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Talmudic dialectic. We look forward with interest,though with some concern, to the International

Congress of Psychotherapy when some of our Germancolleagues will meet us in the serener air of Oxford.

Dr. Eduard Pernkopf, kommissarischer Dekan ofthe faculty of medicine, in the first anatomicaladdress 2 given at the University of Vienna sincethe Anschluss, also deprecates the alien influencewhich till lately dominated science in his countryand wrapped it in speculative imaginings till it no

longer bore the imprint of the character of the people.If it is once more to become " German" in thetruest sense of the word the limits of understandingmust be frankly admitted and science must " notonly be true but also clear as a spring of pure know-ledge." Under the new order of things so-calledfreedom will be impossible ; indeed Dr. Pernkopfconsidered it would be undesirable, for science shoulddevelop according to an ordered plan and strivetowards a definite goal. It is no longer, he said, tobe a question of science for the sake of science-butscience as part of life must be made to serve life, andas guardian of the race the doctor will hold animportant place in the new ideology.

SECRET REMEDIES

WHEN any reform is demanded as urgently as

in the report of the Select Committee on PatentMedicines in 1914, something really ought to be doneabout it. In the latest sixpenny monograph in theFact " series (19, Garrick-street, London, W.C.2)Prof. A. J. Clark of Edinburgh University takes upthis task afresh. He sets out the scandalous short-

comings of the existing laws. As the 1914 reportrevealed, anybody in this country can procure adrug or make a mixture, whether potent or powerless,advertise it as a cure for any ailment, recommend itby bogus testimonials or by the facsimile signaturesof fictitious physicians, and sell it under any namehe chooses, on payment of a small stamp duty, forany price he can persuade a credulous public to pay.The obstacles are few. He cannot traffic in a

scheduled poison or in any of the drugs within theDangerous Drugs Acts. In 1917 Parliament singledout the treatment of venereal disease for exceptionalrestriction. Otherwise the field remains as wide aswhen the Select Committee surveyed it nearly25 years ago. Indeed the position has probablybecome worse because the public, while remainingignorant of therapeutic and dietetic values, hasbecome more health-conscious and, having now

acquired the benefits of elementary education, ismore susceptible to the persuasion of advertisementby way of poster or newspaper. In the eighteenthcentury, says Prof. Clark, a bottle of oil could beadvertised as a cure for scurvy, leprosy, and con-sumption. To-day the modern advertiser woulddeclare it to be rich in all the vitamins and theelements essential for life and would limit his claimsto a statement that it will alleviate all minor ailments.Not that there are no advertisements of remedies for

major illnesses. In 1936 the Medical and SurgicalAppliances (Advertisement) Bill proposed to prohibitthe advertising of cures for blindness, Bright’sdisease, cancer, consumption, epilepsy, fits, and so on.Just as the 1914 report escaped due notice because ofthe preoccupation of the country with Armageddon,so the 1936 Bill was unlucky in coming up for secondreading on a day when our legislators were distractedby the Grand National. The House of Commonswas counted out and the chance was lost to abolish

2 Wien. klin. Wschr. May 20th, 1938, p. 545.

the exploitation of fear. The Government is perhapsthe more complacent because it levies taxation on

proprietary medicines. It is indeed in some degreean accomplice, since the medicine stamp duties givea kind of official recognition. It has shown commend-able interest in the improvement of the national

physique. One simple step in this direction wouldbe the institution of some measure of control ofsecret remedies.

Three essential reforms were propounded by the1914 Committee-first, the registration of manu-

facturers, proprietors, and importers of patent, secret,and proprietary remedies ; secondly, the disclosure ofthe ingredients of these remedies with a full statementof the therapeutic claims made or to be made ; and

thirdly, the control of advertisements. Prof. Clark’slittle book most usefully shows the growing necessityfor such measures as these. His reference to therecent draft of a Food and Drugs Bill as containingprovisions which may check fraudulent advertisementof proprietary remedies is probably too optimistic.The Bill does little more than re-state old statutes.The Committee which produced it confessed thattheir task was not to frame ideal legislation but toreproduce existing laws with merely so much amend-ment as was likely to command general assent. TheBill thus reproduces the 1928 Act which (like theolder Act of 1875) penalises the sale of food or drugsnot of the nature, substance, or quality demanded.The Bill leaves untouched the exemption for a

proprietary medicine if " supplied in response to ademand for medicine." The chief amendment pro-posed by the Bill is in a clause which hopes to checkmisleading advertisements by penalising false and.

