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An Address ON NOTIFICATION OF PULMONARY PHTHISIS.
JULY 21, 1906. machinery." This circular goes straight to the point by declaring that pulmonary phthisis is an infectious disease within the meaning of the Public Health (Scotland) Act, 1897," and after a great deal of excellent advice it goes on to ON say that for the effective application of the Public Health NOTIFICATION OF PULMONARY PHTHISIS. Act to pulmonary phthisis a system of notification is essential but that unless it is to be followed by effective measures Delivered at the Forty-eighth Annual Meeting of the Forfar- for the curative treatment of the patients and for preventior shire Medical Association in University College, Dundee, of the spread of infection the Board will not feel justified ir on June 28th, 1906, approving of the compulsory notification of cases of the disease." In the last sentence there is the true ring of the BY ROBERT SINCLAIR, M.D. GLASG., practical administrator and I am sure that the Board has only LL.D. ST. AND., one object in view-the public welfare-and has no desire to CONSULTING PHYSICIAN TO THE DUNDEE ROYAL IN FIRMARY; PRESIDENT OF THE ASSOCIATION. encourage local authorities in the exercise of arbitrary power. Still, one may be allowed to express regret that phthisis has not been dealt with apart from the Notification Act of 1889 Pasteur of the GENTLEMEN,—When finally disposed. and the Public Health Act of 1897, for it requires only a oxygen theory of fermentation and placed the vitalistic moment’s reflection to convince anyone that fevers of short theory of that process on the basis of demonstrated fact duration and high intensity of infection, for which these he went a long way in the direction of verifying the Acts were manifestly intended, are by no means on all fours remarkable prophecy of Boyle two hundred years earlier. with phthisis, in which the conditions are exactly reversed. a menace to the public health but a "The man," said Boyle, "who shall probe to the bottom Every case of fever is cases of phthisis are not. Someone has said great many the nature of ferments and of fermentations will doubtless very truly that " the consumptive is not a danger in himself, be much more capable than any other of giving a true ex- but only becomes so from bad habits." Yet local authorities
An Address
of the divers morbid phenomena both of fevers as are now endowed with the same powers in both cases, inwell as of other affections." Pasteur’s masterly researches in cluding the right of entry into suspected houses. Notificathe morphology and physiology of micro-organisms laid the tion is therefore in the air and this must be my apology for foundation of that science of bacteriology which enabled bringing the subject before you to-day and for telling you Lister a few years later to rescue the treatment of wounds many things which you already know. Stripped of verbiage from a disastrous empiricism and to replace it by a method the problem can be stated in four words-sputum and its at once scientific and beneficent, and enabled Koch, after a disposal. Patients are dangerous to themselves and others generation, to make his brilliant discovery of the tubercle only when they neglect timely disinfection or destruction of bacillus and to end the long-standing controversies as to the this secretion in the early stages and when their friends nature of pulmonary phthisis and those other tuberculous neglect it for them in the later stages. There are thousands diseases which we now know to have a common origin. It is of consumptives in private life and in hospitals and sanathe merest truism to say that Pasteur, the French chemist, toriums who are absolutely innocent of infective power for Lister, the British surgeon, and Koch, the German patho- the simple reason that they practise regularly a few plain logist, will rank for all time among the foremost men of rules of personal and domestic cleanliness which may be learned in a few minutes. What is wanted is to induce the science and the most honoured benefactors of mankind. Since Koch’s discovery the medical profession and the uninitiated to enter the ranks of the initiated and until they public have not been idle in their efforts to check the do so to devise some means whereby the local authorities a,n spread of tuberculous disease and to help the recovery of guide and direct them for their own advantage and that of its victims. These efforts are too well known to need their neighbours with the least possible sacrifice of personal repetition now. But before entering on questions which liberty. But before the medical officer of health can look will afford opportunities for difference of opinion and dis- after them he must know where they are. How is this to t e cussion, it may be well to clear the air by a brief summary accomplished ?1 Obviously by some means of notification; of the points on which we may be fairly presumed to agree. and ought this to be voluntary or compulsory ? Here I should like to interpose a word in deprecation of Tuberculosis is the most fatal of all the diseases of man and the domestic animals ; it is most prevalent during adolescent the zeal of two classes of reformers, many of them no doubt and adult life ; it is therefore very costly in loss of life and the very salt of the earth, whose intervention has not been working power in the most productive years and those most always helpful. One class regards every consumptive as a important for the welfare of families and communities. It danger to his fellows. In addition to his terrible load of finds its favourite abode amid poverty, overcrowding, want suffering and the prospect of an early death he is to be of cleanliness, air, and light. It is communicable, and the treated as an outcast. A glass spittoon " may be conchief mode of infection is the inhalation of dust containing veniently attached to the person," in imitation, I suppose, of the dried secretions of pulmonary and laryngeal tuberculosis. the clapper of the mediaeval leper. He is to have a card It is not conveyed from the breath or perspiration. There is bearing his name, address, and the date of notification, and if the system is not to be a farce he will