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THE TREATMENT OF FOLLICULAR CONJUNCTIVITIS.
1161 The chorion or is a thing which in origin,3 and which normally has a very short life. The period of its functional activities, as I demonstrated some years ago, varies but is a fixed time for the species : it is 15 days in the rabbit, 22 in the cavy, from 28 to 30 in the sheep, and from 45 to 47 days in man, &c. From this period, the critical period of my researches, it begins to degenerate under the influence of the altered, now pancreatic, digestion and at or near the close of a " normal gestation in man there is no stielt thing as Inormal" trophoblast. Months before that time it had entered upon its long slow course of degeneration. Hence Schmorl’s finds have no bearings upon Dr. Pick’s (or my) conclusions but they are quite in accord with, and indeed might have been predicted from, my work4 of years ago. But in three cases out of the early days of gestation Selmorl found that the trophoblast exhibited the characters of unlimited growthHere i.e., instances of pre-critical or critical abortions, &c. we have to deal with what Professor von Hansemann terms " " pathologicaltrophcblast. But it is only "pathological" in the senses that " the embryo" is absent or aborted and that the trophoblast still retains all those powers of erosion and of unlimited growth which indeed characterise the precritical trophoblast of normal gestation. No new powers have come to it ; there has been no change in its properties ; it has simply not commenced to degenerate, for the change of nutrition of normal gestation is lacking in the absence of
place Schmorl’s finds in another light. trophoblast of mammalian development is not embryonic but pre-embryonic
a
completed embryo.
Professor Blumenthal’s finds concern the chemistry of As he stated, in their essentials they have been made independently by Neuberg, Wolff, and Bergell in Berlin. They confirm and extend my recent conclusions in other directions. Briefly, they have found that : (1) the substance of cancer cells is quite different chemically from that of somatic cells; (2) the pigment of melano.sarcoma is not the same as any pigment occurring in the normal body ; (3) cancer cells contain much albumin and little globulin ; (4) substances are present in cancer cells which hitherto have not been found in the healthy body ; (5) the cells of cancer are much more delicate and they are more easily destroyed than cells of normal tissues; (6) pepsin attacks cancer cells with difficulty, fl:hile trypsin easily and q1liekly dissolves themand (7) a ferment occurs in cancer cells, that first described by Eugen Petry, which possesses the property of digesting not only the albumin of its own cells but it can also completely dissolve all the cells of the body, while ordinary somatic cells contain a ferment which can auto-digest the albumin, 3c,, of these cells alone. Add to these, that in a more recent writing in No. 15 of the same journal (p. 443) Professor Blumenthal mentions that this cancer ferment is intracellular, and it is possible to maintain that the above results furnish as strong a support of my standpoint as could be desired. It would seem to follow from these researches that trypsin, perhaps better when aided by other secretions poured out into the intestine, as Dr. John A. Shaw-Mackenzie has suggested, can destroy the cancer ferment malignin.3 In the ferment malignin, discovered by Petry, we have a substance which can erode and dissolve practically any normal tissue of the body. The only other known normal cells which possess these powers are the cells of the pre-critical trophoblast (or the same cells in hydatid mole or in chorio-epithelioma). One small piece of chemical research alone remains to be made to complete the chain. This is to discover the like ferment, malignin, within the cells of the normal trophoblast of early gestation. I am absolutely sure of its existence there, for without this ferment the cells of the trophoblast could erode neither their way into the maternal tissues nor through the walls of the oviduct in a tubal gestation, nor could they do any of the other things which, on occasion, like the cells of an ordinary cancer.
