IS THERE A PSEUDO-DIPHTHERIA BACILLUS72 1922 the whole goes withouti which some sanitarians contrive to infuse into discussions of the kind and it w...

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1922 the whole

goes withouti which some sanitarians contrive to infuse into discussions of the kind and it will have to be carried on unhampered by But to the question: What is the explanation of the senseless formulae and unlimited by meaningless definitions. I am, Sirs, yours faithfully, tremendous fact that, in spite of the giant strides which EDWARD DEAN MARRIOTT. municipalities have been making in the direction of im- Nottingham, Dec. 22nd, 1900. the lavish in of conditions; spite spendingproved sanitary not to say squandering-of public money on everything which holds out the least hope of sanitary betterment ; IS THERE A PSEUDO-DIPHTHERIA in spite of the great army of sanitary officials which is BACILLUS? exerting itself to the utmost to improve the public health, To Edit0’l’8 the of TH:8I LANCET. .an authority is able to tell us to-day that scarlet fever is in town the United It endemic in every large Kingdom. SiRs,-The report of Dr. J. Priestley, summarised in will be granted that the contagious element of scarlet fever THE LANCET of Dec. 22nd (p. 1821), deals with a ques-the materies morbi-is always derived from a previous case. tion of very great importance-namely, the possibility If, then, isolation be the remedy the aggregation of 93 per of distinguishing between the organisms of diphtheria cent. (practically all) of notified cases must succeed in and pseudo-diphtheria for the purposes of clinical diatamping out the disease at no distant date. If this end is gnosis. The question briefly amounts to this: Is it not attained why is it not attained ?7 Is it not a reasonable possible, in the time allowable for useful clinical dia,presumption that the explanation will be found in the con- gnosis, to distinguish between these two with any degree tinued infectivity of hospital discharged patients ?7 But we ’, of certainty justifying a negative report as to the existence are told that the number of persons who receive their ’, of diphtheria?2 The question has been constantly before infection through the medium of the hospital is so small that me during the last 12 months in which I have examined ,it may be regarded as a quantite nggligeable. This notion is so I cultures from some 1800 throats made in connexion with the preposterous that one cannot help a feeling of astonishment securing of the Greenwich Royal Hospital School against an that medical scientists have allowed themselves to be outbreak of diphtheria. In only two or three of this number ’blinded by a definition so stupid and mischievous have I been able to identify anything as morphologically " .as the accepted definition of a return" case. Dr. Tonkin, identical with Hoffmann’s bacillus, and I certainly do not who errs in good company, informs us that " the dangerous believe it to be wise or right to act upon sucha presumption I to the extent of cases are from 2 to 5 per cent." A case, therefore, treating such cases as non-infectious. it at is not case because does a not no one appears to take such a line, which is as much slays large dangerous Indeed, .conform with the postulate laid down that a "return"" i as to say that those who identify the organism in question, case must arise in the home. As a matter of myself among the number, have not the courage of their the definition, trammelled as it is by limits of place convictions and dare not take the responsibility of acting and time, does not give a scintillation of the extent of upon their opinions. Moreover, it appears to be generally injury inflicted by these institutions. A discharged admitted that the one organism may be converted into the. ,patient may sow the disease broadcast and for various other. Surely this is to give up the whole position and to and obvious reasons leave the home untouched. It fre- introduce a heresy which may attain very dangerous proporquently happens that the other inmates of the home have tions. In order to preserve a distinction between two had a mild, though temporarily protective, attack immeorganisms, it must be shown that they are at all times and diately precedent to the removal of the only well-marked under all circumstances incapable of transmutation. If case to the hospital. There may be no other children in the ever one can turn into the other, then the only logical home, or, if there are, these may have been protected (in deduction is that they are essentially identical. so far as one attack does prevent the occurrence of another) Dr. R. T. Hewlett, who has studied this subject exhaustively, by previous attacks, or may be naturally immune. after giving a careful tabular statement of the differences Dr. Tonkin thinks that the continued infectivity of the between the two organisms, makes the damaging admission home (after removal) may account for some of the cases referred to, the apparent possibility of conversion, and just which pass for return cases. If this be the case no conclusive one of the tests which he furnishes is capable ’he has advanced a second argument against removal ; of within the time at the disposal of a clinical application but new centres of infection are being constantly investigator. This being so, it seems plain that it is the "established by discharged patients who go elsewhere than duty of every person who bears responsibility in this respect to their own homes. Cases in point : 1. The relative of a to refrain, when an organism morphologically resembling distinguished professional man resident here went straight the diphtheria bacillus is found in a culture, from stating ’from the hospital to her home in a distant county, where she that the organism so found is not a dangerous one. promptly spread the disease. 2. A little girl called on her The whole matter is, as I have said, summed up in the one way home from the hospital at the house of a relative, statement which I desire to emphasise in every possible where she played for 20 minutes with her cousin. In a few way-namely, that if there be a possibility ot converting the days the cousin sickened and was presently dead from scarlet pseudo-diphtheria bacillus into the diphtheria bacillus, then fever. 3. A well-known tradesman was asked by a Derby there is no such thing as a pseudo-diphtheria bacillus at aU, friend to receive the son of the latter into his home for a and this is, I confess, my own present position. few weeks’ change, the son being a recently discharged I am, Sirs, yours faithfully, The only .patient from the Derby Isolation Hospital. EDWD. C. BOUSFIELD, OUSFIELD, child of the host sickened a few days after the advent Dec. 22nd, 1900. Bacteriologist of the Borough of Camberwell. of the guest and died at the end of a fortnight. Not one of these cases, be it understood, fulfilled the conditions of a "return" case. They burden no annual reports and THE OPERATION OF CIRCUMCISION. find no place in tabulated returns anywhere. They go, howTo the Editors of THE LANCET. ever, to swell the lists of notified cases and we find them SIRS -Mr. D’Arcy Power, in his interesting paper on again in the Registrar General’s returns. Your correspondent says that these questions will have to be discussed and de- Some Disappointments of Surgery, makes the following termined in the near future, and in that event graciously very apposite remarks :-" There are few operations more credits me with having accomplished some little good. I am often performed than those of circumcision and for hare-lip, obliged to him. When the investigation takes place it will yet there are few which may give more disappointing be found that other questions which have not been raised by results. The aim of a perfect circumcision is to remove this discussion will assume great importance. Amongst just so much of the foreskin as is necessary to liberate these the high mortality rate of hospital-created cases the glans penis and to avoid removing so much as to leave and the occurrence and mortality rate of cases of the patient a ’eurt1tS Judaeus.’ Such a perfect operation is secondary infection will have to come under discus- rare, but I do not recollect that the difficulties were ever -sion. We shall also want to know a little more about pointed out to me." It is undoubtedly true that sucha perfect that formidable disease, post-scarlatinal diphtheria, the operation is rare, but why is this the case1 The fact is that incidence of which is dependent on life in hospitals and the circumcision is generally regarded as a very simple operation mortality of which is 58’3 per cent. as against the 30’4 per and one which any surgeon feels competent to undertake, cent. of cases of ordinary diphtheria. The discussion of but if one may judge from a good many cases which come questions of such serious import to us as a nation will have -to be approached in a spirit somewhat different from that 1 THE LANCET, Dec. 22nd, 1900, p. 1789. case

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