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THREE CONCEPTIONS OF TUBERCULOSIS.
470 alkalosis
following alkaline treatment of ulcer in the THREE CONCEPTIONS OF TUBERCULOSIS. Guy’s Hospital Reports for 1925. For some reason To the Editor of THE LANCET. the condition has in my experience only occurred in SIR,—In his kindly criticism of my paper in your private patients, which may account for the fact that Prof. MacLean has not observed it in his hospital issue of Feb. 4th (p. 259), Dr. Blanford takes the view ’unit, but it is none the less important for the prac- that whenever symptoms and signs suggestive of titioner to recognise the first signs of alkalosis so pulmonary tuberculosis are present the disease is that the treatment may be discontinued without serious ; the outcome cannot be foretold, and
delay.
sanatorium treatment should be advised ; but with efficient medical examination this means sending 30 to 40 per cent. of the population to sanatoria at some time in their lives, most of whom would recover just as well at home. To-day the great majority of these cases recover undiagnosed, there may be suspicions in the practitioner’s mind, but he hesitates to name the complaint until an exact diagnosis can made, which sometimes means that the disease is no longer " minor." In this way special treatment may be dangerously delayed in low-resistant patients. If the real frequency of symptoms due to tuberculosis were generally realised this diagnosis would be much more common, based it is true on ground less sure than at present, though just as scientific as most other diagnoses in general practice. There would then, I think, be more observation, people in time would be less apprehensive, and special treatment
The correct dosage of alkalis is very complicated and biochemical problem, which is at present the subject of active investigation at Guy’s Hospital. The value of the mixture recommended by MacLean is entirely due to the sodium bicarbonate and magnesium carbonate it contains, as the work of Mr. E. Matthews, which will be shortly published in our Reports, shows that bismuth carbonate is almost be completely devoid of neutralising power. On the other hand, the 10 grains of sodium citrate, which MacLean, in common with most physicians, gives with each feed in order to prevent coagulation of the milk, has almost the same neutralising power as the 12 grains of sodium bicarbonate he gives every two hours. Prof. MacLean writes, in reference to infected teeth, that " unless we are misinformed with regard to the general attitude of the profession on the more readily adopted. An acute case is unsuitable for the sanatorium. It subject, there is at present little risk of the teeth, septic or otherwise, being overlooked." From my is the border-line case with some resistance, but not experience I should say that he certainly has been doing well at home, that will benefit there, and misinformed, as out of 126 consecutive cases of nothing is lost for such patients by three months’ duodenal ulcer at New Lodge Clinic 25 per cent. observation and treatment at home. There are, of had well-marked pyorrhoea alone, 9 per cent. had course, certain conditions which make immediate apical infection alone, 40 per cent. bad bouh, 8 per sanatorium treatment advisable :— 1. A positive sputum. cent. were edentulous, and only 18 per cent. had 2. A bad family history. healthy teeth. The corresponding figures for 30 3. Very bad surroundings. cases of gastric ulcer were 23, 20, 21, 13, and 23 per 4. Patient has not improved with home treatment. cent. respectively. I am, Sir, yours faithfully, The constant iteration that early cases must be ARTHUR F. HURST. sent at once to a sanatorium has led to a false position. Some minor cases are sent there unnecessarily (some to be returned with the diagnosis unconfirmed), and in other instances the supposed necessity for such a MASTOID OPERATIONS. step dangerously delays the diagnosis. In dealing To the Editor of THE LANCET. with tuberculosis, the point where medical experience and skill are of the highest value is not so much in SiR,-It is interesting to read in your current issue Sir Charles Ballance’s retrospect. Doubtless he making a diagnosis, but in deciding what should be looked back and was influenced by his teachers when done for the individual patient. If the mere existence he designed his own operation. His, like theirs, of tuberculosis necessitated sanatorium the matter On would be simple, and the recent innovation of appointseems to attract little attention in these days. the other hand, I looked forward and was not at all ing junior men to act as school medical officer, welfare influenced by the work of my predecessors when officer, assistant medical officer of health, and tubercnlosis officer would be justified ; but the matter is not designing my method of operation, because I had so