’
A very interesting and important can eitect. of Professor BlUll1enthal’s speech was devoted to the cancer-cachexia. He has concluded that this heterolytic intracellular ferment, malignin, can auto-digest in the body the cancer cell ; thus the ferment can become freed, get into the circulation, and so by its activities cause untold destruction in other parts of the body. The etiology of carcinoma as an irresponsible trophoblast received confirmation from the cytological side from the researches of Farmer, Moore, and Walker; it is now strongly reinforced from the pathological side by the results of Dr. Pick. The embryological solution of the cancer problem, to all appearance, would also be the physiologico-chemical one, for trypsin can dissolve the cancer cell with ease and it would appear to destroy the cancer ferment too. For some time now in many countries and by many investigators attempts have been made to find a "serum"capable of dissolving the cancer cell. It is, perhaps, not too much to say that these have all been in vain. In your pages of Feb. 4th, 1905, I stated that trypsin was this substance ; on Feb. llth Dr. Shaw-Mackenzie independently confirmed this and for other reasons ; and now Blumenthal, Bergell, Neuberg, and Wolff all independently state that while the cancer ferment malignin can dissolve any somatic cell the cancer cell is easily destroyed by trypsin. So that now the import of trypsin, alone or aided by substances which increase its action, would appear to be indicated in the medical treatment of cancer bv t’.eresearches of six different observers, Blumenthal, Neuberg, Wolff, Shaw-Mackenzie, and myself. As a corollary to these may6 be cited the finds of Professor B. Moore and colleagues, which to my mind go to prove that cancer-cells take from the blood for their own purposes those substances from which the organism usually forms hydrochloric acid in aid of its I am, Sirs, yours faithfully, gastric digestion. J. BEARD. April 16th, 1905.
cancer,
they
portion
Bergell,
THE TREATMENT OF FOLLICULAR
CONJUNCTIVITIS. To the Editors
conjunctivitis that with
of THE LANCET.
high authority has stated that follicular scarcely be called a disease on the ground its microscopical appearances are apparently identical the structure of the follicles in lymphatic glands.
SiRS,—Of
late
a
can
Whatever the anatomical appearances may suggest there are two facts incompatible with this view-viz., the disease is contagious and responds most promptly to treatment. In the Croydon municipal schools the disease was very common but in two years we have reduced the number of cases by at least one half. The fact that the disease is contagious must not be construed as implying that it is necessary to exclude the children who have it from the schools. It would be going too far to say that the disease is innocuous. It was held for many years that these cases were predisposed to granular ophthalmia and not improbably this is true, for the conjunctival tissues being enfeebled by a very chronic inflammation must surely have diminished powers of resistance, and the hypothetical reason why the disease does not oftener pass into the more serious granular type is because the contagion of-the latter affection is fast vanishing from the schools and, indeed, from the community at large. In the Croydon schools, containing 25,000 children, we have succeeded in reducing the cases of granular ophthalmia to about three. It is clear, therefore, in this instance that there is little chance of any of the follicular cases being exposed to the danger of infection with trachoma. When a child is found to be suffering from follicular conjunctivitis our routine is (a) to inform the parents that the child has a contagious disease of the eyes; (b) to urge them to see that the child never touches his eyes without washing his hands afterwards ; (c) that children can attend school provided that they are supplied with a saucer and lotion to wash their fingers with in the event of their 3 In the pregnant uterus of the armadillo, Praopus hybridus, now in mv possession, there are seven well-formed identical foetuses within touching their eyes ; and (d) that the child will require the one chorion. The latter was there before any of the seven and a little attention at the hands of their medical attendant, they arose within it by the independent development of seven single or if this is not expedient at the eye department of a hoscells. 4 For reasons of fact and embryology, which cannot be given in brief pital. In severe cases occurring in more well-to-do children words, it may be concluded that chorio-epithelioma, notwithstanding 6 B. the few apparently but not really well-established cases, is never a Moore, W. Alexander, R. E. Kelly, and H. E. Roaf: On the Absence or Marked Diminution of Free Hydrochloric Acid in the sequel of, and cannot follow the close of, a normal gestation. 5 Dr. G. Cooke Adams, in his articles in THE LANCET of Feb. 13th Gastric Contents, in Malignant Diseases of Organs other than the and 20th, 1904, spoke of "malignic acid." To distinguish the cancer Stomach, Proceedings of the Royal Society, London, March 16th, I now suggest the con- 1905. (A full abstract of this paper is published in THE LANCET this ferment from pepsin, trypsin, secretin, &c., week.—ED. L) venient and natural name of "malignin."
