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CONFERENCE ON RHEUMATICDISEASES.

BATH, MAY 10TH-11TH.

THE Conference on Rheumatic Diseases held inBath last week came to a satisfactory conclusion onFriday, May llth, and all who took part in it wereunanimous about two things-that as a businessmeeting it had been a marked success, and that theopportunity for fellow-workers to meet, afforded bythe amenities of the City that had issued the summons,was unrivalled. The spirit in which those amenitieswere accepted by the congressists showed their fulland unanimous appreciation of their reception. TheConference closed with a unanimous vote of thanksto Mr. Edric Chivers, the Mayor of Bath, alike forthe profuse hospitality granted by the City and forhis own personal endeavours to carry out the objectsof the Conference. The passing of the vote of thanksto the Mayor was accompanied by an acknowledgmentof the particular debt of gratitude owed to the LadyMayoress, Mme. Sarah Grand, and to the OrganisingCommittee, Dr. F. G. Thomson, Dr. Rupert Water-house, Dr. R. G. Gordon (President of the BathBranch of the B.M.A.), Dr. Vincent Coates, and Mr.John Hatton, the director of the Royal Baths, whoacted as organising secretary.

THURSDAY, MAY IOTH.The Conference was opened by a Civic Welcome

Ifrom the Deputy Mayor, after which Sir GEORGENEWMAN (Chief Medical Officer to the Ministry of i

Health) delivered the brief Presidential Address to theConference which we were able to publish last week.Immediately thereon the Conference got to business,the first Session, devoted to the Social Aspects ofRheumatism, being opened by the President of theSession, Lord DAWSON.

FIRST SESSION-SOCIAL ASPECTS.After a few introductory words from Lord DAWSON,

the first paper was read by Sir WALTER KINNEAR(Controller to the Insurance Department of theMinistry of Health), who dealt in a clear andinteresting manner with the problem of the cost tothe country of industrial rheumatism. This paper,which is published on p. 1001 of this issue of THELANCET, revealed what a burden both to themselvesand to the community are our large number ofrheumatic subjects, and proved how urgently neededwas the attempt of the Conference to arrive at somedefinite conclusions regarding setiology and theappropriate methods of prevention and relief.

Sir Walter Kinnear was followed by Dr. H. B.BRACKENBURY (Chairman of Council, B.M.A.), whospoke on the need for the organisation of the facilitiesfor treatment for the whole population. Thesefacilities included : (1) the discovery and eliminationof any infected foci ; (2) the administration of drugs ;and (3) the use of various physical agencies and ’,methods. " The right case must be got to the rightplace for the right purpose." Dr. Brackenburyreferred to the work which had been done in Hollandand in post-war Germany towards this end. Hegathered that these continental organisations were notby any means perfect but that we had something tolearn from their experience. In this country specialistadvice was only at the disposal of a small percentageof insured persons, and it should be made part of thestatutory medical benefit as soon as possible. Twopractical schemes for the organisation of rheumatictreatment were before the public in this country-viz., that of the British Red Cross Society and thatof the British Spa Federation. In order to secure thehearty support of the medical profession these schemesshould be united and should conform to certainrequirements—e.g. : (1) no patient should betreated except on the recommendation of a medicalpractitioner ; (2) patients, who could easily obtainthe requisite treatment should be refused ; (3) the

conditions should envisage the possibility of a patientobtaining advice at the consulting-room of a specialistinstead of at an institution ; and (4) there should besuitable opportunity for practitioners to observe andobtain experience of the methods employed and theirresults. Such organised schemes would affordopportunities for the clinical and pathologicalobservation and research which were essential forsuccess in combating this baffling and obstinatenational scourge.

Dr. J. VAN BREEMEN (Holland), Hon. Secretary,International Committee on Rheumatism, spoke onthe types of rheumatic disorders which were mostprevalent in Holland. He said that official statisticaldata on rheumatism were an unknown quantity inHolland, and that the scientific study of the socialcampaigns against rheumatism were still in theirinfancy. He submitted a table with regard to 832male and 1046 female rheumatic patients, attendingthe Rheumatism Consulting Bureau at Amsterdamduring 1927, classified according to the type of theirdisease. He thought that acute rheumatism wascomparatively rare in Holland, as also heart diseaseand chronic joint disease following acute rheumatism.The number of children, who had died in Holland ofacute endocarditis and myocarditis between theages of 5 and 14 appeared to be much less proportion-ately than the corresponding fatalities in GreatBritain. Gout was also rare in Holland, though theold French Huguenot families often showed thearthritic diathesis in a pronounced degree. Hefound that affections of the knee-joint were strikinglymore frequent in women than in men, and that theshoulder-joint was more frequently affected in men.Arthritis deformans, the equivalent of rheumatoidarthritis, was not very frequent in Holland, and hisimpression from studies in England was that the casesin England were more numerous and more severe.Cases of sciatica over the age of 50, sent to him, wereoften really osteo-arthritis of the hip-joint. Arthritisof the spine was seldom recognised and was morecommon than was formerly thought, though itsprognosis was less grave. The strict separation ofspondylitis deformans and rhizomelic spondylosis(complete vertical ankylosis) was frequently impossible.Arthritis of the spine generally occurred in men andhe had never seen the rhizomelic forms in women.He considered that the influence of occupation inproducing rheumatic affections would be one ofthe great medical problems of the future. Thestatistics of the " Councils of Labour " (Raden vanArbeid) showed that only about one-tenth of theworking people invalided by chronic rheumaticdiseases were medically treated. He hoped thatwithin the next few years it would be possible tofurnish official statistics with regard to all rheumaticaffections in Holland.

