 24s. 9d.-26s. 9d. in generalhospitals-an average difference of 9s. (or more than 50%).This is largely accounted for by the fact that far less is spentin mental hospitals on milk, meat, fish, fruit, vegetables, andeven groceries.The subcommittee estimate that to bring the standardof food up to that of general hospitals an additional 5s.per head per week is needed. They add that appetisingand healthy food is important to build up the physicalcondition not only of voluntary patients but of the manyable-bodied men and women doing outdoor or domestic48. Hutchinson, J. C. D. Ibid, 1947, 1, 231.49. The other members of the subcommittee were the Rt. Hon.

Malcolm McCorquodale, M.P., Mr. O. N. Chadwyck-Healey.Dr. W. Rees Thomas, Sir Wilson Jameson, Mr. A. G. L. Ives.and Miss M. M. Edwards.

50. Report of the Subcommittee on Mental and Mental DeficiencyHospitals in the London Area. King Edward’s Hospital Fundfor London, 10, Old Jewry, London, E.C.2. 1955. Pp. 25.

51. See Hawes, D. G. H. Lancet, 1955, i, 1214.