900
there was much less difference in antibody content between the cells and the plasma. From this they inferred that lymphocytes could readily part with their antibody ; on the other hand, further experiments showed that lymphocytes did not take up antibody when incubated in plasma rich in it. On general grounds, antibody formation might be regarded as a form of secretion-a process which usually requires a cell with a fair quantity of cytoplasm. But the small lymphocyte possesses very little cytoplasm, and by analogy with other secretory cells would not appear to be structurally suited for antibody formation. It is all the more interesting, then, that the view has been gaining ground that a cell with rather more cytoplasm, the plasma cell, is the chief Last year, FAGRAEUS 17 reported source of antibody. that the administration of antigens was a powerful stimulus to the multiplication of plasma cells, which in turn were derived from reticulum cells. This was particularly noticeable in the splenic pulp, where first of all large numbers of immature plasma cells appeared, and then as the titre curve of antibody levelled off these became transformed into mature plasma cells. In-vitro studies of splenic tissue showed that very much more antibody was present in the red pulp than in the lymphoid follicles, while the capacity of the red pulp to form antibodies seemed to be directly related to its content of immature plasma cells. A correlation was also established between the formation of antibody globulin and histochemichal changes in the plasma cells-namely, cytoplasmic basophilia and increased ribonueleotides. It is worth noting in this connexion that DOUGHERTY and WHITE 8 had reported an increased formation of immature plasma cells in the lymphoid tissue of rabbits within a few hours after the injection of cortical hormones. At the same time they had observed increased basophilia in the cytoplasm of many of the smaller lymphocytes, which on superficial examination apparently resembled plasma cells. Lately, EHRiCH and others,18 studying the cellular changes in the popliteal lymph-gland after injection of typhoid bacilli into the pad of the foot, found that the period of maximal antibody formation at 4-6 days after the injection was associated with an increase in ribonucleic acid in the cells. The cellular reaction at this time was mainly of plasma cells, which they decided were formed from specific plasmoblasts and not from lymphocytes. They finally concluded that it was the plasma cell and not the lymphocyte which was responsible for antibody HARRIS and HARRIS,19 however, performation. formed similar experiments-again in rabbits, but using different antigens (dysentery bacilli, influenza
Abortive Treatment of Venereal Diseases THE aphorism " diagnosis before treatment " states a fundamental principle of medical practice on which all sound teachers have laid stress. Does this principle admit of exceptions ? Are there particular circumstances, affecting the patient or the public health, which justify treatment for disease which may not be present ? It has been widely accepted, with
some
dissentients, that the venereal diseases
are
plasma cells but of lymphocytes rich in ribonucleic acid. It is difficult to reconcile their experiments with those of EHRICH and his colleagues, unless one assumes a differential response of the lymphocyte It seems clear too that the to different antigens. newer histochemical methods are reviving the old controversy concerning the origin of plasma cellsare they formed from lymphocytes, or from a specific precursor, the plasmoblast ?
and that some forms of prophylactic treatment are desirable where patients have been endangered by promiscuous intercourse.1 Administration of effective antibiotics is so easy and safe that practitioners must be sorely tempted to give them to patients who are worried and distressed. ALEXANDER et a1.2 and PLOTKE et aL3 have shown that the incidence of early syphilis among people exposed sexually to infectious early syphilis can be much diminished by single injections of 0-6-0-9 mega-units of procaine penicillin ; and this experimental work has so convinced medical opinion in the United States that abortive treatment for syphilis is now common practice there. When the pros and cons of abortive treatment were discussed by the Medical Society for the Study of Venereal Diseases on Oct. 29, Colonel L. W. HARRiOoN " spoke of the increase of sulphonamide-resistant gonorrhoea during the war, when sulphonamides became available for self-treatment, through the agency of seamen and Allies, and were given in subtherapeutic doses by many practitioners. The present wholesale and haphazard use of penicillin filled him with fear for the future, and he thought the use of penicillin by mouth for prophylaxis was particularly dangerous because of irregular absorption, haphazard dosage, and half-hearted treatment. The prevailing practice of treating, without proper diagnosis, lesions and discharges which might or might not be due to syphilis or gonorrhoea was to be condemned : after such treatment correct diagnosis was either impossible or much delayed : and the resulting uncertainty was often disastrous to the patient’s state of mind, making him a candidate for syphilophobia. If the treatment appeared to be successful it was likely that the patient would never be seen by a specialist and would have no proper observation and tests after treatment. Colonel HARRISON referred to the obvious dangers of masking the effects of early syphilis and the probability that the incidence of late serious manifestations affecting the central nervous and vascular systems will increase. With older remedies, such as the arsenicals; it had been shown that under-treatment was liable to increase the risk of neurological manifestations in syphilis ; and though many had claimed that the forms of relapse which affected the nervous system were rare after treatment with penicillin it was still too early to accept this conclusion and the end-results remained to be determined. All these arguments against the treatment for symptoms and signs without accurate diagnosis applied equally, in Colonel HARRISON’S opinion, to treatment of people who had taken a risk but had no manifestations of
17. Fagraeus, A. Acta med. scand. 1948, suppl. 204. 18. Ehrich. W. E., Drabkin, D. L., Forman, C. J. exp. med. 1949, 90, 157. 19. Harris, T. N., Harris, S. Ibid, p. 169.
1. Annotation, Lancet, 1949, i, 1014. 2. Alexander, L. J., Schoch, A. G., Mantooth, W. B. Syph. Gon. ven. Dis. 1949, 33, 429. 3. See Leading Article, Lancet, 1949, i, 1009.
virus, sheep erythrocytes)-and reported
an
increase,
not of
exceptions,
"
Amer. J.