Dr. J. ALISON GLOVER gave particulars from theMinistry of Health’s inquiry, which had reference toa sample population of about 90,000 insured persons.and indicated that the percentage of the total sicknesscaused by rheumatic diseases was about 16.8 formales and 14’4 for females. The lower percentageamong women was due to the younger age of theinsured women, owing to matrimony and otherreasons. The Leipzig statistics, published in 1907,seemed to indicate that rheumatic diseases were

quite as common in Germany as in England, and thisimpression was confirmed by the more recent figuresgiven by Sommerfeld for Berlin. The fact that theincidence of acute rheumatism was undoubtedlydeclining in our country was one of the bright spotsof the problem. Dr. Lambert had shown that thisdecline was also occurring in the experience of theNew York hospitals. The figures for our Navyfrom 1907 to 1923 showed a great decline in rheumaticfever, out of all proportion to the slight fall in theincidence of tonsillitis. These figures, however,referred to frank rheumatic fever, and gave no ideaof the incidence of other manifestations of therheumatic infection in children, which were almostequally important from the point of view of the

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production of heart disease. Probably 1 in 50of the children attending the public elementaryschools required observation and periodic examina-tion on account of some rheumatic manifestation.Dr. Glover, who showed diagrams which indicatedthe attack-rate at various ages in both sexes fromfibrositis and arthritis, referred to the marked effectof occupation upon the incidence of rheumaticdiseases and specially referred to the observation ofvan Breemen that every special trade had its ownrheumatic " deviation." So far our Ministry’sinvestigation had only brought out the fact of thespecial incidence of osteo-arthritis upon the workers inthe heavy metal trades. The statistics of hospitalsshowed that they were only able to admit and treata very small percentage of the cases of chronicarthritis, and further institutional treatment wasobviously needed to provide accurate attention toseptic foci, and the intensive local and physicaltreatment which might be given at a spa hospitalor an out-patient clinic. The number of insuredpatients suffering from chronic arthritis was onlyhalf that of those who suffered from fibrositis, butthe longer period of disablement caused by theformer made the two equal in causing disablement.Thus the drain upon the National Health Insurancefunds for sickness and disablement benefit causedby rheumatic diseases was at least one-seventh of thewhole, one-half of which was due to chronic arthritis.

Dr. R. G. GORDON (Bath) laid emphasis on thefact that in almost every case of chronic rheumaticdisease the skin is at fault in some way or another.Sweat secretion depended upon the sensory stimuliimpinging on the skin. a good cutaneous blood-supply,and proper endocrine balance. A humid coldatmosphere made adequate sweating difficult. Peoplewho had spent their lives in a tropical climate whenthey returned to this country had lost their powerto sweat and frequently developed fibrositis andpanniculitis. Fatigue was an important factor. Asan example of local strain, we had the lumbago ofgardeners, the fibrositis of the shoulders and backsof miners, and the osteoarthritis of the hips in thosewho had ridden and hunted much, but generalfatigue markedly influenced the endocrine systemand through it the action of the skin. In treatingchronic rheumatism it was necessary to find thefatigue limit of the patients and to keep them withinit. Emotion, worry, and depression also affected theendocrine system and the action of the skin.

Dr. HANS JANSEN (Copenhagen) said there wereno statistics available as to the relative prevalenceof rheumatic diseases in Denmark.A further important paper was read to the Session

by Dr. REGIN’ALD MILLER, which will be found onp. 1005. This paper dealt with the influence ofenvironment on rheumatic infection in childhood,and its conclusions formed the topic of comment inmany of the communications which followed.Lord DAWSON closed the debate with a short

reflection on the general messages conveyed by thespeakers. Alluding to the incidence of fatigue, hesaid that everyone, and not only medical men,recognised the magnitude of the evil caused by chronicrheumatism among workers. adding that it was

necessary not merely to think of the many days of chronic

sickness and the heavy loss of life. but also to think lof its affecting the quality of life. It was clear that Ienvironment played a prominent part in the pro- 4duction of rheumatism and the allied sequelae, though 1occupation played its part, as had been shown by i

the speaker who had pointed out how metal workers 1were particularly subject to rheumatic diseases. And 1

while he deplored the idea that they should be charac- <

terised as poverty diseases only, he urged the import- rance of the improvement of housing, of the methods i

of domestic life, of good clothes, and of the open-air Elife. While strongly advocating the value of I

recreation, and of playing rather than watching t’games, and of guarding against anything like fatigue, r

he ventured to raise the issue as to whether the rigid tidea of the eight-hour day was wise, and thought s

it might be better to have occasionally a longerworking day, properly alternated with a shorter,provided the average of the eight-hour day was notexceeded during the week.

FRIDAY, MAY 11TH.

SECOND SESSION&mdash;CAUSATION.