misleading labels on the wrappers and containers offood and drugs and by treating the advertisements(which probably had more influence than the label ininducing the sale) as if they were labels. It must berealised that the Food and Drugs Bill, now beingexamined by a Parliamentary Committee, is not

going to contain anything controversial. It is there-fore not the appropriate vehicle for the reforms whichare required in order to protect the public from themischiefs of secret remedies. Those reforms are

urgently necessary. Perhaps Prof. Clark’s expositionwill stimulate official action.

NASAL SINUSITIS AND MENTAL DISORDER

SOME psychiatrists think that focal infection playsa large part in causing and increasing mental illness.Dr. T. C. Graves contributed a paper to thesecolumns some years ago 1 in which he claimed goodresults from non-specific shock therapy, and in a

monograph 2 appearing soon afterwards he said thatof 1000 cases of mental disorder no less than 818showed evidence of nasal sinus infection. Dr. A. B.Smith and Dr. C. M. Ross, who have studied 818unselected cases in a mental hospital, producestrikingly different findings.3 3 There were 23 cases inwhich the sinuses could not be examined with X rays,but in which there was no reason to suspect sinusdisease. Of the remaining 795 cases, 63 showeddefinite evidence of nasal sinusitis, but 624 could bedefinitely regarded as free from sinus disease, whilein the other 108 the presence of nasal sinus diseasewas doubtful. Thus of the 795 cases 7.9 per cent.had definite sinusitis and in 13.6 per cent. the

diagnosis was inconclusive. Smith and Ross hold it

probable that 32 out of the 108 doubtful cases had1 Lancet, 1932, 2, 57, 115.

2 J. ment. Sci. 1932, 78, 459.3 Edinb. med. J. May, 1938, p. 343.

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sinusitis, and this would give a total figure of 11.9 percent. in the entire series. The methods employedwere similar to those used in the ear, nose, and throat

department of the Edinburgh Royal Infirmary, anddiagnosis rested on the presence of muco-pus or pusin the washout of a suspected sinus, or on radioscopicexamination. It is concluded that nasal sinusitishas no real aetiological significance in any of themain groups of mental disease, except for thetheoretical possibility of a sinus infection producinga toxic confusional state, and in fact no such casewas encountered in the 818 examined. The highestproportional incidence was found in the manic-

depressive group, and may, they say, be correlatedwith the lowered physical vitality so often seen inthese cases. The opinion reached is that mental

patients in general do not stand to gain by treatmentdirected towards their nasal accessory sinuses. Smithand Ross admit that these 818 showed more sinusitisthan would be expected in 818 members of the generalpopulation, but this they think may perhaps be explainedby neglect of nasal hygiene during mental illness andby the overcrowding of many mental hospitals.

DOCTOR TO DOCTOR

A LETTER about a patient, written confidentiallyby one doctor to another upon a question of diagnosisor treatment, ought to be as absolutely privileged ascorrespondence passing between solicitor and counselabout a client. It comes as a shock to find that sucha letter was made public in the disciplinary atmosphereof a health insurance subcommittee’s proceedings.The patient in the case had been struck in the backby a bicycle. He afterwards collapsed at his workand had to be taken home. He was seen by Dr. A,who was acting as deputy for his partner Dr. B,Dr. B being the man’s panel doctor. Dr. A suggestedthat the patient should attend at the local infirmary.He gave him a sealed envelope addressed to the

infirmary doctor. Inside the envelope was a letterwhich contained the following passage: "Do youthink that this man is soft ? simple ? ill ’? I havebeen called to him twice lately and have never beensatisfied that he has been really ill.... I personallythink he is a bit soft and has no " guts.’ I shall be

