136

solution it has a higher osmotic pressure than plasmaand its viscosity though less than that of whole blood isgreater than that of plasma, enabling a higher blood-pressure to be attained. Taylor and Waters haverecorded favourable results when using isinglass to re-place lost blood in dogs and maintain that in manycases the dogs’ lives were saved by it. Their solutioncontains 7% of isinglass, 0-25% of sodium bicarbonateand 0-75% of sodium chloride in distilled water. This issaid to be isotonic and has a pH of about 7-2. They arecareful to point out that the fate of isinglass in the bodyis not known though they believe that it may be usedby the tissues. If this is the case a valuable substitutefor blood will have been discovered. It seems, however,that rather than new substitutes what is required is anefficient manufacturing, distributing and clinical organi-sation, so that those materials which are already availablemay be used to better advantage.

PRESENT POSITION OF VENEREAL DISEASETHE possibility of an increase of venereal disease in

war-time is an inevitable source of anxiety to all whoremember the black record of previous wars. No doubtthis was in the mind of those who organised the meetingof the Medical Society for the Study of Venereal Diseaseson July 26 when Colonel L. W. Harrison utilised hispresidential address to consider the present trend ofincidence of venereal diseases in England and Wales.No-one is better fitted to review the situation than ColonelHarrison by reason of his length of experience and hisbreadth of outlook. He struck a reassuring note at theoutset by pointing out that since the outbreak of warvenereal diseases have not increased to anything likethe extent which we feared. As regards syphilis, beforethe war we had good reason for believing that the greatmajority of early infections in civilians coming undermedical care in this country were being dealt with inthe treatment centres. A suspicion that undetectedsyphilis might be rife in country districts far from treat-ment facilities had been disproved by the fact thatalthough they had since the war been infiltrated withservice personnel, munition workers and evacuees theyhad not been found hot-beds of venereal disease.

In a comprehensive review Colonel Harrison showed thatin 1939 the number of cases of early syphilis dealt withfor the first time at the civilian centres in England andWales was 4986, a decrease of some 45% since 1931 andless than a third of the number in 1920. Collateralevidence of this decline was found in the diminishingrole of syphilis in killing infants ; their death-rate fromthis cause had fallen from 2-03 per 1000 in 1917 to 0-2 in1939. As regards service infections, the admission-ratefor syphilis in the Navy stationed at home fell from 8-1 per1000 per annum in 1921 to 1-96 in 1936, the latest yearfor which published figures are available. In the Armyat home the syphilis rate fell from 9-8 per 1000 per annumin 1921 to 0-9 in 1937. In the Air Force during the sameperiod the rate for primary and secondary syphilis fellfrom 4.1 to 0.5. There are other causes at work in

diminishing venereal infection among recruits, but thehigher rates in stations abroad suggest that the declineis some index of the improvement in the position athome. Returns from civilian clinics indicated, saidColonel Harrison, that from the outbreak of war up tothe end of March, 1940, the fall in the syphilis rate sloweddown ; during the last twelvemonth there has been adefinite increase among both males and females. As aresult of all his calculations Colonel Harrison came tothe conclusion that male syphilitic infections had in-creased in England and Wales in 1940 by about 27%and that the total increase in both sexes was about 23%.

Civilian cases of gonorrhoea were fewer but whenservice cases were added the total males showed anincrease of 9-10%. It was, he thought, disturbing tofind that the centres had dealt with fewer females in

1940 in spite of the clear evidence of increased incidencein the males. On the other hand, as Colonel Harrisonand subsequent speakers recognised, the modern drugtreatment of gonorrhoea has made recourse to privatepractitioners so much more common that clinic statisticsfor this disease are now a very imperfect indication ofincidence and comparisons with previous years are

fallacious: Where, he asked, was this increase ofvenereal disease occurring and is the existing system oftreatment centres sufficient I The best informationavailable comes from the lists of places where servicemen stated they contracted the disease. The over-