require to have his no satisfactory proof of the multiplication of the germs outside the body. No direct germicide has yet been found movements recorded on it as if he were a convict on a which we can use without the certainty of doing infinitely ticket-of-leave. He is to live apart from ordinary domestic more harm to the lung tissue than to the bacillus. The last and social life and every obstacle is to be placed in the way ,fifty years, which witnessed enormous improvements in of his getting honest employment. Hear a London physician general sanitation, have been accompanied by a steady reo on the subject: "Every man, woman, and child who is duction in the mortality from pulmonary phthisis, even tubercular should at once be removed from all possibility of apart from special efforts directed to its prevention. All of contact, direct and indirect, with the healthy community." us are at one in desiring to check its ravages still further. Now hear an Edinburgh physician : " Many of these affected Now I think we may safely venture on the sea of contro. cases are at work fatally infecting their fellow workmen as versy. Many meetings and congresses have been held, some our medical case-books frequently prove." What marvellous of them of prodigious length, and have expressed themselves case-books ! Another enthusiast contributes draft regulafor and against notification. Some medical officers of health tions, one of which reads: " Prohibition of patients with are in favour of voluntary and some of compulsory notifica. actual phthisis [by implication he excludes imaginary tion. In 1902 a Committee of the House of Commons ex phthisis] from frequenting churches, theatres, railway pressed approval of compulsory notification but not of loca: carriages, tramcars, or any public places." Strange to say, enactments. A year ago the Scottish Local Governmeni the clergy appear to have endured in silence this new excuse Board issued a schedule of inquiry on the "administrate for non-church-going. The typical representative of the other control of pulmonary phthisis"with the object of ascertain class is intense. He lives the strenuous life ; he is convinced is delayed solely because the stalwarts, whose ing the practice of local authorities. Briefly put, the resull that victory of the inquiry was that "in no locality have the loca motto is " Thorough," are not allowed to have it all their authority adequately developed the special organisatior own way, and he talks knowingly of stamping out tubercunecessary for the full administrative control of the disease.’ losis as if he were dealing with a sporadic outbreak of typhus In March of this year the Board issued another circular witl or a handful of burning tow. the view, as it was said, of assisting local authorities ÌI L How do things actually stand in this matter of-fact world2 Sootla-Rd I I in developing and completing their administrativi i The conditions in which tuberculosis is most prevalent are
planation
s
No. 4325.
c
140
DR. ROBERT SINCLAIR: NOTIFICATION OF PULMONARY PHTHISIS.
improving steadily but the ending of them under any human possible increase of rates, will be amply satisfied for some system is not yet in sight. The practice is not sufficiently time to come. Finally, it may be well to remember that general of offering disinfection of rooms and houses after Sheffield is the only town which has so far got compulsory notice of death has been received, or ought to have been notification, and that for a period of five years, and that received, from the registrars. The hose and the broom are Dr. J. Robertson, the late medical officer of health there, now too little used on our pavements, closes, back courts, and of Birmingham, has put the following opinion on record: yards. The time-honoured custom of sweeping the street "Ishould strongly deprecate powers being given to any dust over the wayfarers and into the houses of those who sanitary authority who had not first acquired the machinery live up to the standard of open windows still clings to and experience derived from a system of voluntary notinearly every part of the kingdom and the watering cart is fication. You are aware that in the circular of March 10th last seldom seen in the land save as the herald of coming rain. The protection of meat from contamination on its way from already alluded to it is left to each local authority to the abattoir to the shop and from the shop to the consumer, organise the plan considered most appropriate to local conand the supervision of the collection and distribution of ditions, and I must say at once that the scheme recently milk, still leave much to be desired and are questions well submitted to the public health committee of the Dundee worthy of the attention of those placed in authority over us. town council by Dr. Charles Templeman, our excellent Municipal milk depots, of which we have one excellent medical officer of health, appears to me to be sound, example in Dundee, do admirable work in providing a practical, well adapted to our local requirements, and likely number of children with good milk and thus promote a to go a long way towards mitigating the evils which we havethoroughly good social object-the physical well-being in been considering. His recommendations are threefold : early life of a portion of the next generation. But as they (1) voluntary notification ; (2) a central dispensary; and are not likely to meet more than a fraction of the demand (3) provision for the isolation of advanced cases. With the question may be fairlyraised whether the energy so voluntary notification we have already dealt at sufficient expended could not be better employed in a more effective length. A municipal dispensary with the medical officer of control of the whole milk-supply of the district. And of health at its head and coordinated with the admirable outcourse these depots are open to the criticism which sound patient departments of the Dundee Royal Infirmary and the economists apply to all forms of municipal trading-namely, parish council would be a great step forward. It would be tendencies to extravagance, reactionary methods, want of the centre from which patients could be guided as to their habits and mode of life, the depot