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and those who show it, but have histories that are at alluncertain, should be vaccinated again and again.Otherwise some of them will die of smallpox as soon asthey are exposed to it.

5. It is possible to maintain 100% protection in acommunity (vide the records of the London smallpoxhospitals, and others, over long periods), but this is askilled, painstaking, and a personal job in the perform-ance of which scepticism in regard to the results, histories,and records of others plays a not unimportant part.

Dartford, Kent. J. PICKFORD MARSDEN.

SULPHONAMIDE-INHIBITORY SERA

SIR,—The work oy l:5oron reterrea to in your leadingarticle of Nov. 25 (p. 693) may well point the way to stillfurther refinement in our use of the sulphonamides.The fact that " the proportion of successes obtained withsulphonamides in gonorrhoea is progressively falling "is very striking. Is this because there are, as time goeson, less and less people who have never at any timereceived a sulphonamide, who are " virgin soil " as faras these drugs are concerned ? It is clear that successivegroups of patients will contain smaller and smaller pro-portions of such persons, considering the rate at whichthe sulphonamides are now being used for so manyconditions. Have some sulphonamide-inhibitory sera

arisen because the patients concerned have received asulphonamide on a previous occasion or occasions, andare these the sera whose inhibitory effect persists evenafter dilution of the serum to 1 in 20 ? What is the pro-portion of inhibitory sera among people who havenever received a sulphonamide, and are these sera theones whose inhibitory effect is removed (or much re-duced) on dilution-? One is reminded (although thecomparison should be made with caution) of the low-titre " naturally occurring" 0 agglutinins for Bact.typhosum, as distinct from the agglutinins resultingfrom actual experience of the organism itself, whether byimmunisation or infection.

If it can be shown that sulphonamide-inhibition isconditioned " by previous taking of these drugs, thiswill be a strong argument for using them only whenthere is proper indication. County VD Clinic, Camborne. E. C. H. HUDDY.

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VD

SIR,-In your leading article of Dec. 2, you suggest thatService personnel with VD should be rendered non-infectious before demobilisation and that with the newermethods of treatment this standard should not be difficultto attain.

Penicillin, or the modified intensive arsenotherapy,may achieve rapid cure of syphilis, but this can only beproved by prolonged observation of the cases now receiv-ing these treatments. - In the meantime, we shouldremember that similar expectations from a few injectionsof ’ Salvarsan ’ in the last war were not realised.

Service authorities tend to refer to syphilitic cases asnon-infectious when they have received their preliminarytreatment at a VD hospital and are returned to their unitsto continue observation or regular injections at a treat-ment centre. This claim is only true if adequatecontinuation treatment is obtained ; under Serviceconditions this is now generally ensured, but some cases aredischarged from the Services before completion of treat-ment. In such a case, the patient is advised to attend acivilian clinic. This would appear t6 be a simple matter ;in actual practice there are several reasons why manycases do not attend :

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1. The rapid disappearance of the lesions during treatmentencourages the patient to accept a false security.

2. The new employment may not permit attendance duringthe clinic hours, or in rural areas travelling expensesor inaccessibility of the clinic may lead to default.

3. The remaining stigma of these diseases prevents the

patient from applying for any necessary time off duty,or causes anxiety that neighbours or relations maydiscover his infection.’ A person going to the localtown every Wednesday, if that is the day the clinic isheld, can soon become suspect.

As circumstances bring these patients to default, there ispotentially the’ risk of an increased VD problem in thepost-war years, an increased incidence of congenital

syphilis and late manifestations of incompletely cureddisease, with the associated economic problems.You rightly state that the VD case must not be penal-

ised, but it is not so long since penalty was the recognisedServices method of tackling the problem. Would itbe penalising the VD patient to protect him from thesedifficulties, and, by completing his treatment beforedemobilisation, render him safe to return to civil life ? If our outlook tolerates Regulation 33B, surely the logicalsolution would be legislation to empower Service authori=ties to demand an accepted standard of cure beforedemobilisation. The newer methods would be a rapidand justifiable procedure if the longer, proved, schemesof treatment are not practicable. Efforts should bemade to obtain the cooperation of the patient for periodicsurvey after demobilisation, and it is probable that thiswould meet with more success than any continuationscheme which requires weekly treatment. In any casethere are prospects that time will prove that adequatetreatment had been given. - _

Consideration of the future public health surely claimssome such attempt to overcome the difficulties which areat present widely recognised but frequently ignored.

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London, Wl. DAVID ERSKINE.

THE VOLUNTARY HOSPITAL WITH ANUNDERGRADUATE SCHOOL

SIR,—Having read Mr. Layton’s learned address inyour last issue, some of us will no doubt feel that weshould thank him, not only for reconciling us to a futureof practice without proper payment, but also for intro-ducing us to a new word. " Diaspora

" is not containedin the third edition of The Concise Oxford Dictionary.Since the students of the last one or two decades have’entered the profession through the portals of examina-tions, called I believe Higher Certificate or SchoolCertificate, for which Greek is not a necessary subject,one cannot but wonder why he did not use the plainEnglish word " dispersion."

Gloucester. C. DE W. GIBB.

MALIGNANT MELANOMA

SIR,—Miss Tod’s article and the subsequent corres-pondence still leaves the treatment of the pigmentedmole somewhat obscure. Few would accept the advicethat moles must be left strictly alone. I should give thefollowing as indications for surgical removal of a pig-mented mole : (1) cosmetic ; (2) blue-black colour ;(3) when the situation is such that friction may take place-this applies to all moles on the feet ; (4) increase insize ; (5) ulceration ; (6) suspicion of malignancy.When a diagnosis of malignancy has been made clinicallyor pathologically, the tumour must be treated on recog-nised surgical lines.

Surely there can be no doubt about the use of localanaesthesia for the removal of pigmented moles. Theanaesthesia is complete, 100% safe, and should in no waylimit the extent of the operation. It is true that excisionis at times attempted after the injection of a smallquantity of anaesthetic solution beside or beneath thetumour. This results in the inadequate, inefficientremoval that Miss Tod so rightly deplores. The methodshould be complete anaesthesia produced by a field blockwide of the area to be removed. Injection of a localanaesthetic into any malignant tumour has been shownto be harmful and is unnecessary.Manchester. PETER MCEVEDY.

A CHRISTMAS PRESENT

SIR,—In October and again last week Sir ThomasBarlow, as president of the Royal Medical BenevolentFund, appealed in your columns for Christmas giftsfor beneficiaries of the fund, aged or infirm medicalpractitioners, their widows and their dependants.

Sir Thomas Barlow is the senior fellow of the RoyalCollege of Physicians and was its president for fiveyears. This year he has reached his hundredth year, andthe college is anxious to mark this notable occasion. Acheque for one hundred guineas is being sent by .thecollege as a donation to the fund which Sir Thomas hasfor many years so faithfully served. I have no doubtthat many of your readers will wish to be reminded ofthis anniversary.

Royal College of Physicians, SW1.MORAN,President,