1162 note is sent to the medical attendant advising the treatment with cocaine, argyrol, and adrenalin. In practice several varieties of the disease occur. The simplest is that a
so often found after using unsterilised atropine drops for considerable periods. This rapidly subsides on discontinuing the drops and seldom calls for active treatment. In another variety, the commonest, the follicles are few in number and the conjunctiva is slightly, if at all, reddened. In a third variety for which the line of treatment outlined below was designed the follicles are exceedingly numerous, red, and opaque. Several such cases I have followed for over a year, and under the ordinary routine of hospital treatment, so far as I could see, they did not improve in the least. Whatever the variety the following treatment seems infallible. The follicles are painted with cocaine and the lids are held from the eyes. After the drug has been absorbed the follicles are crushed and emptied by trituration and pressure between the two thumb-nails, one nail being next the conjunctiva and the other outside the lid. The third step is to paint the diseased part where the follicles are with argyrol, 20 per cent. After giving the membrane sufficient time to absorb the drug-say, a couple of minutes-the argyrol in the tissues is fixed there by painting on a little adrenalin, 1 in 1000. Cocaine should not be instilled in the ordinary way or the cornea would certainly be damaged irretrievably by the powerful silver salt. The sole object in using the adrenalin is to prevent the blood and lymph from washing away the germicide before it has done its work thoroughly. Two most inveterate cases were cured in three weeks ; they were by far the worst cases I have ever seen. The treatment has been mostly in hospital but several practitioners have carried it out in their surgeries with equal For home use the patients are ordered lot. success. hydrarg. cyan., 1 in 10,000, with instructions to wash the eyes with the lotion by means of cotton wool. A little of the lotion is allowed to go inside the eyes but not enough to cause smarting or pain, the idea being that it is better to have a small quantity at work for a considerable time than to use it in such a quantity as will provoke a rush of tears and therefore prompt removal of the irritant. A bland ointment is used at times for the edges of the lids at night, but when it is ordered the patient is warned that it may disagree, and he is advised to discontinue if it causes the lids to be very red in the morning. The paintings are done about every other day.-I am, Sirs, yours faithfully, CHARLES WRAY, F.R.C.S. Eng., Surgeon to the Western Ophthalmic Hospital; Ophthalmic Surgeon to the Croydon General Hospital and April 19th, 1905. Croydon Council Schools.
IF TUBERCULOSIS SHOULD BE CERTIFIED, WHY NOT SYPHILIS ? To the -Editors
of THE LANCET.
SIRS,-Dr. E. H. Douty’s letter in THE LANCET of p. 956, raises a question which must often present itself to the mind of the medical man. May I attempt to give
April 8th,
answer to it and the reason of the answer, premising first of all that in order to know how to prevent syphilis it is not enough to have made a study of syphilis ; it is necessary also to have made a study of the means of preventing it. The answer is, that we do not certify syphilis because we wish to prevent its spread, not to increase it. It is very natural, and sounds very logical, to argue from tuberculosis to syphilis ; but the analogy is verbal and not practical, for there is one deep-lying difference which vitiates the whole argument. The two diseases which Dr. Douty invites us to certify are in their nature the most concealable of diseases and they are diseases which there is the strongest possible motive for concealing. To make them notifiable-that is, if it means anything at all, to make them liable to compulsory detention and treatment- is to add a fresh and powerful motive for concealment without adding in any appreciable degree to its difficulty. I am not speaking without warrant. If Dr. Douty would turn to the reports and communicated papers of the International Society " Pour la Prophylaxie Sanitaire et Morale," of which the French Society he refers to is an offshoot-volumes which certainly ought to be found on the shelves of every medical library-he would find this subject discussed from every point of view, would find the very greatest anxiety on the part of medical men to introduce notification as a means of ensuring treatment, and would find
an
them
constantly recognising at the same time that to introduce such a measure is to drive the patient away from the medical man who will notify him to the quack who will not, or to nostrums with which he can treat himself, and that the measure is therefore worthless unless accompanied by the most drastic provisions for the discovery and dragooning of these patients--provisions either ludicrously incapable of application or which have been applied again and again with the same result, the continued increase of disease. The result of long experience on the continent comes to this, " that compulsory treatment, while it fails to ’’ stamp out" syphilis. does stamp out voluntary treatment in any class to which it is applied. Accordingly, in Italy, where they havenow established a vast system of gratuitous treatment, they are doing away with compulsory treatment even of the lowest class of woman in the belief that the voluntary system will prove more efficacious. In England, on the other hand, the Physical Deterioration Committee of last year, adopting the view expressed by Sir Victor Horsley and some others, recommended an inquiry with a view to two measuresnotification and the provision of gratuitous treatment. Now it is obviously of the greatest importance that there should be adequate provision for the