for the supply of enterprise, and bureaucracy. Koch himself, in his Nobel lecture, published in THE medicines, sputum flasks, disinfectants, and Japanese paper LANCET of May 26th last, does not go nearly so far as some handkerchiefs to the necessitous poor. It would be also of his followers. He calls, it is true, for compulsory notifi- the headquarters for the supervision of patients and for cation and other measures against open tuberculosis, but not investigation of the conditions in which phthisis arises and at all against the closed form, which he regards as " quite recurs in houses and localities. For the idea of the harmless." Experience has led to the modification of some municipal dispensary the world is indebted to Dr. R. W. optimistic views as to the proportion of recoveries even under Philip of Edinburgh. He organised the first dispensary of the the most favourable conditions. We have long known that kind in Edinburgh, a voluntary one, 20 years ago and he haswhen all the climatic and hygienic advantages which wealth worked it since then with conspicuous success. We are and leisure can procure are present recovery is slow and not glad to have him with us to-day as our guest and we hope always sure, and in the case of those less favourably he may be long spared to continue the efforts which have situated it is still slower and still less sure. The latter form already borne so much fruit. Mr Buist’s last official act, the class which will always constitute the overwhelming before retiring from the chairmanship of our infirmary board, majority of those for whom public health administration is was to express approval of Dr. Templeman’s scheme and the desire of those connected with the infirmary to cooperate in’ required. Dr. R. S. Aitchison and Dr. Edward Carmichael have carrying it out. In this beneficent cooperation his successor, lately presented to the Edinburgh parish council a Mr. Guthrie, and his fellow directors will not be found wanting. report showing that over 90 per cent. of the cases of The isolation of patients who are in an advanced stage ofthis class under their care at Craiglockhart and Craig- the disease and whose homes are unsuitable would be a very leith poorhouses are incurable, and their experience obvious advantage to all concerned, patients, relatives, is to a certain extent corroborated by Dr. R. C. Macfie, neighbours, and the community in which they live. To say who gives the results of treatment during his residence nothing of the humanitarian aspect of the question, which at the Sidlaw Sanatorium in THE LANCET of June 16th is sufficiently clear to everyone, segregation will notably last (p. 1685) showing that even a small rise in the reduce the amount of infective material in any locality, and social conditions above the level of the poorest gives will therefore commend itself to the prudent, just as fire better hopes of recovery. We see constantly around us insurance companies desire the removal of as much comevidence that the law of inheritance by which the offspring bustible material as possible from the premises and the of tuberculous parents are more liable to phthisis than the neighbourhoods in which they are financially concerned. offspring of the non-tuberculous shows no signs of being Should the town council of Dundee decide on the adoption of abolished yet awhile, that as Dr. W. H. Dickinson happily Dr. Templeman’s scheme I am sure we wish them all success puts it, "There is the soil as well as the seed," and that the and we can promise them that cordial cooperation which the parable of the sower is as true to-day as it was when it was medical profession has always most willingly extended to sanitary reform. spoken. The whole case for notification lies in the preventive On this the measures which ought to follow in its wake. SCARLET FEVER.-Scarlet fever is still prevaadvocates of compulsory and the advocates of voluntary notification are agreed. Here they part. Those who favour lent in many parts of the district round Manchester. the long reach of the secular arm hold that compulsion and At Hyde, some days since, there were 85 cases in, efficiency will surely go together. They believe anything the infectious hospital, the largest number on record. less than compulsory notification to be a makeshift and a At Sandbach in Cheshire its spread is attributed to sham, and they think no time ought to be lost in securing a " gossiping mothers," a cause, it is to be feared, system national, uniform, complete, and foreordained to very difficult to remove. The medical officer of health The disciples of voluntaryism, on the other hand, of Gorton, Mr. A. W. Martin, has expressed the opinion success. remind us that compulsion has often brought its friends into that hospital isolation accomplishes very little and is strange and unexpected dilemmas which have led too late to not worth the tremendous expense involved. In his the sorrowful conclusion that it is the first step that counts. annual report he says that the hospital charges for the If, as in They think it best to proceed cautiously, and they prefer to past year for scarlet fever amounted to <668. seek the cooperation of the patients and their friends in neighbouring townships, 80 per cent. of the patients had what is often a long-drawn-out business rather than to been removed to the hospital the bill would have been irritate them by coercive measures. They would give volun- 1360. The council has acted on these views for 12 years, tary notification a fair chance. They point out that it with the saving of more than .815,000 to the ratepayers, and, presents no administrative difficulties and that it has worked in Mr. Martin’s opinion, "at the same time keeping a lower well in several large English municipalities, and they are death-rate and a lower infection-rate from the disease as perhaps not far wrong in the belief that it will give local compared with similar districts removing a large percentage authorities quite enough to do for the present, while the of their cases." This certainly speaks well for what may be public craving for sanitary improvements, coupled with a called the medical discipline of Gorton. "
MR. H. MORRIS: X RAY SHADOWS OF OYSTIC & XANTHIC OXIDE CALCULI.
