842 CONFERENCE OF NATIONAL ASSOCIATION FOR PREVENTION OF TUBERCULOSIS.

pencil, but in this case, again, the prosecution con-tended that the document failed to comply with theRegulations, there being in particular no record ofpurchases. The defendant pleaded forgetfulness, dueto overwork and ill-health, and added that the Actwas difficult to interpret. The magistrate imposed aheavier fine in this case, on the ground that thisdefendant was aware of the need of keeping a register.Members of the medical profession naturally find

the meticulous compliance with the Dangerous DrugsRegulations a troublesome duty which, in moments ofpressure, they may be inclined to postpone. Theincreased vigilance of the police in these mattersbrings irregularities to light sooner or later. It is notthat the police invade the consulting-room at randomin order to see if the Regulations are obeyed ; it israther that the police, in following up some allegationof improper traffic in drugs on the part of laymen, areobliged to trace the documents back to the source.

THE NATIONAL ASSOCIATION FOR THE

PREVENTION OF TUBERCULOSIS.

ANNUAL CONFERENCE IN NEWCASTLE-UPON-TYNE,OCT. 10TH-12TH, 1929.

THE fifteenth annual conference of this Associationwas opened on Oct. 10th by the Lord Mayor (CouncillorA. W. LAMBERT, M.C.), who welcomed the delegateson behalf of the city of Newcastle. Over 350 delegatesattended including more than 200 members of themedical profession. We report the four chief sessions. I

A Sociological Survey.Under the chairmanship of Sir ROBERT PHILIP

(Vice-Chairman of the Council) the first paper wasread by Mr. HENRY A. MESS, Ph.D. (Director of theTyneside Council of Social Research), entitledTuberculosis on Tyneside. Dr. Mess said that asurvey of social conditions in 13 industrial towns onTyneside had been undertaken during the years1925-28, and it had been found that with theexception of two middle-class

" dormitories," all thetowns had death-rates from pulmonary tuberculosisfor the quinquennium 1921-25 considerably in excessof the national death-rate ; in respect of non-

pulmonary tuberculosis the figures were even worse.Overcrowding existed in the houses of Northumber-land and Durham to an extent unparalleled inEngland and Wales, and this coincided, except in themining districts, with the excessive death-rate fromtuberculosis. The overcrowding was not only withinthe homes ; in addition there was overcrowding ofhouses on the land resulting in an unusually largeoutpouring of domestic smoke, with depletion ofsunlight together with the impossibility of effectiveisolation of diseased individuals. The localindustries, shipbuilding and ship repairing, were verysubject to violent fluctuations-livelihood was there-fore uncertain and often scanty, leading to worryand malnutrition, which predispose to the disease.

Discussion was opened by Councillor JOHN BARKER(Chairman of the Tuberculosis Committee, Newcastle-upon-Tyne) who dealt with the local situation andthe facilities provided for handling the problem, andmade special reference to Newcastle’s position. Hewarned local authorities against building types oflow-rented houses which would in 20 years’ timepresent another slum problem, suggested that theNational Association should press the Ministry ofHealth for stricter obligation on local authorities toprovide adequate tuberculosis dispensaries, educa-tional agencies, and institutional segregation, andrecommended the setting up of regional advisorycouncils.-Dr. H. KERR (M.O.H., Newcastle) paid atribute to Dr. Mess’s work locally, and said that ithad aroused the tuberculosis conscience of Tyneside.- Dr. R. VEITCH CLARK (M.O.H., Manchester) stated

that while there must be earlier and more completenotification of all cases occurring, there should beassurance that something would be done for thepersons notified.-Councillor GRIFFITHS (West Ridingof Yorkshire) said that Dr. Mess’s figures onlyapplied to the years 1921-25, and that since 1926the mining population were suffering from tubercu-losis more than ever owing to malnutrition, unemploy-ment, and low wages.-In reply to the last speaker,Dr. S. G. MOORE (M.0.11., Huddersfield) pointed outthat while privation and poverty play an essentialpart in tuberculosis as well as other diseases, thechildren of the rich also suffer and die from the felldisease.

