90 TUBERCULOSIS ASSOCIATION MEETING AT CAMBRIDGE. TUBERCULOSIS ASSOCIATION. ANNUAL PROVINCIAL MEETING, CAMBRIDGE, JUNE 27TH-29TH. (Continued from p. 40.) III. THE CORRELATION OF X RAY FINDINGS IN PULMONARY TUBERCULOSIS WITH THE SYMPTOMS AND PHYSICAL SIGNS. Dr. J. WATT (Godalming) being in the chair, Dr. A. E. BARCLAY (Cambridge) dealt with the physical nature of X rays ; the causation of the shadows seen in a radiogram of the chest; the voltage, the type of tube,the character of the radiations, and the distance at which a chest radiogram should be taken. Standard conditions, he said, were essential, but most radiologists are troubled by such fundamental things as big variations in town main voltages. Such variations play havoc with standardisation, particu- larly in the use of hot cathode tubes, where a slight change in the heating filament made so much difference in the quality of the rays. Longer distances were now used in chest work, giving less distortion of the picture and more definition. The best type of film should show no detail in the bones of the thorax. Stereoscopy as aroutine measure was not particularly valuable. Screening of the chest before taking a film was invaluable, because it gave information as to the movements of the diaphragm, and to the presence of localised areas of deficient air entry. The shadows at the root of the lung were caused mainly by the blood in the pulmonary vessels. Again, there was not so much air at the roots, and on this account the shadows are denser. Personally he was inclined to lay little or no stress on relatively slight increases in the root shadows, provided that there was nothing else to arouse suspicion. Two points which made him take ’, notice were an area of suspected defective air entry, especially if the root shadow seemed to be particularly enlarged towards this area and secondly, any alteration in the nature of the movements of the diaphragm. These features could only be seen on ’, screen examination. The irregular branched striae spreading out from the root were, in his opinion, due almost entirely to blood-vessels. It was, of course, in the detection of early pulmonary tuberculosis that X ray examination was of the greatest importance. Advanced disease was usually quite patent clinically, yet frequently more extensive disease was found radiographically than the clinical signs led one to suspect. But, on the other hand, there was a certain percentage of cases in which the radio- gram showed no disease when the clinical evidence of its presence was quite strong. The obvious and plausible explanation of the failures in the clinical signs of disease was that the disease was deep-seated, whereas physical examination was .more concerned with superficial changes. But why certain cases should fail to give radiographic evidence was not so easy of explanation. Radiographic evidence was naturally confined to macroscopic changes, and if only a few alveoli were affected we were not likely to detect the change. The typical woolly mottling of a tuberculous focus represented not only the disease itself, but a surrounding region filled with the exudate of reaction. He suggested that, in these cases where the radiogram failed to reveal any change, the reaction was deficient. In spite of these exceptions, his faith in the value of an entirely negative X ray examination conducted by a careful radiologist was very high. Radiologists were not justified in calling a shadow tuberculous except on the ground of experience. Exactly the same appearance could be produced by any other low grade localised infection with an inflammatory reaction about it. He held very strongly that the radiographic and clinical examina- tions should be conducted by different observers. The clinician and the radiologist together would arrive at an opinion that would be neither a clinical nor an X ray diagnosis, but something that really mattered—i.e., the diagnosis. It was only by team- work that we could make progress. Dr. S. VERB PEARSON (Mundesley) said that the subject was a wide one and could not easily be covered briefly. Great advances had been made in recent years but there was still much to learn. He recommended a study of the writings of Wessler and Jaches, Alexander and Beekmann, and the publica- tions of Dr. Kenneth Dunham. He thought there was a tendency to-day to over-emphasise the practical deductions to be drawn from X ray findings in pulmonary tuberculosis. After all the symptoms of a patient were more important than either ordinary physical signs or X ray pictures. It was most important, too, to realise that good and constant standards must be set up in making films of chests, because it was easy, if a radiologist were really clever in altering the circumstances of exposure of a chest, even to produce the picture of a cure attained in a few minutes! He thought this subject of the co-relation of X ray findings with