The second session of the Congress was openedpunctually at 9.30 A.M. by Sir HUMPHRY ROLLESTON,who delivered the following

Presidential Address.To begin with, he asked the Conference to consider

what were the connecting links or common eetiologicalfactors in-the rheumatic disorders. At one end of thescale was acute rheumatic fever whilst at the otherwas osteo-arthritis, largely a degenerative disease.Between these two extremes was a chain of gradualtransitions, but clinically the main distinction wasbetween the acute and subacute forms of disease,prone to damage the heart and to react to salicylates,and the chronic forms, permanently damaging thejoints, but seldom, if ever, the heart, and irresponsiveto salicylates. Did chronic joint inflammation developoften enough in persons formerly attacked by rheu-matic fever to suggest that the two diseases were dueto the same infection, or was the sequence morecredibly explained by the supposition of a generalarthritic diathesis P The characteristic lesion ofrheumatic fever, including chorea, was the formationof nodules, large in the subcutaneous tissues, sub-miliary in the heart. These also occurred in rheumatoidarthritis, but had rarely been reported in otherdisorders. The submiliary nodules in the myocardium(often called Aschoff’s bodies) were generally regardedas pathognomonic of acute rheumatic infection.though Geipel and Butterfield dissented and Cowanand Ritchie stated that they occurred in most of theacute infections. Nodules of this kind were found inthe pericardium, cardiac valves, synovial membranesof the joints ; Coombs had described changes in theaorta and nodular periarteritis (1908-09), and Klotzhas commonly found arterial lesions in acute rheu-matism-an inviting subject for further research.

According to Coates and Coombs the histologicalstructure of the subcutaneous nodule in rheumatoidarthritis and Still’s disease was the same as inAschoff’s submiliary nodules in the myocardium.

Subcutaneous nodules had been often found inrheumatoid arthritis and osteo-arthritis, which ledHawthorne to say in 1912 that " either rheumatoidarthritis is rheumatism or the development of fibroustumours in the subcutaneous tissues is not a specialnote of rheumatism." But Sir Humphry Rollestonhad not found any evidence of submiliary nodulesin the heart in chronic rheumatoid arthritis. Fibro-sitis, which was the non-arthritic form of chronicrheumatism and might have the local habitation andname of panniculitis, was also accompanied by nodule-formation, though in this condition the thickeningswere not so histologically characteristic as therheumatic nodule. As Stockman and Weber hadpointed out, panniculitis, like fibrositis and fibro-myositis, might arise from various causes.The much debated streptococcal nature of acute

rheumatism, first raised by Poynton and Paine in 1900.had, in spite of much criticism, been steadily gainingground. Recently Small had described as the specificcause a non-hsemolytic streptococcus, differing fronithe viridans group in its cultural characters, under thename of Streptococcus cardio-arthritidis. His specifictreatment with antiserum and vaccine of’72 acuterheumatic, 25 choreic, and 40 chronic rheumatoidcases had given encouraging and significant results.There was a widespread impression that chronicrheumatoid arthritis and its allies were due tostreptococcal infection, though Warren Crowe inerimi-nated Staphylococcus albu.s, type D, for rheumatoidarthritis and streptococci for osteo-arthritis andnon-articular rheumatism. It might be argued thatthe various members of the rheumatic diseases werestreptococcal in origin, their clinical and structural

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differences depending on (a) variations in the " seed,"and (b) inborn or acquired differences in the soil-namely, the constitution, endocrine, and other factors.The non-infective origin of chronic articular lesions,such as metabolic anomalies in alkaptonuria, in thetrophic (e.g., Charcot’s arthropathy), and psoriaticforms might still be a matter for discussion, and inthese, at any rate, it seemed that, if there were bacterialinvasion, it was secondary and subordinate in import-ance. In both the acute rheumatic and the chronicrheumatoid forms hereditary constitution or an

" arthritic diathesis " must be considered to play apart. Inadequacy of the thyroid had been speciallyput forward, but ovarian and pluriglandular inefficiencyhad also been regarded as responsible. Pemberton hadinsisted on the low Eugar-tolerance of chronic arthriticsand ascribed this to diminished circulation of blood inthe muscles. But the possibility should be borne inmind that both the disturbed endocrine function andthe arthritic manifestations were due to infection ;for example, the correspondence between the geo-graphical distribution of endemic goitre and ofrheumatoid arthritis (McCarrison) might be explainedas different results of an underlying infection. Indescribing the loss of sulphur in chronic rheumaticarthritis Cawadias concluded that the toxic andinfective, and even physical factors, such as damp,responsible for rheumatoid arthritis first acted on theorgans-liver, thyroid, and autonomic nervous

system-regulating metabolism. On the whole itmight be reasonable to suggest that varying degreesof diminished constitutional resistance of the fibroustissues or of sensitisation to infection on the one hand,and on the other hand the action of different kindsof streptococci might explain the different clinicalmanifestations seen among the diseases grouped forconvenience under the heading of rheumatism.