901
disease-so-called abortive treatment. Such treatment was likely to be irregular, haphazard, and insufficient ; there would be no proper follow-up ; and the patient would be indifferent and uncooperative or else seriously overanxious because of the uncertainty about infection. In a long experience Colonel HARRISON had yet to see a case in which the wait-and-see policy had been disastrous. The argument that treatment without diagnosis was beneficial to the public health was equally unsound : the undertreated patient was always a danger, for, though surface lesions might clear or be suppressed, the risk of infection through the seminal fluid, the placenta, and the menstrual fluid remained. Adequate observation and tests of cure were essential in all cases, however treated, and it was probably a sound rule that penicillin should not be used for the treatment of venereal disease unless a sure diagnosis had first been made. In the discussion which followed most speakers agreed with these views, though some adopted the r6le of "devil’s advocate." Dr. ROBERT LEES, the president, thought some latitude must be allowed where there are no laboratory facilities-e.g., with seamen at sea and in certain undeveloped countries
Annotations THE QUEEN IN QUEEN ANNE STREET SEVENTEEN years ago, when the Royal College of Obstetricians and Gynaecologists was only three years old and was struggling for survival, it received encouragement from the Queen, who, as Duchess of York, became its first patron. Her Majesty’s interest has been maintained, and at a meeting of the college at 58, Queen Anne Street, on Nov. 3 she was presented for the honorary fellowship by Sir William Fletcher Shaw, a past president, who asked her admission " for all she has done for the benefit of British womanhood, for the great example she has given us of domestic happiness, and for her constant support of this college." Prof. R. W. Johnstone, senior fellow in Scotland, joining in the presentation as a fellow countryman, referred to the Queen’s therapeutic powers : when she visited a hospital she benefited every patient in it" which is more than any of us can do." Sir William Gilliatt, the president, having admitted Her Majesty, spoke- of her direct help to the college and her indirect help to mothers and children through her moral influence. In her reply the Queen said : "Ishare with all my heart your belief that it is on the happiness of home and family life that the true worth and strength of a nation depend." The graceful ceremonies ended with the installing of Prof. Hilda Lloyd as the first woman president of one of our Royal Colleges, and of Mr. V. B. Green-Armytage and Mr. J. Eric Stacey as vice-presidents. Then the Queen, wearing her new gown of black bordered with blue and silver, took tea with some of the members of the council, and inspected the charming but diminutive premises of the college, to whose general fund she lately made a generous gift.
CLOTHING MAPS ONE of the many urgent questions raised by the late war was how to clothe men who were to be transported from their familiar climate to one of which they, and often those responsible for them, had no experience. It was not enough to issue ducks and topees for the tropics and wool and fur for the Arctic, though such measures may have sufficed in the more leisurely past,
where venereal diseases are very prevalent. Other exceptions to the rule, which seemed to be generally acceptable, were the case in which a pregnant woman has been exposed to syphilitic infection shortly before term, and the one where the appearances are typically those of gonorrhoea but the gonococcus cannot be found. On the subject of oral penicillin for the
of venereal diseases, strong views were and it was even suggested that such treatment should be condemned as a public danger. Reference was also made to the medicolegal difficulties which may arise through abortive treatment or treatment of symptoms and signs without proper diagnosis. The venereologist is unhappily often involved in problems which reach the divorce-court, and the question arises whether the claims of justice can be satisfied on the testimony of a doctor who has given treatment after a risk of infection or because symptoms and signs resembled those of venereal disease. The evidence and the weight of expert opinion is thus on the side of first principles. " Diagnosis before treatment" is not just one of the quaint sayings of the past, and to disregard it is to incur a serious responsibility which should be accepted only in exceptional circumstances. treatment
expressed
when loss of efficiency was accepted with equanimity. Global warfare demanded Olothing for Global Man 1; as Professor Lee of Johns Hopkins and Dr. Lemons of the U.S. Quartermaster-General’s Office put it. Empirical and individual information had to be coordinated and some universal scientific law established from which the clothing requirements for a given situation could be some critical physical characteristics of the situation were known. To this end were bent the energies of physicists, physiologists, textile technologists, and geographers. The result of their labours was new maps of the continents, based not on changing ’national boundaries but on variations in the mean temperature, dividing the earth into eight clothing-allowance and climate zones. In making the maps many factors had to be taken into account, of which temperature and humidity were the most obvious, followed by wind chill, radiant energy, dust, rain, precipitation, altitude, glare, noxious fauna and flora of all kinds, and so on. The men to be clothedwould sometimes be at rest, sometimes working to the limit of their capacity. Incompatibles had to be combined somehow, so that in hot climates the men could keep cool and yet be protected from insects and plants, and in cold climates could keep warm and yet be unimpeded in movement. Both textiles and tailoring were carefully studied ; materials had to allow evaporation and yet not retain so much moisture that chilling would occur ; clothes must fit well enough for physical and mental comfort and yet not be so close that useful insulating air was expelled from between garments. The standard clothing outfit was taken as that which would maintain thermal equilibrium when the man was " standing around or performing very light tasks " (an hourly expenditure of about 75-90 cal./sq.m./hr). For increased activity garments must be removed and for decreased activity added. Garment units or layers were devised, one garment approximating half a layer, and a standard layer being about 1/4 inch thickness of clothing over the entire body and such that it gave adequate environmental protection, under the conditions prescribed, for each range of temperature of 18°F. Finally, clothing almanacs were comniled which showed bv the
predicted provided
1.
Lee, D. H. K., Lemons, H.
Geograph. Rev. 1949, 39, 181.