141
that of a pin’s head to that of a pea, which had been voided at ON THE X RAY SHADOWS OF CYSTIC different times by a man, 40 years of age ; and eight of the AND XANTHIC OXIDE CALCULI. specimens had been obtained from human urinary bladders, six of’ these having been removed by operation during BY HENRY MORRIS, M.A., M.B. LOND., life. There is also in the Museum of the Royal College of PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; Surgeons an admirable skiagram of one of these specimens CONSULTING SURGEON TO THE MIDDLESEX HOSPITAL. taken before its removal by operation from the bladder of a. boy, aged seven years. This specimen is marked "D 8 " in THERE seems to be a pretty general, though erroneous, the catalogue and consists of one-half of a large calculus together with .the skiagram, was presented to the impression that cystin and xanthin calculi give no shadow which, Museum by Mr. John Murray. The skiagram of the other x the test and that the are therefore no Roentgen rays by half of this calculus, which is in the Museum of the Middlesex aid in diagnosis where a calculus of either of these substances Hospital, is shown in Fig. 5 accompanying this paper. To is present in the urinary tract. settle the question as to whether the depth of this shadow was Recently I was asked by a well-known physician to see in in any way due to the presence of phosphates Mr. S. G. Shattock consultation a young woman who was passing large quanti- was good enough to have an analysis of the calculus made by ties of cystin in her urine and whose symptoms pointed to Dr. H. R. Le Sueur, who reported that it consisted almost the presence of renal calculus in one or other or both organs. entirely of cystin with the admixture of only 04 per cent. of Cystin had been passed in the urine of this patient inorganic residue, a very minute portion of which is iron. for a long time and I was given to understand that one of Fig. 6 shows the shadow of a cystic oxide stone removed by her sisters had for five years at least been passing quantities Mr. N. C. McNamara by median lithotomy from a boy, aged of the same material and that the father of these young two years and eight months. It was analysed at the time by women had for a long period excreted cystin in his urine Dr. Dupr6 who could detect nothing in its composition but and was believed to have a renal calculus. I asked if cystin. a skiagram had been taken of the patient I had been Fig. 4 shows the shadow of a calculus removed from the called on to see, and the reply was that cystin calculi kidney of a patient by Mr. W. H. A. Jacobson. No analysis
1. Oxalate of lime.
2.
Cystin with phosphate
of lime.
3.
Cystin with phosphate of lime.
4.
Cystin, D 9.
did not give a shadow and that this statement was of its composition is, so far as I know, recorded, but it has made on the authority of an able pathologist at a well- all the characters of a stone composed exclusively of cystin. known medical school. Recalling the fact related in an It must be well-nigh a unique specimen of a cystin renal early paper on the shadows given by calculi, which I con- calculus removed by operation. The specimen marked tributed some years ago to THE LANCET/ that a gall-stone " D 6" in the catalogue of the College Museum is a large gives a very faint shadow, probably due to the earthy phos- cystin calculus weighing 1050 grains, removed by Mr. phates and other lime salts, aided possibly by the traces of Reginald Harrison from a young man, aged 21 years. It copper, iron, and manganese mixed with the cholestearine was analysed by Professor Campbell Brown and reported by and found in nearly all gall-stones, I doubted the correctness him to consist of cystin with a small quantity of ammonioof the authority. magnesium phosphate and a trace of calcium phosphate. Fusible calculous matter covers some cystin and xanthin Many cystin calculi contain phosphates of lime as well as traces of phosphates of magnesium and ammonium, but stones and oxalate of lime is sometimes mixed up in their what is much more to the point, sulphur is present in all of substance. (See Figs. 2 and 3.) In the specimen marked them to the extent of 25’ 53 or 25’ 81 per cent. It was "D. G. 1"from a youth, aged 19 years, there is seen a therefore a priori improbable that cystic oxide calculi could layer of calcium oxalate around the entire circumference fail to give a very deep shadow and I at once took steps to of the stone at a distance of from one-sixth to one-third of ascertain what really was the result. an inch from its outer surface. In the Museum of the Royal College of Surgeons of From the young woman whose case has given rise to these England I found 11 examples of cystic oxide calculi; one ofremarks, Mr. C. R. C. Lyster, the able electro-therapeutist of them had been removed from the urethra ; one from thethe Middlesex Hospital, obtained very marked shadows of a kidney ; one was a series of small calculi, varying in size fromcalculus in each kidney, but I am not aware of the verification of the composition of these calculi, nor even as to 1 THE LANCET, Nov. 14th, 1896. whether or not they have yet been removed from the patient.
