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THE SIGNIFICANCE OF CAPILLARY MARKINGS IN PULMONARY TUBERCULOSIS.
1014 The nurses will be found in the same place with the necessary qualifications and surroundings. The orderlies could be recruited from the St. John trained orderlies in the district around the hospital. The scheme for an Army Medical Reserve that I proceed to outline consists in the organisation of a system which shall embrace a number of units called civilian auxiliary hospitals, to be set on foot in times of peace and called out for service in times of war and stress. These hospitals would be organised in connexion with, and affiliated to, the general hospitals throughout the Empire. Such institutions would afford an ample and continuous supply of efficient physicians, surgeons, and nurses. It would perhaps simplify matters if I describe shortly the formation of such a unit in connexion with a London general hospital. Let us call it St. George’s Civilian Auxiliary Hospital No. 1. It is suggested that each hospital should be organised and equipped to contain 200 beds, but be capable of expansion to accommodate nearly twice that number. It is a universal experience that medical and surgical work in time of war comes in rushes, either during epidemics or after great battles, and for this reason it is absolutely necessary that hospitals should be capable of expansion.
THE
I
SIGNIFICANCE OF CAPILLARY MARKINGS IN PULMONARY TUBERCULOSIS. To the Editor
of THE LANCET.
SIR,-In THE LANCET of March 4th, 1916, I called attention to the significance of certain red surface-markings in the neighbourhood of the upper dorsal vertebras and their relation to pulmonary tuberculosis. I now have further to offer. Notes of 481 consecutive cases were taken, all of which have been notified to their respective sanitary authorities. 130 were seen in the out-patient department of the Manchester Northern Hospital for Women and Children, the cases over 15 years of age being females.
figures
80 per cent. therefore of the tuberculous out-patients showed markings. Notes of 351 consecutive cases were taken at the Glossop and Chinley Tuberculosis Dispensaries and include in each age-group both sexes. The cases were sent to the dispensaries by their own doctors or by the school medical officers, or were contacts. 288 showed no tubercle bacillus to the usual examination, and 63 were returned as positive.
The 63 cases which showed tubercle bacillus in the classified as folllows :-
are
sputumI
Of the whole number, 57 per cent. showed the markings and 43 per cent. have no markings, whilst in those who were returned as having the tubercle bacillus in the sputum 36 per cent. had markings and 64 per cent. had none. The incidence of the death-rate is three times as great in those free from the markings compared to those showing I am, Sir, yours faithfully, markings. R. CRAWSHAW HOLT. Manchester, June 21st, 1917.
THE
TREATMENT OF TONSILLAR INFECTION. To the Editor
of
THE LANCET.
SIR,-In your issue of June 2nd Dr. F. J. Poynton rightly draws attention to the large part that tonsillar infection plays in rheumatism. The prevailing opinion, at any rate with regard to the etiology of the more chronic forms, is to consider them primarily due to sepsis of the teeth. How often the tonsils get overlooked it is impossible to hazard. It is surprising, when a routine examination is made, from
how many tonsils purulent matter may be exuded. The tonsils are commonly regarded as filters which deal with the organisms of the mouth. Once they have become a cesspool their use as natural immunisers has gone and radical enucleation would seem to be the only course to pursue. The body thus loses a most valuable protective organ, which not even the prolonged use of a vaccine of the predominant organism, usually a short streptococcus, will entirely make good. But the question arises, Is there no means of saving the tonsils ? Dental surgeons are now making efforts to cope with pyorrhoea in order to save the teeth. Can no means be found to save the tonsils ? With this object in view I have recently been making use of a Bier’s cupping apparatus, specially adapted for tonsil application. With a little practice it can be readily applied, and though very uncomfortable the patient soon gets accustomed to its use and can even learn to apply the instrument himself. It is surprising with what ease by this means pus can be squeezed out from the tonsils. The method, systematically and regularly applied, should do much to cleanse badly infected tonsils and give them a chance of recovering their normal powers. In several instances patients have quickly realised the relief afforded and have been only too anxious to continue the treatment. At the present moment scores of soldiers are being thrown out of action by subacute and chronic rheumatism, some few of whom become hopeless cripples. In order that physical and thermal treatment should be used to the best advantage the early and vigorous treatment of sepsis wherever it lies should be thoroughly undertaken, and no advantage should be made of the fact that spontaneous subsidence of the septic focus will very often occur, for just as often it does not, and constant recurrences of rheumatism are only too common after apparent cure in patients whose throats, sinuses, or other foci apparently, but do not really, clear I am, Sir, yours faithfully, up. G. HELY-HUTCHINSON ALMOND. Bath, June 20th, 1917.
