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And now I should humble me.

A steward was sent by his ship’s surgeon to my clinicfor " pus in urine ? g.c." I could detect no g.c., but did

try to treat the painless bloodless " cystitis." After fiveweeks of it he vanished. Six months later, back from avoyage, he called at hospital to see me. Another stewardhad advised him, from first-hand experience, to try a" better clinic with younger doctors." So he did, and ayoung gentleman had " popped it into him good andquick," and he, the patient, heard the chink as " it " hitthe stone. Operation had removed stone from bladderand symptoms with it. Nevertheless, he gave me tounderstand I had been the honourable trier : that youngfellow " seemed to chance it like." Justice is indeed hardto find 1

In conclusion, Sir, may I remind Mr. JohnstonAbraham that from what he thinks of and despisesas too stony a ground-" the mental outlook of theold dead and, gone regimental medical officer "-wasraised up besides John Hunter, a Helmholtz, a

Laveran, a Bruce, Ross, and Leishman ; and onewho should surely be a father for this Abraham, a.Peter Freyer. Doubtless he shares with me the

privilege of having once known and sat under thelast four : and he has forgotten them. These ghostswill not trouble him even though grace is, for the

moment, hard to find in him.And I have the idea that some surgeons had for

long a clear field and few rivals with gonorrhoea inthe male-and left it to us " unsurgical

" newcomers

in the new V.D. clinics.I am, Sir, yours faithfully,

June 20th.

H. M. HANSCHELL,Hon. Med. Supt. and M.O. i/c V.D. Clinic,

Royal Albert Dock Hospital, E.

To the Editor of THE LANCET

SiR,—Mr. Johnston Abraham’s attainments and

experience in the fields of urology and of the venerealdiseases are so well known that his pronouncementsmust receive the greatest respect and attention. Forthis very reason I ask leave to join issue with him onthe subject of his recent damaging statements as tothe training and standard of work of the venerealspecialist.Few will deny that there are disadvantages in the

present system, and I believe that most medicalofficers of venereal diseases clinics would admit thatthe treatment of some patients with gonorrhoea iscontinued beyond the stage in which the benefit oftreatment is apparent. The reason is to be found,not in the ignorance and carelessness of the medicalofficer, as Mr. Abraham suggests, but in the realisa-tion that, in the light of modern improved patho-logical tests, such patients cannot be regarded as non-infectious. The medical officer is between the Scyllaof releasing the infectious patient, and the Charybdisof prolonging treatment unduly. Since he is unwillingto admit, even to himself, that in such patients thedisease is ineradicable, he chooses the secondalternative.

Mr. Abraham truly says that venereal disease hasalways been the Cinderella of medicine, but I cannotagree that the remedy lies in restoring syphilis togeneral medicine and gonorrhoea to urology. It isto the past neglect and indifference of the physicianand the urologist that the present " lowly position "of the venereal diseases is due. I believe that mostof the shortcomings of venereal diseases clinics arisefrom an attitude of mind which Mr. Abraham’s letterwell exemplies. The student gains the impressionfrom his medical and surgical instructors that thesubject of the venereal diseases is an unworthy andslightly unsavoury study which no competent man

in his right mind would adopt as his sole life’swork. In consequence there is small incentive for aman with the necessary medical and surgical back-ground to regard the venereal diseases department asother than a possible convenience-a stepping-stoneto higher things. The appallingly high incidence ofthese diseases among the general population has com-pelled the public health authorities to intervene andendeavour, by public organisation and subsidy, to

provide a remedy for a situation for which the medicalprofession as a whole is woefully to blame. Thepresent inadequacy of the treatment of gonorrhceamust be regarded as a direct legacy from the pastneglect of the urologist.

