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SOCIETY OF MEDICAL OFFICERS OFHEALTH:

TUBERCULOSIS GROUP.

HOSPITAL TREATMENT OF ACUTE AND ADVANCEDPULMONARY TUBERCULOSIS.

AN ordinary general meeting of this group was heldat the house of the society, 1, Upper Montague-street,W.C., on April 1st, Dr. HENRY A. ELLIS in the chair,when a paper was delivered by Dr. H. HYSLOP THOMSON,M.O.H., county of Hertford, on this subject.

Dr. Thomson said: The question of the treatment oftuberculosis may be regarded from two points of view-that of the soil and that of the seed. Hospital treatmenthas for its aim to eliminate the bacillus. One cannotbut be impressed with the limitations of our knowledgewith respect to tuberculosis, and reference must bemade to certain questions regarding the aetiology of thedisease, since the chief aim of hospital treatment is tosecure the segregation of those individuals who areexpelling the bacilli in vast numbers.

The Origin of the Bacillus.Whence does the bacillus come ? Two sources of

origin have been discussed—(1) the bacillus is derivedfrom a pre-existing case of the disease, or (2) it mayarise by transmutation from some non-pathogenic typeof organism. There are those who hold that evolutionmay be at work with the tubercle bacillus as with otherforms of life, subjecting it to the influence of the forcesof natural selection and the survival of the fittest, thatwe only know it in its parasitic phase and that thedisease is practically unknown in natural conditions oflife. The bearing of the problem on the question ofhospital treatment is that if the chief source of originof the bacillus is the sputum from a case of the disease,then the provision of adequate hospital accommodationwill lead in time to its elimination as a pathogenicorganism, whereas if the supply be renewed by trans-mutation of a non-pathogenic organism, then unless theconditions which give rise to this transformation aremodified or changed, elimination will become im-

possible. The disappearance of leprosy in the MiddleAges was due not only to the provision of adequate accommodation for the patients, but also to the factthat altered conditions of living led to modificationsin the virulence of the organism which caused thedisease.

Fourfold Aims of Hospital Treatment.Too much attention has been paid in the past to

institutional treatment of tuberculosis other than

hospital, which should form the foundation of all treat-ment. Its aims are fourfold: to secure the segregationof advanced cases; provide conservative and curativemeasures; provide facilities for the diagnosis of doubtfulcases and measures of relief for the hopelessly diseased.Segregation in advanced cases is necessary because,owing to increasing weakness, the patient becomesunable to expel his sputum properly and is liable forthat reason to contaminate his clothes and other things.Koch himself expressed the opinion that the fall in thedeath-rate from tuberculosis in England was due largelyto the provision made in infirmaries for the segregationof the advanced cases of the disease. But many cases oftuberculosis begin with acute symptoms when the mostimportant thing required is rest in bed, and this canonly be carried out satisfactorily in a well-equippedhospital, as also certain specific methods of treatment-e.g., artificial pneumothorax. A number of bedsshould be set aside for observation cases, since thereare numerous instances of patients who have beendiagnosed as suffering from tuberculosis in whom thediagnosis has not been confirmed. It is unfortunatethat the line of least resistance is for the tuberculosisofficer to make a positive diagnosis. Palliative treat-ment of advanced cases can be much more efficientlycarried out in hospital than at home under unsatis-factory and often unhygienic conditions. Borderlandcases and those where there is doubt as to the bestmethod of treatment should be admitted to hospital forobservation. Perhaps the most difficult cases of all

to deal with would be those of the advanced ambulanttype, who are unable to work, and, if admitted tohospital for an indefinite period, would make heavydemands on the available accommodation. This difn-

culty might, at least partially, be got over by admittingthem for short terms at intervals. Treatment, how-ever provided, must be efficient, economical, and haveregard to the psychology of the patient.In addition to the special hospital it has been sug-

gested that a special hospital block should be providedin every sanatorium, and that the patients should bedistributed in separate homes, which would be a

solution of the question not only unsatisfactory butcostly. One or two special institutions, the numbervarying according to the needs of the population inwhich they are placed, would be the ideal to aim at,although the problem is not an easy one to solve inregard to small areas. At present the advanced case isrefused admittance into a general hospital, but theadvanced case is surely entitled to treatment, and

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this can only be provided in a special institution.No doubt difficulties would arise with regard tothe distance to which patients and their friendsmight have to travel and to the depressing effectswhich the death of one patient might have on theothers, but, whatever the disadvantages, they wouldbe far outweighed by the advantages which wouldaccrue from the best of nursing and attention andtreatment. And together with this higher standard oftreatment would go economy of structure and adminis-tration. Four or five beds to each 1000 of the popula-tion would suffice. The lecturer concluded by statinghis opinion that rest is the one great essential in thetreatment of tuberculosis, and that nowhere can thisbe more effectively carried out than in a special hospital.A discussion followed the reading of the paper in

which Drs. H. A. ELLIS, C. ROLLESTON, CAMPBELLMCCLURE, G. MACDONALD, J. SORLEY, and others tookpart, and a very hearty vote of thanks was awarded to.Dr. Thomson for his paper.

