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SIR,-Professor Thomson’s letter last week containsan interesting idea for dealing with the knotty problemof distinction awards ; but the method suggested is byno means original. This method of drawing namesout of a hat was practised extensively by assessingcommittees in many regions.

I suggest that the medical profession should passaway the quiet winter evenings by playing a new cardgame. Two packs of cards-one pack with names ofdoctors printed on it, the other cards bearing one ofthe many titles now in vogue-should be printed. Each

pack is shuftled and placed in a hat. Cards are drawnand compared. The game is called " anomalies."

Birmingham. F. E. D. GRIFFITHS.

SiR,—I note with interest that Professor Thomson,in his letter last week, says : " An Englishman will

accept misfortune in a lottery with good grace and goodhumour, but he will resent deliberate classification ina grade inferior to that of a colleague as an injustice."He makes this statement about the English in supportof his suggestion that, except for a few superlative indi-viduals whose claims to eminence are unimpeachable,the matter should be decided by a lottery.

It is not unnatural to wonder whether this point ofview has any relevance to some of the results which

emerged in the main grading, and which could be easiestexplained by the operation of a lottery. If this couldbe so it seems a pity that those senior hospital medicalofficers who are now languishing in bewilderment andthe distress of being made deliberately inferior to theircolleagues, were not given this comforting explanationof their misfortune, so that those of them who are

Englishmen could now begin to exercise their prerogativeof behaving as such.

BIRMINGHAM REGIONAL S.H.M.O.

FACIAL PARALYSIS AND POLIOMYELITIS

SiR,-In his valuable report of Sept. 17," Dr. Stapletonconcludes that " though there is a suggestion that the casesof facial palsy unaccompanied by other paralysis hada cause in common with the cases of poliomyelitis, thishypothesis is not, of course, proven."During large-scale epidemics of poliomyelitis, instances

of uncomplicated unilateral paralysis of the face are byno means rare. Epidemiological observations bearingout the relationship have been supported by laboratoryconfirmation. Thus Steigman and Sabin 1 prefer to a

7-month-old infant whose only paralysis involved one sideof the face. Poliomyelitis virus was isolated from heralimentary tract, and antibody to the homologousstrain of virus appeared in convalescence.

Facial " paralysis " is perhaps a better term than thetime-honoured facial " palsy," at least for those caseswhere clinical and epidemiological evidence suggestspoliomyelitis virus as the cause.New York. ALEX J. STEIGMAN.

VENTRICULAR FIBRILLATION

SiR,—Dr. Robertson (Oct. 29) doubts the presence ofventricular fibrillation in the electrocardiogram recordedin my case-report (Oct. 15) because of the " absoluteregularity of the aberrant complexes." I can assure

him that my diagnosis was based on the very fact thatthe complexes are not absolutely regular and showdefinite variations in form and amplitude from beat tobeat in those phases of the record referred to in the

report as fibrillation. These variations can quite easilybe seen in the published reproduction of the E.c.G., butI admit they are clearer in the original record which isnot now in my possession ; I believe that Dr. Robertsonwould have been convinced had he seen this.

Leamington Spa. W. M. PRIEST.

1. Steigman, A. J., Sabin, A. B. J. exp. Med. 1949, 90, 349.

MANTOUX-CONVERSION

SIR,-There is a place in the English language for aterm to indicate a change from the tuberculin-negativestate to the tuberculin-positive state, but the use oftwo different terms with this meaning leads to confusion.In the American and English literature the term " Man-toux-conversion " is used to indicate this change, butsome Scandinavian writers have preferred the term" Mantoux-inversion " and recently one English writerhas followed them To the ordinary English reader,"conversion" clearly indicates a change from a firststate to a newly acquired one, while " reversion "

equally clearly indicates a change from an acquiredstate to a pre-existing one. " Inversion " suggests merelya " turning upside down," with no implication as tothe nature of the change.

For the sake of clarity and uniformity, therefore, itwould be preferable for all writers on tuberculosis to use" Mantoux-conversion " to indicate the change from thetuberculin-negative to the tuberculin-positive state, asshown by the Mantoux technique ; Mantoux-reversionis the correct term to indicate the change from tuberculin-positive to tuberculin-negative. I am sure that- ourScandinavian friends, who have such a remarkable andenviable command of our language, will be willing todrop the term " Mantoux-inversion," which has no realetymological justification for use in the sense it has.acquired.