Dr. C. WILFRED VINING (professor of children’sdiseases, University of Leeds) described an investi-gation carried out in Leeds, by Dr. Wear, by thechildren’s almoner of the infirmary, Miss Finlay,and others, which confirmed his view that thefrank rheumatic child is a child suffering from toxicdebility with added rheumatic infection. He gaveparticulars of the symptoms of the " toxic debility "children, including nervous instability, limb pains,headache, listlessness, and anaemia, and pointed outthat some 25 per cent. of the child population belongingto the social sphere from which rheumatism chieflycomes show these phenomena more or less. These" toxic debility" children exhibit certain intestinalsymptoms assc ciated with mucus in excess andmembranous material in the stools. The actuallyrheumatic children suffer in the same way. Prof.Vining was impressed with the similarity of thesymptoms shown by these sufferers and by McCarrison’s monkeys and pigeons fed on diets deficient invitamin B. He considered that a dietetic theoryexplains why rheumatism does not appear until i

4 or 5 years of age-that is to say, the dietetic deficiency Itakes some years to break down the defence. He found Ithe family incidence of both toxic debility and rheumatism easily explained by the family diet. IIn Leeds he had found nothing to support the belief ’that damp plays an important part in rousing therheumatic infection to activity. On a recent visit toHolland he understood from Dutch medical men,who were also school medical officers, that, whilechorea, joint rheumatism, and cardiac affections wererare in Holland, enlarged tonsils and adenoids wereextremely common. He concluded that most childrenwho develop clinical rheumatism have a previousdefective health history for months or years, which isbrought about by prolonged dietetic deficiency, eitherin vitamin B or in protein in conjunction with excessof carbohydrate, or possibly by both these factors.He explained the sequence of events by dividing theelementary school-children into four main groups :(1) healthy children, comparable to those in othersocial spheres; (2) children who are beginning toexperience the results of the deficient diet and areunder weight, with toneless tissues and alimentary

(’anal disturbances; (3) children with added symp-toms of toxaemia; (4) children with clinical rheu-matism, acute or subacute, the dividing line betweengroups (3) and (4) being one of massiveness of dose,repetition of dose, or lowering of resistance by somefactor or factors unknown. He maintained that if hisconception is right we shall not prevent rheumatismby concentrating on damp houses and the removal oftonsils and adenoids, but rather by the provision ofa well-balanced diet from infancy onwards. Prof.Vining did not rule out the possible effect of damphouses nor deny that the tonsils may be the portalof entry, but held that an exclusive throat aetiology isnot warranted by the evidence at our disposal.

i Dr. H. DINGWALL FoRDYCE (hon. physician, RoyalLiverpool Children’s Hospital) expressed himself as

largely in agreement with Prof. Vining as to theimportance of a proper diet from infancy onwards.Although heredity might be of some importance, wewere granted a postnatal interval of opportunity,lasting for several years, in which to develop effectiveprophylactic measures. Dr. Fordyce gave, as threeimportant predisposing factors, instability of thenervous system, digestive disorder, and weakness ofly-mphoid defence, and sketched some of the homeconditions likely to conduce to these factors. Heconsidered that child welfare work, by its educationalinfluence, had been one of the chief causes of thedecline of acute rheumatism. A close cooperation wasneeded between the administrators and the clinicalphysicians. If we had at our command more beds incountry hospitals and suitable residential schools hefelt that the results would be remarkll le.

Dr. CAREY F. CooMBS (physician, Bristol GeneralHospital).in a review of the bacterial position, submittedevidence that rheumatic fever is an infection ratherthan an intoxication, and that the disease is due to thein-vasion of the brain, joints, hea t, and subcutaneoustissues by streptococci, which are borne thither bythe blood stream. He thought we might accept theview that the tonsil is certainly, and the intestinalmucosa possibly, to blame for admitting this virusinto the systemic circulation. The type of infectionin childhood was, he held, best described as a series ofraids, many of which are stealthy-the organismslinger outside the circulation and revisit the circula-tion from time to time. Dr. Coombs went on to referto the work of Homer Swift and others which suggestedthat rheumatic patients showed a group sensitivenessto streptococcic toxins. This would explain whyStreptococcus viridans succeeded in implanting itselfon valves already injured by the rheumatic strepto-cocci, and also the remarkable relation between scarletfever and rheumatic infection. In spite of the factthat rheumatic infection in childhood created a formof sensitisation, a tide of immunity set in after a certainage, and possibly 30 per cent. of affected childrenrecovered and acquired this immunity. The fact thatthe injuries inflicted conformed closely to a certainpattern was due rather to constancy on the part ofextraneous influences than to the specificity of thestreptococcus. The difference between the naturallyacquired lesions in man and the lesions caused experi-mentally in animals was probably due to theseextraneous influences. In a child the infection appearedto enter by a succession of small doses, perhaps througha mucous membrane, while in the animal, infection,perhaps enhanced by sojourn in the human body, wasinjected directly into the circulation. The latentchorea described by R. Miller, the granules found byV. Coates and Thomas, the pre-rheumatic state ofwhich Vining has written, and the mitral stenosis onlydiscovered in adult life were all explicable by theescape into the body of minute doses of bacteria.