The Factors that Produce Adult PulmonaryTuberculosis.

Dr. EDOUARD RrST (Paris), in introducing thesubject, said that the old traditional idea that con-sumption was due to some mysterious constitutionalor hereditary predisposition must be abandoned. Incivilised communities the adult was not, like theinfant, virgin soil for the tubercle bacillus--diseasein the adult was not the result of a first infection.Infection occurred in childhood, leaving the subjecthealthy and immune for years until, under the stressof adverse conditions, he more or less suddenly fella victim to the disease. Physical vigour in itselfdid not protect against tuberculosis ; the intensivetraining of the pugilist offered no guarantee againstthe disease. While a rational and well-ordered, well-regulated mode of living would undoubtedly reducethe liability to infection, it must be admitted that theactual causes of a breakdown were largely obscure;only a few factors were more or less definitely knownor suspected, and it was left to the coming generationto discover those of which we were to-day utterlyignorant.

Dr. A. F. BERNARD SHAW (College of Medicine,Newcastle-upon-Tyne) followed with a contributionfrom the pathological side. His paper dealt with thevalue of the experimental method and the phenomena.of virulence, resistance, and allergy in the study oftuberculosis. Mentioning that it was extremely rarein civilised communities to find in adults progressivepulmonary lesions resembling those found in theprimary infection of childhood, he maintained thatthe rarity of such cases was in strong support of theidea that the bacilli of childhood infection do notcommonly survive to adult life in numbers sufficientto serve as the origin of adult phthisis, and was ofopinion that pulmonary tuberculosis occurring inadolescence or later was due to reinfection fromwithout.

Dr. C. G. R. GOODWIN (Medical Superintendent,Barrasford Sanatorium), dealing with the subjectfrom the medical standpoint, said that infection withthe tubercle bacillus, though an essential factor, wasnot the sole cause of manifest pulmonary tuberculosis,and was of opinion that active lung tubercle in adultlife was not due to a new or recent infection, but wasan extension from a pre-existing focus, laid down inchildhood, and that this extension and spread were-due to adverse environmental conditions in the homeand/or prolonged chronic fatigue. To reduce theincidence of the disease, he advocated adequateseparation of advanced cases from children, andimprovement of the housing and social conditions,of the poor. Further, he advised that the publicshould be clearly taught, first, that those who gavethemselves no leisure were prone to develop a stateof chronic fatigue with loss of weight and increasedliability to tuberculosis; and, secondly, that whenmaintained loss of weight occurred medical adviceshould be sought.

Sir THOMAS OLIVER (Vice-Chancellor, Durham.University) dealt with the industrial aspect of the

, disease and said that occupation might favour its.development by locally predisposing the pulmonarysoil for the reception of the bacillus and by reducing:

843.CONFERENCE OF NATIONAL ASSOCIATION FOR PREVENTION OF TUBERCULOSIS..

the general resistance of the worker. Speaking of therelationship of pulmonary disease to dust inhaled atwork, he instanced the decreased incidence of

phthisis among steel-grinders as a result of improvedmethods of ventilation and changed methods ofoperating. He considered the granite industry athome and abroad, and directed special attention tothe work of the South African Miners’ PhthisisMedical Bureau. He also detailed some experimentsconducted by himself which showed that the finestparticles of dust did not absorb water, and expressedthe opinion that those particles were the cause ofsilicosis where rock-drilling was accompanied bywater sprinkling.

Instruction of the Public, the Tuberculous, and theMedical Student.

Dr. WILLIAM BRAND (Medical Commissioner to theAssociation) gave an address on a Scheme of NationalPropaganda Regarding Tuberculosis. Quoting theaphorism of the late Dr. Herman Biggs that " healthis purchasable," Dr. Brand said that this was thecase for propaganda in a nutshell provided we knewwhat to buy. It was incumbent upon those withspecialised knowledge to share it with the publicand instruct the masses in tuberculosis, its causes,prevention, and the general principles of treatment.Antituberculosis propaganda must not be inter-mittent, but should be constant and insistent. Thesubject should be approached through every possiblechannel—e.g., the schools, the Boy Scout move-ment, the press, and the medical and nursingprofessions-besides the official public health services.