CHARLES NEWMANChairman, Prophit Tuberculosis Survey Committee,

Royal College of Physicians.

THE M.O.H.

SiR,-Both Dr. Brockington and Dr. H. C. MauriceWilliams speak despondently about the future of publichealth (Oct. 22, pp. 759 and 755), and yet in industrialhealth is a great region of public health which is almostuntouched. The problem is the environmental hygieneof the small factory. Most people are employed in smallfactories, many of which have deplorable standards, andthe medical inspectorate, good though it is, is spread toothinly to produce much improvement. Why not letmedical supply match industrial demand and use theonly sizeable body of men trained in preventive medicineto raise the level of industrial hygiene ? ’? This would

provide an industrial health service where it is mostneeded, at little extra cost in money or medical man-power.

Medical School, King’s College,Newcastle-on-Tyne, 1.

R. C. BROWNE.

VASCULAR STASIS

SiR,—In his letter of Oct 22, Dr. Shubsachs impliesthat my use of the term " whole-skin loss " in burns is

synonymous with blister formation. In so doing hemisunderstands what is meant by the term " whole-skin loss." This means more than mere epidermaldestruction : it means that death of the epithelial ele-ments (follicles, glands, and ducts) has occurred through-out the whole depth of the dermis and that regenerationof epithelium can only take place from the epidermissurrounding the burn.

In my letter of Oct. 15, I attempted to draw attentionto the fact that stasis of the dermal blood-flow mayoccur in burns, and that if it develops through the depthof the dermis it is followed by necrosis of the dermalepithelium. In such -a burn epithelial regenerationfrom the dermis is impossible-in other words, whole-skin loss has developed.From Dr. Shubsachs’s own description of the blister

burns which he has treated with anti-histamine drugs,in which rapid epithelial regeneration from the dermis1. Irvine, K. N. B.C.G. Vaccination in Theory and Practice.

Oxford, 1949.

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occurs, it is clear that only the superficial elements of theskin (epidermis and possibly the most superficial portionof the dermis) had suffered irreversible heat changes.In such burns epithelial regeneration from the under-lying dermis normally takes place fairly rapidly, and theburned area is re-covered with epithelium in 7 to 14 days.There is no reason to assume that the anti-histamine

drugs had any effect whatsoever. Such burns correspondto Dupuytren’s grade 2, and in this unit would be calledsuperficial partial skin-loss burns.

M.R.C. Burns Research Unit,Birmingham Accident Hospital.

S. SEVITT.

LIGUE INTERNATIONALE CONTRE LERHUMATISME

SiR,-The recent International Congress on RheumaticDiseases in New York, at which Hench and Kendallpresented their paper on Cortisone,’ was sponsored bythe Ligue Internationale contre le Rhumatisme, andthere can be no doubt in the minds of those who heardthis paper and availed themselves of the varied oppor-tunities at this congress, of the immense value of suchmeetings.We feel that the British branch of the Ligue is not

sufficiently widely known, and that membership offersnot only individual advantages but an opportunity tofoster friendly international relations at the various

gatherings held in different countries. The next congressof the Ligue Europeen is in Barcelona in 1951, and thewhole of the Ligue Internationale will meet in Zurich in1953. Judging by the high standard of papers in NewYork this year, these two promise to be importantmeetings.

Individual membership of the British branch entitlesattendance at these congresses and also at certain clinical

meetings of the Heberden Society. The British branchis arranging quarterly publication of a pamphlet givingnews of forthcoming meetings of interest and of post-graduate courses, and a list of clinics where postgraduatemembers will be welcome.The annual subscription of one guinea should be sent

to the treasurer, Dr. G. D. Kersley, 6, The Circus, Bath.W. S. C. COPEMAN

President Ligue Européen.OSWALD SAVAGE

Secretary, British branch of the LigueInternationale contre le Rhumatisme.