An Address
of the divers morbid phenomena both of fevers as are now endowed with the same powers in both cases, inwell as of other affections." Pasteur’s masterly researches in cluding the right of entry into suspected houses. Notificathe morphology and physiology of micro-organisms laid the tion is therefore in the air and this must be my apology for foundation of that science of bacteriology which enabled bringing the subject before you to-day and for telling you Lister a few years later to rescue the treatment of wounds many things which you already know. Stripped of verbiage from a disastrous empiricism and to replace it by a method the problem can be stated in four words-sputum and its at once scientific and beneficent, and enabled Koch, after a disposal. Patients are dangerous to themselves and others generation, to make his brilliant discovery of the tubercle only when they neglect timely disinfection or destruction of bacillus and to end the long-standing controversies as to the this secretion in the early stages and when their friends nature of pulmonary phthisis and those other tuberculous neglect it for them in the later stages. There are thousands diseases which we now know to have a common origin. It is of consumptives in private life and in hospitals and sanathe merest truism to say that Pasteur, the French chemist, toriums who are absolutely innocent of infective power for Lister, the British surgeon, and Koch, the German patho- the simple reason that they practise regularly a few plain logist, will rank for all time among the foremost men of rules of personal and domestic cleanliness which may be learned in a few minutes. What is wanted is to induce the science and the most honoured benefactors of mankind. Since Koch’s discovery the medical profession and the uninitiated to enter the ranks of the initiated and until they public have not been idle in their efforts to check the do so to devise some means whereby the local authorities a,n spread of tuberculous disease and to help the recovery of guide and direct them for their own advantage and that of its victims. These efforts are too well known to need their neighbours with the least possible sacrifice of personal repetition now. But before entering on questions which liberty. But before the medical officer of health can look will afford opportunities for difference of opinion and dis- after them he must know where they are. How is this to t e cussion, it may be well to clear the air by a brief summary accomplished ?1 Obviously by some means of notification; of the points on which we may be fairly presumed to agree. and ought this to be voluntary or compulsory ? Here I should like to interpose a word in deprecation of Tuberculosis is the most fatal of all the diseases of man and the domestic animals ; it is most prevalent during adolescent the zeal of two classes of reformers, many of them no doubt and adult life ; it is therefore very costly in loss of life and the very salt of the earth, whose intervention has not been working power in the most productive years and those most always helpful. One class regards every consumptive as a important for the welfare of families and communities. It danger to his fellows. In addition to his terrible load of finds its favourite abode amid poverty, overcrowding, want suffering and the prospect of an early death he is to be of cleanliness, air, and light. It is communicable, and the treated as an outcast. A glass spittoon " may be conchief mode of infection is the inhalation of dust containing veniently attached to the person," in imitation, I suppose, of the dried secretions of pulmonary and laryngeal tuberculosis. the clapper of the mediaeval leper. He is to have a card It is not conveyed from the breath or perspiration. There is bearing his name, address, and the date of notification, and if the system is not to be a farce he will require to have his no satisfactory proof of the multiplication of the germs outside the body. No direct germicide has yet been found movements recorded on it as if he were a convict on a which we can use without the certainty of doing infinitely ticket-of-leave. He is to live apart from ordinary domestic more harm to the lung tissue than to the bacillus. The last and social life and every obstacle is to be placed in the way ,fifty years, which witnessed enormous improvements in of his getting honest employment. Hear a London physician general sanitation, have been accompanied by a steady reo on the subject: "Every man, woman, and child who is duction in the mortality from pulmonary phthisis, even tubercular should at once be removed from all possibility of apart from special efforts directed to its prevention. All of contact, direct and indirect, with the healthy community." us are at one in desiring to check its ravages still further. Now hear an Edinburgh physician : " Many of these affected Now I think we may safely venture on the sea of contro. cases are at work fatally infecting their fellow workmen as versy. Many meetings and congresses have been held, some our medical case-books frequently prove." What marvellous of them of prodigious length, and have expressed themselves case-books ! Another enthusiast contributes draft regulafor and against notification. Some medical officers of health tions, one of which reads: " Prohibition of patients with are in favour of voluntary and some of compulsory notifica. actual phthisis [by implication he excludes