704 BRITISH MEDICAL ASSOCIATION: TUBERCULOSIS.

BRITISH MEDICAL ASSOCIATION.ANNUAL MEETING AT EDINBURGH.

(Concluded from p. 663.)

SECTION OF TUBERCULOSIS.

THIS Section, which met on Friday, July 22nd.under the presidency of Dr. S. VERE PEARSON

(Mundesley), discussed three large topics.Radiology and Diagnosis of Intrathoracic Tuberculosis.The opening paper giving the specialist’s view-

point was read by Mr. H. MORRISTON DAVIES (Valeof Clwyd Sanatorium), who pointed out that thediagnosis of pulmonary tuberculosis was not merelya matter of recognising the presence of the disease,although both the recognition of it and the differentialdiagnosis were of great importance and often a

matter of great difficulty. Diagnosis must necessarilyinclude the character as well as the type of disease.They must know, for example, whether it was acutemiliary, acute pneumonic, acute ulcerative, or chronic ;to what extent the changes due to the tubercle bacilluspredominated, or were complicated or overshadowedby those due to the secondary organisms ; and whatpart was played by the mechanical changes. It wasalso imperative to know the anatomical extent of thelesions, especially when there was any question ofsurgical intervention. ’

The symptoms and signs of the disease varied inevery case, some cases showing but one symptom,such as lassitude or haemorrhage, and no sign otherthan harsh breath sounds. Symptoms such as coughand sputum might be absent for years from theclinical picture, while pyrexia might be an early ora late manifestation. Physical signs might be difficultboth to ascertain and to interpret. Some patientsseemed incapable of using their chest or diaphragm soas to make even the normal breath sounds audiblethrough the stethoscope, other difficulties being thatthere was practically no symptom and no sign thatcould not be produced at one time or another by longintrathoracic disease, and that breath sounds couldbe heard through even a considerable layer of fluid.It was important, therefore, in all cases to check,control, and correct the clinical findings by the

radiological ones. Although clinical examination wasthe most important of all methods of investigation,there was much that could only be revealed byradiology, more especially in cases in which the pleuralcavity was the seat of the lesion or in which it wasinvolved secondarily to the disease in the lung.Radiology had taught them a great deal about pul-monary tuberculosis ; it had corrected the belief thatused to be held that tuberculosis started most com-monly at the apex of the lung ; it had taught themthe limitations of the movements of the domes of thediaphragm ; it had shown them how frequently thedisease was more extensive than was suggested bythe clinical findings, and, conversely, how occasionallythe disease was much more limited than was suspected,owing to the widespread changes in the physical signscaused by local changes in the larger bronchi. Unfor-tunately, radiology had also to some extent confusedthem by demonstrating the shadows known as"

pleural rings " and those changes at the root of thelung which had given birth to the term " hilumtuberculosis."The cases that came before them for diagnosis

belonged to two groups : the one with few symptoms,in which the existence of pulmonary disease had tobe determined, and the group with well-marked I,symptoms and signs, in which the character of the

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disease had to be diagnosed. The great majority ofthe first group consisted of children and young adults, iand the commonest symptoms were cough, which had Ipersisted since a cold or an acute specific illness(especially measles and whooping-cough), lassitude,poor development, and dyspnoea. Occasionally in ;,the more advanced cases there was cyanosis. The I

