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"ENDOGENOUS" TUBERCULOUS INFECTION
267
chemistry, and bacteriology shall be brought within the scope of the Natural Science Tripos. The object of these changes is to build preclinical studies on a
assured scientific basis. Now that a beginning has been made, it is much to be wished that the inquiry be pushed further and the future of the practitioner also determined. The question to be answered is, whether a medical man is any longer capable of acting as a sort of universal medical purveyor; or whether the time has come, when both in his own interests and those of the public, he should be restricted in practice to That some a limited number of medical subjects. reform is necessary in medical practice, I feel sure. I am, Sir, yours faithfully, J. H. E. BROCK. Beckenham, Kent, July 8th, 1933. more
BLOOD CHANGES FOLLOWING IRRADIATION
To the Editor
of THE LANCET
SIR,-I write to give my opinion that it is not
possible to assess the value of the findings of Dr. R. H. Simpson and Dr. G. White Phillips, referred to in the tenth annual report of the British Empire Cancer Campaign, since as far as I am aware neither of these researches have yet been published. Furthermore, since the Radium and X Ray Protection Committee have under consideration the question of blood counts in radium and X ray workers, it would be unwise to prejudice the case by premature judgment. It is evident that Dr. Simpson stresses once again the wide variation in normal white cell counts and the danger, which is well recognised, of drawing conclusions from single counts giving figures just within or near to normal limits. This, of course, applies to persons exposed to radiation as well as to patients in general. Dr. White Phillips finds that patients having treatment with radium and X rays do not show blood changes. This is the usual experience except when patients are subjected to a long series of such treatments.
already stated, it is necessary to publication before giving judgment in detail, of blood more especially as regards the value examinations in persons subjected to radiations. I am, Sir, yours faithfully, However,
as
await
J. C. MOTTRAM. Mount Vernon Hospital, Northwood, Middlesex, July 22nd, 1933.
LACTIC ACID AS A FACTOR IN RHEUMATISM To the Editor of THE LANCET SiR,-In your annotation of July lst (p. 33) on the report of the committee that recently considered the problems of rheumatism, you would appear to favour the suggestion that, of the many hypotheses put forward to account for rheumatic disorders, lactic acid as a causative factor may now be ignored. This on the grounds that lactic acid was to be found as much in the normal as rheumatic subject. Nevertheless I venture to submit that we are far from having done with this particular by-product of fatigue. I suggest that rheumatic complaints are universal because fatigue is universal, and that rheumatism in its chronic forms is less evident in countries wherein a warm, damp heat encourages free and daily skin action. Clinical evidence appears to be growing in volume that in the metabolism of fatigue lies that fine line between physiological acidosis and its pathological equivalent, rheumatism. The determinant factor would appear to lie in a disparity between the elimination and creation of fatigue products, and in this the skin plays an allimportant part. The whole problem, therefore, appears to demand investigation as to the results of
lactic acid accumulations in the tissues. It seems highly probable that the acid-base imbalance induced by such accumulation affects the endocrine balance, thereby laying the subject open to the attack of any prevalent bacteria. Those who cannot contemplate any disease except in terms of bacteria might spend a fraction of thought in considering the types of soil upon which such bacteria as they may find appear to thrive. Space forbids discursiveness on this fascinating problem, but I would just like to enter a mild protest against any facile assumption that lactic acid can be ignored in its relation to chronic rheumatism. I am. Sir. vours faithfullv. DRURY PENNINGTON. London, W., July 19th, 1933. "ENDOGENOUS" TUBERCULOUS INFECTION To the Editor of THE LANCET has been suggested to me that my paper SiR,—It the Role of Infection for the National with dealing Association for the Prevention of Tuberculosis, an abstract of which appears in your issue of July 22nd, implies my acceptance of the theory that adult tuberculosis is a late and separate manifestation of a childhood infection. I think I misused the word " endogenous " in my paper, and should like to make it clear that I do not accept the theory that adult tuberculosis is a separate manifestation of previous infection. My remark that the majority of cases of adult tuberculosis were the result of an endogenous spread from a lesion, was intended to imply that clinical tuberculosis does not necessarily follow a fixed latent period after exposure to infection as, for example, is the case with measles. If a patient fails to develop measles three weeks after exposure to infection one In the case of can release him from quarantine. tuberculosis, however, a lesion giving no symptom or clinical sign at the time may have formed and after remaining latent, perhaps for years, may break down, release tubercle bacilli into the blood or lymphatic stream, and cause clinical disease of essentially the same type as if there had been no stationary intermediate lesion. In my opinion the patient who lives in contact with a so-called open case of tuberculosis receives continual and repeated small infections. Many of these completely heal; some, however, remain latent so that one frequently sees somewhat extensive fibrosis in the lungs of such contacts although they have enjoyed good health. By " endogenous infection " I mean that some lesion has been present in the body, not necessarily since childhood, but for some time without producing symptoms, and it is from this infection that the disease develops. Since the lungs are the big filters. of venous blood and disease is often blood borne, it is not remarkable that the lungs should be the organs so commonly infected. In some cases exposure to infection is followed by clinical disease without a definite latent period, and this I referred to All infection originally as "exogenous infection." must, of course, be exogenous. I am, Sir, vours faithfullv. L. S. T. BURRELL. Chandos-street, Cavendish-square, W., July 25th, 1933. SODIUM EVIPAN
To the Editor
of THE LANCET with this product differs SIR,-My experience somewhat from that of the anaesthetics committee of the Medical Research Council (THE LANCET, July 1st, p. 43). Is this to be explained by the
°
chemistry, and bacteriology shall be brought within the scope of the Natural Science Tripos. The object of these changes is to build preclinical studies on a
assured scientific basis. Now that a beginning has been made, it is much to be wished that the inquiry be pushed further and the future of the practitioner also determined. The question to be answered is, whether a medical man is any longer capable of acting as a sort of universal medical purveyor; or whether the time has come, when both in his own interests and those of the public, he should be restricted in practice to That some a limited number of medical subjects. reform is necessary in medical practice, I feel sure. I am, Sir, yours faithfully, J. H. E. BROCK. Beckenham, Kent, July 8th, 1933. more
BLOOD CHANGES FOLLOWING IRRADIATION
To the Editor
of THE LANCET
SIR,-I write to give my opinion that it is not
possible to assess the value of the findings of Dr. R. H. Simpson and Dr. G. White Phillips, referred to in the tenth annual report of the British Empire Cancer Campaign, since as far as I am aware neither of these researches have yet been published. Furthermore, since the Radium and X Ray Protection Committee have under consideration the question of blood counts in radium and X ray workers, it would be unwise to prejudice the case by premature judgment. It is evident that Dr. Simpson stresses once again the wide variation in normal white cell counts and the danger, which is well recognised, of drawing conclusions from single counts giving figures just within or near to normal limits. This, of course, applies to persons exposed to radiation as well as to patients in general. Dr. White Phillips finds that patients having treatment with radium and X rays do not show blood changes. This is the usual experience except when patients are subjected to a long series of such treatments.