imaginary tion. In 1902 a Committee of the House of Commons ex phthisis] from frequenting churches, theatres, railway pressed approval of compulsory notification but not of loca: carriages, tramcars, or any public places." Strange to say, enactments. A year ago the Scottish Local Governmeni the clergy appear to have endured in silence this new excuse Board issued a schedule of inquiry on the "administrate for non-church-going. The typical representative of the other control of pulmonary phthisis"with the object of ascertain class is intense. He lives the strenuous life ; he is convinced is delayed solely because the stalwarts, whose ing the practice of local authorities. Briefly put, the resull that victory of the inquiry was that "in no locality have the loca motto is " Thorough," are not allowed to have it all their authority adequately developed the special organisatior own way, and he talks knowingly of stamping out tubercunecessary for the full administrative control of the disease.’ losis as if he were dealing with a sporadic outbreak of typhus In March of this year the Board issued another circular witl or a handful of burning tow. the view, as it was said, of assisting local authorities ÌI L How do things actually stand in this matter of-fact world2 Sootla-Rd I I in developing and completing their administrativi i The conditions in which tuberculosis is most prevalent are
planation
s
No. 4325.
c
140
DR. ROBERT SINCLAIR: NOTIFICATION OF PULMONARY PHTHISIS.
improving steadily but the ending of them under any human possible increase of rates, will be amply satisfied for some system is not yet in sight. The practice is not sufficiently time to come. Finally, it may be well to remember that general of offering disinfection of rooms and houses after Sheffield is the only town which has so far got compulsory notice of death has been received, or ought to have been notification, and that for a period of five years, and that received, from the registrars. The hose and the broom are Dr. J. Robertson, the late medical officer of health there, now too little used on our pavements, closes, back courts, and of Birmingham, has put the following opinion on record: yards. The time-honoured custom of sweeping the street "Ishould strongly deprecate powers being given to any dust over the wayfarers and into the houses of those who sanitary authority who had not first acquired the machinery live up to the standard of open windows still clings to and experience derived from a system of voluntary notinearly every part of the kingdom and the watering cart is fication. You are aware that in the circular of March 10th last seldom seen in the land save as the herald of coming rain. The protection of meat from contamination on its way from already alluded to it is left to each local authority to the abattoir to the shop and from the shop to the consumer, organise the plan considered most appropriate to local conand the supervision of the collection and distribution of ditions, and I must say at once that the scheme recently milk, still leave much to be desired and are questions well submitted to the public health committee of the Dundee worthy of the attention of those placed in authority over us. town council by Dr. Charles Templeman, our excellent Municipal milk depots, of which we have one excellent medical officer of health, appears to me to be sound, example in Dundee, do admirable work in providing a practical, well adapted to our local requirements, and likely number of children with good milk and thus promote a to go a long way towards mitigating the evils which we havethoroughly good social object-the physical well-being in been considering. His recommendations are threefold : early life of a portion of the next generation. But as they (1) voluntary notification ; (2) a central dispensary; and are not likely to meet more than a fraction of the demand (3) provision for the isolation of advanced cases. With the question may be fairlyraised whether the energy so voluntary notification we have already dealt at sufficient expended could not be better employed in a more effective length. A municipal dispensary with the medical officer of control of the whole milk-supply of the district. And of health at its head and coordinated with the admirable outcourse these depots are open to the criticism which sound patient departments of the Dundee Royal Infirmary and the economists apply to all forms of municipal trading-namely, parish council would be a great step forward. It would be tendencies to extravagance, reactionary methods, want of the centre from which patients could be guided as to their habits and mode of life, the depot for the supply of enterprise, and bureaucracy. Koch himself, in his Nobel lecture, published in THE medicines, sputum flasks, disinfectants, and Japanese paper LANCET of May 26th last, does not go nearly so far as some handkerchiefs to the necessitous poor. It would be also of his followers. He calls, it is true, for compulsory notifi- the headquarters for the supervision of patients and for cation and other measures against open tuberculosis, but not investigation of the conditions in which phthisis arises and at all against the closed form, which he regards as " quite recurs in houses and localities. For the idea of the harmless." Experience has led to the modification of some municipal dispensary the world is indebted to Dr. R. W. optimistic views as to the proportion of