Dr. A. H. MACPHERSON (Medical Superintendent,Burrow Hill Sanatorium Colony) read a paper on theCombined Treatment and Technical Education ofTuberculous Youths. The Burrow Hill SanatoriumColony had been reorganised, he said, to providecombined treatment and technical training for youthsbetween the ages of 14 and 19 years. Courses oftraining were given in gardening and clerical work.The cost, 62 10s. per week, was defrayed by theauthority responsible for the patient’s admission.Forty-six youths from various parts of the countrywere in residence and the results were very hopeful,but the success of the scheme depended largely uponthe cooperation of the local care committees and theirability to find permanent employment for the trainees.- Dr. NOEL BABDSWBLL (Medical Adviser to theLondon County Council) followed with a glowingaccount of the colony, its situation, surroundingsand its work, and expressed the opinion that thepatients should derive great and lasting benefit fromresidence in the institution.

Prof. THOMAS BEATTIE (Durham University),speaking of the Teaching of Tuberculosis to Under-graduates, deprecated the institution of special coursesin tuberculosis, and expressed the fear that the generalstandard of medical education would suffer if morespecial subjects were included in the curriculum.He held that tuberculosis was so intimately connectedwith general medicine and surgery that teaching in itcould be best imparted by the professors of thesesubjects supplemented by instruction gained in thebacteriological and pathological departments. Hehoped that the present inadequate supply of clinicalmaterial would be increased when the poor-lawhospitals were taken over by the local authorities.-Dr. FERGUS HEWAT (Edinburgh University) said thatthe teaching of tuberculosis to undergraduates wasregarded as an essential part of the medical curriculumin all Scottish universities. Such teaching should begiven in the final year of study.-Dr. JAJMEES CROCKET(Glasgow University) said that only two things hadto be considered : (1) Was there the need ? and(2) Was there the time ? He maintained that theneed and the time for special study of tuberculosisboth existed, and outlined the course at Glasgow.-Dr. A. TRIMBLE (Belfast) thought that the teachingof tuberculosis was so necessary that it would pay the

municipalities to subsidise a lectureship in everymedical school.-Dr. M. DAVIDSON (Brompton Hos--pital) remarked upon the lack of clinical material for-the teaching of pulmonary tuberculosis in the generals.hospitals and advocated closer cooperation betweenthese and the poor-law hospitals.

Dr. W. H. DICKINSON (Newcastle-upon-Tyne) read:a paper on the

Training of Tuberculosis Medical Officers.After the usual house appointments, he advised ac.

period of general practice, followed by a post in somedepartment of the public health service other than,tuberculosis, so that the prospective tuberculosisofficer might be imbued with spirit and ideals of-prevention. A junior appointment in a large sana-torium or special " chest " hospital should precedeapplication for a post as assistant tuberculosis officer..Dr. Dickinson laid special stress upon the importanceof post-graduate study in general medicine as well astuberculosis and the recommendations of the AstorCommittee regarding study leave were quoted.-Dr..J. D. LEIGH (Sunderland) said that special trainingin surgical tuberculosis was necessary, and pointed-out that some hospitals contended that non-pulmonarytuberculosis should be prevented and treatmentought to be a direct charge on the municipalities.-Dr. F. J. H. Cours (Ministry of Health)’emphasised the importance of the subject and paid a,handsome tribute to the zeal and enthusiasm of themembers of the tuberculosis service under difficultconditions.-Dr. J. CROCKET (Glasgow) said that thecourse of study for the D.P.H., as at present consti--tuted, was not of much value to the tuberculosisofficer. He suggested that the value would beenhanced if the examination could be modified toallow candidates to pass in special subjects-e.g.,.tuberculosis.-Dr. J. C. GILCHRIST (Welsh NationalMemorial, Cardiff) pointed out the value of contactwith students to tuberculosis workers, and mentionedthat the tuberculosis officers and sanatorium superin--tendents were recognised teachers in the Universityof Wales. He also alluded to the value of the quarterly-meetings of the staff of the Welsh National MemorialAssociation, with clinical discussions and pathologicaldemonstrations.