treatment of thesepatients and every inducement to seek it, and the fact of such provision being made by the State would doubtless. attract patients and make early and prolonged treatment much more common ; but to introduce at the same time a measure like notification with its necessary corollary of compulsory detention or supervision is precisely the way to drive the willing patient from the doorstep and make the outlay incurred in providing gratuitous treatment a mere waste of public money. Those who advocate these measures have not considered what they mean from the point of view of the patient. They mean that from the first confession of syphilis the patient ceases to be a free agent and we may be very sure that where this is the case the confession will not be lightly made. I am not without sympathy for the impatience of medical men who, like Dr. Douty, see this scourge raging around them and are ready to seize on any weapon which seems to offer the means of combating it. But experience proves that this is a matter in which it is fatally easy to make things worse in trying to make them better. Bad as things are at present, they are in England, by every test that can be applied, steadily becoming less bad, and however desirable it may be to hurry improvement it is still more desirable not to risk checking it. As to sanatoriums for syphilitics, while fully recognising the value of fresh air in thee cases it has to be remembered that people of the comfortable classes can get fresh air without sanatoriums and that people of the not-comfortable classes mostly have families to support. Sanatoriums, whether for tuberculosis or syphilis, can afford only a very limited remedy and it seems almost like a satire on our civilisation to take here and there one out of our overcrowded, underfed, and drink-sodden population, feed him up for a few months with good food and fresh air, and then send him back to the old conditions. The garden city and the farm colony are surely a truer prophylactic. As to education, the continental experts are absolutely agreed. It is the first thing to be done. With your permission I should like to say a few words on this subject in another letter. I
am.
Sirs-
vours
faithfullv. B.
LEPPINGTON,
Oxford, April
Member of the International 10th, 1905.
SHOCK
AND
Prophylactic Society.
COLLAPSE.
To the Editors of THE LANCET. SIRS,-Dr. C. Powell White in his letter in THE LANCET of April 15th, p. 1029, says that I haveproduced no evidence that increased atmospheric pressure is of value in the treatment of shock and that the statement rests upon my assertion alone. He has evidently not read my lectures very carefully or he would hardly make such a statement. A series of careful experiments to prove this point were carried out by Crile and are referred to in my second lecture on p. 782. The experiments themselves are recorded in Crile’s book, "Blood Pressure in Surgery." Dr. White asks me to explain how the vaso-motor system is able to compensate for variations in external pressure. I thought I had already explained this in my lectures. Compensation is obtained by alterations in the calibre of the blood-vessels-that is to say, the vaso-motor centre compensates for external influences by altering the capacity of
place Schmorl’s finds in another light. trophoblast of mammalian development is not embryonic but pre-embryonic
a
completed embryo.
Professor Blumenthal’s finds concern the chemistry of As he stated, in their essentials they have been made independently by Neuberg, Wolff, and Bergell in Berlin. They confirm and extend my recent conclusions in other directions. Briefly, they have found that : (1) the substance of cancer cells is quite different chemically from that of somatic cells; (2) the pigment of melano.sarcoma is not the same as any pigment occurring in the normal body ; (3) cancer cells contain much albumin and little globulin ; (4) substances are present in cancer cells which hitherto have not been found in the healthy body ; (5) the cells of cancer are much more delicate and they are more easily destroyed than cells of normal tissues; (6) pepsin attacks cancer cells with difficulty, fl:hile trypsin easily and q1liekly dissolves themand (7) a ferment occurs in cancer cells, that first described by Eugen Petry, which possesses the property of digesting not only the albumin of its own cells but it can also completely dissolve all the cells of the body, while ordinary somatic cells contain a ferment which can auto-digest the albumin, 3c,, of these cells alone. Add to these, that in a more recent writing in No. 15 of the same journal (p. 443) Professor Blumenthal mentions that this cancer ferment is intracellular, and it is possible to maintain that the above results furnish as strong a support of my standpoint as could be desired. It would seem to follow from these researches that trypsin, perhaps better when aided by other secretions poured out into the intestine, as Dr. John A. Shaw-Mackenzie has suggested, can destroy the cancer ferment malignin.3 In the ferment malignin, discovered by Petry, we have a substance which can erode and dissolve practically any normal tissue of the body. The only other known normal cells which possess these powers are the cells of the pre-critical trophoblast (or the same cells in hydatid mole or in chorio-epithelioma). One small piece of chemical research alone remains to be made to complete the chain. This is to discover the like ferment, malignin, within the cells of the normal trophoblast of early gestation. I am absolutely sure of its existence there, for without this ferment the cells of the trophoblast could erode neither their way into the maternal tissues nor through the walls of the oviduct in a tubal gestation, nor could they do any of the other things which, on occasion, like the cells of an ordinary cancer.
