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MANCHESTER MEDICAL SOCIETY.
1118
MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH. 1’reatment of ’l’1tberc1110sis. AT a meeting of this society held on May 5th, a discussion took place on the Treatment of Tuberculosis. The discussion was opened by Sir ROBERT PHILIP, who read a paper on the Modern Outlook on the Treatment of Tuberculosis, and by Sir HENRY GAUVAIN, who dealt with the Management of Non-Pulmonary
Tuberculosis. Sir Robert Philip contrasted the Hippocratic conception of phthisis with the modern outlook on tuberculosis, and showed how the disease, formerly regarded as always fatal, was one which satisfactorily yielded to treatment, particularly in the early stages. The widespread occurrence of tuberculosis and its natural tendency to cure had been demonstrated by many observers. Amongst the most striking figures were those of Reinhardt of Berne, who, in an extensive series of post-mortem examinations, made on individuals who had died from all varieties of disease, found evidences of tuberculosis in 96 per cent. of cases-32 per cent. showing active and 64 per cent. It was well recognised that nature healed tubercle. cured cases of the disease every day. The essentials of the development of tuberculosis were infection by the tubercle bacillus, the reaction of the tissues to invasion, and later the occurrence of systemic intoxication. The seat of the immediate localisation of the tubercular process was relatively unimportant. There was considerable resemblance between infection with tubercle and infection with syphilis, but tubercle was much more difficult to diagnose with certainty in the early stages. Its incubation period was prolonged and ill-defined; the possibilities of infection were numerous, obscure, and often connected with environment. After local infection with tubercle a sore might develop at the seat of inoculation, and in the guinea-pig after experimental injection with tuberculous material the occurThe tubercle bacillus rence of a sore was characteristic. might enter the body by many different channels. The tonsils and posterior nares were important points of entry, and spread was by the lymphatics. A very acute form of lymphatic tuberculosis affected the Senegalese troops in France, and was accompanied by a high mortality. After entry of the bacillus, it might be conveyed to any part of the body, and the local lesion must be regarded as more or less incidental. The ultimate danger was the occurrence of systemic intoxication, which showed its effects most markedly upon the neuro-muscular structures, and which manifested itself early before the development of local physical signs. Cases should be frequently re-surveyed because of the possibility of recurrent manifestations, as even after apparent cure these cannot be excluded with certainty. Tuberculosis was a slow process as a rule, and a long period was required for efficient treatment. The official three months given under the National Health Insurance Act was useless, and was a waste of time and money. There was ample proof that proper treatment was followed by good results. Thirty years ago it was common to see advanced cases of pulmonary tuberculosis for the first time, whereas it was now rare. The progress that had been made was shown by the falling death-rate. In the 30 years from 1870 to 1900 the percentage fall in mortality was 41, and in the succeeding 20 years it The age of death was also considerably later. was 45. There was need for continuous investigation and fuller training of men on modern lines. Sir HENRY GAUVAIN said that the treatment of nonpulmonary tuberculosis had largely been neglected owing to lack of opportunity. The average period of treatment usually accorded to such cases in hospital was one month, whereas it was recognised that cases. of pulmonary tuberculosis required about two years. Surgical tuberculosis should no" longer be considered as a local condition only. The "soil" was very important, and very largely influenced dissemination of the disease. Conservative treatment-by which was meant the adoption of all measures capable of increasing resistance-should be practised in preference to radical treatment, which was designed to remove the local manifestations. Conservative treatment meant suitable climate, fresh air, personal hygiene, and proper diet. While undergoing treatment proper occupation was necessary, and this should be of a kind to suit the particular class of case. A certain amount of discipline was also a necessity. Cases of surgical tuberculosis could be divided into three classes-those which required absolute rest in the recumbent posture, subacute or chronic cases, which needed immobilisation of the affected part to allow of repair and to prevent deformity, and a class where support only was required. Heliotherapy was of value in some cases, which showed reaction to it by pigmentation.
Excessive reaction must be avoided, and the patient should gradually be acclimatised to the treatment. Surgical treatment might be necessary for special complications such as tuberculous abscess or sinuses. Spontaneous opening of abscesses should never be allowed, as sinus formation was Instead of incision the part should be sure to follow. immobilised, and the abscess aspirated. By so doing, use was made of nature’s barrier in the form of muscular aponeuroses and fascise. The good results following treatment along conservative lines were strikingly demonstrated by figures from the special hospital at Alton. Mr. JOHN FRASER agreed with the efficacy of conservative methods in the treatment of surgical tuberculosis. He advocated, however, in addition, early operation in certain classes of cases, especially in early tubercle affecting the cervical glands, and where there was a focus of disease in a, bone near a joint. In infants also, early operation might be desirable in some cases where it would be undesirable in older children. Extremely bad social conditions might also make operative interference more necessary. Professor G. L. GULLAND emphasised the importance of goodwill on the part of the patient in making treatment a
j,
success.
Dr. I. STRUTHERS STEWART dealt with certain aspects of sanatorium treatment which were at present unsatisfactory, and urged the necessity for development and coordination of research. Sir DAVID WALLACE referred particularly to tuberculosis of the genito-urinary tract. Dr. LOGAN TURNER spoke of the frequency of laryngeal tuberculosis and of its influence on the prognosis in cases of phthisis, showing that the mortality was very appreciably increased. Dr. FERGUS HEWAT referred to irritable heart as an important systemic manifestation in certain cases, and also of the necessity for repeated examination of the
sputum.
