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TANNIC ACID FOR BURNS.
1011 stimulus suddenly applied, in a short contraction of all the fibres of the part and a diminution of the diameters of the whole classes of vessels, but more particularly of the arteries, which is followed, at a greater or less distance of time, by a corresponding dilatationaccording to the extent of which, the phenomena of inflammation will be more or less observable ; and more so, if the vis a tergo be powerful or stimulated." "Sixth.-A gentle or lesser stimulus produces an evanescent contraction, followed by relaxation, increased redness, and a slight acceleration of blood in the leading capillary arteries and veins ; owing, it seems, to the increased capacity of the distended reticular vessels, while the former are yet " relatively contracted." " Seventh,.-The circulation in the capillary system is as independent of the controul [sic] of the heart, except so far of this organ affords a constant pressure and a ready supply blood, upon which the capillary vessels may act; and it is still more independent of the brain." " Tenth.-The condition of a part, in what is termed inflammation, is essentially seated in the capillary vessels, and primarily and chiefly in those of the veins."
" .Ftf
time, produces
strong a
,
Black then points out that his observations are in sharp contradiction to the conclusions of Haller (1766) that the capillaries were passive agents, whose diameter depended only upon the pressure of blood passing in them. The author considered the possibility that the capillaries may act as peripheral hearts, but draws no definite conclusion. In discussing the structure of the capillaries, he says. " the muscular or elastic tunic of the larger arteries, about which there has been so much controversy, is either lost in the capillary tissue or is so entirely attenuated that it is incapable of demonstration, even by the aid of a strong microscope." Black records (p. 50), that his observations " were instituted in the summer of 1822. They would have been prosecuted to a much greater extent if an amaurotic affection of one eye of the experimenter had not made its appearance during these and some other optical pursuits." He was born in Scotland, and was admitted a Licentiate of the Edinburgh Royal College of Surgeons in 1808 and M.D. of Glasgow in 1820. From 1810 to 1839 he practised at Bolton, and then moved for ten vears to Manchester. his medical writings, which In addition to on were numerous, he contributed several papers geology and Roman archaeology to the Manchester
Philosophical Society. I am,
Sir,
yours
faithfully,
J. F. FULTON. Magdalen College, Oxford, Oct. 15th, 1929. PS.-Since writing this letter I have come upon a work of Marshall Hall entitled " A Critical and Experimental Essay on the Circulation of the Blood, especially as observed in the Minute and Capillary Vessels of the Batrachia and of Fishes " (London : 1831, 187 pp., 10 plates). The anatomical distinction between arterioles and capillaries is here clearly set forth, but the writer was unable to detect independent contraction of capillary vessels, and he concludes that " every fact relative to the capillary circulation leads us to ascribe its various phenomena to forces impressed upon it from without," and " there is nothing of satisfactory evidence or argument for an automatic power in them" (p. 90). Marshall Ha.11 exerted a powerful influence upon contemporary physiological thought and his conclusions were
undoubtedly responsible for the scant attention which the observations of Black and Wilson Philip received. -J. F. F. TANNIC
ACID
FOR
BURNS.
To the Editor of THE LANCET. Sm,—The results of a questionaire sent out to various hospitals and authorities have been considered by the medical advisory committee of the Industrial Welfare Society. The consensus of opinion shows that, although it has been proved to be of considerable value, especially in hospitals, it should be used only under medical supervision and not as a first-aid application for burns by the general public or ambulance attendants. Nor in the nursery, owing to
complicated character of the treatment, and the extremely poisonous nature of the corrosive sublimate
the
suggested to
be used with the tannic acid. I am, Sir, yours faithfully, D. A. COLES, Chairman, Medical Advisory Committee of the Industrial Welfare Society. 51, Palace-street, Westminster, S.W. 1, Nov. 1st, 1929.
THE DIAGNOSIS OF LARYNGEAL CANCER. To the Editor of THE LANCET.
SiR,-Sir James Dundas-Grant has mentioned my May I reply ? The battle of the biopsies will be fought by laryngologists as long as that of white and brown bread by dietitians, but the recent discussion and a subsequent correspondence with Sir James has suggested to me a classification that may prevent our talking at cross-purposes.
name.