physical signs usually consisted of impaired resonance,deficient air entry, and some moist sounds. A numberof these cases were labelled hilum (or pulmonary)tuberculosis, some being treated as such and bearingthe stigma for the rest of their lives. It was herethat radiology, with increasing knowledge, wouldprove of immense benefit. The great difficulty layin the inability to establish just when the hilumshadow ceased to be normal, and what were thecharacteristics of early disease as opposed to chronicirritation. It was well known that an impure atmo-sphere led to increase in density in shadows, thatchronic irritation caused enlargement of glands andincreased striation, and that in some cases, especiallyafter bronchitis, broncho-pneumonia, and in associa-tion with chronically enlarged tonsils, such changesmight be very striking. Two things had struck himin X raying a large number of apparently healthymedical students 16 years ago -: the enormousvariations that occurred in the so-called normalsubject (only one of the students had subsequentlydeveloped tuberculosis, and his original radiogram hadshown nothing striking) ; and the fact that the trac-tion of the heart to the left with a normal-looking lungand pleura was invariably due to a basal pneumoniain the past. He agreed with Dr. Agassiz that radio-logy was of the utmost importance in differentiatinga non-tuberculous fibrosis from other affections of thelungs. He himself had had many cases sent to himas suffering from pulmonary tuberculosis who weresuffering from some other disease-in a large pro-portion of cases from bronchiectasis. In the majorityof these cases radiological examination would settlethe diagnosis, although there were some very old-standing cases where the secondary bronchiectaticchanges associated with chronic bronchitis were sopredominant that it was hard to differentiate betweenthem and a non-tuberculous bronchiectasis. A lessfrequent mistake was to label cases of malignantdisease and of syphilis as cases of tuberculosis. Inmost of these cases an X ray photograph would haveobviated the error. When they turned to the pleuraland mediastinal cases the importance of radiologybecame even greater. An interlobar effusion mightbe suspected, but it was rarely more than a guessuntil confirmed by the X rays, while the difficultywas even greater in cases of mediastinal effusion. Inthe diagnosis of activity of a tuberculous lesion it wasthe clinical signs and not radiology which had to berelied on, though information could also be obtainedfrom the latter source also. The snow-flake fluffyshadow of an acute lesion was in striking contrast tothe denser, sharply defined outline of the fibroticlesion. At times there was a great temptation todiagnose on clinical examination the presence of acavity when the radiogram showed that the signswere due to a dense area of fibrosis contiguous witha large bronchus. Occasionally the radiogram wouldreveal a cavity in the centre of a densely fibrotic areawhich was unsuspected from clinical examination.The X rays would, moreover, reveal in a large cavitythe efficiency or otherwise of such a cavity, and anyretained products that might be present. When thecase under investigation was one with an effusion orpneumothorax, or a combination of the two, it mightbe impossible to obtain by clinical examination anyidea of the extent of the collapse or the character ofthe collapsed part of the lung. If on examination apatient was found to have a pleural effusion, it wasnot sufficient to be content with that as a diagnosis;it was necessary to know the cause of the effusion.It might be failing heart or kidney, trauma, suppura-tion above or below the diaphragm, an infection, orgranuloma inside the pleural cavity or in the lung.It might be secondary to an inflammatory lesion, suchas pneumonia, or to carcinoma. It might be primarytuberculosis of the pleura, or secondary to pulmonarytuberculosis. The diagnosis might be easy or itmight be extremely difficult, especially if the primarylesion was in a collapsed lung surrounded by liquid.But if the liquid was replaced by air and the collapsedlung partially re-expanded, it became possible, by

705BRITISH MEDICAL ASSOCIATION : TUBERCULOSIS.

radiology, to see the character of the lesion whichwas primarily responsible.

Precision in diagnosis was essential for determiningprognosis and treatment; it was absolutely impera-tive before any surgical treatment could be considered.To attempt treatment of a case of pulmonary tuber-culosis by operative intervention without the mostthorough radiological as well as clinical examinationwas to make the patient run a serious risk. In thosecases it was not so much the precise condition of themore affected side, but the character and extent ofthe lesion in the sound lung which was so important.The value of a radiogram lay in its clarity and intheir power to interpret it. An indifferent radiogrammight be not only worthless but a source of danger,as they might fail to detect the existence of importantlesions, and act on the erroneous idea that they werenot present.The question of the interpretation of the film

brought them to one of the most difficult problems.The radiologist who handled hundreds of films coulddetect abnormalities and describe the shadows farbetter than the average medical man, but his oppor-tunities for studying the radiogram and the clinicalpicture side by side and following the developmentof the case were limited. The physician who special-ised in pleuro-pulmonary diseases had very greatexperience, but it was possibly somewhat less thanthat of the radiologist, while he was also less awareof the allowance to be made for imperfect exposureor development. He had, however, the advantage ofhis knowledge of the clinical side. The generalpractitioner, with the wide range of knowledgerequired of him, could not be expected to have athorough understanding of the interpretation ofradiograms, and he should, in all obscure cases, callin a specialist or consultant and a radiologist. Afrequent cause of delay before patients applied forsanatorium treatment was wrong diagnosis, and inorder to obviate this he urged that an invariable ruleshould be made that when there had been persistencefor more than three months of symptoms whichmight be due to tuberculosis, any sputum presentshould be examined and a radiogram taken.

