1179FOUR PHASES IN SYPHILIS

in the degree of immunity, toxin-antitoxin reactions,nutritional disturbances, and so forth.ALMKVIST postulates that broadly speaking

there are only two types of reaction to the spiro-chaete demonstrable by microscope-proliferativeand degenerative. In the epidermal layer there isa proliferation of new cells of the same type asthe mother cells, with resultant hypertrophy ofthe rete Malpighii and the interpapillary epithelialprocesses, which is the process mainly responsiblefor the initial chancre. The connective tissue

responds similarly, but here we find a more variedmicroscopic picture, for new cell elements-plasmacells, round cells, and lymphocytes-make their

appearance, and the resulting histology is thereforenot always the same. For this type of reactionALMKVIST proposes the term " infiltration," andas connective tissue is more widespread than anyother in the body, we find it, as we should expect,the commonest of all syphilitic processes throughoutthe entire course of the disease. Lymphaticvessels and blood capillaries are similarly stimulatedto proliferate, but the specialised and more highlyorganised cells, such as the nervous, muscular,hepatic, and renal, cannot do so. Their connectivetissue framework will react as described above ;they themselves however in course of time, eitherin response to the toxic effects of spirochsetalinvasion or as a result of circulatory deprivation,undergo "late degenerative alterations." Infiltra-tive and degenerative changes are similarlyobserved in the walls of the larger blood-vessels andmay later account for the symptoms of aneurysmand arterio-sclerosis. Two other subsidiary changeshave to be noted-the pustular and necrotic.The pustule is less commonly met with than

formerly. It is never a primary reaction but alwaysoccurs in previous infiltrations of the connectivetissue. When well developed it is the histologicalbackground of so-called malignant syphilis. Necroticchanges are similarly superimposed. In his con-clusions it would seem that ALMKVIST is stillinclined to favour a phase or period progress ofthe disease. In place of the established divisioninto three stages he now proposes a classificationon a "real pathological basis " into four stages :

1. Initial or humoral stage, when the spirochaetesare in the blood (the disease is held to be " con-stitutional " from the outset) and other fluids, andin the chancre. In this stage therefore are includedthe former primary and secondary periods of Ricord,with chancre, fever, splenic enlargement, albuminuria,and so forth.

2. Usematogenous syphilis. All the organs andtissues, especially the lymph glands, are now invaded.by the spirochaetes conveyed to them by blood orlymphatic channels. (It seems to us that this phase onthe author’s own showing is practically the sameas the preceding.)

3. Serpiginous or creeping syphilis. From a former" infiltration " as a focus, the spirocheptes creep orinsinuate themselves into the interstices of tissuesin their neighbourhood, initiating visible cutaneouschanges, and hidden transformations at a deeperlevel. Clinical examples of the former are the oldtertiary circinnate syphilide, the condylomata, andvarious forms of rarer occurrence-e.g., impetiginoussyphilide of the scalp, pustular syphilides, andgummata, which may be either superficial or deep.

4. Late degenerative syphilis, in which are includedall the various forms of cerebro-spinal lues-tabes,G.P.I., and so forth-and the vascular lesions whichdevelop in the walls of the larger blood-vessels.The new conception excludes such theories as the

allergic of von Pirquet as applied to syphilis andaccording to ALMKVIST renders the three-stagedoctrine of RICORD no longer tenable. Time willshow whether these elaborate histological studieswill prove a sufficient reason for so radical analteration as is proposed, especially in view of thefact that on the author’s own showing phase 2differs very little from phase 1. There can be nodoubt, however, that that histological approach isone to which insufficient importance has beenattached in the past and that the new ideaselaborated on this foundation by ALMKVIST willmaterially assist the labours of those engaged onthe many problems of prognosis and treatment inall parts of the world.

IS PASTEURISATION HARMFUL?

It remained a very good beverage, but it did not remainmilk....

THUS Lord CRANWORTH in the Lords’ debate on

pasteurisation reported in our last issue ; his

opinion was forcibly supported by the Bishop ofNORWICH when the debate was resumed (see p. 1196)and is widely shared in the medical profession.But how far is it justified ? Of the published evidencevery little is convincing and much is contradictory. Inelaborate experiments at the National Institute forResearch on Dairying rat families tended to die outon a diet of sterilised milk (and biscuits), while thoseon pasteurised milk showed some inferiority includingsigns suggesting deficiency of vitamin B 1. Suchresults, however, require very cautious applicationto human nutrition, and it will be easier to form ajudgment from the more comprehensive inquirieslately made at the same institute, and at the RowettInstitute, on behalf of the Milk Nutrition Com-mittee which was established in 1934 with LordAstor as chairman. The object of these inquiries 2has been to determine the effect of commercial

pasteurisation on the various constituents of milkand also to decide whether a pint of pasteurised milkis equal to a pint of raw milk from the nutritionalstandpoint. Their answers 2 are that the changescaused by pasteurisation are not serious. Thusmoderate heat does not (as has been alleged) affectthe nutritional availability of the calcium and thephosphorus, or the biological value and true digesti-bility of the nitrogen. Neither vitamin A nor its

precursor carotene is damaged by pasteurisation.There is some loss of vitamin B-probably in the Blfraction-and about 20 per cent. of the vitamin C

disappears if (as is usual) the milk has been exposedto light before heating. The committee does not

propose to discuss the bearing of these laboratoryresults on human nutrition until it has publishedcomplementary observations on calves and school-children. But they already show that milk suffers nodamage by pasteurisation that is important, comparedwith the risks of drinking it raw.

1 Mattick, E. C. V., and Golding, J., Lancet, 1931, 1, 662 ;1936, 1, 1132 ; 1936, 2, 702.

2 Milk and Nutrition. Part I : Effect of Commercial Pasteurisa-tion on the Nutritive Value of Milk, as determined by LaboratoryExperiment, 1937. Obtainable from the National Institute forResearch on Dairying, Shinfield, Reading. Pp. 67. 2s. 6d.By post 3s.