Dr. RALPH STOCKMAN (professor of materia medicaand therapeutics, University of Glasgow) dealt withthe causation of fibrositis and panniculitis, which hedescribed as really the sequelse of various precedingdiseases. He illustrated by lantern slides the gradualformation of a definite fibrous tissue from the loosesoft texture with a sero-fibrinous matrix, resultingfrom the exudation of serum and proliferation of

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fibroblasts, the common reaction to bacterial andchemical irritants. What happened in muscularrheumatism and panniculitis did not differ essentiallyfrom the histology of infected wounds with painfuladhesions, thickened pleura, and cirrhosis of the liver.In fibrositis the irritant was most commonly a bacterialtoxin produced on the site by a colony of microbes orpossibly carried from a distance by the blood stream.Fibrositic patches might affect one area of the bodyonly or be widespread, and in some localities took theform of pea-like masses with a core of inflamed fibroustissue surrounded by fat. In the early stage theselittle swellings might disappear or be dispersed bymassage. He regarded cold and wet as exacerbatingfactors of lesions already present rather than as causesof chronic rheumatism. He did not consider changesin the activity of the endocrine glands a cause ofpanniculitis. Increase in adiposity was apt to occurat the menopause and tension or pressure increasedthe sufferings of women who were already the subjectsof subcutaneous fibrositis. ’

Dr. W. LANGHOON BROWN (physician to St. Bar- Itholomew’s Hospital) dealt with the endocrine factorand thought we might confine our attention to thethyroid and ovaries. He agreed with the pioneerHertoghe, whose recent death was a real loss to theprofession, that it was most important to look forindications of hypothyroidism. He also agreed withLlewellyn that hyperthyroidism might be operativeand that thyroid instability was the importantthing. There might be a background of hypo-thyroidism with spurts of hyperthyroidism. Lack ofiodine was a feature in both. Tonsillar sepsis wasassociated with thyroid derangement. Studies of theblood-sugar in rheumatism would throw light on theendocrine factor. The thyroid gland mobilises thesugar into the blood stream, whilst insulin leads tothe storage of sugar as glycogen in the liver andmuscles. Insulin might be useful for rheumatichyperpyrexia. Thyroid inadequacy might be theinherited factor in rheumatism. Iodine was usefulboth for rheumatism and goitre. The thyroid andtonsils were only factors-not the whole story. Theovaries might have an effect at puberty and themenopause and act through the thyroid. The conditionof the thyroid was the chief endocrine factor inrheumatism and rheumatoid affections.

Dr. GEOFFREY HADFIELD (demonstrator ofpathology, University of Bristol) discussed the

specificity of the tissue reactions in rheumatic diseases,and referred to the subcutaneous millet seed granulesof Vincent Coates. These, he said, were composed ofproliferating reticulo-endothelium, were rich in newlyformed capillaries, and presented similarity to whatwas supposed to be the primary tissue reaction inthe infective arthritic group. The granules werethe classical nodules in miniature. This reaction, whilenot so spectacular as the giant-cell system of tubercle,was as constant as that of gumma formation. Therewas little difference between the early skin noduleof infective arthritis and the submiliary myocardialnodule of acute rheumatism. In panniculitis thereaction was not exclusively confined to the local

reticulo-endothelium. as in acute rheumatism andinfective arthritis, and this dissimilarity indicated amore virulent infection or a lessened local immunityin panniculitis. Much more work was needed, butup to now the infection of chronic infective arthritisappeared to be one by a saprophytic streptococcusto which the patient had a high degree of generalimmunity but a low degree of local immunity in thesynovia of his joints.

Dr. P. LAZARUS-BARLOW described work which hehad done with Small’s streptococcus cardio-arthritidis.

Prof. ISIDORE GUNZBURG (Medical Director) laidemphasis on the bad state of the skin as a causativefactor. ’

Prof. ToM HARE (Royal Veterinary College)described the types of rheumatic disease prevalent Iin animals and the research work as to setiology in pro-gress. In horses and dogs we had rheumatic disease, thenatural course of which is within the experimental 4

period and which can be terminated at any stageat the will of the investigator. The investigation ofthis disease in its pathogenic phases offered greatpossibilities of advancing our knowledge of rheumaticdisease in man.

Dr. L. BERTRAND (Antwerp) described work donewith a polymorphic anaerobic organism discovered30 years ago, which sometimes took the diplococcalform. If the proper technique was employed it was tobe found in rheumatic lesions, and its changes underculture perhaps accounted for its varying effects onhuman tissue. A vaccine made from it was efficacious.

Dr. R. WATERHOUSE (Bath) thought rheumatoidarthritis and osteo-arthritis had little in common.Heberden’s nodes were found more in the well-to-dothan in the poor.

Dr. J. B. BURT (Buxton) believed the investigationof arthritis in animals would be helpful. One in 8cab horses had arthritis. Trauma alone would causeit ; the position of osteophytes was determined bystrain and heredity-e.g., a short pastern, had its effect.

I Surgeon Vice-Admiral GASKELL, R.N., said acuterheumatism was now very rare in the navy. Therehad also been a decline in chronic rheumatism, butthey had not yet found any lessening of the prevalenceof heart disease of rheumatic origin.

Dr. F. G. THOMSON (Bath) showed that Graves’sdisease and infective arthritis had a similar agecurve, chiefly from 16 to 40 years. Chronic villousarthritis of the menopause was always associatedwith thyroid deficiency.

Dr. WATSON-WILLIAMS (Bristol) thought endocrineimbalance was the result and not the cause of thesechronic infections.

