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SYPHILIS, YAWS, AND BEJEL
1456
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T
careful examination of such cases by means of the sternal puncture. The existence of such a group as Wilkinson conceives is very important to a study of the physiology of the bone-marrow. With regard to the value of the oxidase reaction, I would like to add that it was never meant that a myeloblast must be oxidase-positive. The ferment seems to appear in the cell before the granules, and hence a myeloblast may be oxidase-positive. I that in the quite agree myeloblastic leukaemia, greater part or sometimes the whole mass of the cells may be oxidase-negative, but if a few of these cells show a positive reaction, it confirms the identification of the rest as myeloblasts. A fresh film stained carefully by Graham’s method often reveals oxidase-positive granules in a small proportion of these myeloblasts. Dr. Knyvett Gordon’s remark about admixture of the sternal-puncture contents with blood is quite true, and this, as well as the importance of careful examination of the peripheral blood, has been already emphasised. Nevertheless a bone-marrow film contrasts markedly with a blood film in many diseases and marrow cells can be easily recognised. I am,
Sir,
yours
faithfully, A. F. ZANATY.
Dept.
Pathology, Faculty of Medicine, Cairo, Egypt, Nov. 30th.
of Clinical
THE MEDICAL PROFESSION IN NATIONAL EMERGENCY
To the Editor of THE LANCET
SIR,-The committee of the Medical Peace Campaign wishes to associate itself with the opinions expressed by the Socialist Medical Association in its letter to THE LANCET of Dec. 4th. Since, in the event of war, medical men and women will be called upon to play a leading part in safeguarding the population it seems fitting that their fullest cooperation should be enlisted in preparing in advance the best measures for minimising suffering and loss of life. The Government’s scheme for organising a medical service fails in this respect. Action has been taken undemocratically without any previous consultation with the profession and no time has been allowed for due discussion, either through the medical press, or at meetings called for the purpose by the branches of the British Medical Association throughout the country. Free discussion is surely necessary both in order to find the best method to be employed for organising and utilising the services of medical practitioners and at the same time to safeguard that independence of conscience and judgment to which the profession is entitled and which it is its duty to claim. On behalf of the committee, I am, Sir, yours faithfully, STELLA CHURCHILL,
CHURCHILL,
Hon. Sec.
Cumberland-terrace, N.W., Dec. 10th.
SYPHILIS, YAWS, AND BEJEL To the Editor
of THE
LANCET
SIR,-Apropos your annotation (Nov. 6th, p. 1087) in which you discuss a form of treponematosis endemic in the Bedouins of the Euphrates valley, described in several papers by Dr. Ellis Hudson, may I call attention to an instructive paper by the veteran Prof. E. von During of Frankfurt University This appeared in Forschungen und Fortschritte of May lOth, 1935. I have not seen the original and am quoting from an annotation in the British ]Jfedical Journal of
June 22nd, 1935, p. 1275, von Diiring was professor of syphilography at the Constantinople Medical School from 1889 to 1902, and was inspector-general of the north-western provinces of Asia Minor from 1896. He described a type of syphilis exactly similar to that called " bejel " in Syria. The disease was only exceptionally transmitted by sexual intercourse. Primary lesions were rarely seen and secondary manifestations were almost confined to children. von During noted, as did Hudson, that the larger the population the rarer the disease, and that in some villages 100 per cent. of the inhabitants might be affected, which is again exactly Hudson’s experience. Infantile mortality was extremely high in the infected villages. No single case of tiabes or general paralysis was seen amongst 80,000 cases of syphilis which came under the notice of the author. von During attri, buted the peculiarities of this form of endemic syphilis to the fact that the disease was introduced into Asia Minor in 1829 by Russian troops. In this connexion may be mentioned Finger’s observations on the remarkable prevalence of extragenital syphilis, in certain parts of Czarist Russia. The most striking examples were the province of Vladimir with 91 per cent. of extragenital infections and that of Kursk with 92 extragenital cases to 8 genital. It was generally assumed that overcrowding and particularly the habit of herding round, and on, the stove during the winter were the causes of this high incidence of extragenital infections in the poorer classes. Finger found in his Vienna clinic that extragenital infections were present in 6 per cent. of his patients. In 141 males attending the London Hospital I obtained definite evidence of extragenital infection in only 3.3 per cent. The evidence as regards females is unreliable because so large a proportion of primary infections occur on the cervix uteri. Bejel certainly deserves further investigation which might profitably be extended from Syria to Asia Minor. I am, Sir, yours faithfully, JAMES H. SEQUEIRA. Makuyu, Kenya, Dec. 2nd. SEDIMENTATION TESTS
To the Editor
of
THE LANCET
SIR,-There are, I think, two further points that should be stressed in comparing the " standard " and " differential " sedimentation tests. First, I have observed that the agglomeration of cells, which Dr. L’Estrange Orme describes as the cause of the increase in the rate of fall in the standard test, is not due to simple clumping. The cells are arranged in rouleaux. These rouleaux not only vary in length, with variations in the sedimentation-rate, but have a tendency to gather together loosely in figures resembling Chinese characters when the rate is moderately increased, and in compact groups Y7hen the rise in the rate of fall is great. These changes appear to be constant, and it is possible accurately to forecast whether the sedimentation-rate of a given blood will be within normal limits, or not, by examining a sample of the citrated blood under the microscope. Secondly,
this characteristic arrangement of the cells appears to be due to a factor present in the citrated plasma and absent in the serum. Cells suspended in serum will of course form rouleaux, but they will not adopt the formations described, nordoes the length of the rouleaux show any apparent variation when sera from bloods of widely divergent sedimentation-rates are used. The citrated plasma on the other hand tends to produce the arrangement of cells characteristic of the sedimenta-
e
T
careful examination of such cases by means of the sternal puncture. The existence of such a group as Wilkinson conceives is very important to a study of the physiology of the bone-marrow. With regard to the value of the oxidase reaction, I would like to add that it was never meant that a myeloblast must be oxidase-positive. The ferment seems to appear in the cell before the granules, and hence a myeloblast may be oxidase-positive. I that in the quite agree myeloblastic leukaemia, greater part or sometimes the whole mass of the cells may be oxidase-negative, but if a few of these cells show a positive reaction, it confirms the identification of the rest as myeloblasts. A fresh film stained carefully by Graham’s method often reveals oxidase-positive granules in a small proportion of these myeloblasts. Dr. Knyvett Gordon’s remark about admixture of the sternal-puncture contents with blood is quite true, and this, as well as the importance of careful examination of the peripheral blood, has been already emphasised. Nevertheless a bone-marrow film contrasts markedly with a blood film in many diseases and marrow cells can be easily recognised. I am,
Sir,
yours
faithfully, A. F. ZANATY.