ACUTE MASTITIS

SiR,-Mr. Walsh (Oct. 8) refers to the responsibilityof the general practitioner in the early diagnosis andtreatment of acute mastitis, and in discussing the

cetiology he mentions cracked nipple as an importantfactor; but leaves one in doubt as to what exactlyis included under this head. Suckling is, or should be,a painless process. In cases where the nipple is sore,macroscopic cracks may be observed, but one cannotalways find them. That the sore nipple, without obviouscracks, belongs to the same class as the cracked nippleis suggested by the fact that both respond rapidly topenicillin ointment applied to the nipple after each feed.Mr. Hogg’s letter (Oct. 22) about veterinary experience

was very interesting. I have never attempted to admini-ster penicillin directly into the mammary ducts, andthe problem obviously varies from one species to another.Wiedersheim, in his Comparative Anatomy of Vertebrates(1897, p. 28), gives illustrations to show the lactiferousducts of carnivora and ungulates opening into the bottomof a teat canal (it is into this that Mr. Hogg has injectedpenicillin), while in primates, rodents, and marsupialsthe lactiferous ducts open into the apex of the nippleand there is no teat canal. Mr. Hogg’s concludingobservation, that " the wise farmer nowadays has hispenicillin ointment always handy for immediate applica-tion at the merest suspicion of an abrasion, crack, or

sore in the region of the teat orifice," is in strangecontrast to the fact that midwives are not issued withpenicillin ointment for use in the human subject.

Oulton Broad, Lowestoft. N. B. EAST-WOOD.

MEASLES IN LONDON

SiR,-Dr. Breen and Mr. Benjamin, in their articleof Oct. 1, maintain that since 1940 " the biennial

epidemic rhythm [of measles in London] has disappeared."This might be true without invalidating the generaltruth as to the persistence of this feature when units ofpopulation far transcending that even of London areobserved. The discovery of a type may be difficult ;it may be a tardy induction based on a group of hithertounrelated facts or quickly seen in an accidental illumina-ting flash of vision. But, once established as a more orless permanent feature of distributed phenomena or ofrecurring events, it is usually easy to recognise. A typemay disappear, be transformed in its features, or surviveso changed as scarcely to preserve its identity. Dr. Breenand Mr. Benjamin conclude that in London, since 1940,biennial rhythm, in any form hitherto recognised, can nolonger be observed.

Controversy during many years has been as to itsnature and description rather than as to the fact ofthe occurrence of biennial rhythm. Its disappearancewith the advent of notification of measles in a populationso large as that of London would be a noteworthyevent. But the evidence on which the conclusion isbased, as set out in the paper, is far from convincing ;and it is not a little remarkable that it was upon thedata from 1940 to the end of 1945, relating severallyto London, to London and the great towns, to othertowns and areas, and to England and Wales as a whole,that I formulated the thesis of the recurring multiphasiccharacter of biennial incidence in measles.’ The authors

say that " a series of alternate heavy and light years,one year being mainly covered by an epidemic and thenext year being mainly interepidemic

" is to be observedboth in London and New York. This description may bea facile way of distinguishing biennial epidemicity, but,exclusively so used, is little likely to disclose the naturalcourse of measles epidemics. So to describe it is to ignoreall but the gross annual numbers or recognise only thehigh peaks as evidence of epidemics. As I observednearly three years ago 2

" In the graphs of incidence of recent years there is seento be comprised within a single span of four-and-twentymonths the proportioned phases not alone of epidemicprevalence but also of the low levels of intercurrent sub-epidemicity. Thus seen, periodicity ceases to be a biennialrecurrence of punctual maxima and becomes a periodicrepetition of like prevalences each in its due season, oncewithin two years."Serial distribution of cases as they occur shows types

of biennial periodicity not properly to be described asrecurrences of epidemics in alternate years. And themain conclusion of the authors-that in London since1940 the biennial epidemic rhythm of measles has

disappeared at least temporarily-is not borne out bya detailed survey of the ten years 1940-49. The

epidemics of 1940-41, 1942-43, and 1944-45 as shownin the graphs exhibit a biennial periodicity more com-prehensive than that of biennially recurring peaks-though these also are to be observed ; and while sincethen what might be regarded as fundamental changeshave been noted, these are not coincident with thenotification period. As Taylor 3 has demonstrated,measles outbreaks in lesser constituent populations maynot conform to the type of incidence observable in thelarger inclusive units such as England and Wales.

1. Butler, W. Mon. Bull. Min. Hlth, P.H.L.S. 1946, 5, 81.2. Butler, W. Proc. R. Soc. Med. 1947, 40, 384.3. Taylor, I. Mon. Bull. Min. Hlth, P.H.L.S. 1948, 7, 254.