Dr. E. RIST (Paris), who followed, emphasised theimportance of X rays in correcting physical signs.This was best seen in cases in which there was a deep-seated cavity near the hilum, but even superficialcavities were sometimes absolutely silent to thestethoscope. In pneumothorax work X rays wereoften helpful in deciding whether the signs heard inthe less affected lung were an indication that it, too,was affected, or whether the sounds were merelytransmitted from the worse lung. Dr. Rist thoughtthat many cases suitable for pneumothorax had nothad the benefit of this treatment owing to the failureof the physician to make use of X rays to assist himon this point. He concluded with a plea for moreX ray screen examinations, which had the advantageof showing movement, and should always precede thetaking of a film. No chest could now be said tohave been properly examined unless a screen examin-ation had been made. Objections on the ground ofexpense should be met by the reply that there wasa time when physicians said they could not affordstethoscopes.

Dr. J. LOGAN STEWART (Manchester) consideredthat the term " hilum tuberculosis " was far toowidely used. It should be dropped as misleading inall cases in which lung tissue was affected ; and wherethe disease was confined to bronchial glands theappropriate name should be used. He showed a

number of slides to illustrate the various types of casein which an increase of the hilar shadows was noted.A sharp distinction was drawn between cases in whichthe adjacent lung was infiltrated and those in whichit was not. In the latter class plates were shown inwhich the heavy shadows were due to pleural thicken-ing over the root of the lung, to interlobar pleurisy,and to vascular congestion in cases of mitral disease.

Dr. T. M. WooDBURN MORISON (Edinburgh), speak-ing as a radiologist with experience of general prac-

tice, considered X rays to be an integral part of thephysical examination. A diagnosis on the strengthof an X ray examination alone should, however,never be made ; and the custom adopted by somespecialists of sending a patient to a radiologist witha card marked " X ray of chest, please," was not tobe recommended. To illustrate this point three slideswere shown, in all of which a very similar picture wasgiven, but which were taken from cases of hydro-pneumothorax, subphrenic abscess, and diaphrag-matic hernia.

Dr. C. P. LAPAGE (Manchester) considered fibrosisof the root of the lung to be a common condition inchildhood ; in these cases the most important func-tion of the physician was to determine whether or notthe disease was active. The speaker looked upon lossof tone of the skin between the scapulas as a usefulindication of toxaemia in these cases.

Dr. L. D. PARSONS (Ceylon) advocated the use oftuberculin tests in the diagnosis of early tuberculosis.

Mr. DAVIES, winding up the discussion, agreed withDr. Rist as to the importance of fluoroscopy, and withDr. Morison that all doctors engaged in chest workshould have some knowledge of radiology. He feared,however, that too much emphasis on X ray signsmight result in the neglect of the more importantclinical side, which should always come first.

Pathology of the Tuberculosis of Childhood.Prof. EUGENE L. OPIE began by discussing the ques-

tion of latent tuberculosis. By this term he did notmean that the disease was dormant or arrested, butmerely that it gave no symptoms or signs which couldbe detected by patient or physician. A comparisonwas made between latent and open tuberculosis onthe one hand and uncomplicated measles and measlesfollowed by pneumonia on the other-a striking illus-tration of the importance of early diagnosis and treat-ment. Attention was called to the fact that inchildren the disease progressed more in the lymphaticglands than in the lung parenchyma. Althoughbronchial gland tuberculosis was often associated withinfection of the lung tissue adjacent, a primary focuscould usually be found in the part of the lung drainedby the affected gland. Prof. Opie also recalled the factthat when there was a focal lesion of the lung themesenteric glands were rarely affected, and vice versa,and referred to the curious and inexplicable way inwhich adult phthisis tended to affect the apex of thelung, in which respect it was in sharp contrast withchildhood tuberculosis and animal tuberculosis.Although the adult lesion tended to be chronic itremained confined to the lung for a long time, and forsome unexplained reason the lymph glands wereusually unaffected. The speaker ended by giving somestatistics to illustrate the high incidence of latenttuberculosis in the children of tuberculous parents.