Dr. G. L. KERR PRINGLE (Harrogate) said theatrophic type of rheumatoid arthritis only occurredin females. It might be associated with the beginningof menstruation. Pregnancy relieved it. but itreturned at the puerperium. It began in the smalljoints, was centripetal and symmetrical. Diathermyof the ovaries probably removed the endocrineimbalance.

Dr. HENRY ELLIS (London) stressed the importanceof biochemistry and the acid-base equilibrium of theurine. Endocrine rheumatism caused no alterationin this equilibrium. The cases with excess of uricacid were a special type. The alkaline and acidtypes were hereditary and needed different treatment.

Dr. A. P. CAWADIAS (London) referred to the sulphurmetabolism in arthritis deformans-i.e., rheumatoidarthritis-and said more study of the metabolicchanges was needed.

Dr. F. B. S. HOLMES (Bury) referred to 50 cases ofafebrile chronic arthritis, all able to stand upright,in whom the basal metabolism was normal. Neverthe-less we knew that thyroid benefited such cases.

Prof. PISANI (Florence) referred to acute rheumatismas a germ disease and to chronic forms as largely dueto endocrine and sympathetic disturbances andanaphylaxis.

Dr. LANGDON BROWN, in replying upon thediscussion, insisted that there must be no unduestressing of the endocrine and metabolic factors andthat the infective theory still ranks high.

Communications. which will be published with theproceedings, were also submitted by authors unableto be present--viz., by Dr. GUNNAR KAHLMETER(Stockholm) on the prognostic value of the rate ofsedimentation of the erythrocytes : by Prof. H.STRAUSS (Berlin) to the effect that endocrine factorsare not truly causal; by Dr. HoMER SwiFT (NewYork) on rheumatic fever as a manifestation ofhypersensitiveness to streptococci ; by Dr. RALPHPEMBERTON (Philadelphia) on stasis of the capillarycirculation and delayed sugar removal ; by Dr. A.GORDON WATSON (Bath) on the hepatic and pancreaticfunctions in chronic rheumatic diseases ; and byMr. A. G. TiMBRBLL FISHER (London) on the pathologyof chronic arthritis with special reference toosteo- arthritis.To this Session of the Conference there was also

communicated an interesting paper dealing with

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rheumatic fever, viewed as essentially a cardiacproblem, contributed by Dr. Weil, of Paris, and Dr.F. Bezancon, which is published in another column.

THIRD SESSION&mdash;&mdash;TREATMENT.

The Third Session commenced punctually at I3 o’clock with brief introductory words fromSir FARQUHAR BuzzARD, who called upon

Dr. R. L. J. LLEWELLYN (Member of the Committeeof the Medical Research Council on Chronic Rheu-matism) to read his paper on Prevention. Dr.Llewellyn related the classification of rheumaticdiseases adopted by the Ministry of Health, which,with other considerations, he thought supplied a goodbasis for provisional working, though a change inattitude was required in respect of treatment ; thereshould be less dwelling-on " end-results " and morestress laid on " beginnings." He insisted on theimportance of considering rheumatic diseases from thephysiological standpoint, and advocated investigationof abnormalities in sweat secretion, believing that themaintenance of the skin in its functional efficiency wasof essential importance. In this connexion he urgedearly resort to spa treatment, as detoxication couldthus be effected and the blood-supply of the skinand the sweat secretion could be stabilised.

Dr. F. J. PoYNTON (physician to University CollegeHospital) gave his reasons for thinking that salicylateof soda is not a specific for acute rheumatism inchildhood in the same sense that quinine is for malaria;although it relieved the joint pains it did not seem toinfluence the subcutaneous nodules or to benefitthe heart. Further, he thought its use, if pushed, wasdistinctly dangerous, especially in fragile children withsevere carditis. The dangers which he feared, andwhich he attributed to the drug rather than to theillness, were death from coma or excessive vomiting,intense depression, pronounced cardiac weakness, andpossibly cedema of the lungs. He had now used" tolysin " for four years and had found it to be asafe drug, even in cases of severe pancarditis, and withan action comparable to that of the salicylates onrheumatic symptoms. He usually gave from 30 to50 grains in the 24 hours to young children. Dr. Poyntoncommunicated notes of cases illustrating the effect oftolysin.

Dr. A. P. THOMSON (physician to the Children’sHospital, Birmingham) gave the requirements of theordinary rheumatic child as: (1) hospital treatment inthe acute stage, for perhaps six weeks; (2) treatment ina convalescent home, mostly at rest in bed, for aperiod varying from 1 to 6 months ; (3) treatment inan institution hospital in which the child’s returnto activity is regulated under careful supervision.Baskerville School, in the suburbs of Birmingham,was such an institution and 7 years’ experience of ithad convinced him of its value and shown that theaverage case needed a stay of 9 months. Thetreatment of rheumatism must not be cut off fromthe hospitals and the school of recovery could belinked up, as had been done in Birmingham, by havinga common medical staff. Baskerville was a " specialeducation " school and education was helpful totreatment. Support from the public funds was neededfor the establishment of such institutions throughoutthe country. Dr. Thomson described details ofmanagement and showed lantern slides of the schoolat work.

