42 JAN.
7, 1933] CORRESPONDENCE
for their origin on the physico-chemical nature of
colloidal matter in its reaction to the diffusion through
it of solutions of electrolytes, or, in certain cases, to the
liberation within it of such substances. From this point
of view there may be a definite relationship between the
mechanism of causation of this condition and that of the
pigmentary or gaseous deposits in banded or striated
hairs and feathers, which are of much more common
occurrence in nature.
The microscopical appearance in Tomkinson's article
of a single hair may be compared with the illustration
given by McCall Anderson (Fig. 7, p. 59) of six hairs
from five affected persons in the family group he recorded.
-I am, etc.,
Mlanchester, Dec. 20th, 1932. W. J. RUTHERFURD.
Mastoid Drainage
SIR,-I should have thought that in the experience of
most aural surgeons the drainage of the mastoid was
rather too long delayed instead of being premature, as
suggested by Mr. Douglas Crow in his note in your issue
of December 17th, 1932 (p. 1104). I hope this note will
not lead to practitioners postponing sending their cases
for investigation and operation at an early date.
I have consistently urged that an earlier mastoid opera-
tion is indicated, and although one realizes quite clearly
Mr. Crow's point, yet I should have thought that most
aural surgeons would never have considered operation
at the stage to which he objects. Broadly speaking, I
think it is necessary to impress upon practitioners that
large numbers of cases of mastoid involvement are treated
as though the disease were confined to the middle ear;
in my personal experience I have never opened a
mastoid antrum without finding a serious involvement of
the structures, and this may, I think, occur at an earlier
date than is appreciated by Mr. Crow, as the fulminating
type is by no means uncommon, especially when arising
as a complication of influenza.-I am, etc.,
Bath, Dec. 22nd, 1932. H. NORMAN BARNETT, F.R.C.S.
Classification of Arthritis
SIR,-In trying to assess the value of any treatment
for arthritis the chief difficulty is in the classification
of the disease. There is a wide divergence of opinion
as to when any particular type begins, when it ends, and
when it merges into another type. Since it is generally
accepted that a good x-ray negative is the best means of
determining the actual condition of the joint, it should
be possible to make clearly defined subdivisions according
to the stage of the disease as follows:
Stage 1: Articular Arthritis.-The x-ray findings are nega-
tive or in favourable cases show cloudy inflammatory changes
in the cartilage and the joint space.
Stage 2: Osteo-articular Arthritis.-The disease has also
invaded the adjacent bone but the joint-space is still intact-
that is, the joint is still a cartilage-bearing one.
Stage 3: Osteo-arthritis.-The joint-space is partially or
completely obliterated and the joint is now a bone-to-bone-
bearing one.
Stages 2 and 3 to be subdivided into " hypertrophic " and
" atrophic " according to whether or not there is evidence
of bone reaction with lipping, osteophytic overgrowths, etc.
The type of disease could be added as a prefix-rheumatoid,
infective, or gouty. Without this prefix it would mean true
osteo-arthritis, subdivided according to its stage into osteo-
articular arthritis and osteo-arthritis.
A classification along these lines would give a definite
clinical picture of the actual condition of the joint at
the commencement of treatment, and would be especially
valuable where the disease is limited to one or two large
THEDICAL JOURNAS
or an isolated group of small joints. In the polyarticular
types, however, it might necessitate the placing of a
patient in more than one stage. It would limit the word
cure" to Stages 1 and 2, and also exclude all cases
of retrogression from Stage 2 to Stage 3. It would tend
to promote earlier diagnosis by emphasizing the possibility
of a cure or a marked improvement in the earlier stages.
If adopted in various centres, collective information would
soon be available and the results of any particular form
of treatment more accurately assessed.-I am, etc.,
London, W.1, Dec. 21st, 1932. W. L. WATT.
The Medical Profession and the Lay Press
SIR,-Sir Harold Gillies (December 24th, 1932, p. 1166)
raises an issue that requires solution, not only for the
protection of the interests of the medical profession, but
also in order to safeguard the public. The value of new
methods of treatment can rarely be correctly estimated
by the public, and editors of newspapers do not always
appear to recognize fully their responsibility to the public
for medical items in their columns. My work, for instance,
has recently been referred to by a section of the lay press
(it is hardly necessary to say, without my personal know-
ledge) in a way that is grossly inaccurate. It has been
implied that I have discovered new methods of treatment,
and from letters I have received it is clear that one effect
of this has been to arouse false hopes in the minds of
friends and relations of patients who are incurable. Even
if the lay press has little concern in causing embarrass-
ment to members of the medical profession and to their
work, surely it would wish that its information to the
public on medical matters should not give rise through its
inaccuracy to unnecessary mental suffering.-I am, etc.,
London, Dec. 24th, 1932. HUGH CAIRNS.
British and Foreign Spas
SIR,-Dr. Geoffrey Holmes, in his letter which you
published on December 17th, 1932, very successfully
refutes a statement made by a medical correspondent in.
a newspaper that British spas compared with German
spas do little for poor patients. He mentions the hos-
pitals at Bath, Buxton, and Harrogate. It is of general
interest to add that at Droitwich there are two hospitals,
a clinic, a convalescent home, and a hostel, with some
two hundred and fifty beds, available for the same class.
-I am, etc.,
Droitwich, Dec. 28th, 1932. A. R. NELIGAN.
Coroners and Evidence
SIR,-It is true that eminent judges have said that the
coroner is not fettered by the strict rules of evidence
which prevail in ordinary common law courts. On the
other hand, if the coroner had at his elbow a voice which
first softly murmured, " You can't ask that," and then,
rather louder, " That's not evidence; don't answer," and,
finally, if a robed figure stood up beside him and re-
marked, in a tone of pity rather than contempt, " My
friend knows he can't ask that," we might hear less
nonsense in the coroner's court. Counsel who persist after
such interruptions may receive some such rebuke as this:
" Mr. Jones, if what you say is right, I have yet to learn
my business, after forty years in the law."
During the twelve years I was at the Common Law bar
I came to see that examination-in-chief required even
greater skill than cross-examination; that able advocates
often reduced their cross-examinations to very few ques-
tions, turned .to the jury with a smile, and sat down.