recoveries even under Philip of Edinburgh. He organised the first dispensary of the the most favourable conditions. We have long known that kind in Edinburgh, a voluntary one, 20 years ago and he haswhen all the climatic and hygienic advantages which wealth worked it since then with conspicuous success. We are and leisure can procure are present recovery is slow and not glad to have him with us to-day as our guest and we hope always sure, and in the case of those less favourably he may be long spared to continue the efforts which have situated it is still slower and still less sure. The latter form already borne so much fruit. Mr Buist’s last official act, the class which will always constitute the overwhelming before retiring from the chairmanship of our infirmary board, majority of those for whom public health administration is was to express approval of Dr. Templeman’s scheme and the desire of those connected with the infirmary to cooperate in’ required. Dr. R. S. Aitchison and Dr. Edward Carmichael have carrying it out. In this beneficent cooperation his successor, lately presented to the Edinburgh parish council a Mr. Guthrie, and his fellow directors will not be found wanting. report showing that over 90 per cent. of the cases of The isolation of patients who are in an advanced stage ofthis class under their care at Craiglockhart and Craig- the disease and whose homes are unsuitable would be a very leith poorhouses are incurable, and their experience obvious advantage to all concerned, patients, relatives, is to a certain extent corroborated by Dr. R. C. Macfie, neighbours, and the community in which they live. To say who gives the results of treatment during his residence nothing of the humanitarian aspect of the question, which at the Sidlaw Sanatorium in THE LANCET of June 16th is sufficiently clear to everyone, segregation will notably last (p. 1685) showing that even a small rise in the reduce the amount of infective material in any locality, and social conditions above the level of the poorest gives will therefore commend itself to the prudent, just as fire better hopes of recovery. We see constantly around us insurance companies desire the removal of as much comevidence that the law of inheritance by which the offspring bustible material as possible from the premises and the of tuberculous parents are more liable to phthisis than the neighbourhoods in which they are financially concerned. offspring of the non-tuberculous shows no signs of being Should the town council of Dundee decide on the adoption of abolished yet awhile, that as Dr. W. H. Dickinson happily Dr. Templeman’s scheme I am sure we wish them all success puts it, "There is the soil as well as the seed," and that the and we can promise them that cordial cooperation which the parable of the sower is as true to-day as it was when it was medical profession has always most willingly extended to sanitary reform. spoken. The whole case for notification lies in the preventive On this the measures which ought to follow in its wake. SCARLET FEVER.-Scarlet fever is still prevaadvocates of compulsory and the advocates of voluntary notification are agreed. Here they part. Those who favour lent in many parts of the district round Manchester. the long reach of the secular arm hold that compulsion and At Hyde, some days since, there were 85 cases in, efficiency will surely go together. They believe anything the infectious hospital, the largest number on record. less than compulsory notification to be a makeshift and a At Sandbach in Cheshire its spread is attributed to sham, and they think no time ought to be lost in securing a " gossiping mothers," a cause, it is to be feared, system national, uniform, complete, and foreordained to very difficult to remove. The medical officer of health The disciples of voluntaryism, on the other hand, of Gorton, Mr. A. W. Martin, has expressed the opinion success. remind us that compulsion has often brought its friends into that hospital isolation accomplishes very little and is strange and unexpected dilemmas which have led too late to not worth the tremendous expense involved. In his the sorrowful conclusion that it is the first step that counts. annual report he says that the hospital charges for the If, as in They think it best to proceed cautiously, and they prefer to past year for scarlet fever amounted to <668. seek the cooperation of the patients and their friends in neighbouring townships, 80 per cent. of the patients had what is often a long-drawn-out business rather than to been removed to the hospital the bill would have been irritate them by coercive measures. They would give volun- 1360. The council has acted on these views for 12 years, tary notification a fair chance. They point out that it with the saving of more than .815,000 to the ratepayers, and, presents no administrative difficulties and that it has worked in Mr. Martin’s opinion, "at the same time keeping a lower well in several large English municipalities, and they are death-rate and a lower infection-rate from the disease as perhaps not far wrong in the belief that it will give local compared with similar districts removing a large percentage authorities quite enough to do for the present, while the of their cases." This certainly speaks well for what may be public craving for sanitary improvements, coupled with a called the medical discipline of Gorton. "
MR. H. MORRIS: X RAY SHADOWS OF OYSTIC & XANTHIC OXIDE CALCULI.