LIVERPOOL MEDICAL INSTITUTION.

AT a meeting of this society held on March 31st,Mr. THURSTAN HOLLAND, Vice-President, in the chair,Mr. BLAIR BELL discussed the

Indications for Blood Transfusion,giving illustrative cases. He divided the conditions forwhich blood transfusion is required into three maingroups, with various subdivisions in each.Group A contained those cases in which there is loss of

all the constituents of the blood from an acute large haamor-rhage, of the solid constituents occurring in chronic limitedhaamorrhages, or of much fluid, as in cases of shock.Group B contained those cases in which there is absent

from the blood some constituent present in normal circum-stances, or one usually formed in response to specific stimu-lation. In this group are such conditions as hæmophilia,in which disease operations may safely be performed imme-diately after blood transfusion. Included also are cases ofeclampsia when a chemical antibody to placental toxin isbelieved to be absent from the blood, and acute and chronicinfections in which the patient’s own bacterial antibodies areinsufficient.Group C contained those diseases in which there is blood

destruction. Although good results were claimed for thetreatment by blood transfusion of pernicious anaemia it isprobable that the result was only temporary and that trans-fusion must often be repeated.Mr. Blair Bell gave a short account of the blood

grouping of donors of blood and of the problems whichmay be connected with the grouping, such as the

heteroplastic grafting of tissues and selective sterility.Finally he discussed the various methods of bloodtransfusion and emphasised the fact that, in his

opinion, the citrated blood method is the only generallyapplicable and safe procedure. He described anddemonstrated his own apparatus (a full account ofwhich will be published) whereby the blood of thedonors is automatically citrated as it leaves thevein, and all the fluids are kept at body temperatureduring the necessary steps in the operation.Dr. J. H. RAWLINSON presented the subject from the

surgical point of view.

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Dr. JOHN HAY read a paper dealing with

Prognosis in Patients presenting a Rapid Heart Action.Tatients with rapid action of the heart could be classedinto two groups : (1) those in whom the rhythm isphysiological, and (2) those in whom it is pathological.In the first group* the rapid action is secondary to suchcauses as emotion, effort, toxins, &c., and the prognosisdepends on an accurate recognition of the primarycause. Dr. Hay referred to the rapid action in patientssuffering from aortic regurgitation, and also to apyretictachycardia of early tuberculosis, and discussed thecombination of functional and organic diseases of theheart. In the second group he dealt with three condi-tions-paroxysmal tachycardia, auricular flutter, andauricular fibrillation-and described typical cases,defining the general principles on which prognosisdepended.

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NORWICH MEDICO-CHIRURGICAL SOCIETY.

Exhibition of C’a.ses and Specimens.A CLINICAL meeting of this society was held on

March 1st, Sir HAMILTON BALLANCE, the President, inthe chair.Dr. W. TYSON showed a girl on whom he had operated for

Thrombosis of the Lateral Sinus. He had opened themastoid cells to relieve symptoms of severe pain in the rightear, tenderness over the mastoid, foul discharge from theear, and an oscillating temperature. After the mastoidoperation she had a severe rigor, and he therefore exploredthe lateral sinus, having first tied the internal jugular veinin order to limit the infection. He removed a foul-smellingclot from the lateral sinus, and the patient made a goodrecovery.The PRESIDENT congratulated Dr. Tyson on the result of

the case, and remarked that there were several symptomswhich were pathognomonic of lateral sinus thrombosis,including a history of purulent discharge and a suddenonset, with oscillating temperature, vomiting, repeatedrigors, local tenderness, and stiffness of muscles.Dr. W. WYLLYS showed a patient in whose orbit a Mule’s

globe which had been inserted several years previously hadsuddenly burst. He removed the fragments under an anæs-thetic and inserted another Mule’s globe, which, however,also got broken. After eight days he had to remove somefragments, and as the eye was now septic he determined totry the effects of yadil as an antiseptic, using a solutionof 3i. to 4 oz. of water, which was instilled every two hoursfor two days, when another globe was inserted with satis-factory results. He brought the case forward chiefly toshow the beneficial results of what he considered a suitableantiseptic to be used where a plastic operation was under-taken in an inflamed area.Dr. E. B. HINDE showed a case of Hemianopia with Visual

Hallucinations, and also related a peculiar case of SuddenProlapsus Uteri after delivery, in which the patient statedthat she had felt a sensation of " something giving wayinside her," and the midwife and another nurse reportedthat they had heard a loud noise as of something giving wayimmediately after the birth of the child.Dr. TYSON showed a specimen of Adeno-carcinoma of the

Cæcum, for which he had performed resection of the bowel.Dr. V. H. BLAKE showed the Kidneys from a Man with

Polycystic Disease. At the autopsy the liver was foundcovered with tiny cysts, and the kidneys were composedentirely of cysts. It was remarkable that the subject of this- disease had lived an active life for over 70 years, that therehad been no albuminuria, and the only signs of urasmia were-occasional attacks of vomiting.

