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The War and After.
817 of influenzal
pneumonias (more than in pneumonias of other causation) by the introduction of air into the pleural cavitythe commonly bilateral distribution, the solid condition of the diseased lung, the tendency of the air to rise to the highest point, &c., and these call for ingenuity, though they do not present insuperable obstacles. This letter, however, was not written to discuss the pneumothorax treatment of to point out that the beneficent effect pneumonia, but only no new discovery, and that its explanaof lung-puncture is tion is probably other than that put forward in the interesting and useful paper which appears in your current issue under the above
heading.-
I am, Sir, yours
Queen Anne-street, W., May 4th, 1919.
faithfully, RiVIERE. CLIVE RIVIERE. OLIVE
THE LITERATURE OF HÆMATOLOGY. To the Editor
(If THE LANOET.
SIR,-I am endeavouring to make a collection of reprints, of papers on all aspects of hsematology. These will be filed and indexed and may, I hope, be of permanent value. May I ask those interested in this subject to be so good as to let me have any reprints they can spare, on either the clinical or experimental aspects of disorders of the blood. I am, Sir, yours faithfully, GORDON WARD. The Vine, Sevenoiks, Ap’i1 30th, 1919.
practically useless"is only true in so far that can be definitely said to be non-syphilitic. Very many chancres can, however, with absolute certainty, be diagnosed as syphilitic on their appearance alone. Captain Gibson’s standard of cure for gonorrboea is an unusual one, and probably most venereologists will prefer
to
be
no sore
Mr. Frank Kidd’s as stated in his excellent little book on "Common Diseases of the Male Urethra." Usually when, after massage of the prostate, pus cells are found in the fluid expressed, this is considered an ominous sign, while a few staphylococci in the urine are not considered to be of much import. Captain Gibson’s standard of complete absence of all organisms from the urine after prostatic massage seems to show that he considers a staphylococcus more suggestive than pus cells. Captain Gibson’s conclusion that the germicidal properties of potassium permanganate are almost negligible, Npeeially as regards the gonococcus, think that comes as a shock to those accustomed to potassium permanganate and silver salts have an almost selective action on the gonococcus, and who only use oxycyanide of mercury for mixed infections. It is worthy of note that Colonel Harrison, with his very extensive experience of all irrigating fluids, including Ravine, still considers potassium permanganate the best disinfectant for routine use. Gonococcus strains vary so much in virulency that many experienced observers would not think it safe to recommend initial doses of 20 to 50 millions. Captain Gibson’s remarks concerning prostatic massage and complete irrigation in acute prostatitis and acute epididymitis seem to suggest that he does not consider such treatment absolutely contraindicated, which is the view held by nearly all writers on the subject. Captain Gibson concludes by saying" one has sometimes to prescribe action is to sandal oil as a placebo, but its only upset the digestion." That the balsams do not cure gonorrheea is now universally admitted, but there can be few who have not experienced the marked palliative effect of sandalwood oil in very acute inflammation of the mucous membrane of the urethra or bladder I am, Sir, yours faithfully, HUGH WANSEY BAYLY. W., Harley-street, May 6th, 1919.
DIAGNOSIS
LABORATORY METHODS AND THE OF VENEREAL DISEASES. To the Editor
ot THE LANCET. I be SIR,-May permitted to make a few remarks on two articles dealing with venereal disease that appeared in your issue of May 3rd, one on "Primary Syphilis," by Staff Surgeon S. F. Dudley, R.N., and the other on the " Treatment of Gonorrhoea," by Captain H. E. Gibson, R.A.M.C. (T.F.). Staff Surgeon Dudley considers that it is a great advantage that the same medical man should undertake both the laboratory and clinical work, a point emphasised in regard to dark-ground examinations for Spiroehaeta pallida, by Colonel L. W. Harrison in his valuable work on venereal diseases, and by myself in an article in your columns.l If, however, the doctor in charge of the clinic has had no special training and experience in clinical pathology, probably it would’ be better to leave the blood examinations to a clinical pathologist, as the Wassermann reaction is almost valueless unless carried out with great care by an experienced person. Staff Surgeon Dudley thinks that "many medical men fail to realise the overwhelming superiority of laboratory methods in the early diagnosis of syphilis." In this I cannot agree with him. As I was early in preaching the gospel of the value of laboratory methods of diagnosis it is unlikely that I should now undervalue their importance. Probably, however, the present-day tendency is to put too great faith in laboratory findings and to unjustifiably decry the value of clinical experience in diagnosis. Staff Surgeon Dudley’s statistics are based on the assumption that a positive Wassermann reaction alone and unsupported by other evidence is certain proof of syphilis, an assumption which I consider cannot be accepted.2 Staff Surgeon Dudley says that"a result is .not called positive unless almost eomplete inhibition of haemolysis has taken place.’’ When using the original technique, unless the reaction is strongly positive with complete inhibition of haemolysis, it cannot be accepted as positive evidence of syphilitic infection, and even a strong positive is not pathognomonic. My experience of galyl is not the same as Staff Surgeon Dudley’s, as I have had many more relapses after galyl than after the other preparations, and the Spirookeeta pallidtz can frequently be found in scrapings of the chancre 24 hours after a galyl injection, whereas spirochastse have practically always entirely disappeared after injection with other preparations. Staff Surgeon Dudley’s conclusion that "two or three doses of salvarsan followed by a long course of mercury is a good routine treatment" must be received with caution in view of the very large amount of evidence in favour of a routine course of 6 or 7 injections of arsenobenzol preparations, except when signs of intolerance occur. The statement that "clinical diagnosis is so uncertain as 1
THE
LANCET, Nov. 3rd, 1917. May 4th, 1918.
