London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1920

Annual report of the Council, 1920. Vol. III. Public Health

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xiv
exact amount of the grant in aid available for the payment of the staff was made known to the boards
of the hospitals by the councils of the participating authorities. It must be said, however, that the
arrangements as a whole for this purpose have been devoid of any organised principles and have been
allowed to drift on, mainly because the councils concerned have been anxious not to interfere between
the hospital board and the medical staff, in so delicate a matter as remuneration, unless asked to do so
by both parties.
It appears to be open to question whether the present arrangements should be allowed to continue.
The position is unsatisfactory, both to the boards of the hospitals and their medical staffs, and not less
so, in some respects to the public authorities concerned with the work. From enquiries made it is
believed that the matter is one which can quite easily be adjusted, and that the fixing of a scale of
remuneration would be warmly welcomed by the hospital boards and the medical staff engaged in the
work, both in the treatment centre and in the laboratories. It may be observed here that the British
Medical Association issued an expression of opinion on this subject some years ago, and stated, inter
alia, that they considered a fee of three guineas per session was a reasonable payment for the chief
officer of the clinic, and some of the hospital clinics have adopted the scale suggested by this body.
Treatment of gonorrhoea.—The most striking feature of this section is the lack of facilities for the
intermediate treatment of gonorrhoea in both males and females. This must militate very strongly
against the success of any measures adopted for the treatment of this very prevalent complaint. It is
realised how difficult it is to induce patients to attend daily, and this is a strong argument for the establishment
of facilities for daily intermediate treatment which will involve a minimum inconvenience
and loss of time to the patient.
In many clinics a lack of system was noted in the management of cases of chronic gonorrhoea.
These are not subjected at periodical intervals to a thorough examination, but only to a section of that
examination and that at uncertain intervals. For example, on one day the prostate may be examined,
on another, some weeks later, the urethroscope may be used and so on, so that at no time is a complete
picture of the patient's condition obtained. The result of this system, or rather lack of system, is that
patients may be allowed to drift on for weeks under a haphazard form of treatment. No doubt this is
due in the main to the unsatisfactory conditions under which the work is carried on, especially the
overcrowding and the inconvenient arrangement of premises.
Treatment of syphilis.—While there is great uniformity in the employment of "914" and mercury
in the routine treatment of syphilis, the greatest divergence of practice was found in the matter of the
total amount administered, which varied from six injections of "914" to thirty or more. Those who give
the smaller amounts mentioned usually stop arsenobenzol when the Wassermann reaction becomes
negative and may or may not follow up this course with mercurial treatment by mouth, or by regular
courses of injections (generally the former) for one or two years. In such cases the arsenobenzol treatment
is usually resumed if the Wassermann reaction returns to positive. Those who give large total
amounts of arsenobenzol and mercury in successive courses usually do so regardless of the Wassermann
test, proceeding on the assumption that the attainment of a negative Wassermann reaction does not
necessarily herald the death of the last syphilitic organism, a fact which everyone will admit. There
is much that is unsatisfactory in this diversity of practice, and it is earnestly to be desired that a closer
agreement than prevails at present could obtain in the routine practice, with regard, especially, to early
cases of syphilis. Whilst not venturing to lay down a course which should be carried out in all cases,
since this is a matter for responsible clinicians, one cannot help feeling that in some cases
there is a lack of consistency in the principles adopted. For instance, assuming that everyone
admits that the first negative Wassermann reaction does not necessarily herald the cure, and that
this is the reason for the continuation treatment with mercury alone, which is most commonly adopted.
One cannot understand why, in a treatment which continues on the assumption that syphilitic
organisms are still alive in the patient, the more powerful arsenobenzol remedies are not employed also.
Alternatively, assuming that the clinician believes arsenobenzol to be only a symptomatic remedy,
useful only for dissipation of skin and mucous membrane lesions (an opinion which has been expressed
to us), it is difficult to discover the reason for a resumption of arsenobenzol by the same clinician when the
only sign of a relapse is not a skin or mucous membrane lesion, but simply a positive Wassermann
reaction. Again, some clinicians consider that it is unsafe to employ arsenobenzol in continuation
courses, but again employ it if the Wassermann reaction returns to positive or clinical symptoms reappear.
In mentioning the above difficulties reference is being made particularly to the practice in regard to
early cases of syphilis, and it is felt that a closer agreement on principles than obtains at present is most
desirable. In some hospitals there is almost as great a divergence of practice amongst the various
members of the staff as amongst all the clinics, and here it seems to us that it would be a simple thing
for the staff engaged in this work to meet together and thresh out the matter in discussion. It is noteworthy
that arsenobenzol treatment does not now make the demand on beds which was formerly
considered necessary. This is due to the use of "914," which is followed by immediate reaction in such
a slight proportion of cases that hardly any patients need remain for rest after the injection.
Recording of toxic results of arsenobenzol treatment.—Toxic results following arsenobenzol treatment
appear to have been very rare in the London clinics. This probably accounts for the fact that, in
many clinics, the existence of a form, V.20, on which such results are to be reported to the Ministry of
Health was unknown. Attention is drawn to this fact here, as the rendering of this report enables a
proper estimate of the proportion of side-effects to be formed., and it also assists those whose duty it is
to control the quality of arsenobenzol compounds issued for sale to relate the toxic effects following
injections of different batches of the products to the results of animal tests applied before they were


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