SEROUS IRIDO-CYCLITIS. To the Editor of THE LANCET.
SIR,-In the report in your issue of June 23rd of the meeting of the Section of Ophthalmology of the Royal
Society of Medicine not one word is mentioned of what I for many months past have looked upon as one of the prime factors in the causation of those cases of serous irido-cyclitis(keratitis punctata, &c.) which, through the admirable and thorough work of Mr. W. Lang and others, have been-and I consider correctly-put down as frequently the result of pyorrhoea alveolaris. This complaint, serous cyclitis, is common enough in both sexes, but, in my experience, is far more frequently met with in the female, and at any age, roughly speaking, between 35 and 65; it is not found in very young of very old and edentulous people. Women certainly outnumber men, yet that would not account for the difference in the proportion affected ; they pay quite as much attention to their teeth as the opposite sex, yet they more frequently fall victims to this serious complaint-and it is a. very serious one. Why is this ? It is not due to a less-resisting power of the female sex, nor to any idiosyncrasy thereof, but the missing link is constipation, and of that I have no manner Women are far of doubt, no possible doubt whatever. more constipated than men ; they are more sensitive on the matter, and do not like to be seen repairing to, or issuing from, lavatories ; they from early girlhood often neglect themselves in consequence. Again, they take less exercise, drink less fluid, are more careful and finicking in their diet, avoiding coarse foods more than we do, and-except in the case of the modern young lady-they smoke less or not at all ; all this conduces to a sluggish state of the bowels. So, consequently, ptomaines-or whatever they are-passing in equal degree into the alimentary canals of both sexes, stand a much better chance of being absorbed into the lacteals or blood-vessels of the gut and "coming out in the eyes." This theory fits in with practical experience, for all these patients are constipated, both men and women, some of them very much so ; or, if they say their bowels are regular and act daily, the motions will be found dry and hard, absorption of the more fluid part having taken place. The treatment, therefore, is comparatively simple : whatever one treats one must not neglect the bowels, the teeth, or the
,
THE
I
SIGNIFICANCE OF CAPILLARY MARKINGS IN PULMONARY TUBERCULOSIS. To the Editor
of THE LANCET.
SIR,-In THE LANCET of March 4th, 1916, I called attention to the significance of certain red surface-markings in the neighbourhood of the upper dorsal vertebras and their relation to pulmonary tuberculosis. I now have further to offer. Notes of 481 consecutive cases were taken, all of which have been notified to their respective sanitary authorities. 130 were seen in the out-patient department of the Manchester Northern Hospital for Women and Children, the cases over 15 years of age being females.
figures
80 per cent. therefore of the tuberculous out-patients showed markings. Notes of 351 consecutive cases were taken at the Glossop and Chinley Tuberculosis Dispensaries and include in each age-group both sexes. The cases were sent to the dispensaries by their own doctors or by the school medical officers, or were contacts. 288 showed no tubercle bacillus to the usual examination, and 63 were returned as positive.
The 63 cases which showed tubercle bacillus in the classified as folllows :-
are
sputumI
Of the whole number, 57 per cent. showed the markings and 43 per cent. have no markings, whilst in those who were returned as having the tubercle bacillus in the sputum 36 per cent. had markings and 64 per cent. had none. The incidence of the death-rate is three times as great in those free from the markings compared to those showing I am, Sir, yours faithfully, markings. R. CRAWSHAW HOLT. Manchester, June 21st, 1917.