Sir WILLIAM WILLCOX (physician to St. Mary’sHospital) read a communication on the treatment ofunderlying infection in all the diseases comprised bythe terms : (1) acute and subacute rheumatism : and(2) infective rheumatism, the latter term covering acuteinfective arthritis, fibrositis. and chronic arthritis.He analysed the arguments for the various directionsof treatment, and in discussing special biologicalmeasures issued a grave warning against the abuseof vaccine therapy although pointing out the value ofvaccines when properly administered. He concludedby noting that vaccines can with advantage becombined with other methods of treatment. I

Dr. J. CAMPBELL MCCLURE (physician to the FrenchHospital) spoke as one not now engaged in supervisingphysical treatment but rather as one who saw manycases before and after physical treatment. The bestresults, he said, were obtained by a combinationof methods, and the choice of the proper combinationwas no easy matter and demanded an intimateknowledge of the conditions underlying the lesionstreated and a very practical knowledge of the bestmethods of physiotherapy. Physical methods wereof great value and disbelief in their efficacy had beencaused by unskilful application and unwise prescrip-tion. For example, massage might be too roughor baths might be too hot, and he had known anobstinate mucous colitis caused by a badly administeredPlombieres douche in combination with an excessivediet of lactic oats. The attendants needed to bewell trained and well directed.

Prof. ISIDORE GuNZBURG described the anti-rheumatic centre established in connexion withthe University of Brussels, with its very completeequipment for treatment, consultation, and research,and gave a sketch of the encouraging results obtainedalthough most of the patients came for treatmentvery late. At the beginning of such a scheme it wasperhaps natural that the severest and oldest caseswere the first comers. A referendum indicated, hesaid, that the patients who have ceased to attendhave derived considerable benefit. A detaileddescription of the Antwerp scheme was given in thehope that it would stimulate the creation of centresin all countries and thus help on the internationalstruggle against rheumatism.

Dr. B. WHITCHURCH HowELL (London) referredto the use of traction and immobilisation and operativeprocedures for securing stiff painless joints and newjoints with a limited mobility, and illustrated hisremarks by photographs. For spondylitis rest inthe prone position was imperative and manipulationmust only be undertaken in the chronic stage, afterX ray examination and the certainty that there wereno loose osteophytes. Much relief could be given bysurgery.

Dr. H. WARREN CROWE (London) believed thatvaccines were not more used on account of faultytechnique. Some got no result because the dosewas too small : others a bad result because the dosewas too big. The first principle was to begin with avery small dose; streptococci which were the easiestto grow were often non-pathogenic and the vaccinesmade from them might be quite inert. Staphylococciwere quite as important as streptococci in chronicrheumatic diseases and a focal joint reaction with astaphylococcus should be regarded as specificallyincriminating that organism.

Dr. C. W. BuciCLBY (Buxton) said there shouldbe facilities at spas to enable general practitioners tolearn about the treatment done.

Dr. VINCENT COATES (hon. medical secretary tothe Conference) said obvious foci must be removed,but the systemic nature of the disease must not belost sight of. The essentials of treatment were theraising of immunity and the correction of biochemicalabnormalities. Fractional test-meals, the - carefulexamination of the stools, and the estimation of theblood- gave indications for the treatment of achlor-hydria, secondary anaemia, and leucopenia, and forthe selection of a suitable diet. Joints were toomuch manipulated ; they required splinting in theacute stage. Hydrotherapy was always useful andmud baths were sometimes so.

Dr. A. P. CAWADIAS (London) said that endo-crines had a limited use in treatment. He hadfound colloidal sulphur useful. Auto-vaccines wereno better than stock vaccines and all vaccine treatmentwas shock therapy. Arthritis deformans was not dueto one cause but to a conjunction of causes.

Dr. HANS TANSEN (Copenhagen) outlined the formsand combinations of physical treatment which headvocated for the various types of chronic rheumatism.

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Dr. DONALD BRIMS (London) explained thetechnique which he employed for the subdermalinjection of oxygen, the application to the skin ofemanations of radium and thorium, and the intradermaluse of a new entero-antigen, with the protein andmicrobes removed, consisting only of lipoids andamino-acids. He claimed " amazingly good " resultsfrom this treatment in Paris, London, and Croydon.

Dr. WATSON-WILLIAMS (Bristol) described an

unusual case where the focus had been postnasalcatarrh and advocated a very careful search for focibefore having the teeth out. Care was needed to seethat only a subsidiary focus had been removed.He thought vaccine treatment was mostly shocktherapy.

THE SOCIAL SIDE.

The City of Bath and the local branch of the BritishMedical Association received the members of theConference with profuse hospitality. The City hadarranged rooms at the various hotels for theirnumerous guests, while members of the medicalprofession at Bath showed the same hospitality. Thewhole organisation of the Baths was placed freely-at the disposal of the visitors, and the Pump Room,built round the famous Roman bath, provided, ason many previous occasions. a model centre for thecomfortable entertainment of a crowd of guests.On Thursday evening a dinner was given by the

City over which the Deputy Mayor and the Mayoress ofBath presided, and at which all the company had thepleasure of listening to excellent speeches from Sir I,GEORGE NEWMAN, in returning thanks for the guestsand delegates, and from Lord DAWSON, who describedthe beauties of Bath with real eloquence. Upon thisthere followed a reception by the Lady Mayoress,and later various entertainments were given, at theclose of which many members of the Conference, andnot only the youngest among them, proceeded todance enthusiastically till a late hour.