whelming majority of places where more than 10 infec-tions had occurred were already provided with treatmentcentres. Nevertheless the details showed that a gooddeal of sporadic infection was occurring in places out ofrange of the clinics. And yet in some places whererelatively heavy infections of service men had takenplace the number of females dealt with had actuallydeclined. From October, 1940, the Ministry of Healthhad been in a position to refund local authorities three-quarters of the approved cost for new treatment facili.ties ; 16 new centres are being set up as a result of thisoffer and 14 county authorities are making arrangementswith practitioners to treat cases in their own surgeriesin areas where the amount of disease does not justifythe establishment of a clinic. Colonel Harrisonattached considerable importance to this new departurewhich is to be supervised by the county V.D. consultants ;it would go far, he hoped, to solve the problems of ruralareas. Later speakers from the services and civilianclinics supported the evidence of slight increase only invenereal diseases except in the ports much frequentedby foreign seamen where a substantial rise had beennoted locally. In the Army at home the incidence hadbeen curiously uniform week by week, and the totalV.D. rate has fallen from 11-3 per 1000 in 1938 to 8-7 per1000 in 1940 and 8-4 per 1000 in the first five months of1941. The ratio of gonorrhoea to’syphilis has remainedremarkably steady at 8 to 1. Everything possible isdone to ensure that V.D. is treated as far as possible likeany other disease. In the Navy, it was stated, thepresent return of syphilis is the lowest on record. TheR.A.F. can also claim a very low incidence of bòthdiseases, the total ratio being 6-3 per 1000. Two

representatives of the medical services of the A.T.S.and W.R.N.S. said that the amount of V.D. amonguniformed women was negligible, though every practic-able effort was made to encourage ascertainment andpromote treatment. There was in fact much cause inthis survey for thankfulness for the results achieved inthe past quarter of a century but no excuse for slackeningof effort if the ground won is to be maintained. Therural areas certainly need more attention, for soldiers’wives are becoming infected and both knowledge andsympathy are required for the organisation of rural clinics.

Admittedly the weak spot in our measures of controlis the failure to bring under treatment sufficient females.In this Colonel Harrison was strongly supported by thespokesmen of civilian clinics who found that even incountry districts the " vicious amateur " forms a

dangerous focus of disease and remains impervious toreason and education. Is any form of compulsionpracticable ? Though no vote was taken the meetingappeared to be unanimously of the opinion that it was.Suggestions for compulsory notification or treatment ofvenereal -disease have been vigorously opposed in thepast, partly because they recalled the ill-inspired Con-tagious Diseases Acts and regulation 40D of the lastwar, partly because it appeared impossible to devise ascheme equitable as between the sexes and free from thedanger of injustice to individuals. If improved methodsof diagnosis and administration can enable local authori-ties to eliminate the hard core of recalcitrant offenderswithout injury to the public a great advance will have

137

been made in the campaign against venereal disease.The benefit to the coming generations would itself

justify the Minister of Health in testing medical opinionon the point.

CLOSE-UP OF SPERMATOZOA

THE electron microscope, which gives effective magni- JL

fications of 50,000 or more diameters, and has alreadytold us much about bacterial appearances under electronbombardment, has lately been turned on the sperma- E

tozoon in the hope of resolving some of the outstanding (doubts about its structure. In this apparatus magnetic- ]field " lenses " replace the glass ones of compound 1

microscopes and differentiation depends on differences in J

density within the specimen rather than on variation inrefractive indices or colour. The conditions for examin-

ing specimens by electron microscopy are importantbecause the vacuum, the drying of the specimen or eventhe electron bombardment itself may cause artefacts 1

which can masquerade as normal structure. It seems, <

however, that Seymour and Benmosche 1 have seen more i

clearly than hitherto a normal human spermatozoon <<and their pictures-three are needed to include a single sperm-have, at 13,500 and 27,000 diameters, clear-cut definition. At these magnifications the pear-shaped <<head of the human sperm has a crater-like notch on the <<vertex and within it a structure less opaque than therest of the head. The body of the spermatozoon, which (

when seen by refractive microscope was called the neck, :

is segmented, having 9-12 segments in the specimens ]examined. Throughout the length of the body runs acore, uniform in diameter and denser than the surround- 1ing segments, and it is this core which becomes the tail. 1The tail does not end abruptly but breaks up into ablurred smudge and it is much longer than has pre-viously been described. The belief that the body of thesperm contains a skein formation was not confirmed butthe segmentation probably explains the extraordinarymotility qf the head as it is propelled forwards. Withmotion pictures Seymour and Benmosche watched thehead of a spermatozoon penetrating the ovum in thefirst stage of fertilisation and they speculate on thepossibility of the notch on the vertex containing somesort of suction apparatus which helps penetration.