Dr. DARLEY WYNNE read notes and showed microscopicslides of an unusual case of Endothelioma of the Leg, withpresumed recurrence in the brain. The patient was awoman aged 70, who for some years had suffered fromextensive varicose veins in the right leg. A tumourabout the size of a small walnut developed over theinternal saphenous vein, about half-way between thesaphenous opening and the knee. This was at firstconsidered to be a thrombosis in the vein, an opinion sharedby Mr. J. Burfield in consultation. Mr. Burfield operatedand found a series of small tumours growing from the vein,which were at first thought to be melanotic sarcomata, buta microscopic examination by Dr. Claridge showed that thenature of the growth was endothelioma, growing from theendothelium of the vein. [Microscopic slides of the tumourwere exhibited.] The subsequent history of the case wasinteresting. The patient never had any further troublewith the veins and enjoyed good health for 18 months, when-she was one day suddenly seized with vomiting and rapidlv

became unconscious and died three days later. There hadbeen some prodromal symptoms, such as left-side headacheand dimness of vision. The left pupil was widely dilatedand inactive to light, the right normal, and there wasmarked left optic neuritis. Unfortunately no post-mortemcould be obtained, but from the association of optic neuritis,dimness of vision, headache, and vomiting Dr. Wynne cameto the conclusion that the patient’s death was due to arecurrence of the tumour in the brain. Dr. Claridge agreedthat there probably was a secondary growth in the brainconnected with some of the blood-vessels, but thought thefinal issue was due to haemorrhage, possibly from a vesselinvolved in the growth.Dr. G. P. C. CLARIDGE exhibited a Uterus which was the

subject of Chorion Epithelioma. The patient had sufferedfrom uterine haemorrhage for two years and was curettedby Mr. Burfield, who afterwards removed the uterus, ascuretting had given no relief. The uterus contained twotumours, which were found on microscopic examination tobe chorion epithelioma. There was also a tumour in thevagina, probably secondary.-Mr. BURFIELD, the PRESIDENT,and other speakers discussed the connexion between chorionepithelioma and hydatid mole, as it had been stated thatnearly half the cases of chorion epithelioma were subsequentto hydatid moles, an opinion which did not meet with generalagreement.Dr. J. DuNCAN HART exhibited an Ovarian Dermoid, the

clinical history of which was interesting from the point ofview of diagnosis. The patient was a young, healthy, robustwoman of 28 who was taken suddenly ill with severe pain inthe epigastrium and tenderness on deep pressure, but norigidity of muscles. Some albumin was found in the urine,but after a fortnight’s illness she apparently recovered. Asthe abdominal tenderness persisted she was sent to see Mr.Burfield, who found tenderness in the appendix region, andtook her into hospital, where she was X rayed by Dr. A. J.Cleveland, who gave it as his opinion that there was acalculus in the right ureter. On operation the appendixshowed signs of recent inflammation, but no stone wasfound in the ureter, which was quite free. An ovariandermoid cyst on the right side was found and removed. Onexamination of the contents of this cyst after removal asmall perfect tooth was discovered, and it was this foreignbody which had caused the shadow on X ray examinationand had been mistaken for a calculus in the ureter.

SHEFFIELD MEDICO-CHIRURGICAL SOCIETYAND BRITISH MEDICAL ASSOCIATION.

Veneral Disease Commission to the Far East.

A JOINT meeting was held on March 24th in theFirth Hall of the University. Dr. RUPERT HALLAMwas the lecturer, and the chair was taken by Dr. F. J.SADLER.Dr. Hallam gave a short account of his journey round the

world as the medical member of a Commission which wasdispatched to the Far East by the National Council forCombating Venereal Diseases with the approval of theColonial Office. The Commission first visited New York,arriving there early in November, 1920, where Dr. Hallamhad the opportunity of seeing several of the well-known skinand venereal clinics. It is interesting to note that themajority of patients pay for their treatment, but thatnecessitous patients are able to obtain free treatment.Compulsory notification and treatment of venereal diseasehas been in force for more than a year, and the consensusof opinion is that this has not acted as a deterrent to

patients to seek treatment. He next visited the New YorkState Laboratory at Albany, a large, splendidly equippedbuilding presided over by Dr. Wadborough.The Commission journeyed across Canada, making brief

stays at Toronto, Winnipeg, Regina, and Victoria, wheremeetings were held under the auspices of the CanadianCouncil for Combating Venereal Disease. In Japan usefulinformation was obtained from the officials of the Govern-ment Health Department, and visits were paid in twohospitals in Tokio. At the invitation of the ShanghaiMunicipal Council the Commission conducted a campaignof public enlightenment in that city, and Dr. Hallam gave aseries of lectures and demonstrations to the medical practi-tioners in the diagnosis and treatment of venereal disease.The incidence of both syphilis and gonorrhoea among theChinese in the seaport towns is very high, and before thevisit of the Commission there was no treatment by modernmethods available for them. The Commission conducted asimilar campaign at Hong-Kong, Singapore, and Colombo,and in each of these ports recommended that the freediagnosis and treatment of venereal disease should beprovided.Dr. Hallam afterwards showed a kinema film produced

by the American Hygiene Association, New York.