726

and low acid) and of renal function (inconstant olig-uria) with results that fulfil physiological prediction.The increased production of 5-H.T. in response to

reserpine is also not unexpected, but the failure of5-H.T. antagonists to influence the syndrome is hardto account for. It is especially disappointing to find afailure to confirm BLEEHEN’s 12 report of an alimentarystimulus to 5-H.T. secretion, in which we once 13

thought we saw evidence of an intermediary hormonalmechanism.

This syndrome is only one of the many aspects ofthe biochemistry and pharmacology of the aromaticamino-acids in which, largely under the influence of

chromatographic methods,14 rapid advances are being-made. Two recent studies remind us that the aromaticamino-acids and their derivatives should not alwaysbe considered separately : first, the description byWALDBNSTROM et a1.15 of an argentaffinoma whichappears to secrete large amounts of histamine as wellas 5-H.T. ; and second, the demonstration that 5-H.T.metabolism is involved in phenylketonuria.16 We

might also note the claim of BOYLAND andWILLIAMS 17 that some normal urinary indolederivatives may be carcinogenic for the bladder.

12. Bleehen, N. M. Ibid, p. 1362.13. Ibid, p. 1369.

14. Dalgliesh, C. E. Biochem. J. 1957, 65, 21P.15. Waldenström, J., Pernow, B. Silwer, H. Acta med. scand.

1956, 156, 73.16. Pare, C. M. S., Sandler, M., Stacey, R. S. Lancet, March 16,

1957, p. 551.17. Boyland, E., Williams, D. L. Biochem. J. 1956, 64, 578.

Annotations

THE BOMB TESTS

ON his return from Bermuda, the Prime Ministerdeclared that the forthcoming tests of thermonuclear

weapons at Christmas Island in the Pacific would be "

sc

small and on such a restricted scale that they cannotreally add to anything that would be dangerous to theworld" 1; and on Monday he said he was satisfied thatthe radiation effects would be insignificant. The most

likely interpretation of " small " is that the bombs willcontain only a lithium-deuterium mixture detonated byan "ordinary" atomic bomb, and that the mass ofuranium which gave earlier hydrogen bombs their enorm-ous power, and which was responsible for most of theradioactive contamination they caused and are still

causing, will be omitted or much reduced. If that is infact what is planned, the new tests will generate muchless radioactivity than previous thermonuclear explosions,and immediate fears about their consequences willbe eased.

Small " clean " bombs may have been the Govern-ment’s intention all the time, and the outcry at home andabroad against the tests may have forced it to disclosewhat they hoped to keep secret. On the other hand, asmall explosion would be something of an anticlimax :one of the main reasons for having the tests (and it is areason which, in the Government’s view, may outweighpotential dangers) is presumably to demonstrate thatBritain possesses a weapon of devastating and deterringpower : and, as Mr. Angus Maude puts it,2 " the peculiareffectiveness of the H-bomb as a deterrent ... is that itis a total destroyer." Before the Bermuda conference,few people doubted that at least one full-scale hydrogenbomb was on the programme for Christmas Island, aroundwhich an enormous danger area had been outlined. Witha wider realisation of what radioactive fallout may con-ceivably do and, more specifically, of the ignorance ofthe ultimate effects of even small doses of strontium 90on bone and blood, opposition to continued nuclear testshas hardened. And the Government may have beenconstrained by the vehemence of the protests to modifythe tests.For those who fear, as we do, that the radioactive

accumulation from thermonuclear explosions may be nearthe danger point, there can be little lasting comfort inthe news that British bombs are small bombs, while theaction of other countries remains in doubt. The onlycourse that does not involve risks which, in relation tomankind as a whole, are utterly unjustifiable is for thethree governments so far concerned to stop thermonuclearexplosions of all kinds. Proposals for limiting or abandon-ing tests have had to be revised because it is now appar-

1. Times, March 28, 1957.2. New Scientist, March 28, 1957.

ently possible to hold tests in secret. Nevertheless, wehope the Government will now press forward with

negotiations-and with a far greater sense of urgencythan they or other governments have shown in the past.Putting the risks at their lowest, continued explosions ofmegaton bombs can hardly fail in the end to kill a certainnumber of people by giving them bone tumours that theywould not otherwise have had ; at worst, accumulatedfallout could be responsible for a great many early deathsfrom malignant disease or other hazards of internal orexternal radiation of which we know even less-prematureageing is one. Those who are unconcerned at the waybombs have been exploded in recent years are fortifiedby the belief that the present rate of firing can be con-tinued for a long time without seriously endangeringanyone’s health. They put their faith (as Mr. Macmillanseems to do) in the hypothetical existence of a thresholdbelow which no harm is done. In this belief they maybe right : but what matters now is that no-one can yetsay for certain that they are not very wrong.