Mr. Abraham deplores with Mr. Nicholls the

" unhappy and incompatible " marriage of two suchwidely dissimilar diseases as gonorrhcea and syphilis,yet he himself has shown by his able writings on thesubjects of the treatment of both these’ diseases thatthe gulf of dissimilarity can be bridged. To thevenereal diseases medical officer this incompatibilityis less obvious, since his daily problems in psychology,arising from the patients’ shame and the necessity forconcealment, and his difficult task of handling familysituations, are almost identical in relation to the twodiseases. There is also the practical considerationthat it is common to find patients who are sufferingfrom both gonorrhoea and syphilis. There are manifestadvantages in treating both infections in the samedepartment.A sound knowledge of the fundamental principles

of medicine and surgery is essential in venereal diseasespractice as in all other branches of medical science;but the occasional dabbler in surgery, the surgicaltinker, is always a menace. I do not agree that it iseither necessary or desirable for the venereal diseasesofficer to be able to perform the surgical operationswhich Mr. Abraham enumerates. The necessity is aclose liaison between venereal disease departmentsand the departments of gynaecology and urology. Bythis means a competent surgical opinion is alwaysavailable, and the venereal diseases cease to " live

apart in a dark and uncritical world of their own."Mr. Abraham describes one case in which the

blunder of a venereal diseases officer resulted tragicallyfor his patient. It would be possible to give otherinstances where ignorance of the fundamentals of thediagnosis and treatment of venereal diseases on thepart of the urologist and physician have resultedmost tragically for patients and their families. Butsuch recriminations are valueless and even harmful.From the wealth of Mr. Abraham’s experience onemight have hoped for some more helpful and con-structive suggestions in dealing with the undeniabledifficulties of the present situation.

I am, Sir, vours faithfullv.AMBROSE J. KING.

RECENT ADVANCES IN OBSTETRICS

To the Editor of THE LANCET

SiR,—In the report of Miss Keren Parkes’s paperat the London Association of the Medical Women’sFederation, published on p. 1465 of your last issue,there are two mis-statements which I feel should becorrected.

(1) Discussing the Aschheim-Zondek and b’riedma7ztests Miss Parkes is quoted as stating that thesetests are of use in the diagnosis of intra-uterine deathof a foetus. I published a small series of cases inwhich the date of intra-uterine death was known

(Lancet, 1935, 2, 364). In two the Friedman testwas still positive 6 weeks after the foetus died. In

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the reports of cases collected from the literature atthat time there were four in which a positive resultwas obtained at even longer intervals, the longestbeing 91 days. A positive result therefore does notdefinitely establish the fact that the foetus is alive.Nor does a negative result definitely establish thefact that the foetus is dead. I have obtained negativeFriedman reactions in three cases of threatened abor-tion. In one of these, tests performed before andafter the time at which the patient was threateningto abort were positive, though a negative resultwas obtained at the time of threatening. Prof.James Young (Brit. med. J. 1937, 1, 954) obtainednegative pregnancy tests at times when the foetuswas alive in over half the cases on which such testswere performed in his habitual abortion series. It

is, I feel, important that this point should be empha-sised, for one is frequently asked to perform a " preg-nancy

" test to settle the question as to whether theovum is alive or dead. The curve of oestrin excretionin the urine drops more rapidly than does the prolancurve, and an cestrin test is therefore of more value,but still highly unreliable.

(2) In discussing the treatment of habitual abortionMiss Parkes is reported as advocating the use of"

large doses of a substance stimulating luteal activitywhich was found in the urine of pregnant women,marketed as Antuitrin S or Progynon." Progynonis not a gonadotropic extract but the standardisedpreparation of cestrin marketed by Schering Ltd.It should not be used in the treatment of habitualabortion. Miss Parkes’s reason for advocatinggonadotropic extracts rather than extracts of corpusluteum is that the latter are " unfortunately still

very expensive." The price of 50 ampoules of pro-gestin, each containing 1 mg. (1 rabbit unit), as sup-plied by a certain firm is 142s. The price of 50ampoules of the luteinising gonadotropic extract

prepared by the same firm is 90s. if the strength ofeach ampoule is 100 rat units, or 180s. if of 500 rat-unit strength, which is the strength presumablyreferred to when Miss Parkes mentions " largedoses." I am, Sir, yours faithfully,