On Friday the Bath Branch of the British MedicalAssociation were the hosts of the Conference atlunch at the Grand Pump Room Hotel, whenDr. R. G. GORDON, President of the Branch, presidedand indicated in his speech of welcome how deeplythe Association had at heart such great social medicalrluestions as the incidence of rheumatic diseases.Sir FARQUHAR BUZZARD having replied for the-guests, Sir HUMPHRY ROLLESTON proposed the healthof Dr. F. G. Thomson, the Chairman of the Conference,after whose reply Dr. GuNZBURG set out the pleasurewhich the visit had given to himself and all his confreres.

The annual meeting of the Balneological Section ofthe Royal Society of Medicine was held on Saturday,May 12th, following the Conference, and in connexionwith it demonstrations of treatment on appropriatecases were given at the Hot Mineral Baths throughoutthe early morning. Clinical cases were demonstratedlater at the Royal Mineral Water Hospital by Dr. R.Waterhouse (osteo-arthritis), Dr. J. Lindsay (gout),Dr. Vincent Coates (infective arthritis), Dr. R. G.Gordon (fibrositis), and Dr. A. Gordon Watson(sciatica). In the afternoon a motor tour gave theguests an opportunity of seeing Bath thoroughly,its environment, and its historic features. On Sundaythere was a service at the Abbey at 11, to whichdelegates were bidden, and in the afternoon a motortour of the Mendips was arranged, giving the visitorsthe chance of seeing the famous Cheddar Gorge.

FRANCES WOOD MEMORIAL PRIzE.-This year theCouncil of the Royal Statistical Society will again awardthis prize, of the value of 230, for the best investigation,on statistical lines, of any problem affecting the economicor social conditions of the wage-earning classes. Essaysshould be sent not later than Oct. 31st to the hon. secretariesof the Royal Statistical Society, at 9, Adelphi-terrace,London, W.C. 2, from whom particulars may be had as toeligibility to compete.

Reviews and Notices of Books.THE BLOOD-VESSELS OF THE HUMAN SKIN AND THEIR

RESPONSES.

By THOMAS LEWIS, M.D., F.R.S., Physician of theStaff of the Medical Research Council; Physicianof University College Hospital. London : Shawand Sons, Ltd. 1927. With 76 figures. Pp. 332.37s. 6d.

Harvey raised at least as many problems as hesolved in the discovery which we celebrate this week.It is appropriate to draw attention to some of therecent efforts made by a physician-physiologist, whoselife-work has been the study of the circulatorymechanism, to throw light. on the control of thecirculation in the organ most distal from the heart.Much of the work published by Sir Thomas Lewisin this monograph has been carried on with hiscollaborators over a period of 11 years, and hasalready appeared in original articles in Heart and inthe Journal of Physiology. These the author hascollected not merely with the idea of presenting hisobservations in a more readable form, but with thepurpose of stimulating a wider study and teaching ofhuman physiology.The ultimate object of his researches is to examine

more accurately the various ways in which theblood flow to the skin is controlled, and to accountmore fully for variations in cutaneous colour. In theintroductory chapter, therefore, he gives an account,based on the work of Spalteholz, of the anatomyof the blood-vessels of the skin, and describes indetail the methods employed in examining thosevessels microscopically, and in studying by means ofthermo-electric couples skin temperature and itschange in response to various influences. Apartfrom this, his apparatus and technique are of thesimplest order. With keen observation and greatingenuity in constructing experiments, he has studiedthe pallor of the skin produced, after a latent period,by a slight mechanical stimulus, and has provedconclusively that it is due to actual contraction ofthe minute vessels in response to tension of theirwalls. He further brings out the surprising fact thatthe force exerted by these terminal arterioles,capillaries, and small venules is at least equal to,if it does not exceed, any pressure which can bebrought to bear on them from the arterial side. If agreater stimulus is applied to the skin, a red insteadof a white reaction is produced, due to active dilatationof the minute vessels, and this appears without theintervention of the central nervous system or of alocal nervous reflex. Only if the skin is susceptible,or the stroke stimulus unusually strong, does thereappear surrounding the red line a spreading flush or" fiare," the result of dilatation of the stronglymuscular arterioles by a local axon-reflex. This leadshim to the central theme of his monograph, the" triple response" of the skin to injury. Thisresponse consists of localised capillary dilatation, thecoincident local oedema or wheal which succeeds it,and the surrounding " flare." Whether the injury bemechanical, electrical, chemical, or thermal, thetriple vascular reaction is essentially the same. SirThomas Lewis examines the factors responsible forthe production of the three phases of this complexresponse, and presents a considerable amount ofevidence to show that injury of the skin liberates asubstance exerting a local action indistinguishablefrom that of histamine, on the cutaneous vesselsand nerves. He is unable to prove conclusivelythat it is histamine, and wisely refers to it as the" H-substance." The idea that tissue destructionleads to the production of a histamine-like body is,of course, not novel, for the work of H. H. Dale,W. B. Cannon, and many others has shown that thereis a remarkable similarity between wound-shock andthe shock resulting from the intravenous injection ofhistamine. But the fact that the simple response ofa healthy human skin to trivial injuries is of a similar