relapse in pulmonary tuberculosis

1266

of offering financial premiums-easily called bribes-to facilitate, in suitable cases, voluntary sterilisation,would have to be carried out with considerablecaution, and might, in view of the religious opposition,be followed by unforeseen complications.

Lastly, it is noteworthy that in none of the itemsof Clause 1 of the draft Bill is there any specificmention of sterilisation being applied to foreignraces, and I hope that Dr. Vellguth’s recommendationthat the measure be specifically imposed on Jewswill not be adopted. If the German nation as a

whole decides to discourage the propagation of Jews,that is its affair. But let it not be alleged, on themost dubious scientific grounds, that such a measurehas a eugenic justification. It is very difficult tofind satisfactory evidence as to the harmful effectsof a moderate mixture of races as nearly allied asthe ’Jewish, the Nordic, the Alpine, and the Medi-terranean. Evidence has in fact been adduced thata moderate intermixture produces racially beneficialresults. By most observers in this country it isbelieved that Germany has benefited rather thansuffered culturally through the admixture of Jewsin her population. In the interests of elementaryjustice it is to be sincerely hoped that in Germanysexual sterilisation will not be applied in a spirit ofracial animosity; but if it is so utilised, may themotive not be misconstrued as either eugenic or

economic in the senses advocated in the Germandraft Bill.At present a departmental committee is in this

country giving detailed consideration to the problem ofsterilisation. It is as yet impossible to foretell whatattitude it will adopt in its final report. Should thecommittee pronounce a cautiously favourable verdictthat voluntary sterilisation has a limited applicationto carefully selected persons within certain generalgroups, it is to be hoped that public opinion willnot run away with the idea that the adoption ofsuch a policy will be the logical prelude to its misuseas an instrument of tyranny by racial or socialmajorities. No biological innovation of social signifi-ance is free from possibilities of abuse ; and all suchinnovations are likely to find different legal expres-sions in different countries. If the principle ofsterilisation is, with appropiate safeguards, adoptedin this country, it can be taken as certain that itwill be applied in a way that expresses the socialconsciousness which prevails in England rather thanthat which is now sweeping through Germany.

I am, Sir, yours faithfully,C. P. BLACKER.

General Secretary, The Eugenics Society.20, Grosvenor-gardens, S.W., June 6th, 1933.

JEJUNOSTOMY

To the Editor of THE LANCET

SIR,-Please allow me a brief reply to your anno-tator (p. 1190). It still seems to me a pity that thiseasy operation is " so seldom performed," and Iventure to suggest to younger colleagues that theyshould try it. My results have been so good that Iam glad to learn that Lameris came to the sameconclusions. To the question, "Will a duodenaltube do all that jejunostomy can accomplish I " Ishould reply, "Certainly not!" Compare thecalibre of a duodenal tube with the 14-16 F. catheterused in jejunostomy as regards the amount of nourish-ment which can be given. Food introduced into theduodenum is apt to regurgitate into the stomachand promotes the flow of gastric juice which physi-cians want to avoid. A jejunal tube is discreetly

hidden by the clothing and does not prevent work.But the crucial question for any one of us, if we hadan ulcer would be, " What is the relative mortalityof jejunostomy and partial gastrectomy ? " Myanswer would be (cf. Mayo), " Any surgeon-evenan expert’—who wished to resect my stomach forulcer would have to run much faster than I could! "

I am, Sir, yours faithfully,Stoke-on-Trent, June 7th, 1933. HAROLD HARTLEY.

RELAPSE IN PULMONARY TUBERCULOSIS

To the Editor of THE LANCET

SiR,—Dr. Wingfield’s suggestive communication tothe Tuberculosis Association (THE LANCET, June 3rd,p. 1166) provokes further speculation. He attributesrelapses in pulmonary tuberculosis largely to allergichypersensitiveness, but suggests no cause for this.The following considerations will, I think, supply areasonable explanation. The primitive defencesagainst microbic invasion-inflammation and fever,with the associated blood changes-may be regardedas mainly non-specific ; allergic sensitiveness and theformation of antibodies are largely specific, andresult from actual contact with the microbe or itstoxins. Antibody formation calls for more coördi-nated expenditure of energy than local allergicsensitiveness, and is likely to come later in an

emergency.From experience with tuberculin injections we

know that by suitable progressive dosage very largedoses are tolerated without either noticeable localor focal allergy, or fever. If, however, the dose istoo rapidly increased the allergic response is exces.sive. So long as there is free humoral communicationbetween an active focus in the lungs and the immu-nising organs (largely reticulo-endothelial and bloodforming), antibody formation may increase in pro-portion to the increase in toxin formation, so thatwe may have no marked general symptoms in spiteof much circulating toxin-a state of " compensa-tion." If, however, the active focus is insulated bya shield of fibrous tissue or otherwise, toxins mayincrease in the focus without corresponding anti-

body formation. Then if a leak is sprung in the

insulating capsule, a large dose of toxin escapessuddenly into circulation and a " flame up

"

results,because in the absence of sufficient antibody forma-tion there are only the primitive means of defenceavailable-i.e., allergic hypersensitiveness and fever.

Dr. Wingfield is disposed to confine the term" relapse " to those cases in which no obvious reasonis discoverable. I would suggest that there is always.a reason, even though this is often difficult to find,and that the commonest cause is a breach in thesurrounding zone leading to a rather sudden increasein circulating toxin. Such a breach would perhapsbe due to unnoticed mechanical causes. Dr. Walther,of Nordrach, used to insist on abstention from active.arm exertion for two years after apparent recovery ;and, excepting for very small lesions, I think it stillremains a good rule. Periodical examinations as

suggested by Dr. Wingfield would probably make theprogressive occupational treatment of convalescentsreasonably safe. Another safeguard would be

periodical comparison of Mantoux tests with anti-.body tests. Whether, or when, tuberculin treatment.would be advisable in relapse cases would depend onthe response to rest and immobilisation, and someother circumstances. The obvious indication wouldbe the existence of a growing lesion with low antibodyf01’m!’l.tion-T !’I.m ir_ V0111’>( f!’l,ithfnllv.

Farnham, June 5th, 1933. IF. R. WALTERS.