Dr. HARLEY WILLIAMS (Assistant Medical Com-missioner, N.A.P.T.), in the course of an address onMethods of Local Propaganda Regarding Tubercu--losis, said that it was only in recent years thatpropaganda had come to be regarded as a legitimatepart of the campaign against disease. The greatestdifficulty was the ignorance surrounding the questionof tuberculosis, and he urged a great extension of’the teaching of the subject to the lay public, especially-through the medium of the schools.

The session concluded with an address on Dentistry -in Relation to Tuberculosis by Dr. WILLIAM * Gu-z(Edinburgh), in which he laid emphasis upon theimportance of preventive measures before infectionoccurred, and upon the necessity of an efficientdental service at all sanatoriums, clinics, anddispensaries.

A HOSPITAL BANNER.-A banner made by thepatients of Grangethorpe Ministry of Pensions Hospital {in 1927, in memory of the 330 patients who have died withinits walls, has been placed in St. James’s Church, Birch-in-Rusholme, Lancashire, and dedicated by the Bishop of-Middlesex. Grangethorpe, which was originally a militaryhospital, ceases to be a Ministry of Pensions institution at.the end of the present month.

WEST BROMWICH GENERAL HOSPITAL.-The reportof the medical committee for the year ended on June 30thlast, signed by Dr. L. A. Dingley, the chairman, states thatthe 1533 in-patients formed a

" record." The generaldeath-rate was 4-3 per cent. ; 2-3 per cent. died within.48 hours of admission. In the casualty department 10,171cases were treated, and the medical staff urge the importanceof replacing this building, which is out of date and unsuit-able to the heavy demands upon it-

844 SCOTLAND.-BERLIN.

SCOTLAND.

(FROM OUR OWN CORRESPONDENT.)

Nursing and Midwifery.ADDRESSING the annual meeting of the Midlothian

County Nursing Association, Dr. Parlane Kinloch,Chief Medical Officer of the Department of Health forScotland, spoke of the need for a radical reorganisationof the training of nurses. At present any girl lookingforward to making a comprehensive profession ofnursing would be in a position of tutelage for ten years,including three or four years of general training, threeyears’ experience of fevers, one year of maternitywork, a year at mental diseases, and so on. Thething was ridiculous. He looked forward to thetime when a woman going in for nursing would get acomprehensive training within four to five years. Heaimed at the orientation of the county service ofScotland round the medical schools of Edinburgh,Glasgow, St. Andrews, and Dundee and Aberdeen.This would provide the utmost efficiency, withreasonable economy. A million and a half pounds ayear were being spent on a national health insurancesystem that was breaking down at the vital point-where the person needed nursing and hospital treat-ment. In the women’s wards of the general hospitals75 per cent. were there to seek remedy from the resultsof the present state of midwifery practice in Scotland.These things could be put right by a proper systemof prenatal service, which the local authorities werecalled upon to provide, and by a proper midwiferyservice ; but it could only be done by a combinationof the voluntary and official organisations. Theyhad met the voluntary hospitals, and got themorganised into regions. When they knew what thevoluntary systems could do, they would say to thelocal authorities : " You fill up the gap." Thesame thing held as regards this great nursing service.

Highlands and Islands Medical Service.The Secretary of State for Scotland has received

Cabinet sanction to introduce a Bill to amend theHighlands and Islands Medical Service Act. Underthis Act an annual expenditure of 242,000 was

authorised, but after 15 years’ experience it hasbeen found that the sum is too small for the schemesalready developed, and the annual total expended forthe last few years has been over 260,000. The newAct will probably provide for a larger annual sum,and may contain some amendments indicated byexperience. The medical service (including nursing)arranged under the Act is, at least in GreatBritain, a unique experiment in so-called " Statemedical service." Its success is now recognised.

