Annotations.

A NEW RESEARCH HOSPITAL.

"Ne quid nimis."

A DRASTIC change in the scope and purpose of anycharitable institution must have parliamentarysanction and past subscribers may be assured thatthis would be withheld unless the alteration waswarranted by a change in the needs of the populationserved. The fact that an Enabling Act was passed inMay of this year, allowing responsible authorities ofthe Mount Vernon Hospital, Northwood, to use theirlands and investments for the investigation andtreatment of malignant disease instead of for diseasesof the chest is an indication of such a change. Inrecent years the establishment of sanatoriums bylocal authorities has so diminished the number ofpatients applying for admission to the hospitalthat its council, with the full consent of the medicalstaff, sought and obtained permission to turn theirefforts in a new direction. A scheme of work anddevelopment, framed with the help of experts, has beengenerally approved and is being put into speedyeffect. The council of management of the hospitalon which the medical staff is represented is beingassisted by an advisory committee whose duties willbe to give advice on the staffing of the hospital, onmedical and scientific matters, and on the forms oftreatment and research to be undertaken in thehospital. The new organisation differs in manyimportant points from that of hospitals not primarilydedicated to investigation. A whole-time directorof research is to be appointed to devise and coordinateschemes of work and the appointments of the honorarystaff 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 ofevents might equally well have occurred in the lifeof any hospital designed to treat cases of infectiousdisease which are now for the most part being dealtwith effectively in rate-supported institutions. Somewill regret the change, but it may be a prototype ofother changes and may point the way to the soundallotment of work between voluntary hospitals andthose organised and supported by the local authori-ties. Routine treatment of disease by establishedmethods can be carried out safely in any well-conductedhospital. The critical investigation of pathologicalprocesses and the assessment of the scope and limita-tions of methods of combating them is essentiallywork to be carried out in a hospital designed for thepurpose. Medical students would, in an ideal state, ’,have access to both types of hospitals, though notnecessarily at the same stage of their careers. Theconversion of the Mount Vernon Hospital to otherpurposes from those which it was intended to serveis not likely to be an isolated one.

ERROR IN DIFFERENTIAL BLOOD COUNTS.

THAT even in the most carefully prepared bloodsmear the white cells are far from being evenlydistributed is recognised by everyone who has everlooked at such a preparation. That the variousclasses of white cells alter in their distribution indifferent portions of such a smear is well known to allwho study them with any closeness. And that thesefacts must have a disturbing effect in a differentialcount of white cells is self-evident. Most workers havebeen content to do as best they can by the randomselection of a few fields in a smear ; others, followingNaegeli, have tried to reduce the error by countingup to a thousand cells. Meanwhile, the laws governing I

distribution of the white cells in a smear have notcome in for much careful consideration, and this is anomission which Curt Gyllensward, of Stockholm,1has tried to remedy. His results are reported in avery long paper which bristles with formidablecalculations and should be consulted in the originalby those interested. In brief, it may be said that hecondemns the cover-slip method of preparation, andrecommends that form in which the blood is smearedon a microscope slide by drawing a second slide alongits length. In such preparations, however, thesmaller cells tend to be deposited more quickly thanthe larger cells as the movement of the blood overthe receiving slide decreases. The result of this isthe formation, at the top and bottom of the slideand in the " tongue

" at the end, of " zones

" oflymphocytes, neutrophiles, eosinophiles, and mono-cytes. Counts conducted in these zones may show arelative distribution of the different classes of cellsvery different from that which obtains in the circu-lating blood. To avoid the influence of such zonesGyllensward recommends that in making a differentialcount the first and the last five millimetres of thesmear should never be included, and that the countshould be made on the central portion of the slide intransverse travels. If these precautions are takenhe finds no advantage in including more than 300white cells in the count.

BISMUTH IN THE TREATMENT OF SYPHILIS.

EVER since bismuth was introduced into thetreatment of syphilis in 1921 it has been regardedalmost universally as a valuable spirochseticidaldrug. From time to time, however, a voice has beenraised to question the advisability of using it in placeof the older remedies, mercury and arsenic. In1927 2 Dr. T. Anwyl-Davies discussed the action ofbismuth on the Spirochceta pallida and, following theconclusions of W. Kolle and his collaborators, declaredthat bismuth had no direct curative action on theinfection but merely inhibited the disease. Kolle’sexperiments and Anwyl-Davies’s conclusions werediscussed and strongly contested by Dr. C. Levaditiand Dr. L. Fournier.3 We publish this week and lasttwo further papers on the subject and a report of thediscussion at the Venereal Diseases Section of theBritish Medical Association at Manchester last July.Dr. T. M. Ling has been working at St. Thomas’sHospital with bisoxyl, a suspension in water of bismuthoxychloride and chloretone. Subcutaneous injectionof this preparation does not lead to the persistentpain and swelling characteristic of many forms ofbismuth, and Dr. Ling has found it extremely usefulin congenital syphilis, especially in lues tarda. Hesuggests that the spirochaete can acquire resistanceto arsenic and mercury after prolonged treatment,and that in cases of this kind bismuth, without causingany untoward symptoms, will render serologicallynegative 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 abismuth compound of a highly valent oxybenzoicacid in olive oil. They have found this eminentlysatisfactory, and declare that it has an abortive actionon the disease. A number of patients have beentreated by bismuth exclusively.The case for bismuth is strengthened by these new

reports. Prof. Ritter and Dr. Karrenberg suggestthat many of the objections alleged against it dependon the very inadequate knowledge that the physicianhas of the exact amount of bismuth metal he isgiving and its fate in the body. They also point outthat the criteria for a successful antisyphilitic remedyare by no means standard. The amount of bismuthvaries 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.