1. Tönnis, W. Gefassmissbildungen und Gefassgeschwulste desGehirns. Leipzig, 1936.

2. Oliveerona, H., Riives, J. Arch. Neurol. Psychiat. 1948, 59, 567.3. Gushing, H., Bailey, P. Tumors Arising from Blood Vessels of

the Brain. Springfield, Ill, 1928.4. Mackenzie, I. Brain, 1953, 76, 184.5. Paterson, J. H., McKissock, W. Ibid, 1956, 79, 233.

EPILEPSY, MIGRAINE, AND SUBARACHNOIDHÆMORRHAGE

IN the past two decades the syndromes associatedwith intracranial angiomas have been more clearlydefined. This clarification has been largely due to theintroduction by Egaz Moniz, in 1929, of cerebral angio-graphy, which enables the condition to be unequivocallydiagnosed in most cases. In 1936 T6nnis 1 reported 22cases investigated in this way. Most of these were studiedin Olivecrona’s clinic, and in 1948 Olivecrona and Riives 2reviewed a further 43 cases. Of these, 17 had epilepsy,usually with focal features, as the initial symptom;while subarachnoid haemorrhage occurred first in 12.The two cardinal clinical features 3 of the condition-focal epilepsy, which may precede other signs by years,and recurrent intracranial bleeding-were thus clearlyestablished. Olivecrona noted one other presentingfeature : hemiplegia, either sudden from intracerebralhaemorrhage or insidious by direct involvement of cerebraltissue in the angioma. Mackenzie 4 added episodicheadache as a common initial symptom (present in 12of his 50 cases) ; and he emphasised that the associationof migraine, focal epilepsy, and subarachnoid bleedingwhich Adie had remarked on in 1930 was sometimespart of the angioma syndrome. Paterson and McKissock,5in a careful study of 110 cases, found that 38% presentedwith subarachnoid haemorrhage, 26% with epilepsy, 21%with headaches (of episodic " migrainous " type in

15%), and 7% with progressive hemiparesis-thus

727

’

confirming once more the importance of the triad ofsubarachnoid haemorrhage, epilepsy, and "

migra,ine."They observed in 14% of their cases dementia, which

, Olivecrona had noted to a mild degree in as many as’ 50% of his. Discussing the mode of progression of

angiomas they pointed out that, although not neoplastic,these abnormalities can become truly progressive space-filling lesions as small recurrent haemorrhages resultin the formation of cerebral cysts or false aneurysms.These lesions are liable to cause severe disability or

even death by sudden severe haemorrhage or graduallyincreasing impairment by recurrent epilepsy and dementia.Treatment is therefore important. Olivecrona was a

pioneer in establishing the possibility of radical excision,and McKissock undertook this in almost a third of hiscases. Ligation of feeding-vessels is less satisfactory andmay damage normal brain tissue by general changesin cerebral blood-flow. The value of X-ray treatment,in vogue for many years, is dubious, though Potter 6has recently suggested that it may help. It is evident thatif these lesions are progressive, as McKissock believes,then prompt diagnosis should be followed by surgicaltreatment. Angiography, the diagnostic linchpin, shouldalways be considered in subarachnoid haemorrhage, focalepilepsy, and even migraine.

6. Potter, J. M. Ann. R. Coll. Surg. Engl. 1955, 16, 227.7. Lind, A. R., Weiner, J. S., Hellon, R. F., Jones, R. M., Frazer,

D. C. Reactions of Mines-Rescue Personnel to Work in HotEnvironments. Medical Research Memorandum no. 1, NationalCoal Board Medical Service. Pp. 68. 10s. Obtainable fromthe board at Hobart House, Grosvenor Place, London, W.1.