glad of your opinion." The envelope was never

delivered. The patient was tot) ill to get out of bednext day, and he died nine days later. On the dayof the funeral the widow opened the letter which wasintended for the infirmary doctor. The matter camebefore the medical service subcommittee on her

complaint and the letter was included in the sub-committee’s report. At the subcommittee’s inquiryDr. B, who had attended the patient after he becamevery ill, stated that he did not think the accidenthad any bearing on the death ; the man was of aneurotic type ; death was due to heart failure whichhad developed in the last few days before he died.No complaint was made against Dr. B, but the sub-committee recommended that the Minister of Healthshould withhold a sum from Dr. B’s remunerationbecause Dr. A, his deputy, had failed to exercisereasonable skill and care. When the subcommittee’sreport came before the Lancashire insurance com-mittee last week, the chairman of the latter bodyprotested against the inclusion of the private letterin the report.

It may be hoped that this protest will be vigorouslysustained. Two practitioners, engaged in the treat-ment of a patient, must be allowed the frankestconsultation. Of the details on which the allegationof default on the part of Dr. A was based, no informa-tion is at present available. In so far as the private

letter forms part of them, it is no basis at all. Dr. Ais presumably being censured not because he wrote aletter which was perfectly proper as between onedoctor and another, but because the letter wasopened by someone for whom it was never intended.Many communications must be made confidentiallyin the course of professional consultation which

might, if subsequently disclosed to the parties or theirrelatives, sound harsh and unsympathetic. Thismust be true of professional practice in other fieldsbesides medicine and surgery. The spoken wordmay run less risk of misunderstanding than thewritten word which remains on record. But speechis not always practicable. It is, of course, in theinterests of the patients or clients that this profes-sional privilege is essential, not in the interests ofthe practitioners.

TECHNIQUE OF WASSERMANN ANDFLOCCULATION TESTS

A CLINICIAN asked to say what he knows about theWassermann test for syphilis would probably saythat it depends upon the fact that a syphilitic serumfixes complement in the presence of a suitable antigenand that sensitised red cells are used as the indicatorof the presence of any unfixed complement. Ofthe details of the technique for carrying out thereaction he would probably confess to knowing verylittle, and of the many pitfalls which have to be avoidedand of the intricate mechanism of the test almostnothing. Such ignorance matters little, providedthe work of interpretation is entrusted to a reliableserologist whose reports can be understood by theclinician, and that the latter is able to collate theinformation received with the clinical condition of thepatient. It has become important for practitionersto know something of the interpretation of quanti-tative tests, doubtful reactions, anticomplementaryserum reactions, and, above all, of the spinal fluidfindings, and unfortunately many of them ignorethe significance of such things. Even the extentto which the Wassermann and flocculation tests

give comparable results is a matter to which clinicianshave given little attention. According to Dr. HarryEagle, who has gone fully into the physico-chemicalbasis of the two types of reaction, they involve thesame phenomenon, namely, the combination of

reagin-globulin with the lipoid particles of the antigenand the flocculation of the compound ; the same

reagin determines both complement fixation andprecipitation. He does not explain how it is thatone comes across sera which give a positive Wasser-mann reaction yet a negative flocculation test.Not only practising physicians, but serologists

will find Dr. Eagle’s informed comments valuable,though they may turn to different sections of hiswork. The former will find in chapters VI, VII, andIX an account of the mechanism of the Wassermannand flocculation tests, and in chapters XVI to XXIIopinions on their clinical evaluation which will leadto a revision of many of his preconceived ideas.The serologist will note the criticisms of the conclusionsreached at the serological conferences held under theauspices of the League of Nations Health Organisationin 1923, 1928, and 1930, and Dr. Eagle’s view thatthe outcome of two subsequent serological studiesand conferences carried out under the auspices

1 The Laboratory Diagnosis of Syphilis. By Harry Eagle,M.D., passed Assistant Surgeon, United States Public HealthService, Washington, D.C.; Lecturer in Medicine, Johns HopkinsUniversity Medical School, Baltimore; formerly Assistant Professorof Bacteriology, University of Pennsylvania Medical School.London: Henry Kimpton. 1937. Pp. 440. 21s.