symptoms and physical signs might best be illustrated by him by showing some slides of chests where there was an exceptional correlation one way or the other. It was well known, for example, that severe laryngeal cases and cases complicated by chronic alcoholism often had paucity of ordinary physical signs in the chest, yet X rays revealed extensive disease. He then showed amongst other slides (1) a picture of a very big apical cavity in the case of a man who had been repeatedly examined over many weeks without ever finding any of the ordinary signs of excavation. (2) A couple of slides showing what appeared from X ray examination to be a severe and extensive case compared to one of a much slighter nature; but when the symptoms were compared the former had no fever or other severe symptoms, whereas as in the latter case it was necessary to keep the patient in bed for months and the severity of the illness was great. (3) Two films of the same chest at an interval of nine months looking almost exactly the same, yet from emaciation and feverishness the patient had in the interval progressed to decent body-weight and capability for walking exercise up to ten miles a day. (4) A slide which showed a recent lesion in the left lower lobe producing relapse, which lesion was unsuspected before the X ray film was taken, which saved the patient from having a right-sided artificial pneumothorax attempted, and some other slides where the physical signs were described and were somewhat unusual in their correlation to the X ray appearance or the clinical condition. Dr. G. T. HEBERT (London) said there could be no two opinions concerning the value of X ray examina- tion to the clinician. Unsatisfactory films, it was true, were unreliable and misleading, but for the purposes of the discussion we must assume that first-class apparatus and technique were used. If X ray findings always agreed with the results of ordinary clinical examination they would be of no service to the clinician. When confronted with a doubtful case of tuberculosis the physician had to make up his mind on four problems-viz., the presence or not of tuberculosis, its extent and character, its activity and the prognosis. In the correlation of X ray findings with physical signs all cases could be divided into four groups : (1) When symptoms and signs were negative and X ray findings negative. This group was usually a large one, and included most of the contact cases. (2) When symptoms and signs were negative and X ray findings positive. If X ray examination was carried out as a routine in this group of cases it would probably be found now and then that one which the clinician would have passed over as non-tuberculous showed a definite radiological lesion. (3) When symptoms and signs were suggestive but the X ray findings positive. Most patients with pulmonary tuberculosis had passed the incipient stage when they first presented themselves. They could be diagnosed with a fair degree of certainty by symptoms, signs, and sputum examination, and for the purposes
PULMONARY TUBERCULOSIS WITH THE SYMPTOMSAND PHYSICAL SIGNS.
Dr. J. WATT (Godalming) being in the chair,Dr. A. E. BARCLAY (Cambridge) dealt with the
physical nature of X rays ; the causation of theshadows seen in a radiogram of the chest; thevoltage, the type of tube,the character of the radiations,and the distance at which a chest radiogram shouldbe taken. Standard conditions, he said, were essential,but most radiologists are troubled by such fundamentalthings as big variations in town main voltages. Suchvariations play havoc with standardisation, particu-larly in the use of hot cathode tubes, where a slightchange in the heating filament made so much differencein the quality of the rays. Longer distances werenow used in chest work, giving less distortion of thepicture and more definition. The best type of filmshould show no detail in the bones of the thorax.Stereoscopy as aroutine measure was not particularlyvaluable. Screening of the chest before taking a filmwas invaluable, because it gave information as to themovements of the diaphragm, and to the presence oflocalised areas of deficient air entry. The shadowsat the root of the lung were caused mainly by the bloodin the pulmonary vessels. Again, there was not somuch air at the roots, and on this account the shadowsare denser. Personally he was inclined to lay littleor no stress on relatively slight increases in the rootshadows, provided that there was nothing else toarouse suspicion. Two points which made him take ’,notice were an area of suspected defective air entry,especially if the root shadow seemed to be particularlyenlarged towards this area and secondly, anyalteration in the nature of the movements of thediaphragm. These features could only be seen on ’,screen examination. The irregular branched striaespreading out from the root were, in his opinion, duealmost entirely to blood-vessels.
