248 DRS. CRAMER & HORNING : EXPERIMENTAL PRODUCTION OF TUMOURS

tions so far. A sixth tumour was found in a castratedmale mouse of this strain which had been paintedwith keto -hydroxy-oestrin for 19 weeks. An apparentlyparadoxical result is that none of the females of thisstrain developed a tumour after treatment withoestrin lasting for more than 6 months, althoughtumours appear in 60-70 per cent. of untreatedfemales of this strain when they are over six monthsold. Of the mixed strain, neither the males nor thefemales have so far developed a tumour.The results confirm the observations of Lacassagne,l

who first demonstrated the appearance of mammarycarcinoma in male mice by injections of oestrin.While these experiments were in progress, Burrows 2has also recorded the development of mammarycancer in 2 male castrated mice out of 20 mice of amixed strain, after painting the skin with cestrinfor a period of 25 weeks and 41 weeks respectively.No tumour had appeared in 110 male non-castratedmice of the same strain, which showed a very lowincidence of spontaneous mammary tumours in thefemale. In our experiment, the cestrin-painted mice

demonstrates equally clearly the importance of the extrinsiccarcinogenic factor, in this case oestrin.

4. The sensitiveness of the male mamma in its carcino-genic response to oestrin, contrasted with the great insen-sitiveness to cestrin of the female mamma in animals ofa pure strain in which the female mamma develops cancerspontaneously in a very high percentage, suggests thateither the female organism is able to destroy effectivelythe excess of cestrin administered experimentally, or thatthe carcinogenic response of the mammary epitheliumdepends on an indirect and not on a direct interactionbetween cestrin and the cells.

The second object of this communication is torecord the occurrence of changes after the prolongedadministration of oestrin which extend beyond thesex organs and which have not been recognisedpreviously. It was found that an outstanding changein mice treated with oestrin over a prolonged periodwas the complete disappearance of fat, in fact a

condition of cachexia. There were also extensivedegenerative changes in the adrenal (Fig. 6), withactive secretion of adrenaline by the medulla, and ahypertrophy in the islets of Langerhans. These

EXPLANATION OF PLATE

FIG. 1.-Naked-eye view of pituitary gland of normalmale mouse, showing size and relation of gland to theoptic nerves.

FIG. 2.-Naked-eye view of pituitary gland of male mouseof D.Z. strain after 6 months’ painting with cestrin(Ref. No. 202 in Table of text), showing intense conges-tion of the pars anterior and compression of optic nerve.

FIG. 3.-Section through anterior lobe of gland illustratedin Fig. 2, showing large haemorrhagic areas.

FIG. 4.-Section through anterior lobe of normal mousepituitary at a magnification slightly higher than in Fig. 3,to illustrate degree of enlargement of the adenoma.

FIG. 5.-Section through testis of a mouse after 6 monthsapplication of cestrin, showing absence of spermatidsand spermatozoa, and arrest of the process of celldivision, so that practically all the cells are immobilisedin mitosis.

FIG. 6.-Adrenal gland of a male mouse after 5 months’application of cestrin. Osmic vapour fixation. Roundmasses of degenerating cells are conspicuous aroundthe medulla. In a more advanced stage they almostcompletely replace the medulla. There is activesecretion of adrenaline in the medulla.

showed the extensive changes in the uterus and

vagina in the females and the atrophy of the testiclesin the males which have been described previously.Scrotal hernia was observed to occur only in themales of the high cancer strain. The histologicalexamination of the testis disclosed a condition whichdoes not appear to have been described previously:oestrin inhibits the formation of spermatids and ofspermatozoa and at the same time arrests divisionin the primary and secondary spermatocytes, thegreat majority of which present themselves in theprocess of cell division (Fig. 5). CEstrin therefore

appears to arrest the process of cell division in thetestis.