’
A very interesting and important can eitect. of Professor BlUll1enthal’s speech was devoted to the cancer-cachexia. He has concluded that this heterolytic intracellular ferment, malignin, can auto-digest in the body the cancer cell ; thus the ferment can become freed, get into the circulation, and so by its activities cause untold destruction in other parts of the body. The etiology of carcinoma as an irresponsible trophoblast received confirmation from the cytological side from the researches of Farmer, Moore, and Walker; it is now strongly reinforced from the pathological side by the results of Dr. Pick. The embryological solution of the cancer problem, to all appearance, would also be the physiologico-chemical one, for trypsin can dissolve the cancer cell with ease and it would appear to destroy the cancer ferment too. For some time now in many countries and by many investigators attempts have been made to find a "serum"capable of dissolving the cancer cell. It is, perhaps, not too much to say that these have all been in vain. In your pages of Feb. 4th, 1905, I stated that trypsin was this substance ; on Feb. llth Dr. Shaw-Mackenzie independently confirmed this and for other reasons ; and now Blumenthal, Bergell, Neuberg, and Wolff all independently state that while the cancer ferment malignin can dissolve any somatic cell the cancer cell is easily destroyed by trypsin. So that now the import of trypsin, alone or aided by substances which increase its action, would appear to be indicated in the medical treatment of cancer bv t’.eresearches of six different observers, Blumenthal, Neuberg, Wolff, Shaw-Mackenzie, and myself. As a corollary to these may6 be cited the finds of Professor B. Moore and colleagues, which to my mind go to prove that cancer-cells take from the blood for their own purposes those substances from which the organism usually forms hydrochloric acid in aid of its I am, Sirs, yours faithfully, gastric digestion. J. BEARD. April 16th, 1905.
cancer,
they
portion
Bergell,
THE TREATMENT OF FOLLICULAR
CONJUNCTIVITIS. To the Editors
conjunctivitis that with
of THE LANCET.
high authority has stated that follicular scarcely be called a disease on the ground its microscopical appearances are apparently identical the structure of the follicles in lymphatic glands.
SiRS,—Of
late
a
can
Whatever the anatomical appearances may suggest there are two facts incompatible with this view-viz., the disease is contagious and responds most promptly to treatment. In the Croydon municipal schools the disease was very common but in two years we have reduced the number of cases by at least one half. The fact that the disease is contagious must not be construed as implying that it is necessary to exclude the children who have it from the schools. It would be going too far to say that the disease is innocuous. It was held for many years that these cases were predisposed to granular ophthalmia and not improbably this is true, for the conjunctival tissues being enfeebled by a very chronic inflammation must surely have diminished powers of resistance, and the hypothetical reason why the disease does not oftener pass into the more serious granular type is because the contagion of-the latter affection is fast vanishing from the schools and, indeed, from the community at large. In the Croydon schools, containing 25,000 children, we have succeeded in reducing the cases of granular ophthalmia to about three. It is clear, therefore, in this instance that there is little chance of any of the follicular cases being exposed to the danger of infection with trachoma. When a child is found to be suffering from follicular conjunctivitis our routine is (a) to inform the parents that the child has a contagious disease of the eyes; (b) to urge them to see that the child never touches his eyes without washing his hands afterwards ; (c) that children can attend school provided that they are supplied with a saucer and lotion to wash their fingers with in the event of their 3 In the pregnant uterus of the armadillo, Praopus hybridus, now in mv possession, there are seven well-formed identical foetuses within touching their eyes ; and (d) that the child will require the one chorion. The latter was there before any of the seven and a little attention at the hands of their medical attendant, they arose within it by the independent development of seven single or if this is not expedient at the eye department of a hoscells. 4 For reasons of fact and embryology, which cannot be given in brief pital. In severe cases occurring in more well-to-do children words, it may be concluded that chorio-epithelioma, notwithstanding 6 B. the few apparently but not really well-established cases, is never a Moore, W. Alexander, R. E. Kelly, and H. E. Roaf: On the Absence or Marked Diminution of Free Hydrochloric Acid in the sequel of, and cannot follow the close of, a normal gestation. 5 Dr. G. Cooke Adams, in his articles in THE LANCET of Feb. 13th Gastric Contents, in Malignant Diseases of Organs other than the and 20th, 1904, spoke of "malignic acid." To distinguish the cancer Stomach, Proceedings of the Royal Society, London, March 16th, I now suggest the con- 1905. (A full abstract of this paper is published in THE LANCET this ferment from pepsin, trypsin, secretin, &c., week.—ED. L) venient and natural name of "malignin."
