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Annotations. A NEW RESEARCH HOSPITAL. "Ne quid nimis." A DRASTIC change in the scope and purpose of any charitable institution must have parliamentary sanction and past subscribers may be assured that this would be withheld unless the alteration was warranted by a change in the needs of the population served. The fact that an Enabling Act was passed in May of this year, allowing responsible authorities of the Mount Vernon Hospital, Northwood, to use their lands and investments for the investigation and treatment of malignant disease instead of for diseases of the chest is an indication of such a change. In recent years the establishment of sanatoriums by local authorities has so diminished the number of patients applying for admission to the hospital that its council, with the full consent of the medical staff, sought and obtained permission to turn their efforts in a new direction. A scheme of work and development, framed with the help of experts, has been generally approved and is being put into speedy effect. The council of management of the hospital on which the medical staff is represented is being assisted by an advisory committee whose duties will be to give advice on the staffing of the hospital, on medical and scientific matters, and on the forms of treatment and research to be undertaken in the hospital. The new organisation differs in many important points from that of hospitals not primarily dedicated to investigation. A whole-time director of research is to be appointed to devise and coordinate schemes of work and the appointments of the honorary staff will be subject to annual consideration in accord- ance with the particular object of the hospital’s re- search into various treatments for malignant disease. The survey of the history of this hospital and the reasons for its reconstruction, given on another page, is of more than local import. The same sequence of events might equally well have occurred in the life of any hospital designed to treat cases of infectious disease which are now for the most part being dealt with effectively in rate-supported institutions. Some will regret the change, but it may be a prototype of other changes and may point the way to the sound allotment of work between voluntary hospitals and those organised and supported by the local authori- ties. Routine treatment of disease by established methods can be carried out safely in any well-conducted hospital. The critical investigation of pathological processes and the assessment of the scope and limita- tions of methods of combating them is essentially work to be carried out in a hospital designed for the purpose. Medical students would, in an ideal state, ’, have access to both types of hospitals, though not necessarily at the same stage of their careers. The conversion of the Mount Vernon Hospital to other purposes from those which it was intended to serve is not likely to be an isolated one. ERROR IN DIFFERENTIAL BLOOD COUNTS. THAT even in the most carefully prepared blood smear the white cells are far from being evenly distributed is recognised by everyone who has ever looked at such a preparation. That the various classes of white cells alter in their distribution in different portions of such a smear is well known to all who study them with any closeness. And that these facts must have a disturbing effect in a differential count of white cells is self-evident. Most workers have been content to do as best they can by the random selection of a few fields in a smear ; others, following Naegeli, have tried to reduce the error by counting up to a thousand cells. Meanwhile, the laws governing I distribution of the white cells in a smear have not come in for much careful consideration, and this is an omission which Curt Gyllensward, of Stockholm,1 has tried to remedy. His results are reported in a very long paper which bristles with formidable calculations and should be consulted in the original by those interested. In brief, it may be said that he condemns the cover-slip method of preparation, and recommends that form in which the blood is smeared on a microscope slide by drawing a second slide along its length. In such preparations, however, the smaller cells tend to be deposited more quickly than the larger cells as the movement of the blood over the receiving slide decreases. The result of this is the formation, at the top and bottom of the slide and in the " tongue " at the end, of " zones " of lymphocytes, neutrophiles, eosinophiles, and mono- cytes. Counts conducted in these zones may show a relative distribution of the different classes of cells very different from that which obtains in the circu- lating blood. To avoid the influence of such zones Gyllensward recommends that in making a differential count the first and the last five millimetres of the smear should never be included, and that the count should be made on the central portion of the slide in transverse travels. If these precautions are taken he finds no advantage in including more than 300 white cells in the count. BISMUTH IN THE TREATMENT OF SYPHILIS. EVER since bismuth was introduced into the treatment of syphilis in 1921 it has been regarded almost universally as a valuable spirochseticidal drug. From time to time, however, a voice has been raised to question the advisability of using it in place of the older remedies, mercury and arsenic. In 1927 2 Dr. T. Anwyl-Davies discussed the action of bismuth on the Spirochceta pallida and, following the conclusions of W. Kolle and his collaborators, declared that bismuth had no direct curative action on the infection but merely inhibited the disease. Kolle’s experiments and Anwyl-Davies’s conclusions were discussed and strongly contested by Dr. C. Levaditi and Dr. L. Fournier.3 We publish this week and last two further papers on the subject and a report of the discussion at the Venereal Diseases Section of the British Medical Association at Manchester last July. Dr. T. M. Ling has been working at St. Thomas’s Hospital with bisoxyl, a suspension in water of bismuth oxychloride and chloretone. Subcutaneous injection of this preparation does not lead to the persistent pain and swelling characteristic of many forms of bismuth, and Dr. Ling has found it extremely useful in congenital syphilis, especially in lues tarda. He suggests that the spirochaete can acquire resistance to arsenic and mercury after prolonged treatment, and that in cases of this kind bismuth, without causing any untoward symptoms, will render serologically negative a fair proportion of apparently Wassermann- fast patients. Prof. H. Ritter and Dr. C. L. Karren- berg have been working at Hamburg with intra- muscular injections of bismogenol, a suspension of a bismuth compound of a highly valent oxybenzoic acid in olive oil. They have found this eminently satisfactory, and declare that it has an abortive action on the disease. A number of patients have been treated by bismuth exclusively. The case for bismuth is strengthened by these new reports. Prof. Ritter and Dr. Karrenberg suggest that many of the objections alleged against it depend on the very inadequate knowledge that the physician has of the exact amount of bismuth metal he is giving and its fate in the body. They also point out that the criteria for a successful antisyphilitic remedy are by no means standard. The amount of bismuth varies extraordinarily in different preparations and 1 Acta Pædiat., 1929, vol. iii., Suppl. ii. 2 THE LANCET, 1927, i., 148, 199. 3 Ibid., 1928, i., 692.