141
that of a pin’s head to that of a pea, which had been voided at ON THE X RAY SHADOWS OF CYSTIC different times by a man, 40 years of age ; and eight of the AND XANTHIC OXIDE CALCULI. specimens had been obtained from human urinary bladders, six of’ these having been removed by operation during BY HENRY MORRIS, M.A., M.B. LOND., life. There is also in the Museum of the Royal College of PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND; Surgeons an admirable skiagram of one of these specimens CONSULTING SURGEON TO THE MIDDLESEX HOSPITAL. taken before its removal by operation from the bladder of a. boy, aged seven years. This specimen is marked "D 8 " in THERE seems to be a pretty general, though erroneous, the catalogue and consists of one-half of a large calculus together with .the skiagram, was presented to the impression that cystin and xanthin calculi give no shadow which, Museum by Mr. John Murray. The skiagram of the other x the test and that the are therefore no Roentgen rays by half of this calculus, which is in the Museum of the Middlesex aid in diagnosis where a calculus of either of these substances Hospital, is shown in Fig. 5 accompanying this paper. To is present in the urinary tract. settle the question as to whether the depth of this shadow was Recently I was asked by a well-known physician to see in in any way due to the presence of phosphates Mr. S. G. Shattock consultation a young woman who was passing large quanti- was good enough to have an analysis of the calculus made by ties of cystin in her urine and whose symptoms pointed to Dr. H. R. Le Sueur, who reported that it consisted almost the presence of renal calculus in one or other or both organs. entirely of cystin with the admixture of only 04 per cent. of Cystin had been passed in the urine of this patient inorganic residue, a very minute portion of which is iron. for a long time and I was given to understand that one of Fig. 6 shows the shadow of a cystic oxide stone removed by her sisters had for five years at least been passing quantities Mr. N. C. McNamara by median lithotomy from a boy, aged of the same material and that the father of these young two years and eight months. It was analysed at the time by women had for a long period excreted cystin in his urine Dr. Dupr6 who could detect nothing in its composition but and was believed to have a renal calculus. I asked if cystin. a skiagram had been taken of the patient I had been Fig. 4 shows the shadow of a calculus removed from the called on to see, and the reply was that cystin calculi kidney of a patient by Mr. W. H. A. Jacobson. No analysis
1. Oxalate of lime.
2.
Cystin with phosphate
of lime.
3.
Cystin with phosphate of lime.
4.
Cystin, D 9.
did not give a shadow and that this statement was of its composition is, so far as I know, recorded, but it has made on the authority of an able pathologist at a well- all the characters of a stone composed exclusively of cystin. known medical school. Recalling the fact related in an It must be well-nigh a unique specimen of a cystin renal early paper on the shadows given by calculi, which I con- calculus removed by operation. The specimen marked tributed some years ago to THE LANCET/ that a gall-stone " D 6" in the catalogue of the College Museum is a large gives a very faint shadow, probably due to the earthy phos- cystin calculus weighing 1050 grains, removed by Mr. phates and other lime salts, aided possibly by the traces of Reginald Harrison from a young man, aged 21 years. It copper, iron, and manganese mixed with the cholestearine was analysed by Professor Campbell Brown and reported by and found in nearly all gall-stones, I doubted the correctness him to consist of cystin with a small quantity of ammonioof the authority. magnesium phosphate and a trace of calcium phosphate. Fusible calculous matter covers some cystin and xanthin Many cystin calculi contain phosphates of lime as well as traces of phosphates of magnesium and ammonium, but stones and oxalate of lime is sometimes mixed up in their what is much more to the point, sulphur is present in all of substance. (See Figs. 2 and 3.) In the specimen marked them to the extent of 25’ 53 or 25’ 81 per cent. It was "D. G. 1"from a youth, aged 19 years, there is seen a therefore a priori improbable that cystic oxide calculi could layer of calcium oxalate around the entire circumference fail to give a very deep shadow and I at once took steps to of the stone at a distance of from one-sixth to one-third of ascertain what really was the result. an inch from its outer surface. In the Museum of the Royal College of Surgeons of From the young woman whose case has given rise to these England I found 11 examples of cystic oxide calculi; one ofremarks, Mr. C. R. C. Lyster, the able electro-therapeutist of them had been removed from the urethra ; one from thethe Middlesex Hospital, obtained very marked shadows of a kidney ; one was a series of small calculi, varying in size fromcalculus in each kidney, but I am not aware of the verification of the composition of these calculi, nor even as to 1 THE LANCET, Nov. 14th, 1896. whether or not they have yet been removed from the patient.