EXTRA MILK

THE medical certificate required under the Sale ofMilk (Restriction) Order, 1941, has come in for somecriticism, and the Ministry of Food is discussing possible alternatives with the B.M.A. Extra milk, up to a limit

-

of 2 pints a day, may only be recommended if the patientis suffering from (a) active tuberculosis ; (b) silicosis ; ,

(c) conditions in which the patient is unable to swallowsolids by reason of an affection of the mouth, throat or ]gullet ; (d) gastric, duodenal or anastomotic ulcer ; (e) :illnesses characterised by high and prolonged fever ; or

(f) the results of a major operation. This list was drawnup by the special diets committee of the M.R.C. andmust cover the majority of indications. It is question-able, however, whether the doctor should not have beenleft free to consider each case on its merits. On theother hand, it is an unenviable task to refuse milk tQ anypatient, and the doctor may sometimes be glad of suchdefinite grounds for refusal. The certificate when com-

’

pleted is handed by the householder direct to the milk-man. This is intended to simplify and hasten procedure,but many patients will object to their disabilities beingthus revealed to tradespeople. It would surely besufficient if the doctor stated that the patient wassuffering from one 01 the conditions on the prescribed listwithout specifying which. Members of the nationalmilk scheme, children receiving milk in schools, andpatients in hospitals and nursing-homes are excluded1. Seymour, F. I., and Benmosche, M. J. Amer. med. Ass. 1941,

116, 2489.

from the restrictions, and other people who are accus-tomed to drink a lot of milk will automaticallv have alarge ration, since this is calculated as six-sevenths ofthe previous consumption. The number of cases whichcannot be met by a little readjustment within the house-hold is therefore likely to be small.

Colonel (temporary Brigadier) ALEXANDER HOODsucceeds Lieut.-General Sir William MacArthur as

director-general of the Army Medical Services on Aug. 1.Brigadier Hood graduated from the University of

Edinburgh in 1910 and received a commission in theR.A.M.C. two years later.

SYSTOLIC MURMURS

IN his Honyman-Gillespie lecture in Edinburgh lastweek Prof. D. M. Lyon said that up to the end of lastcentury any cardiac murmur was usually taken toindicate heart disease. Then began a swing in theopposite direction and the study and significance ofmurmurs became derided. He believed that a balancewas necessary. Murmurs were produced when turbulencewas introduced into the blood-flow. This could becaused by changes in the speed of flow, or the viscosityof the fluid, and by constriction of the channel. Mereroughening of the surface of the channel did not produceeddying. Mitral systolic organic murmurs varied fromsoft gentle blowing sounds to loud rasping sounds accord-ing to the state of activity of the heart muscle. Themurmur of dilatation was softer and not so well propagated.Tricuspid systolic organic murmurs were relatively rare ;they were of higher pitch than mitral murmurs andpoorly propagated. In view of the reputation of thetricuspid valve as an escape valve it was surprising thattricuspid murmurs were heard so seldom. At theaortic valve organic narrowing was relatively rare andmost systolic murmurs were due to dilatation of theaorta along with thickening of the valve, especially theslight projection of a fibrous or calcified cusp. Pul-monary systolic murmurs were still rarer and most werecongenital. Functional murmurs were always systolicexcept for the murmur of pulmonary incompetencesometimes found in conditions of raised pulmonaryblood-pressure. They were mostly feeble and poorlyconducted. They were probably found in 3% of allrecruits and in 80% of athletes after severe exercise.In children various reports put the incidence at between10 and 60%. The cardio-respiratory murmur was heardalong the left border of the heart and beyond ; lessfrequently over the right side. It often occurred inhealthy persons. In quality it resembled interruptedbreath sounds of which it was really an accentuation.An interrupted puffing or whiffing sound was presentduring the whole of inspiration and might extend intoexpiration. It was usually heard best with the subjectin the upright position and stopped if he held his breath.Exercise increased its intensity which, however, wasvery variable at different examinations. Haemic mur-

murs were caused by turbulence due to decreasedviscosity of the blood ; they w re heard at both base andapex but the mechanism must be different-turbulenceof the flow at the aortic and pulmonary valves anddilatation of the mitral valve. Hsemic murmurs shouldnot be diagnosed in the absence of severe anaemia.When the heart was over-active or too rapid functionalmurmurs might be heard at the apex. These werecommon during excitement and in " soldier’s heart." Athrill might be palpable and the first sound appearrough. These features disappeared when the heart-ratefell and must not be taken as indicating mitral stenosis.The murmurs of hyperthyroidism and fever were of thesame nature. Pulmonary functional systolic murmurswere mostly faint and poorly conducted and were largelydue to slight variations in shape or deformity of thepulmonary vessels; that was apart from cardio-respiratoryand hsemic murmurs. - They were found largely inchildren and young people with plastic chest walls, andmight be produced by pressure of the stethoscope. Itwas important to remember the subclavian murmurheard beneath the clavicle when the arm was raised.