THE
TREATMENT OF TONSILLAR INFECTION. To the Editor
of
THE LANCET.
SIR,-In your issue of June 2nd Dr. F. J. Poynton rightly draws attention to the large part that tonsillar infection plays in rheumatism. The prevailing opinion, at any rate with regard to the etiology of the more chronic forms, is to consider them primarily due to sepsis of the teeth. How often the tonsils get overlooked it is impossible to hazard. It is surprising, when a routine examination is made, from
how many tonsils purulent matter may be exuded. The tonsils are commonly regarded as filters which deal with the organisms of the mouth. Once they have become a cesspool their use as natural immunisers has gone and radical enucleation would seem to be the only course to pursue. The body thus loses a most valuable protective organ, which not even the prolonged use of a vaccine of the predominant organism, usually a short streptococcus, will entirely make good. But the question arises, Is there no means of saving the tonsils ? Dental surgeons are now making efforts to cope with pyorrhoea in order to save the teeth. Can no means be found to save the tonsils ? With this object in view I have recently been making use of a Bier’s cupping apparatus, specially adapted for tonsil application. With a little practice it can be readily applied, and though very uncomfortable the patient soon gets accustomed to its use and can even learn to apply the instrument himself. It is surprising with what ease by this means pus can be squeezed out from the tonsils. The method, systematically and regularly applied, should do much to cleanse badly infected tonsils and give them a chance of recovering their normal powers. In several instances patients have quickly realised the relief afforded and have been only too anxious to continue the treatment. At the present moment scores of soldiers are being thrown out of action by subacute and chronic rheumatism, some few of whom become hopeless cripples. In order that physical and thermal treatment should be used to the best advantage the early and vigorous treatment of sepsis wherever it lies should be thoroughly undertaken, and no advantage should be made of the fact that spontaneous subsidence of the septic focus will very often occur, for just as often it does not, and constant recurrences of rheumatism are only too common after apparent cure in patients whose throats, sinuses, or other foci apparently, but do not really, clear I am, Sir, yours faithfully, up. G. HELY-HUTCHINSON ALMOND. Bath, June 20th, 1917.
SEROUS IRIDO-CYCLITIS. To the Editor of THE LANCET.
SIR,-In the report in your issue of June 23rd of the meeting of the Section of Ophthalmology of the Royal
Society of Medicine not one word is mentioned of what I for many months past have looked upon as one of the prime factors in the causation of those cases of serous irido-cyclitis(keratitis punctata, &c.) which, through the admirable and thorough work of Mr. W. Lang and others, have been-and I consider correctly-put down as frequently the result of pyorrhoea alveolaris. This complaint, serous cyclitis, is common enough in both sexes, but, in my experience, is far more frequently met with in the female, and at any age, roughly speaking, between 35 and 65; it is not found in very young of very old and edentulous people. Women certainly outnumber men, yet that would not account for the difference in the proportion affected ; they pay quite as much attention to their teeth as the opposite sex, yet they more frequently fall victims to this serious complaint-and it is a. very serious one. Why is this ? It is not due to a less-resisting power of the female sex, nor to any idiosyncrasy thereof, but the missing link is constipation, and of that I have no manner Women are far of doubt, no possible doubt whatever. more constipated than men ; they are more sensitive on the matter, and do not like to be seen repairing to, or issuing from, lavatories ; they from early girlhood often neglect themselves in consequence. Again, they take less exercise, drink less fluid, are more careful and finicking in their diet, avoiding coarse foods more than we do, and-except in the case of the modern young lady-they smoke less or not at all ; all this conduces to a sluggish state of the bowels. So, consequently, ptomaines-or whatever they are-passing in equal degree into the alimentary canals of both sexes, stand a much better chance of being absorbed into the lacteals or blood-vessels of the gut and "coming out in the eyes." This theory fits in with practical experience, for all these patients are constipated, both men and women, some of them very much so ; or, if they say their bowels are regular and act daily, the motions will be found dry and hard, absorption of the more fluid part having taken place. The treatment, therefore, is comparatively simple : whatever one treats one must not neglect the bowels, the teeth, or the
,