It was, of course, in the detection of early pulmonarytuberculosis that X ray examination was of thegreatest importance. Advanced disease was usuallyquite patent clinically, yet frequently more extensivedisease was found radiographically than the clinicalsigns led one to suspect. But, on the other hand, therewas a certain percentage of cases in which the radio-gram showed no disease when the clinical evidenceof its presence was quite strong. The obvious andplausible explanation of the failures in the clinicalsigns of disease was that the disease was deep-seated,whereas physical examination was .more concernedwith superficial changes. But why certain cases
should fail to give radiographic evidence was not soeasy of explanation. Radiographic evidence wasnaturally confined to macroscopic changes, and if onlya few alveoli were affected we were not likely todetect the change. The typical woolly mottling of atuberculous focus represented not only the diseaseitself, but a surrounding region filled with the exudateof reaction. He suggested that, in these cases wherethe radiogram failed to reveal any change, thereaction was deficient. In spite of these exceptions,his faith in the value of an entirely negative X rayexamination conducted by a careful radiologist wasvery high. Radiologists were not justified in calling ashadow tuberculous except on the ground of experience.Exactly the same appearance could be produced byany other low grade localised infection with aninflammatory reaction about it. He held verystrongly that the radiographic and clinical examina-tions should be conducted by different observers.The clinician and the radiologist together wouldarrive at an opinion that would be neither a clinical
nor an X ray diagnosis, but something that reallymattered—i.e., the diagnosis. It was only by team-work that we could make progress.
Dr. S. VERB PEARSON (Mundesley) said that thesubject was a wide one and could not easily becovered briefly. Great advances had been made inrecent years but there was still much to learn. Herecommended a study of the writings of Wessler andJaches, Alexander and Beekmann, and the publica-tions of Dr. Kenneth Dunham. He thought therewas a tendency to-day to over-emphasise the practicaldeductions to be drawn from X ray findings inpulmonary tuberculosis. After all the symptoms of apatient were more important than either ordinaryphysical signs or X ray pictures. It was mostimportant, too, to realise that good and constantstandards must be set up in making films of chests,because it was easy, if a radiologist were really cleverin altering the circumstances of exposure of a chest,even to produce the picture of a cure attained ina few minutes! He thought this subject of theco-relation of X ray findings with symptoms andphysical signs might best be illustrated by him byshowing some slides of chests where there was anexceptional correlation one way or the other. It waswell known, for example, that severe laryngeal casesand cases complicated by chronic alcoholism oftenhad paucity of ordinary physical signs in the chest,yet X rays revealed extensive disease. He thenshowed amongst other slides (1) a picture of a verybig apical cavity in the case of a man who had beenrepeatedly examined over many weeks withoutever finding any of the ordinary signs of excavation.(2) A couple of slides showing what appeared fromX ray examination to be a severe and extensive casecompared to one of a much slighter nature; but whenthe symptoms were compared the former had no feveror other severe symptoms, whereas as in the lattercase it was necessary to keep the patient in bed formonths and the severity of the illness was great.(3) Two films of the same chest at an interval of ninemonths looking almost exactly the same, yet fromemaciation and feverishness the patient had in theinterval progressed to decent body-weight andcapability for walking exercise up to ten miles a day.(4) A slide which showed a recent lesion in the leftlower lobe producing relapse, which lesion was
unsuspected before the X ray film was taken, whichsaved the patient from having a right-sided artificialpneumothorax attempted, and some other slideswhere the physical signs were described and weresomewhat unusual in their correlation to the X rayappearance or the clinical condition.
Dr. G. T. HEBERT (London) said there could be notwo opinions concerning the value of X ray examina-tion to the clinician. Unsatisfactory films, it wastrue, were unreliable and misleading, but for thepurposes of the discussion we must assume thatfirst-class apparatus and technique were used. If X rayfindings always agreed with the results of ordinaryclinical examination they would be of no service tothe clinician. When confronted with a doubtful caseof tuberculosis the physician had to make up hismind on four problems-viz., the presence or not oftuberculosis, its extent and character, its activity andthe prognosis. In the correlation of X ray findingswith physical signs all cases could be divided intofour groups : (1) When symptoms and signs werenegative and X ray findings negative. This groupwas usually a large one, and included most of thecontact cases. (2) When symptoms and signs werenegative and X ray findings positive. If X rayexamination was carried out as a routine in this groupof cases it would probably be found now and thenthat one which the clinician would have passed overas non-tuberculous showed a definite radiologicallesion. (3) When symptoms and signs were suggestivebut the X ray findings positive. Most patients withpulmonary tuberculosis had passed the incipient stagewhen they first presented themselves. They could bediagnosed with a fair degree of certainty by symptoms,signs, and sputum examination, and for the purposes
91TUBERCULOSIS ASSOCIATION MEETING AT CAMBRIDGE.