The Glasgow Mental Colony.A -considerable time ago the Glasgow District

Board of Control decided to convert the house andgrounds of Lennox Castle, Stirlingshire, into a colonyfor the care and treatment of mental defectives. Thescheme is one of the largest ever undertaken by theGlasgow Board, which will now be able to classifytheir mental defectives in a much more satisfactoryway. Lennox Castle will accommodate 1000 patients,and this will probably meet the needs of Glasgow andthe west of Scotland for some years. Stone-Yetts,another large colony both for epileptics and mentaldefectives, which has been worked on modern linesunder Dr. Chislett for many years, will now be availablefor other poor-law purposes. With the Gogar-BurnInstitutions for Edinburgh and the east, LennoxCastle and Stone-Yetts in the -west, and the RoyalInstitution at Larbert in the centre, Scotland israpidly making up leeway in her provision for theselected feeble-minded and their permanent care.

The Young Offender.Mr. Tom Johnston, Under Secretary of State for

Scotland, at the annual meeting of the Glasgow

Council of Juvenile Organisations, said that hethought there was great need for more careful examin-ation into the causes and prevention of crime. Thetheory of public and legal vengeance was archaic.It got nowhere at all, and a deterrent theory wasgetting but a very short distance. It had been statedin America that nine-tenths of the criminals inprisons ought never to have been there. He hadheard the chairman of the Glasgow Parish Council saythat three-quarters of the unfortunates who reachedthe Council under the label of " mentally deficient "

ought never to be there either. In view of suchstatements he thought it was time that they bestirredthemselves municipally in an endeavour to preventthese institutions from being choked with boys andgirls, young men and women, and also old men andold women, who ought never to have been allowedto drift that length.

BERLIN.

(FROM OUR OWN CORRESPONDENT.)

Stresemann’s Illness.

THE late Mr. Stresemann suffered from nephritis,which was discovered about six years ago. Notwith-standing the great strain of his political work, he feltcomparatively well until he contracted pneumonia in1926. After that his general health deteriorated andhe nearly died of renal insufficiency in 1928. Herecovered sufficiently to take up again the burden ofhis office as Foreign Minister, but attacks of cardiacweakness gradually developed and on his journeys toconferences abroad he had to be accompanied by hismedical attendant. At the Hague Conference thissummer, which was associated with an enormousamount of work and much excitement, his illnessgrew worse, and his foreign colleagues noticed agreat change in his condition. After the Hague andGeneva Conferences he took a short holiday at -Vitznau on the Lake of Lucerne. A few days beforehis death he returned to Berlin, where party troublesinduced him to leave his bed against medical advice.He was not a very obedient patient and it was verydifficult for his medical advisers to make him followtheir prescriptions. He indulged in smoking and wasnot a total abstainer, contrary to dietetic rules. Onthe evening of Oct. 2nd he had a cerebral haemorrhagewith paralysis of the left side. His medical attendant,Prof. Zondek, and Prof. Kraus were called in, but hedied six hours later without regaining consciousness.

Lead Poisoning as a Legacy of Gunshot Wounds.Notwithstanding the enormous number of gunshot

wounds received in the late war in which bullets orfragments of metal remained in the body, the numberof cases of lead poisoning from this cause has beenvery small ; in fact no more than eight seem to havebeen recorded. In the Deutsche Zeitschrift fiirChirurgie Dr. Hage has lately described a new case,in which the patient was a meat inspector who hadbeen wounded in the war in German South-WestAfrica 22 years ago. In 1926 he complained oftremor of the fingers, headache, and colics, andgradually his complexion got the characteristic leadpallor, whilst a blue line developed on the gumsand there was weakness of the extensor muscles.The presence of basophile erythrocytes and an

increase of haematoporphyrin in the urine left nodoubt of the diagnosis of lead poisoning, and byradiography it was ascertained that there were somesplinters of metal in the femur. As the man hadnothing to do with lead, the poisoning was evidentlydue to those splinters. Hage draws attention to thelapse of 20 years since the injury, and suggests thatthis time interval may explain why but few casesof lead poisoning have so far been noticed among menwounded in the late war.