These results will be described in greater detailin a separate publication. For the present we wishmerely to emphasise the following conclusions as

being of general significance :—

1. GEstrin is absorbed by the unbroken skin withoutproducing in it any carcinogenic effect.

2. Unlike the other carcinogenic substances so farstudied experimentally, the carcinogenic effect of oestrinis restricted to a tissue remote from the site of applica-tion of the carcinogenic agent, but possessing a specificphysiological sensitiveness to it. The action of cestrinresembles that of the other carcinogenic agents in pro-ducing first a hyperplasia of the tissue in which the cancersubsequently develops-the precancerous condition-andin the long period of time necessary to induce cancer.

3. The striking difference between the carcinogenicresponse to oestrin of male mice belonging to two differentstrains demonstrates clearly the importance of the factor"

susceptibility," which in this case is genetic in origin,in the setiology of cancer. The fact that cancer developshere in a site in which it never appears spontaneously

1 Lacassagne, A. : Compt. rend. Soc. de Biol., 1932, CXCV., 630.2 Burrows, H. : Amer. Jour. of Cancer, 1935, xxiv., 613.

effects will be described in greater detail in subse-quent publications.The spleen was sometimes reduced to a thin red

ribbon, and the thymus was atrophied. The changesin the testis have been mentioned above. These

changes suggested a general effect of oestrin, andfurther search led us to a systematic examinationof the pituitary. During this experiment we have so farexamined the pituitary gland of 12 mice treated withcestrin over a prolonged period. Of these, only1 gland was normal to the naked eye, 8 were macro-scopically enlarged without an alteration in the generalshape of the organ and without gross pathologicallesions in the gland, and 3 were definite adenomatoustumours, nodular, round, deeply congested and

hsemorrhagic, and from five to ten times the sizeof the normal gland, so that the tumour extendedover the optic nerves and in one case (No. 217)compressed them, producing degenerative changesin the nerve (Fig. 2). Even with the naked eye itcould be seen that the changes affected mainly, ifnot entirely, the anterior part of the gland. Theexperimental details concerning the three animalsin which these tumours were found are given in thefollowing Table :-

DRS. CRAMER AND HORNING : EXPERIMENTAL PRODUCTION OF PITUITARY

TUMOURS AND OF MAMMARY CANCER BY PAINTING THE SKIN WITH CESTRIN

MR. RYCROFT: CORNEAL GRAFTS MR. HOSFORD : KÜMMELL’S DISEASE

MR. MONTEITH : BEDSIDE RADIOGRAPHY FOR A FRACTURE

MR. COSBIE ROSS : LIPIODOL IN SURGERY OF BILIARY PASSAGES

249MR. J. P. HOSFORD : SUMMELL’S DISEASE

The pituitary tumours were found, therefore, in miceof both strains and in mice with and without the

presence of a mammary cancer.The detailed histological examination of the

pituitaries has not yet been completed, but a pre-liminary microscopic examination of the threeadenomata has shown extensive haemorrhages andcongestion, confined almost entirely to the parsanterior and disorganising it (Fig. 3). There was alsoan excessive number of the chromophobe type of

cell, so that the condition may be described as a

hsemorrhagic chromophobe adenoma of the anteriorpart. This was associated with a general conditionof the animals, which is generally taken to be hypo-pituitarism. In man also chromophobe adenomasare known to produce a state of hypopituitarism. 3The condition produced by us experimentally re-

sembles in many respects the syndrome of a diseasein man known as Simmonds’ disease. This disease,which is found more frequently in women than inmen and is said often to follow parturition,4 is asso-ciated with an extensive destruction of the anteriorpart of the pituitary.According to the prevailing conception, the pitui-

tary presides over the whole endocrine apparatus,and it is therefore probable that the changes observedby us in the other endocrine organs are secondary tothe changes in the pituitary. But if the pituitarypresides, its position is not that of a dictator butrather of a primus inter pa.res. For as our experi-ments show, it is itself susceptible to hormonalinfluences coming from another part of the endocrineapparatus. Since in these experiments the changesin the pituitary and the development of malignancyin the mammary gland are both produced by cestrinit is reasonable to suspect that the two may be

setiologically related. Further investigations are

necessary to determine how the chain of events islinked together.As this paper is a preliminary communication we

have restricted ourselves to statements on new and

outstanding changes which we believe to have estab-lished on a sufficiently large material, and we haverefrained from mentioning observations which willhave to be repeated and checked by further experi-ments. Since cestrin preparations are now beingused extensively in gynsecological practice it may be