Dr. R. G. CANTI (London) discussed some of thetheories as to the path of infection in tuberculosis,based on his observations in more than eightyautopsies on children suffering from intrathoracictuberculosis. He considered mediastinal infection tobe almost invariably secondary to a pulmonary focus,the following reasons being given in support of thisview : (1) the glands were involved whenever therewas tubercle of the lung ; (2) when the glands wereaffected a focus could usually be found in the lung ;(3) the glands which were involved were those whichmight be expected to be so if the pulmonary focuswere primary. The path of infection through themesenteric glands to the lung was unlikely becausethese glands were rarely affected in lung cases. Thesuggestion that bacilli of human type passed throughthe glands and affected the lung was not tenable,because these glands were just as easily affected bythe human as by the bovine bacillus.

Dr. P. F. ARMAND-DELILLE (Paris) showed aninteresting series of post-mortem specimens and com-pared them with X ray plates of the same cases takena few days before death. The accuracy of the com-parison was increased by the speaker’s method ofhardening the inflated lung in a cast of the chest wall

706 BRITISH MEDICAL ASSOCIATION : TROPICAL DISEASES.

before cutting sections. The chief point brought outby these observations was that only a small part ofthe periphery of the hilar region was visible on theX ray plate, the greater part being hidden by theheart. Prof. Opie, in replying, referred to the

unexpected opposition to the views he had expressedas to the pulmonary origin of bronchial gland tuber-culosis, and recalled that Parrot and Kuss had bothdescribed these primary foci before Ghon, and theirwork- had been acknowledged by him.

Interrelation of Physician and Surgeon in Non-pulmonary Tuberculosis.

Dr. D. A. POWELL (Cardiff) opened the third dis-cussion. In non-pulmonary as in pulmonary tubercu-losis, he said, the physician and surgeon should be oneand the same individual for all purposes of dia-gnosis and treatment, except those involving majoroperations or a few highly technical procedures. Thetuberculosis officer, to attain this end, should seizeevery opportunity to train himself to become a com-petent surgeon, first, by looking upon a period ofresidence in a surgical tuberculosis or orthopaedichospital as quite as essential a part of his training asresidence in a chest hospital or sanatbrium ; and,secondly, by close linking up of his area surgical workwith that of an institution, frequent reciprocal visitsand interchange of medical staff being an essentialpart of the scheme. The speaker believed that inthis way the present unfortunate tendency to divorcethe conception of tuberculosis of bones and jointsfrom general tuberculosis would be checked. Tuber-culosis, whatever its site, was the same pathologicalprocess, diagnosed by the same procedures, and treatedon the same principles ; and he urged that the mereutilisation of methods of treatment similar to thoseof orthopaedics should not blind them to the fact thatthe essential element in the successful management ofcases was a sound knowledge of the disease as awhole, fortified by manual dexterity and reinforcedwhen required by the operative skill and expertknowledge of the general or orthopaedic surgeon.Among the definite advantages that would accrue ifthis unification or closer interrelation could be carriedout would be the addition of some much-neededprecision to their diagnostic criteria, especially intuberculosis of glands, and their recommendations fortreatment would be based on fact rather than onprophecy. By refraining from making up their mindsas to the diagnosis until there was a practical certainty Iabout it, they would obviate, in a large proportionof cases, the mental trauma they so lightly inflicted I

upon their patients to-day, and would avoid the ’,finality of notification with its consequences. Thespeaker took, as an instance, tuberculous glands, andpointed out that if the tuberculosis officer or hisresidential colleague became the surgeon oftener andearlier and excised doubtful glands for examination,their ideas as to the distinction between tuberculousand non-tuberculous glands would be clarified, andthey would also realise more clearly that although itwas broadly true that a tuberculous lesion was thelocal manifestation of a general infection, yet thatin cervical adenitis both lesion and infection mightbe localised, accessible, and suitable for eradication.Few problems in medicine required nicer judgment