simple, and a lifetime is not too long to learn how learnt a great deal by observing Nature’s attempts to cure mastoid disease, and based my technique on to treat the individual patient. The experience of the sanatorium officer is likely ’, these. Dr. Percy Jakins, of the Central London Ear and to be wider, and his advice more sound, in dealing Throat Hospital, was the first surgeon to visit the with major tuberculosis, but the tuberculosis officer Throat Hospital to see me perform one of these has the advantage in advising about tuberculosis as practice. operations. He made this remark in the operating ’ met with in everyday I am. Sir. vours faithfullv. theatre : " Your operation will take the place of all E. WARD. Schwartze operations and most of Stacke’s radical ones." Evidence of the soundness of his opinion was forthcoming last week, for on the 23rd inst. I perINCIDENCE OF THE MINOR PSYCHOSES. formed one of these operations, exhibited a cured To the Editor of THE LANCET. ’ , patient, and subsequently lectured on Diagnosis in SIR,—The views of Dr. T. A. Ross and myself Mastoid Disease at the Burton-on-Trent Hospital by invitation of the local Medico-Chirurgical Society. are so much in accord that I can treat his letter in There I was informed that 76 mastoid operations had your issue of Feb. 25th only as an opportunity of been performed in the hospital in the past year, that defining my position when I challenge the current 74 of these were carried out by my method, and two usage of words like " neurosis." I am in agreement by Stacke’s (radical) method-the radical measure with him as to the important difference between the major and minor psychoses, and being adopted on account of the presence of cholestea- groups that I call for also as to the need using words that our patients, toma in the attic. I may mention that many aural surgeons have and their friends, will not misunderstand. I regret informed me that they perform no mastoid operations that the word benign " did not occur to me instead which was suggested by the French except by my method ; I hope, before long, that all of minor," mentaux. petits to deal with be the ear will towns competent large I In talking to patients I have, like him, to accept diseases that occur in them. their distinction between and nervous mental," I am. Sir, yours faithfully, and this distinction would be useful and harmless CHARLES J. HEATH. it were recognised that, like hysteria, some of these a
physicochemical
"
"
"
if
"
"
following alkaline treatment of ulcer in the THREE CONCEPTIONS OF TUBERCULOSIS. Guy’s Hospital Reports for 1925. For some reason To the Editor of THE LANCET. the condition has in my experience only occurred in SIR,—In his kindly criticism of my paper in your private patients, which may account for the fact that Prof. MacLean has not observed it in his hospital issue of Feb. 4th (p. 259), Dr. Blanford takes the view ’unit, but it is none the less important for the prac- that whenever symptoms and signs suggestive of titioner to recognise the first signs of alkalosis so pulmonary tuberculosis are present the disease is that the treatment may be discontinued without serious ; the outcome cannot be foretold, and
delay.
sanatorium treatment should be advised ; but with efficient medical examination this means sending 30 to 40 per cent. of the population to sanatoria at some time in their lives, most of whom would recover just as well at home. To-day the great majority of these cases recover undiagnosed, there may be suspicions in the practitioner’s mind, but he hesitates to name the complaint until an exact diagnosis can made, which sometimes means that the disease is no longer " minor." In this way special treatment may be dangerously delayed in low-resistant patients. If the real frequency of symptoms due to tuberculosis were generally realised this diagnosis would be much more common, based it is true on ground less sure than at present, though just as scientific as most other diagnoses in general practice. There would then, I think, be more observation, people in time would be less apprehensive, and special treatment
The correct dosage of alkalis is very complicated and biochemical problem, which is at present the subject of active investigation at Guy’s Hospital. The value of the mixture recommended by MacLean is entirely due to the sodium bicarbonate and magnesium carbonate it contains, as the work of Mr. E. Matthews, which will be shortly published in our Reports, shows that bismuth carbonate is almost be completely devoid of neutralising power. On the other hand, the 10 grains of sodium citrate, which MacLean, in common with most physicians, gives with each feed in order to prevent coagulation of the milk, has almost the same neutralising power as the 12 grains of sodium bicarbonate he gives every two hours. Prof. MacLean writes, in reference to infected