8 Gushing, Harvey : The Pituitary Body, &c., Baltimore, 1932,P. 15.

4 Graubner, W.: Zeits. f. klin. Medizin., 1925, c., 249.

well to point out that the carcinogenic changes heredescribed were produced by the administration ofcestrin prolonged over a period representing a con-siderable fraction of the normal span of life of amouse and corresponding in man to a period of from7 to 10 years, while the therapeutic administrationof oestrin preparations in man is, in skilled hands,limited to short periods of a few weeks or months.The development of mammary cancer described inthis paper should not, therefore, be used as an argu-ment against the therapeutic application of cestrin

preparations. The discovery that the sphere ofaction of oestrin preparations extends beyond thegenerative organs and embraces the whole endo-crine apparatus is likely to enhance greatly theirtherapeutic importance.

KÜMMELL’S DISEASE

BY JOHN P. HOSFORD, M.S. Lond., F.R.C.S. Eng.ASSISTANT DIRECTOR, SURGICAL PROFESSORIAL UNIT,

ST. BARTHOLOMEW’S HOSPITAL

(WITH ILLUSTRATION ON PLATE)

IN 1894 Kummell gave an account of six cases ofa condition of the spine which he said had not

previously been described. Actually Verneuil haddescribed it in 1892. Since that date Kummellhas published several more papers on the subjectand other writers have reported many cases. Thecondition has come to be known as KummelTsdisease (Kummellsche Krankheit).Kummell divided the course into three stages,

but Cardis, Walker, and Olver have described five

stages. Briefly they are :-1. History of an injury.-This may be quite slight, or

severe enough to keep the patient in bed. The injuryis not usually directly to the spine but affects it indirectlyby sudden forced flexion, as, for example, a doubling-upinjury when a mine shaft collapses on a man, or a fallon to the buttocks from a height causes a sudden jar tothe spine.

2. Post-traumatic period.-This also is very variable.There may be no symptoms. On the other hand, theremay be local pain in the back and rarely even paraplegiais seen.

3. Latent period.-During this stage there are no

symptoms. Any pain or paraplegia has disappeared

EXPLANATION OF PLATE

MR. RYCROFT

FIG. VII. (CASE 1).-Before operation (left) the rightcornea is completely grey and opaque. The graft(right) is not bevelled and its appearance should becompared with that of the bevelled graft shown inFig. VIII.

FIG. VIII. (CASE 3).-The condition of the only eye.The vacant staring appearance contrasts with thatafter operation shown on the right.

MR. MONTEITH

FIG. I.-Fracture: paratrochanteric and of shaft andlesser trochanter.

FIG. II.-Protraction, abduction, and flexion : detach-ment of lesser trochanter.

FIG. III.-Metal stay incorporated, maintaining abductionand flexion without protraction : reposition of lessertrochanter.

FIG. IV.-State of femur seven months after injury.

MR. HOSFORD

Compression fracture of ninth dorsal vertebra in case.

clinically and radiographically resembling Kummell’sdisease.

MR. COSBIE ROSS

FIG. I. (CASE 1).-The narrower tube is the one

draining the common bile-duct. The radiogram showsthe lipiodol, part of which is filling the duct, and theremaining part in the duodenum.

FIG. II. ’(CASE 2).-The common duct is outlined by athin column of lipiodol, part of which has passed on intothe duodenum. The two translucent smaller areas are dueto air bubbles which entered with the lipiodol.

FIG. III. (CASE 3).-This reveals the second part of theduodenum clearly outlined by lipiodol, while thecommon duct is barely seen.

FIG. IV. (CASE 4).-In this case the whole biliary tractis outlined, there is dilatation of the common duct butfree entrance to the duodenum.

FIG. V. (CASE 5).-This again reveals free passage of thelipiodol into the duodenum.

E2