or greater patience than to decide in bone and jointcases when the disease was quiescent and treatmentcould be altered, or when the disease was arrestedand treatment could be discontinued. In early lunginvolvement the issue was usually clear-cut-namely,the presence or absence of tuberculosis ; in non-pulmonary tuberculosis this issue was complicatedby the necessity in addition of differentiatingbetween tuberculosis and a number of conditionswhich might closely simulate it. As a general rule,tuberculosis officers should content themselves witha provisional diagnosis and act upon it. Until tuber-culosis officers were physicians and surgeons too theymust follow up a preliminary, provisional, or approxi-mate diagnosis by such action as requiring the attend-ance of the patient at a clinic or his admission to

hospital, where the differential diagnosis could beelucidated without detriment to the patient, andwhere treatment could be initiated without loss oftime. By a closer cooperation or unification therewould be, among other advantages, a more generalrecognition of the fact that in associated pulmonaryand non-pulmonary disease premature success inarresting the local lesion (especially if the former werethe primary manifestation) might even activate orreactivate the trouble in the lung. It would beremembered also that, while the development of

secondary deformities was a reproach, caution in

attempts at preventing or correcting the primarydeformity might not be too high a price to pay forlife. The surgeon’s association with the tuberculosisofficer would enable him to realise more vividly theeconomic repercussion in adult patients of his occa-sionally too conservative methods in some lesions ofthe lower limb. He would also realise that after-carein tuberculosis, as opposed to orthopaedics, was morethan a medical problem, and connoted much morethan the correct use of appliances ; that failure wasnot necessarily due to indifference or carelessness,but to those social and economic disabilities thatexerted such a profound effect upon the prognosisof tuberculosis in any form.

Prof. JOHN FRASER (Edinburgh) said that thetreatment of tuberculosis might be considered underfive headings : (1) excision of the lesion ; (2) stim-ula-tion of the organism by general treatment; (3) rest-the basis of all treatment ; (4) chemotherapy, fromwhich nothing of proved value had resulted ; (5)tuberculin. This last was criticised in that it causedan increase in the blood-supply to the affected part,whereas Nature’s way of healing involved a diminu-tion of blood-supply, following endarteritis obliterans.Prof. Fraser summed up by saying that if the part wereput at rest, Nature would supply the fibrous tissue.

Mr. G. H. GIRDLESTONE (Oxford) deprecated thetendency for the tuberculous cripple to be separatedfrom other cripples, and advocated a national schemeto deal with all bone and joint cases requiring hospitalobservation and treatment. He considered that therewas danger of the non-tuberculous cripple being over-looked unless he was treated by the same organisationthat was caring for the tuberculous cases. Far frombeing an appendage of orthopaedics, the tuberculouscases formed the majority of those treated in ortho-psedic hospitals.

In his reply Dr. PowELL stated that he favouredcooperation rather than amalgamation in the treat-ment of tuberculous and non-tuberculous cripples.

In the afternoon Dr. ARMAND-DELILLE and Prof.OpiiE each showed a series of slides to illustrate thepapers they had read in the morning.

SECTION OF TROPICAL DISEASES.

WEDNESDAY, JULY 20TH.. ABOUT 85 persons were present on Wednesday,July 20th, when the President, Dr. ANDREW BALFOUR,opened the Section and recalled that on the lastoccasion on which the Association met in EdinburghSir Patrick Manson announced Sir Ronald Ross’sdiscoveries regarding malaria, and reminded hishearers that those discoveries marked the beginningof a new era in tropical medicine.Recent Advances in the Treatment of Amaebic Dysentery.

Dr. P. H. MANSON-13AHIt (London), who read apaper by himself and Dr. E. G. SAYERS, said thatipecacuanha powder by the mouth and emetineinjections had both been found unsatisfactory as ameans of eradicating amoebic infection, but the use ofemetine-bismuth-iodide, in powder form in gelatincapsules, had proved a distinct step forward. Forlasting results a dosage of 36 gr. spread over 12 nightswas required along with dietetic restrictions. Hequoted some striking cases where this treatment hadbrought about permanent cure, and as a general rulethe more acute the symptoms the more satisfactory and