RESCUE IN THE MINES

AFTER a mining accident, rescue workers have oftento contend with extreme heat and humidity in an

atmosphere in which they must use breathing apparatus.No laboratory conditions can simulate all facets of an

underground disaster ; but men can be set equivalenttasks in conditions of high temperature and humidity,like those encountered underground, and they can

wear various forms of rescue apparatus while doing them.By such means, an attempt has been made to establishlimits of tolerance for typical members of rescue teamsunder anticipated rescue conditions. The memorandum

by Lind et al.,7 published by the National Coal Board,contains detailed physiological data and consequentrecommendations for the guidance of those concernedwith rescue teams.The investigation was in two parts, carried out at

Oxford and Doncaster. The subjects were undergroundworkers, divided into two age-groups, 19-31 and 39-45.The Oxford programme was intended to assess theintrinsic individual variations of the subjects, and tocompare the reactions of the two age-groups to a standardtask under hot and humid conditions while not wearingrescue apparatus. At Doncaster the men were givena work-routine representing a rescue in a mine, to estimate" tolerance-time " in various saturated environments,and to determine any differences in reactions betweenthe two age-groups and between men normally employedon different types of mine work. In these Doncaster teststhe men wore one of two different types of apparatuscommonly used in rescue operations.As might be expected, the physiological data show

that the older men are less adaptable to stress ; for

example, their rectal temperature and pulse-rate rosemore than those of the younger group under identicalconditions. But in spite of this, age did not affect thetolerance-time, and men from the older group could workhard in hot wet surroundings for as long as the youngermen. There was no evidence that men in a particularclass of pit work were any better or worse physiologicallyat rescue work than those doing other jobs.On the basis of these data, the National Coal Board

memorandum recommends safe working-times for rescue

teams for a given temperature and humidity-the" confidence limit." If a team exceeds this limit, thepossibility of collapse of any member with a low heattolerance increases. No routine medical examinationcan assess an individual’s heat tolerance, and until asuitable heat selection test has been devised, Lind etal. think that rescue workers should face hot conditionson their routine practices, so that " heat-intolerantmen may be detected.Though only two instances are reported in the

memorandum, tolerance is lowered by minor infections(such as mild food-poisoning and an early head cold).Such minor ailments may prove serious under stress.An appendix to the memorandum sets out the recom-

mendations arising out of the investigations, with detailsof the precautions to be observed in the conduct ofrescue operations, and tables of maximum safe periodsof exposure under various specified wet and dry bulbtemperatures.

1. F.T.R. circular 70.2. Counseller, V. S., McIndoe, A. H. Arch. intern. Med. 1926, 37,

363.3. Hoyne, R. M., Kernohan, J. W. Ibid, 1947, 79, 532.4. Strong, G. F., Pitts, H. H. Ann. intern. Med. 1932, 6, 485.5. Charache, H. Amer. J. Surg. 1939, 43, 96.6. Berman, C. Primary Carcinoma of Liver. London, 1951.

NEW SALARY-SCALES FOR DENTAL TECHNICIANS

THE new salary-scales for dental technicians employedin hospitals and local-authority health services 1 probablyoffset the rise in the cost of living since the previousscales were put into effect ; but the remuneration ofskilled technicians still seems inadequate, comparedwith, for example, that of many grades of local-govern-ment employees. Moreover, the " differential " betweenthe salary of a technician immediately on completion ofhis apprenticeship (£430, rising step-wise to L535 aftersix years) and that of a chief technician of many years’experience in charge of a technical staff (£ 45—760according to length of service and size of staff) hardlyseems -to take account of the considerable responsibilityinvolved in the latter post.

PRIMARY HEPATIC CARCINOMA

THE incidence of primary carcinoma of the liver,judged by necropsy findings, has increased distinctly inrecent years. Thus, at the Mayo Clinic in 5976 necropsiesreported in 1926 the frequency was 0.083%,2 whereas in16,303 necropsies reported in 1947 the frequency was0.19% 3-more than double that observed twenty yearsearlier. Similarly in Vancouver 4 the incidence doubled intwenty years.

These and other figures show that primary carcinomaof the liver is still rare in North America and Europe ;but in Oriental countries it is three to four times as com-mon as in the Occident, and in parts of Africa it is nolonger rare, the incidence being highest in members of theBantu tribe. The report of the South African Institutefor Medical Research 5 that primary carcinoma of theliver was present in 39-56% of all necropsies, and theobservation that this tumour constitutes 86% of all

primary carcinomas in the natives in the gold-mines ofthe Witwatersrand,6 are overwhelming evidence of theimportance of local factors in this disease. The relative

importance of racial and environmental factors is still notclear, but the pronounced tendency for the incidence todecrease among Oriental and African immigrants toNorth America suggests that environment may be themore significant factor ; and the most importantenvironmental variable is probably the diet.The relation of dietary deficiency to cirrhosis in both

man and laboratory animals is now well established. Theassociation of primary carcinoma with cirrhosis of theliver is equally well established : cirrhosis is presentin about 80% of cases of hepatocellular carcinoma and inabout 50% of cases of cholangiomatous carcinoma. In