of diagnosis a radiogram was unnecessary. If sputumexamination were negative a positive X ray examina-tion would confirm the diagnosis. (4) Whensymptoms and signs were suggestive of tuberculosisbut the X ray findings negative. It was possible fordefinite tuberculosis, proved by more than one
positive sputum examination, to exist withoutdefinite X ray changes, but such instances were veryuncommon. Haemoptysis, pleural effusion, andspontaneous pneumothorax were presumably tuber-culous manifestations, but in a considerable percentageof these cases no radiological evidence of disease inthe lungs was discoverable. He pointed out that inthe non-tuberculous chronic interstitial fibrosis, theabnormal physical signs were usually very marked,whereas the radiogram frequently showed little ornothing wrong. This contrast in the signs and X raypicture he considered to be proof of the non-tuber-culous character of the lesion. In tuberculosis theradiogram provided very good evidence of the extentof the lesion. As a rule the disease was more extensivethan the physical signs indicated. In regard toactivity of the disease, radiological examination wasnot of much value. It was true that active lesionshad certain characteristics, but these were oftenobscured when active and old foci were intermingled,and on the whole the question of activity was betterdecided on purely clinical grounds. Concerning thequestion of prognosis by means of the radiogram,if the condition of the patient was good, he likedto see well-developed mottling. On the other hand,when symptoms, signs, and pyrexia were prominentfeatures but X ray examination showed relativelylittle, he inferred that the prognosis was bad.
In summing up he made the following points:(1) The clinician would derive most benefit fromX ray examination in the province of diagnosis.(2) It was often useful in excluding tuberculosis aswell as for confirming clinical evidence which was notquite strong enough to be conclusive. (3) It wasessential in cases of initial haemoptysis, after anidiopathic pleural effusion, or spontaneous pneumo-thorax, in cases of probable laryngeal tuberculosis,and in some cases of non-pulmonary tuberculosis.(4) It was essential before artificial pneumothoraxtreatment was commenced and at intervals duringthe treatment. (5) It often helped in other caseswhen, for instance, symptoms were severe and thesigns slight, or vice versa. (6) It was liable to bemisleading when it showed a generalised lesion or
indefinite when a homogeneous opacity was presentwhich might be due either to fluid or consolidation.(7) Every clinician should study the X ray films ofhis cases, because it was only by experience that thesignificance of X ray findings be discovered and theirhelp utilised to the best advantage.
Discussion.The CHAIRMAN agreed that while radiograms were
useful, they were not infallible. The clinician and theradiologist should work together.
Dr. ERNEST WARD (Paignton) spoke of the variationsin the ability of radiologists to take good chest films.He asked what was the significance of pleural ringsand cart-wheel shadows.
Dr. GEORGE JESSEL (Lancashire) said it was mostvaluable to compare X ray findings and physical signswith autopsies, and in this respect the large hospitalshad a great advantage over the tuberculosis officer.He thought that diagnosis had not become moreaccurate in recent years but that there had been agreat increase in interest and that treatment on thewhole was better. He uttered a warning againstdepending too much on radiology and neglecting thesymptoms and physical signs.
Dr. W. STOBIE (Oxford) was of the opinion that theinterpretation of the films should be left to theclinician. Radiograms were part and parcel of ourdiagnostic equipment, but he thought that all thesequestions about the correlation of physical signs werehighly speculative in the absence of autopsies. He
maintained that it was impossible to make a prognosisfrom a radiogram.
Dr. W. ARNOTT DICKSON, Dr. W. H. DICKINSON,and Dr. F. A. L. HAMMOND also took part.