Class A.-The removal of a piece of the primary lesion by an endolaryngeal method : (1) when any subsequent operative treatment will be a laryngectomy or pharyngectomy ; (2) when any subsequent operative treatment will be a laryngo-fissure or the making of a window in the thyroid cartilage for the insertion of radium. Class B.-The removal of a lymph gland for evidence of
secondary involvement. In Class A (1)Iwill
agree that a biopsy may be made before submitting the patient to an operation of such a magnitude. In such cases the growth is extrinsic or if primarily intrinsic is becoming secondarily extrinsic. Further, it is large. For these two reasons it is probable that the piece removed will be large enough and central enough to produce a section from which a certain diagnosis may be made. It is in Class A (2 that the difference of opinion prevails. I belong to the school that would make the diagnosis by clinical observation, by waiting and watching. and the exclusion of other diseases by general medical and by bacteriological and serological investigations. In my opinion it is wrong to attempt a biopsy in these cases. The growth is intrinsic and limited to the cord, and it is small. Therefore there is a chance that the piece removed will be small and from the periphery with the result that the section may not enable a definite decision to be made. The diagnostician is then in a worse position than before ; he must fall back upon the policy of waiting and watching, but under great difficulties. The wound must first heal, and when it has healed the observer cannot be sure what part of the change from the original picture is due to the trauma, and what part is due to an extension of the disease. Further, in both cancer and tuberculosis the removal of a piece may do harm. In cancer it may result in a rapid extension of the growth so that it passes from the stage where the relatively minor operation of laryngo-fissure must be replaced by the major one of laryngectomy. In tuberculosis it is equally harmful. To call the operation of laryngofissure life-endangerins " in tuberculosis may be correct ; but one cannot deny the science epithet to the removal of a piece for microscopical section. A study of the cases recorded at the last meeting of our section bears out this view. Sir James showed microscopical sections of two cases. In each they confirmed that which he had made. In his second case the patient was referred to him as one of tuberculosis. and I infer that he took a piece for microscopical section because he disagreed with this. In the third case the patient was sent to him with the diagnosis of growth and he thought it tubercle. Again, the section proved him to be right. In neither in his case therefore did the sections help him diagnosis ; they merely gave him pathological support in his difference of opinion with others. He produced no section in which his clinical diagnosis was proven wrong and by which he was saved from calamity. Against biopsy we have Dr. Andrew Wvllie’s case (Proc(J,’!di’Y/(!,", 1920, p. 7?) where the microscopist was wrong, and Dr. Jobson Horne’s case (Pr3.,p. 6R) where even after operation the opinions of mi01’oscopists
" .Ftf
time, produces
strong a
,
Black then points out that his observations are in sharp contradiction to the conclusions of Haller (1766) that the capillaries were passive agents, whose diameter depended only upon the pressure of blood passing in them. The author considered the possibility that the capillaries may act as peripheral hearts, but draws no definite conclusion. In discussing the structure of the capillaries, he says. " the muscular or elastic tunic of the larger arteries, about which there has been so much controversy, is either lost in the capillary tissue or is so entirely attenuated that it is incapable of demonstration, even by the aid of a strong microscope." Black records (p. 50), that his observations " were instituted in the summer of 1822. They would have been prosecuted to a much greater extent if an amaurotic affection of one eye of the experimenter had not made its appearance during these and some other optical pursuits." He was born in Scotland, and was admitted a Licentiate of the Edinburgh Royal College of Surgeons in 1808 and M.D. of Glasgow in 1820. From 1810 to 1839 he practised at Bolton, and then moved for ten vears to Manchester. his medical writings, which In addition to on were numerous, he contributed several papers geology and Roman archaeology to the Manchester
Philosophical Society. I am,
Sir,
yours
faithfully,
J. F. FULTON. Magdalen College, Oxford, Oct. 15th, 1929. PS.-Since writing this letter I have come upon a work of Marshall Hall entitled " A Critical and Experimental Essay on the Circulation of the Blood, especially as observed in the Minute and Capillary Vessels of the Batrachia and of Fishes " (London : 1831, 187 pp., 10 plates). The anatomical distinction between arterioles and capillaries is here clearly set forth, but the writer was unable to detect independent contraction of capillary vessels, and he concludes that " every fact relative to the capillary circulation leads us to ascribe its various phenomena to forces impressed upon it from without," and " there is nothing of satisfactory evidence or argument for an automatic power in them" (p. 90). Marshall Ha.11 exerted a powerful influence upon contemporary physiological thought and his conclusions were
undoubtedly responsible for the scant attention which the observations of Black and Wilson Philip received. -J. F. F. TANNIC
ACID
FOR
BURNS.