teeth, that " unless we are misinformed with regard to the general attitude of the profession on the more readily adopted. An acute case is unsuitable for the sanatorium. It subject, there is at present little risk of the teeth, septic or otherwise, being overlooked." From my is the border-line case with some resistance, but not experience I should say that he certainly has been doing well at home, that will benefit there, and misinformed, as out of 126 consecutive cases of nothing is lost for such patients by three months’ duodenal ulcer at New Lodge Clinic 25 per cent. observation and treatment at home. There are, of had well-marked pyorrhoea alone, 9 per cent. had course, certain conditions which make immediate apical infection alone, 40 per cent. bad bouh, 8 per sanatorium treatment advisable :— 1. A positive sputum. cent. were edentulous, and only 18 per cent. had 2. A bad family history. healthy teeth. The corresponding figures for 30 3. Very bad surroundings. cases of gastric ulcer were 23, 20, 21, 13, and 23 per 4. Patient has not improved with home treatment. cent. respectively. I am, Sir, yours faithfully, The constant iteration that early cases must be ARTHUR F. HURST. sent at once to a sanatorium has led to a false position. Some minor cases are sent there unnecessarily (some to be returned with the diagnosis unconfirmed), and in other instances the supposed necessity for such a MASTOID OPERATIONS. step dangerously delays the diagnosis. In dealing To the Editor of THE LANCET. with tuberculosis, the point where medical experience and skill are of the highest value is not so much in SiR,-It is interesting to read in your current issue Sir Charles Ballance’s retrospect. Doubtless he making a diagnosis, but in deciding what should be looked back and was influenced by his teachers when done for the individual patient. If the mere existence he designed his own operation. His, like theirs, of tuberculosis necessitated sanatorium the matter On would be simple, and the recent innovation of appointseems to attract little attention in these days. the other hand, I looked forward and was not at all ing junior men to act as school medical officer, welfare influenced by the work of my predecessors when officer, assistant medical officer of health, and tubercnlosis officer would be justified ; but the matter is not designing my method of operation, because I had so simple, and a lifetime is not too long to learn how learnt a great deal by observing Nature’s attempts to cure mastoid disease, and based my technique on to treat the individual patient. The experience of the sanatorium officer is likely ’, these. Dr. Percy Jakins, of the Central London Ear and to be wider, and his advice more sound, in dealing Throat Hospital, was the first surgeon to visit the with major tuberculosis, but the tuberculosis officer Throat Hospital to see me perform one of these has the advantage in advising about tuberculosis as practice. operations. He made this remark in the operating ’ met with in everyday I am. Sir. vours faithfullv. theatre : " Your operation will take the place of all E. WARD. Schwartze operations and most of Stacke’s radical ones." Evidence of the soundness of his opinion was forthcoming last week, for on the 23rd inst. I perINCIDENCE OF THE MINOR PSYCHOSES. formed one of these operations, exhibited a cured To the Editor of THE LANCET. ’ , patient, and subsequently lectured on Diagnosis in SIR,—The views of Dr. T. A. Ross and myself Mastoid Disease at the Burton-on-Trent Hospital by invitation of the local Medico-Chirurgical Society. are so much in accord that I can treat his letter in There I was informed that 76 mastoid operations had your issue of Feb. 25th only as an opportunity of been performed in the hospital in the past year, that defining my position when I challenge the current 74 of these were carried out by my method, and two usage of words like " neurosis." I am in agreement by Stacke’s (radical) method-the radical measure with him as to the important difference between the major and minor psychoses, and being adopted on account of the presence of cholestea- groups that I call for also as to the need using words that our patients, toma in the attic. I may mention that many aural surgeons have and their friends, will not misunderstand. I regret informed me that they perform no mastoid operations that the word benign " did not occur to me instead which was suggested by the French except by my method ; I hope, before long, that all of minor," mentaux. petits to deal with be the ear will towns competent large I In talking to patients I have, like him, to accept diseases that occur in them. their distinction between and nervous mental," I am. Sir, yours faithfully, and this distinction would be useful and harmless CHARLES J. HEATH. it were recognised that, like hysteria, some of these a
physicochemical
"
"
"
if
"
"