Dept.
Pathology, Faculty of Medicine, Cairo, Egypt, Nov. 30th.
of Clinical
THE MEDICAL PROFESSION IN NATIONAL EMERGENCY
To the Editor of THE LANCET
SIR,-The committee of the Medical Peace Campaign wishes to associate itself with the opinions expressed by the Socialist Medical Association in its letter to THE LANCET of Dec. 4th. Since, in the event of war, medical men and women will be called upon to play a leading part in safeguarding the population it seems fitting that their fullest cooperation should be enlisted in preparing in advance the best measures for minimising suffering and loss of life. The Government’s scheme for organising a medical service fails in this respect. Action has been taken undemocratically without any previous consultation with the profession and no time has been allowed for due discussion, either through the medical press, or at meetings called for the purpose by the branches of the British Medical Association throughout the country. Free discussion is surely necessary both in order to find the best method to be employed for organising and utilising the services of medical practitioners and at the same time to safeguard that independence of conscience and judgment to which the profession is entitled and which it is its duty to claim. On behalf of the committee, I am, Sir, yours faithfully, STELLA CHURCHILL,
CHURCHILL,
Hon. Sec.
Cumberland-terrace, N.W., Dec. 10th.
SYPHILIS, YAWS, AND BEJEL To the Editor
of THE
LANCET
SIR,-Apropos your annotation (Nov. 6th, p. 1087) in which you discuss a form of treponematosis endemic in the Bedouins of the Euphrates valley, described in several papers by Dr. Ellis Hudson, may I call attention to an instructive paper by the veteran Prof. E. von During of Frankfurt University This appeared in Forschungen und Fortschritte of May lOth, 1935. I have not seen the original and am quoting from an annotation in the British ]Jfedical Journal of
June 22nd, 1935, p. 1275, von Diiring was professor of syphilography at the Constantinople Medical School from 1889 to 1902, and was inspector-general of the north-western provinces of Asia Minor from 1896. He described a type of syphilis exactly similar to that called " bejel " in Syria. The disease was only exceptionally transmitted by sexual intercourse. Primary lesions were rarely seen and secondary manifestations were almost confined to children. von During noted, as did Hudson, that the larger the population the rarer the disease, and that in some villages 100 per cent. of the inhabitants might be affected, which is again exactly Hudson’s experience. Infantile mortality was extremely high in the infected villages. No single case of tiabes or general paralysis was seen amongst 80,000 cases of syphilis which came under the notice of the author. von During attri, buted the peculiarities of this form of endemic syphilis to the fact that the disease was introduced into Asia Minor in 1829 by Russian troops. In this connexion may be mentioned Finger’s observations on the remarkable prevalence of extragenital syphilis, in certain parts of Czarist Russia. The most striking examples were the province of Vladimir with 91 per cent. of extragenital infections and that of Kursk with 92 extragenital cases to 8 genital. It was generally assumed that overcrowding and particularly the habit of herding round, and on, the stove during the winter were the causes of this high incidence of extragenital infections in the poorer classes. Finger found in his Vienna clinic that extragenital infections were present in 6 per cent. of his patients. In 141 males attending the London Hospital I obtained definite evidence of extragenital infection in only 3.3 per cent. The evidence as regards females is unreliable because so large a proportion of primary infections occur on the cervix uteri. Bejel certainly deserves further investigation which might profitably be extended from Syria to Asia Minor. I am, Sir, yours faithfully, JAMES H. SEQUEIRA. Makuyu, Kenya, Dec. 2nd. SEDIMENTATION TESTS
To the Editor
of
THE LANCET
SIR,-There are, I think, two further points that should be stressed in comparing the " standard " and " differential " sedimentation tests. First, I have observed that the agglomeration of cells, which Dr. L’Estrange Orme describes as the cause of the increase in the rate of fall in the standard test, is not due to simple clumping. The cells are arranged in rouleaux. These rouleaux not only vary in length, with variations in the sedimentation-rate, but have a tendency to gather together loosely in figures resembling Chinese characters when the rate is moderately increased, and in compact groups Y7hen the rise in the rate of fall is great. These changes appear to be constant, and it is possible accurately to forecast whether the sedimentation-rate of a given blood will be within normal limits, or not, by examining a sample of the citrated blood under the microscope. Secondly,
this characteristic arrangement of the cells appears to be due to a factor present in the citrated plasma and absent in the serum. Cells suspended in serum will of course form rouleaux, but they will not adopt the formations described, nordoes the length of the rouleaux show any apparent variation when sera from bloods of widely divergent sedimentation-rates are used. The citrated plasma on the other hand tends to produce the arrangement of cells characteristic of the sedimenta-