To the Editor of THE LANCET. Sm,—The results of a questionaire sent out to various hospitals and authorities have been considered by the medical advisory committee of the Industrial Welfare Society. The consensus of opinion shows that, although it has been proved to be of considerable value, especially in hospitals, it should be used only under medical supervision and not as a first-aid application for burns by the general public or ambulance attendants. Nor in the nursery, owing to
complicated character of the treatment, and the extremely poisonous nature of the corrosive sublimate
the
suggested to
be used with the tannic acid. I am, Sir, yours faithfully, D. A. COLES, Chairman, Medical Advisory Committee of the Industrial Welfare Society. 51, Palace-street, Westminster, S.W. 1, Nov. 1st, 1929.
THE DIAGNOSIS OF LARYNGEAL CANCER. To the Editor of THE LANCET.
SiR,-Sir James Dundas-Grant has mentioned my May I reply ? The battle of the biopsies will be fought by laryngologists as long as that of white and brown bread by dietitians, but the recent discussion and a subsequent correspondence with Sir James has suggested to me a classification that may prevent our talking at cross-purposes.
name.
Class A.-The removal of a piece of the primary lesion by an endolaryngeal method : (1) when any subsequent operative treatment will be a laryngectomy or pharyngectomy ; (2) when any subsequent operative treatment will be a laryngo-fissure or the making of a window in the thyroid cartilage for the insertion of radium. Class B.-The removal of a lymph gland for evidence of
secondary involvement. In Class A (1)Iwill
agree that a biopsy may be made before submitting the patient to an operation of such a magnitude. In such cases the growth is extrinsic or if primarily intrinsic is becoming secondarily extrinsic. Further, it is large. For these two reasons it is probable that the piece removed will be large enough and central enough to produce a section from which a certain diagnosis may be made. It is in Class A (2 that the difference of opinion prevails. I belong to the school that would make the diagnosis by clinical observation, by waiting and watching. and the exclusion of other diseases by general medical and by bacteriological and serological investigations. In my opinion it is wrong to attempt a biopsy in these cases. The growth is intrinsic and limited to the cord, and it is small. Therefore there is a chance that the piece removed will be small and from the periphery with the result that the section may not enable a definite decision to be made. The diagnostician is then in a worse position than before ; he must fall back upon the policy of waiting and watching, but under great difficulties. The wound must first heal, and when it has healed the observer cannot be sure what part of the change from the original picture is due to the trauma, and what part is due to an extension of the disease. Further, in both cancer and tuberculosis the removal of a piece may do harm. In cancer it may result in a rapid extension of the growth so that it passes from the stage where the relatively minor operation of laryngo-fissure must be replaced by the major one of laryngectomy. In tuberculosis it is equally harmful. To call the operation of laryngofissure life-endangerins " in tuberculosis may be correct ; but one cannot deny the science epithet to the removal of a piece for microscopical section. A study of the cases recorded at the last meeting of our section bears out this view. Sir James showed microscopical sections of two cases. In each they confirmed that which he had made. In his second case the patient was referred to him as one of tuberculosis. and I infer that he took a piece for microscopical section because he disagreed with this. In the third case the patient was sent to him with the diagnosis of growth and he thought it tubercle. Again, the section proved him to be right. In neither in his case therefore did the sections help him diagnosis ; they merely gave him pathological support in his difference of opinion with others. He produced no section in which his clinical diagnosis was proven wrong and by which he was saved from calamity. Against biopsy we have Dr. Andrew Wvllie’s case (Proc(J,’!di’Y/(!,", 1920, p. 7?) where the microscopist was wrong, and Dr. Jobson Horne’s case (Pr3.,p. 6R) where even after operation the opinions of mi01’oscopists