IV. GAS POISONING AND GUNSHOT WOUNDS OF THECHEST IN RELATION TO TUBERCULOSIS.
Dr. F. W. BURTON-FANNING (Norwich) being in thechair,Surgeon-Commander A. FAIRLEY (Chemical Warfare
Research Department, Porton) spoke on the after-effects of war gassing in relation to the incidence oftuberculosis, on which he said his mind was still open.The clinical side came under the Ministry of Pensions.With much that had been published on the matter inother countries, his department found itself in generalagreement. Owing to the fact that warfare gas was asurprise weapon introduced against modern rules ofwarfare, it had received a vast amount of unfavourablepress attention throughout the world. As a result,gas was being blamed for more dire iniquities thanhad ever before been associated with any war weapon.It was credited for many ailments for which it wasin no way responsible. This was borne out by the factthat in the American Army there were only 70,552gas casualties, but the number of applications forcompensation greatly exceeded that number. ABoard of American medical officers had examinedover two thousand cases claiming disability fromgas poisoning. They concluded that gas victims,irrespective of the type of gas used and the severityof attack sustained, showed no marked predispositionto active pulmonary tuberculosis, or to reactivationof a healed or quiescent pulmonary lesion. Further,gas victims presented little evidence of materialdestruction of lung tissue. French, German, and Swissauthorities had issued reports with similar conclusions
In the differential diagnosis of pulmonary tuber-culosis from the late effects of gas poisoning, Hawesof Boston had stressed that a general appearance ofrobust health associated with marked symptoms wasagainst tuberculosis, that the lung complicationsresulting from gas poisoning were usually basal andnot apical, and that, following gas poisoning therewas apt to be a marked increase in nervous symptomsof every kind. In order to trace any connexionbetween war gassing and tuberculous or any otherdisability it was of fundamental importance that therecord of war gassing should be unimpeachable.
Dr. G. BASIL PRICE (Ministry of Pensions) dealtwith the incidence of pulmonary tuberculosis bothafter gas poisoning and gunshot wounds of the chest,He was able to show that a marked contrast as tothe incidence of tuberculosis existed between the twotypes of case-viz., that whereas tuberculosis was arare sequel of gas poisoning, in gunshot wounds ofthe chest it formed a small but definite percentagewhich was likely to increase as time went on. Duringa detailed review of the literature he quoted Sergent’sconclusions in 1925 that gassing by itself didnot provoke tuberculosis ; that where tuberculosisfollowed gassing, active or latent tuberculosis musthave been present; and that if at a later date gassingwas followed by tuberculosis, the occurrence was
accidental. Dr. Price found in a series of 200cases in which there had been a definite history ofgas poisoning only nine were diagnosed as pulmonarytuberculosis. Of these nine cases in only two wasthere a probability that the condition was directlycaused by the gassing. In a series of 50 cases ofwounds of the chest he found pulmonary tuberculosisin 37 of them. The tuberculosis was regarded as adirect sequel of the trauma in 29 cases. He concludedthat whereas gassing is unimportant in the laterdevelopment of pulmonary tuberculosis, in gunshotinjuries of the chest (of all types, surface and pene-trating), tuberculosis develops later in a smallbut appreciable percentage. He considered thatsurface injuries not involving the thoracic cage didnot appear to be an astiological factor in the onset of
92 NATIONAL HEALTH INSURANCE IN SCOTLAND.
tuberculosis. When the pulmonary tissue had beendefinitely injured, and especially when a foreign bodywas retained in or near the damaged area, activationof tubercle might occur even after a prolonged period.
Discussion.Dr. A. SANDISON (Ministry of Pensions) said that
the mystery of tuberculosis had been increased.The results quoted by Dr. Price were somewhatunexpected, as we now found that it was probablyan advantage to have been gassed. The papershowed the value of continuity of records. Hesupposed that the Ministry of Pensions possessed themost complete health records of a section of thecommunity than had elsewhere been collected.Statistics made from such records were certainly ofgreat value. He pointed out that there was a greatincrease in the diagnosis of tuberculosis just after thewar mainly on account of the possibility of a pensionbeing obtained.
Dr. PEARSON gave some additional details about acase, to which Dr. Price had referred, of oesophagealstricture said to be a sequel to gas poisoning.
Dr. NEVILLE Cox (Brighton) asked what proportionof cases with foreign bodies in the lung had received afinal award. He thought that it would be of greatadvantage if these cases could be sent to thetuberculosis officers for purposes of observation.
Dr. JESSEL said that in 1920 he had been asked towork out the connexion between tuberculosis andgas poisoning. In 1281 pulmonary cases he found asmall percentage, similar to that stated by Dr. Price,had developed tuberculosis following gas poisoning.
Dr. W. ARNOTT DiCESON (Gloucestershire) saidthat there now seemed to be three almost sure
preventives of tuberculosis-viz., gassing, enlargedtonsils, and delicacy in childhood.