1162 note is sent to the medical attendant advising the treatment with cocaine, argyrol, and adrenalin. In practice several varieties of the disease occur. The simplest is that a
so often found after using unsterilised atropine drops for considerable periods. This rapidly subsides on discontinuing the drops and seldom calls for active treatment. In another variety, the commonest, the follicles are few in number and the conjunctiva is slightly, if at all, reddened. In a third variety for which the line of treatment outlined below was designed the follicles are exceedingly numerous, red, and opaque. Several such cases I have followed for over a year, and under the ordinary routine of hospital treatment, so far as I could see, they did not improve in the least. Whatever the variety the following treatment seems infallible. The follicles are painted with cocaine and the lids are held from the eyes. After the drug has been absorbed the follicles are crushed and emptied by trituration and pressure between the two thumb-nails, one nail being next the conjunctiva and the other outside the lid. The third step is to paint the diseased part where the follicles are with argyrol, 20 per cent. After giving the membrane sufficient time to absorb the drug-say, a couple of minutes-the argyrol in the tissues is fixed there by painting on a little adrenalin, 1 in 1000. Cocaine should not be instilled in the ordinary way or the cornea would certainly be damaged irretrievably by the powerful silver salt. The sole object in using the adrenalin is to prevent the blood and lymph from washing away the germicide before it has done its work thoroughly. Two most inveterate cases were cured in three weeks ; they were by far the worst cases I have ever seen. The treatment has been mostly in hospital but several practitioners have carried it out in their surgeries with equal For home use the patients are ordered lot. success. hydrarg. cyan., 1 in 10,000, with instructions to wash the eyes with the lotion by means of cotton wool. A little of the lotion is allowed to go inside the eyes but not enough to cause smarting or pain, the idea being that it is better to have a small quantity at work for a considerable time than to use it in such a quantity as will provoke a rush of tears and therefore prompt removal of the irritant. A bland ointment is used at times for the edges of the lids at night, but when it is ordered the patient is warned that it may disagree, and he is advised to discontinue if it causes the lids to be very red in the morning. The paintings are done about every other day.-I am, Sirs, yours faithfully, CHARLES WRAY, F.R.C.S. Eng., Surgeon to the Western Ophthalmic Hospital; Ophthalmic Surgeon to the Croydon General Hospital and April 19th, 1905. Croydon Council Schools.
IF TUBERCULOSIS SHOULD BE CERTIFIED, WHY NOT SYPHILIS ? To the -Editors
of THE LANCET.