P. M. F. BISHOP.Endocrine Clinic, Guy’s Hospital, S.E., June 19th.

THE SEVENTH ENGLISH-SPEAKINGCONFERENCE ON MATERNITY AND CHILD

WELFARE

To the Editor of THE LANCET

SiR,-The report of this conference in THE LANCETof June 12th states that " reprints of a brief historyof the child welfare movement," written by me, weredistributed to the delegates, and that this " history "did not mention " the roots of the movement." MayI say that my paper, which was entitled the PresentPosition of Maternity and Child Welfare in the

English-speaking Countries, was not a " history "

but a brief summary of a large number of documentsreceived by the Conference Committee from theUnited States, the Dominions, and the British

Colonies, Protectorates, and Dependencies describingwhat is now being done for the welfare of mothersand young children in those countries respectively.The paper began by explaining that the conferencewas the latest of a long series beginning with thenational conference of 1906, which had its originin a meeting of the British delegates to an inter-national congress in Paris in the preceding year, butexcept for those introductory remarks the paperwas given up not to the past but to the present.What your correspondent specifies as among " the

roots of the movement " are of course well known tostudents of the movement, and are discussed in mybook, " The Early History of the Infant WelfareMovement," published in 1933.

I am. Sir. vours faithfullv.G. F. MCCLEARY.

Brockham Green, Betchworth, Surrey, June 19th.

ANTIBODIES AGAINST HORMONES

To the Editor of THE LANCET

SIR,-In the leading article on p. 1471 of your lastissue there is a statement suggesting that Collip andAnderson introduced the study of antihormones.Over thirty years ago I remember the late Sir EdwardSharpey-Schafer stating that Swale Vincent, alsorecently deceased, had discovered a type of immunityto internal secretions. Writing on the injection ofsuprarenal extracts, Schafer said, concerning Vincent’sexperiments, that " Doses insufficient to cause a fatalresult produce immunity to larger doses which wouldotherwise be fatal, and this effect may last a fewweeks " (E. A. Schafer, Text Book of Physiology, Edin-burgh and London, 1898, vol. i, p. 951). As both ofthese authorities have joined the great majority,I feel that justice should be done to them as pioneers.Vincent’s paper is, I believe, in the Journal ofPhysiology (1897, 22, 111).

I am, Sir, yours faithfully,J. ARGYLL CAMPBELL.

National Institute for Medical Research,Hampstead, N.W., June 18th.

REGIONAL ILEITIS

To the Editor of THE LANCET

SiR,-Gastro-enterologists and clinicians generallywill be interested to know that Charles Combe andWilliam Saunders, a fellow of the Royal College ofPhysicians of London, reported a case of terminalor regional ileitis (Crohn-Braun type) before the

College, on July 4th, 1806, 131 years ago ! The titleof the report was "A singular case of Stricture and

Thickening of the Ileum."The patient was William Payne Georges, Esq., of a

very nervous and delicate habit... at necropsy(Monday, Feb. 10th, 1806) ... it was found that thestomach, duodenum, the jejunum, and the upper partof the ileum, liver, pancreas, spleen, and kidneys werein a natural and sound state. The lower part of the ileumas far as the colon, was contracted, for the space of threefeet, to the size of a turkey’s quill..... (MedicalTransactions, published by the College of Physicians inLondon, iv. 16-21, 1813, London.)John Abercrombie (1780-1844) discusses pathologic

states of the ileum and reports cases of terminalileitis (Combe-Saunders-Crohn-Braun type). On

p. 263 of John Abercrombie’s book, " Pathologicaland Practical Researches on Diseases of the Stomach,the Intestinal Canal, the Liver and other Visceraof the Abdomen " (Edinburgh edition, pp. 238-263,Waugh and Innes, 1828, report V., Case CII), he tellsof " a girl, aged 13, about a year before her death,began to be affected with pain of the abdomen andfrequent vomiting...." The lower end of the ileum,to the extent of about eighteen inches, was "distended,thickened in its coats, externally of a reddish colour,and internally covered by numerous well-definedulcers, varying in size from the diameter of a splitpea to that of a sixpence." The lungs and all otherviscera were healthy.

I am. Sir. vours faithfullv.HYMAN I. GOLDSTEIN.

Camden, New Jersey, U.S.A., May 27th.