Dr. T. ELLioTT (Shropshire), after quoting the workof the Henry Phipps’ Institute on the question oflatent tuberculosis, asked whether or not it wapossible that the trauma to the lung opened up a
latent lesion instead of causing a fresh onset of thEdisease.The CHAIRMAN was interested in the question of
laryngitis following gassing, and instanced a case ofmustard gas poisoning, followed by aphonia anddyspnoea. A diagnosis of tuberculous laryngitis wasmade, and the patient was found later to havepulmonary tuberculosis. He gave some figures ofpatients in Kelling Sanatorium with tuberculosisfollowing gassing and wounds of the chest, andinquired whether it was a fact that the nature of theforeign body played a part in the development oftuberculosis. It was possible that rounded smoothforeign bodies were less harmful than those consistingof roughened angular fragments.
Replies.Commander FAIRLEY thought that cesophageal
stricture was an unlikely sequel to gas poisoning.In experimental work in animals fed on gas-impregnated water no lesion had been found in theoesophagus. A concentration of gas sufficient tocause ulceration of the stomach was quite withouteffect on the oesophagus. He did not think it waspossible to have food impregnated with a concentrationof gas sufficient to cause poisoning and in any case itwould be extremely unpalatable.
Dr. PRICE said that the men who had received afinal award would come to the tuberculosis officer ifthey became worse. He had found few primarylaryngeal complications following gassing, and in anycase tuberculous laryngitis was usually associatedwith advanced pulmonary tuberculosis.
NEW CANCER HOSPITAL FOR MANCHESTER.-It isstated that a new Manchester hospital for the treatment ofcancer and for research is. to be provided by uniting theChristie (Cancer) Hospital and the Radium Institute on thesite of Groombridge House, Withington.
NATIONAL HEALTH INSURANCE.WORKING OF THE ACTS IN SCOTLAND.
THE tenth annual report of the Scottish Boardof Health, which appeared recently, contains a
careful study of the working of the National HealthInsurance system up to the end of the year 1928, whenthe Board was superseded by the new Departmentof Health for Scotland. The summary, which coversa period of ten years, deals with the work of theapproved societies, the insurance committees, theBoard’s inspectors, and the district medical officers,who correspond to the regional medical staff inEngland and Wales.
APPROVED SOCIETIES.
, A reduction in contribution income for 1928was due to the lowering of the insurable age limiton June 2nd from 70 to 65 years. The state of theseveral industries is reflected in the sale of insurancestamps, which has dropped in varying degreeaccording to the extent to which their membersbelonged to the depressed trades. Nevertheless,as in England and Wales, the expenditure on benefitswas maintained at a high level. The actual costof sickness and disablement benefits in Scotlandincreased from :81,293,000 in 1921 to a peak of32,021,000 in 1927, falling to jBl.756,000 in 1928,when the figure of 1928 would have been still lowerhad not the disablement benefit kept up, especiallyin the case of men, the rise in the cost of disablementpointing to an increase either in the number ofclaimants or in the average duration of the claims.The claims of women are in excess of those of menand there is a movement to separate the two fundsfor the purposes of valuation.
Elimination of bad claims is the duty of the districtmedical officers who advise and assist insurancepractitioners in counteracting the effect of laxcertification, and also help the societies in the selectionof cases for reference. As in England and Wales,it has been found that some societies have adoptedan arbitrary basis of selection which results in a
clogging of the machinery.The special concession made to genuinely unem-
ployed persons whereby despite their inabilityto contribute they remain entitled to cash benefitsat the minimum rate was continued during theyear 1927-28. For this purpose societies receivedsome of the unclaimed money in the stamp salesaccount and the grants will be more generous infuture. In the terms of the amending Act of 1928such arrears will be entirely excused and will involveno reduction whatever in the cash benefits providedthe insured person is able to satisfy his society thathe has really been available for employment ofan insurable nature, but unable to obtain it. TheMinistry of Labour have now arranged to stampthe cards of such persons at the exchanges duringeach week of unemployment.
Additional Benefits.-The funds allocated to dentalbenefit were found inadequate to meet the demands,and in many societies the grants had to be reducedfrom 100 to 75 per cent. of the cost of extractionsand conservative treatment, while half the costof dentures was reimbursed. The amount of moneyavailable was further curtailed by the fact thatpart of the 1928 moneys allocated had been usedin the previous year. The amount of money spenton other forms of additional benefit was small.Certain benefits which ceased to operate at the endof the year included medical attendance on dependentsand payment of disablement allowance to membersnot totally incapable of work. Power given by the1924 Act to expend money on such benefits withoutapproval was repealed in favour of new provisionswhich enable societies to expend moneys on bona-fidecharitable objects, subject to the approval of theBoard.