2 THE LANCET,
apparent
THE MEDICAL PARLIAMENTARY COMMITTEE. To the Editor of THE LANCET. of the Medical Central Hall, stated in the 20 per cent. of the coopted members of the Permanent Medical Parliamentary Committee not more than one-quarter should be engaged in general practice; this is a serious mistake. It should read, "not more than one-quarter of the coopted members should be engaged in (Consulting work." We should be greatly obliged if you would kindly publisb this in your next issue.-Yours faithfully,
SiR,-In the reports of the Conference Parliamentary Committee held at the Westminster, on May 2nd, 1919, it was Morniuag Post and the Times that of the
ARTHUR
LATHAM,
CHARLES BUTTAR, Hon. Secretaries.
20, Hanover-square, London, W.1, May 6th, 1919.
The War and After. THE CASUALTY LIST. THE name of the fol10wiog medical officer appears among the casualties announced since our last issue :Prm:iou"ly Reported Missing, giore Reported Killed. Capt. J. M. Evatt, R.A.M.C., attached R.F.A., was a student at University College Hospital, London, and qualified in 1913. He held an appointment at the hospital, and afterwards joined the R.A.M.C.
CASUALTIES
AMONG THE
SONS OF MEDICAL MEN.
The following additional casualties among the so is of medical men are reported :Capt. W. N. Gale. York and Lancaster Regiment, previously reported missing, now believed killed in May, 1917, elder son of Dr. A. K. Gale, of Norton Woodseats, Sheffield.’ Capt. E. M. Knott, A.F.C., R.A.F., died of wounds, only son of Dr. E. M. Knott, of Sutton Coldfield, Birmingham.
’
pneumonias (more than in pneumonias of other causation) by the introduction of air into the pleural cavitythe commonly bilateral distribution, the solid condition of the diseased lung, the tendency of the air to rise to the highest point, &c., and these call for ingenuity, though they do not present insuperable obstacles. This letter, however, was not written to discuss the pneumothorax treatment of to point out that the beneficent effect pneumonia, but only no new discovery, and that its explanaof lung-puncture is tion is probably other than that put forward in the interesting and useful paper which appears in your current issue under the above
heading.-
I am, Sir, yours
Queen Anne-street, W., May 4th, 1919.
faithfully, RiVIERE. CLIVE RIVIERE. OLIVE
THE LITERATURE OF HÆMATOLOGY. To the Editor
(If THE LANOET.
SIR,-I am endeavouring to make a collection of reprints, of papers on all aspects of hsematology. These will be filed and indexed and may, I hope, be of permanent value. May I ask those interested in this subject to be so good as to let me have any reprints they can spare, on either the clinical or experimental aspects of disorders of the blood. I am, Sir, yours faithfully, GORDON WARD. The Vine, Sevenoiks, Ap’i1 30th, 1919.
practically useless"is only true in so far that can be definitely said to be non-syphilitic. Very many chancres can, however, with absolute certainty, be diagnosed as syphilitic on their appearance alone. Captain Gibson’s standard of cure for gonorrboea is an unusual one, and probably most venereologists will prefer
to
be
no sore
Mr. Frank Kidd’s as stated in his excellent little book on "Common Diseases of the Male Urethra." Usually when, after massage of the prostate, pus cells are found in the fluid expressed, this is considered an ominous sign, while a few staphylococci in the urine are not considered to be of much import. Captain Gibson’s standard of complete absence of all organisms from the urine after prostatic massage seems to show that he considers a staphylococcus more suggestive than pus cells. Captain Gibson’s conclusion that the germicidal properties of potassium permanganate are almost negligible, Npeeially as regards the gonococcus, think that comes as a shock to those accustomed to potassium permanganate and silver salts have an almost selective action on the gonococcus, and who only use oxycyanide of mercury for mixed infections. It is worthy of note that Colonel Harrison, with his very extensive experience of all irrigating fluids, including Ravine, still considers potassium permanganate the best disinfectant for routine use. Gonococcus strains vary so much in virulency that many experienced observers would not think it safe to recommend initial doses of 20 to 50 millions. Captain Gibson’s remarks concerning prostatic massage and complete irrigation in acute prostatitis and acute epididymitis seem to suggest that he does not consider such treatment absolutely contraindicated, which is the view held by nearly all writers on the subject. Captain Gibson concludes by saying" one has sometimes to prescribe action is to sandal oil as a placebo, but its only upset the digestion." That the balsams do not cure gonorrheea is now universally admitted, but there can be few who have not experienced the marked palliative effect of sandalwood oil in very acute inflammation of the mucous membrane of the urethra or bladder I am, Sir, yours faithfully, HUGH WANSEY BAYLY. W., Harley-street, May 6th, 1919.