SIRS,-Dr. E. H. Douty’s letter in THE LANCET of p. 956, raises a question which must often present itself to the mind of the medical man. May I attempt to give
April 8th,
answer to it and the reason of the answer, premising first of all that in order to know how to prevent syphilis it is not enough to have made a study of syphilis ; it is necessary also to have made a study of the means of preventing it. The answer is, that we do not certify syphilis because we wish to prevent its spread, not to increase it. It is very natural, and sounds very logical, to argue from tuberculosis to syphilis ; but the analogy is verbal and not practical, for there is one deep-lying difference which vitiates the whole argument. The two diseases which Dr. Douty invites us to certify are in their nature the most concealable of diseases and they are diseases which there is the strongest possible motive for concealing. To make them notifiable-that is, if it means anything at all, to make them liable to compulsory detention and treatment- is to add a fresh and powerful motive for concealment without adding in any appreciable degree to its difficulty. I am not speaking without warrant. If Dr. Douty would turn to the reports and communicated papers of the International Society " Pour la Prophylaxie Sanitaire et Morale," of which the French Society he refers to is an offshoot-volumes which certainly ought to be found on the shelves of every medical library-he would find this subject discussed from every point of view, would find the very greatest anxiety on the part of medical men to introduce notification as a means of ensuring treatment, and would find
an
them
constantly recognising at the same time that to introduce such a measure is to drive the patient away from the medical man who will notify him to the quack who will not, or to nostrums with which he can treat himself, and that the measure is therefore worthless unless accompanied by the most drastic provisions for the discovery and dragooning of these patients--provisions either ludicrously incapable of application or which have been applied again and again with the same result, the continued increase of disease. The result of long experience on the continent comes to this, " that compulsory treatment, while it fails to ’’ stamp out" syphilis. does stamp out voluntary treatment in any class to which it is applied. Accordingly, in Italy, where they havenow established a vast system of gratuitous treatment, they are doing away with compulsory treatment even of the lowest class of woman in the belief that the voluntary system will prove more efficacious. In England, on the other hand, the Physical Deterioration Committee of last year, adopting the view expressed by Sir Victor Horsley and some others, recommended an inquiry with a view to two measuresnotification and the provision of gratuitous treatment. Now it is obviously of the greatest importance that there should be adequate provision for the treatment of thesepatients and every inducement to seek it, and the fact of such provision being made by the State would doubtless. attract patients and make early and prolonged treatment much more common ; but to introduce at the same time a measure like notification with its necessary corollary of compulsory detention or supervision is precisely the way to drive the willing patient from the doorstep and make the outlay incurred in providing gratuitous treatment a mere waste of public money. Those who advocate these measures have not considered what they mean from the point of view of the patient. They mean that from the first confession of syphilis the patient ceases to be a free agent and we may be very sure that where this is the case the confession will not be lightly made. I am not without sympathy for the impatience of medical men who, like Dr. Douty, see this scourge raging around them and are ready to seize on any weapon which seems to offer the means of combating it. But experience proves that this is a matter in which it is fatally easy to make things worse in trying to make them better. Bad as things are at present, they are in England, by every test that can be applied, steadily becoming less bad, and however desirable it may be to hurry improvement it is still more desirable not to risk checking it. As to sanatoriums for syphilitics, while fully recognising the value of fresh air in thee cases it has to be remembered that people of the comfortable classes can get fresh air without sanatoriums and that people of the not-comfortable classes mostly have families to support. Sanatoriums, whether for tuberculosis or syphilis, can afford only a very limited remedy and it seems almost like a satire on our civilisation to take here and there one out of our overcrowded, underfed, and drink-sodden population, feed him up for a few months with good food and fresh air, and then send him back to the old conditions. The garden city and the farm colony are surely a truer prophylactic. As to education, the continental experts are absolutely agreed. It is the first thing to be done. With your permission I should like to say a few words on this subject in another letter. I
am.
Sirs-
vours
faithfullv. B.
LEPPINGTON,
Oxford, April
Member of the International 10th, 1905.
SHOCK
AND
Prophylactic Society.
COLLAPSE.
To the Editors of THE LANCET. SIRS,-Dr. C. Powell White in his letter in THE LANCET of April 15th, p. 1029, says that I haveproduced no evidence that increased atmospheric pressure is of value in the treatment of shock and that the statement rests upon my assertion alone. He has evidently not read my lectures very carefully or he would hardly make such a statement. A series of careful experiments to prove this point were carried out by Crile and are referred to in my second lecture on p. 782. The experiments themselves are recorded in Crile’s book, "Blood Pressure in Surgery." Dr. White asks me to explain how the vaso-motor system is able to compensate for variations in external pressure. I thought I had already explained this in my lectures. Compensation is obtained by alterations in the calibre of the blood-vessels-that is to say, the vaso-motor centre compensates for external influences by altering the capacity of