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prefer to designate all mixed salivary -tumours adenomasunless they are malignant. Unfortunately, their

malignancy is revealed not to the pathologist but tothe surgeon, when he finds recurrences or metastases.

Working on submaxillary tumours only, because of thegreater ease with which they may be totally extirpated,Dockerty and Mayo 15 come to the conclusion that allthe mixed tumours and " cylindromas " should be

regarded as adenocarcinomas. Of about 90 of thesetumours they found 51 to be adenocarcinomas of theso-called mixed tumour type, 15 cylindromas (that is,chiefly solid or hollow acinar adenocarcinomas) and 7intermediate in form. They put the cylindromas in aseparate category-though one finds all kinds of inter-mediate forms between the cylindromas and the so-calledmixed type-because of their greater malignancy andtendency to metastasise, as well as their predilection forspread along nerve-fibres. They found metastases in

only 2 out of 14 regional lymph-nodes examined in themixed type, but in 4 out of 9 in the cylindroma type.They can give the surgeon no sure guide as to whichtype he is dealing with -at the time of operation, and thehistory and naked-eye appearances of the growth arenot of conclusive help ; later, though, when the histo-logy is available, this will give a good indication of theprognosis. They therefore recommend the maximumof " tissue sacrifice " in all cases, including the wholeof the submaxillary salivary gland and its regionallymph-nodes. They condemn the practice of " shellingout " these tumours. Their figures giving the resultof treatment may not be statistically significant, butthey do suggest that recurrence takes place not only incases where the tumour is of more malignant characterbut also in those in which tissue sacrifice has beeninadequate. The average age of their patients wasforty, which is in accordance with other publishedfigures. They support Kennon 16 in saying that patientsshow a curious pride and affection for their salivarytumours and are loth to be separated from their slowlyenlarging companion ; for the average duration of

symptoms before medical aid was sought was seven years.BACTERIA AND THEIR TOXINS IN FOOD

BACTERIAL food-poisoning may be caused by eatingfood which contains toxins or living organisms whichproduce toxin in the intestine or both. Staphylococciand streptococci and possibly proteus and some aerobicspore-bearers may cause the first or toxin type of poison-ing ; the salmonella and dysentery groups and occasion-ally Bacterium paratyphosum B may produce the secondor infection type. The two types can typically bedistinguished clinically by the time of incubation-thetime between supping and suffering. When a dose oftoxin is swallowed symptoms usually follow in 2-4hours ; when contaminated food is eaten 6-14 or evenup to 40 hours may elapse before the patient feels ill.But the distinction is not always easy. Pollock 17describes a small* outbreak of food-poisoning caused byBact. enteritidis in which severe symptoms began 3 hoursafter eating corned-beef hash. In such cases one must

suppose either a very heavy contamination or the

presence of preformed toxin as well as organisms in thefood. From the public-health point of view it is of greatimportance to distinguish between the two types. Inthe toxin type danger ends with the destruction of thefood ; in the infection type those who eat also excretethe infecting organism. In the outbreak mentioned oneof three people who handled the hash was found to beexcreting Bact. enteritidis but gave no history of recentillness. Pollock suggests that the food was contaminatedbefore it was fried in boiling fat and that Bact. enteritidismay have survived the frying process. To find if this

15. Dockerty, M. B. and Mayo, C. W. Surg. Gynec. Obstet. 1942, 74,1033.

16. Kennon, R. Brit. J. Surg. 1921-22, 9, 76.17. Pollock, M. R. Bull. emerg.publ.Htlh Lob.Serv. January, 1943, p. 2.

was possible corned brisket beef was cut into half-inchcubes, a broth culture of Bact. ente.ritidis was pouredover them and they were left for 4 hours at room tem-perature. The cubes were then fried in fat over a lowflame and samples were removed at intervals and cul-tured. The organism was recovered from the meatafter as long as 13 minutes steady frying. In this

experiment contamination was intentionally heavy butno attempt was made to inoculate the centre of thecubes and the hash was over- rather than under-done.While it has long been known that some bacterial toxinsare highly resistant to heat it has usually been assumedthat non-sporing bacteria would be readily killed bymost cooking processes. It seems, however, that thefrying-pan may be a healthier place for bacteria thanwe had imagined.

BLEEDING PEPTIC ULCER

THE diagnosis of bleeding from a peptic ulcer may notalways be easy. On the one hand, a daily loss of bloodfrom an ulcer may be missed in the stool through failureto carry out the simple test for occult blood ; on theother, a severe open haematemesis may arise from manyother causes than a peptic ulcer. Stool examinationsmust be assessed with care. The benzidine test is sodelicate that a faintly positive result is of little signific-ance, and experiment has shown that even the lessdelicate guaiac test may remain positive for as long as tendays after the swallowing of only 8 ounces of blood.Nor do tarry stools necessarily mean a large haemorrhage-under half a pint of swallowed blood is enough toproduce them-and they may persist for at least fivedays after one isolated administration of blood by mouth.These facts, while not lessening the value of tests for

the presence of haemorrhage in peptic-ulcer cases, doemphasise the need for caution in planning therapeuticmeasures on their results alone. In both the differentialdiagnosis and the treatment of gastroduodenal hsemor-rhage the factors of age and pain are of especial import-ance. Many severe haematemeses are unassociated withany pain, but absence of pain does not by any meansexclude an ulcer. The first indication of a chronic

peptic ulcer often may be a violent haemorrhage, whileothers bleed in’a, quiescent phase after relatively mildbouts of ulcer symptoms for which they have had littleor no special treatment. As a rule, however, painlesshaematemesis comes from some form of superficialgastroduodenitis, with or without visible mucosalerosions or ulcers. Thus of 14 patients who had diedafter gross painless gastroduodenal haemorrhage Moschco-witz, Mage and Kugell found at autopsy that only 3 hadchronic peptic ulcers. The frequency of hwmorr-agic,gastritis, duodenitis and postoperative jejunitis is not yetsufficiently realised ; they must be kept in mind whendeciding on treatment, and in particular surgical treat-ment. Kiefer,2 for instance, reporting on the failures ofsubtotal resection of the stomach for peptic ulcer, des-cribes 8 cases in which operation for proved duodenalulcer was followed by recurrent gastro-intestinal bleedingwith trivial pain or distress, and in none of these was anyjejunal ulcer found. So important do Hinton andChurch 3 regard the presence of pain that they seldom ifever recommend operation for massive haemorrhage induodenal ulcer where there is no pain.

In prognosis age is the outstanding factor. In a studyof deaths after haemorrhage from peptic ulcer in 120 menand 31 women Blackford and Allen 4 noted only onedeath in the twenties, one in the thirties, six between40 and 45, and the remaining 95% at over 45, most beingin the fifties. Scherf and his collaborators 5 have re-

1. Moschcowitz, E., Mage, S. and Kugel, V. Amer. J. med. Sci.1941, 202, 48.

2. Kiefer, E. D. J. Amer. med. Ass. 1942, 120, 819.3. Hinton, J. W. and Church, R. E. Ibid, p. 816.4. Blackford, J. M. and Allen, H. E. Ibid, p. 811.5. Scherf, D. Rev. Gastroenterol. 1941, 8, 343.