DIAGNOSIS
LABORATORY METHODS AND THE OF VENEREAL DISEASES. To the Editor
ot THE LANCET. I be SIR,-May permitted to make a few remarks on two articles dealing with venereal disease that appeared in your issue of May 3rd, one on "Primary Syphilis," by Staff Surgeon S. F. Dudley, R.N., and the other on the " Treatment of Gonorrhoea," by Captain H. E. Gibson, R.A.M.C. (T.F.). Staff Surgeon Dudley considers that it is a great advantage that the same medical man should undertake both the laboratory and clinical work, a point emphasised in regard to dark-ground examinations for Spiroehaeta pallida, by Colonel L. W. Harrison in his valuable work on venereal diseases, and by myself in an article in your columns.l If, however, the doctor in charge of the clinic has had no special training and experience in clinical pathology, probably it would’ be better to leave the blood examinations to a clinical pathologist, as the Wassermann reaction is almost valueless unless carried out with great care by an experienced person. Staff Surgeon Dudley thinks that "many medical men fail to realise the overwhelming superiority of laboratory methods in the early diagnosis of syphilis." In this I cannot agree with him. As I was early in preaching the gospel of the value of laboratory methods of diagnosis it is unlikely that I should now undervalue their importance. Probably, however, the present-day tendency is to put too great faith in laboratory findings and to unjustifiably decry the value of clinical experience in diagnosis. Staff Surgeon Dudley’s statistics are based on the assumption that a positive Wassermann reaction alone and unsupported by other evidence is certain proof of syphilis, an assumption which I consider cannot be accepted.2 Staff Surgeon Dudley says that"a result is .not called positive unless almost eomplete inhibition of haemolysis has taken place.’’ When using the original technique, unless the reaction is strongly positive with complete inhibition of haemolysis, it cannot be accepted as positive evidence of syphilitic infection, and even a strong positive is not pathognomonic. My experience of galyl is not the same as Staff Surgeon Dudley’s, as I have had many more relapses after galyl than after the other preparations, and the Spirookeeta pallidtz can frequently be found in scrapings of the chancre 24 hours after a galyl injection, whereas spirochastse have practically always entirely disappeared after injection with other preparations. Staff Surgeon Dudley’s conclusion that "two or three doses of salvarsan followed by a long course of mercury is a good routine treatment" must be received with caution in view of the very large amount of evidence in favour of a routine course of 6 or 7 injections of arsenobenzol preparations, except when signs of intolerance occur. The statement that "clinical diagnosis is so uncertain as 1
THE
LANCET, Nov. 3rd, 1917. May 4th, 1918.
2 THE LANCET,
apparent
THE MEDICAL PARLIAMENTARY COMMITTEE. To the Editor of THE LANCET. of the Medical Central Hall, stated in the 20 per cent. of the coopted members of the Permanent Medical Parliamentary Committee not more than one-quarter should be engaged in general practice; this is a serious mistake. It should read, "not more than one-quarter of the coopted members should be engaged in (Consulting work." We should be greatly obliged if you would kindly publisb this in your next issue.-Yours faithfully,
SiR,-In the reports of the Conference Parliamentary Committee held at the Westminster, on May 2nd, 1919, it was Morniuag Post and the Times that of the
ARTHUR
LATHAM,
CHARLES BUTTAR, Hon. Secretaries.
20, Hanover-square, London, W.1, May 6th, 1919.
The War and After. THE CASUALTY LIST. THE name of the fol10wiog medical officer appears among the casualties announced since our last issue :Prm:iou"ly Reported Missing, giore Reported Killed. Capt. J. M. Evatt, R.A.M.C., attached R.F.A., was a student at University College Hospital, London, and qualified in 1913. He held an appointment at the hospital, and afterwards joined the R.A.M.C.
CASUALTIES
AMONG THE
SONS OF MEDICAL MEN.
The following additional casualties among the so is of medical men are reported :Capt. W. N. Gale. York and Lancaster Regiment, previously reported missing, now believed killed in May, 1917, elder son of Dr. A. K. Gale, of Norton Woodseats, Sheffield.’ Capt. E. M. Knott, A.F.C., R.A.F., died of wounds, only son of Dr. E. M. Knott, of Sutton Coldfield, Birmingham.
’