already stated, it is necessary to publication before giving judgment in detail, of blood more especially as regards the value examinations in persons subjected to radiations. I am, Sir, yours faithfully, However,
as
await
J. C. MOTTRAM. Mount Vernon Hospital, Northwood, Middlesex, July 22nd, 1933.
LACTIC ACID AS A FACTOR IN RHEUMATISM To the Editor of THE LANCET SiR,-In your annotation of July lst (p. 33) on the report of the committee that recently considered the problems of rheumatism, you would appear to favour the suggestion that, of the many hypotheses put forward to account for rheumatic disorders, lactic acid as a causative factor may now be ignored. This on the grounds that lactic acid was to be found as much in the normal as rheumatic subject. Nevertheless I venture to submit that we are far from having done with this particular by-product of fatigue. I suggest that rheumatic complaints are universal because fatigue is universal, and that rheumatism in its chronic forms is less evident in countries wherein a warm, damp heat encourages free and daily skin action. Clinical evidence appears to be growing in volume that in the metabolism of fatigue lies that fine line between physiological acidosis and its pathological equivalent, rheumatism. The determinant factor would appear to lie in a disparity between the elimination and creation of fatigue products, and in this the skin plays an allimportant part. The whole problem, therefore, appears to demand investigation as to the results of
lactic acid accumulations in the tissues. It seems highly probable that the acid-base imbalance induced by such accumulation affects the endocrine balance, thereby laying the subject open to the attack of any prevalent bacteria. Those who cannot contemplate any disease except in terms of bacteria might spend a fraction of thought in considering the types of soil upon which such bacteria as they may find appear to thrive. Space forbids discursiveness on this fascinating problem, but I would just like to enter a mild protest against any facile assumption that lactic acid can be ignored in its relation to chronic rheumatism. I am. Sir. vours faithfullv. DRURY PENNINGTON. London, W., July 19th, 1933. "ENDOGENOUS" TUBERCULOUS INFECTION To the Editor of THE LANCET has been suggested to me that my paper SiR,—It the Role of Infection for the National with dealing Association for the Prevention of Tuberculosis, an abstract of which appears in your issue of July 22nd, implies my acceptance of the theory that adult tuberculosis is a late and separate manifestation of a childhood infection. I think I misused the word " endogenous " in my paper, and should like to make it clear that I do not accept the theory that adult tuberculosis is a separate manifestation of previous infection. My remark that the majority of cases of adult tuberculosis were the result of an endogenous spread from a lesion, was intended to imply that clinical tuberculosis does not necessarily follow a fixed latent period after exposure to infection as, for example, is the case with measles. If a patient fails to develop measles three weeks after exposure to infection one In the case of can release him from quarantine. tuberculosis, however, a lesion giving no symptom or clinical sign at the time may have formed and after remaining latent, perhaps for years, may break down, release tubercle bacilli into the blood or lymphatic stream, and cause clinical disease of essentially the same type as if there had been no stationary intermediate lesion. In my opinion the patient who lives in contact with a so-called open case of tuberculosis receives continual and repeated small infections. Many of these completely heal; some, however, remain latent so that one frequently sees somewhat extensive fibrosis in the lungs of such contacts although they have enjoyed good health. By " endogenous infection " I mean that some lesion has been present in the body, not necessarily since childhood, but for some time without producing symptoms, and it is from this infection that the disease develops. Since the lungs are the big filters. of venous blood and disease is often blood borne, it is not remarkable that the lungs should be the organs so commonly infected. In some cases exposure to infection is followed by clinical disease without a definite latent period, and this I referred to All infection originally as "exogenous infection." must, of course, be exogenous. I am, Sir, vours faithfullv. L. S. T. BURRELL. Chandos-street, Cavendish-square, W., July 25th, 1933. SODIUM EVIPAN
To the Editor
of THE LANCET with this product differs SIR,-My experience somewhat from that of the anaesthetics committee of the Medical Research Council (THE LANCET, July 1st, p. 43). Is this to be explained by the
°