Dr. GEORGE MACKAY and Dr. W. G. SYM dealt with tuberculous infections of the eye.-Professor F. M. CAIRD, Mr. C. W. CATHCART, and Dr. CHALMERS WATSON also spoke.
MANCHESTER MEDICAL SOCIETY. Psychotherapy. A MEETING of this society was held on March 3rd, Professor R. B. WILD, the President, being in the chair. A discussion was introduced by Professor T. H. PEAR in a paper on Psychological Analysis. By psychological analysis, he said, is meant here " any .
whereby the nature and relationship of the causes responsible for the patient’s (mental) condition are determined, and the condition removed by the rearrangement and readjustment of these causes."1 The term is wider than psycho-analysis; the latter should be reserved to describe that method which owes its inception to Sigmund Freud. The present discussion attempted to describe the nature and uses of psychological analysis (of which psychoanalysis is one example) in the diagnosis and treatment of method
what are known as the "functional nervous disorders." Of these disabilities there are two kinds, often, but not always, sharply distinguished from each other : (a) conversion hysteria; (b) the anxiety neuroses. These two types of disorder may be symptomatic of different kinds of mentality in a patient, and the cure may necessitate different methods of treatment. The thesis here put forward is that though psychological analysis is only one method in psychotherapy; it is (a) sometimes the only method which will be ultimately successful; because it is (b) the only 11 radical " method. The different psychological processes involved in the methods known as suggestion, persuasion, and analysis were then discussed and compared. Reference was made to the view taken of the differences between these disorders by Dr. Bernard Hart. It was pointed out that the meaning attached to the word " suggestionis usually extremely vague, and that though probably suggestion enters into treatment both by persuasion and analysis, it can be theoretically distinguished from them. The definitions of suggestion and persuasion, given in the article quoted above, In conclusion, it was pointed out were further discussed. that the adoption of all methods of psychotherapy, and in particular of the analytic method, assumed a knowledge of the technique and of the psychological processes underlying them. Emphasis was laid upon the necessity of training medical students in the future to understand and to discriminate between the uses of these various methods. The following took part in the discussion: Professor E. S. REYNOLDS, Dr. D. E. CORE, Dr. S. HERBERT, Dr. A. V. STOCKS, Dr. S. R. WILSON.
1
Bernard Hart, " The Methods of Psychotherapy," Proc. Roy. Soc. Med., vol. xii. (Section of Psychiatry), pp. 15-34.
MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH. 1’reatment of ’l’1tberc1110sis. AT a meeting of this society held on May 5th, a discussion took place on the Treatment of Tuberculosis. The discussion was opened by Sir ROBERT PHILIP, who read a paper on the Modern Outlook on the Treatment of Tuberculosis, and by Sir HENRY GAUVAIN, who dealt with the Management of Non-Pulmonary
Tuberculosis. Sir Robert Philip contrasted the Hippocratic conception of phthisis with the modern outlook on tuberculosis, and showed how the disease, formerly regarded as always fatal, was one which satisfactorily yielded to treatment, particularly in the early stages. The widespread occurrence of tuberculosis and its natural tendency to cure had been demonstrated by many observers. Amongst the most striking figures were those of Reinhardt of Berne, who, in an extensive series of post-mortem examinations, made on individuals who had died from all varieties of disease, found evidences of tuberculosis in 96 per cent. of cases-32 per cent. showing active and 64 per cent. It was well recognised that nature healed tubercle. cured cases of the disease every day. The essentials of the development of tuberculosis were infection by the tubercle bacillus, the reaction of the tissues to invasion, and later the occurrence of systemic intoxication. The seat of the immediate localisation of the tubercular process was relatively unimportant. There was considerable resemblance between infection with tubercle and infection with syphilis, but tubercle was much more difficult to diagnose with certainty in the early stages. Its incubation period was prolonged and ill-defined; the possibilities of infection were numerous, obscure, and often connected with environment. After local infection with tubercle a sore might develop at the seat of inoculation, and in the guinea-pig after experimental injection with tuberculous material the occurThe tubercle bacillus rence of a sore was characteristic. might enter the body by many different channels. The tonsils and posterior nares were important points of entry, and spread was by the lymphatics. A very acute form of lymphatic tuberculosis affected the Senegalese troops in France, and was accompanied by a high mortality. After entry of the bacillus, it might be conveyed to any part of the body, and the local lesion must be regarded as more or less incidental. The ultimate danger was the occurrence of systemic intoxication, which showed its effects most markedly upon the neuro-muscular structures, and which manifested itself early before the development of local physical signs. Cases should be frequently re-surveyed because of the possibility of recurrent manifestations, as even after apparent cure these cannot be excluded with certainty. Tuberculosis was a slow process as a rule, and a long period was required for efficient treatment. The official three months given under the National Health Insurance Act was useless, and was a waste of time and money. There was ample proof that proper treatment was followed by good results. Thirty years ago it was common to see advanced cases of pulmonary tuberculosis for the first time, whereas it was now rare. The progress that had been made was shown by the falling death-rate. In the 30 years from 1870 to 1900 the percentage fall in mortality was 41, and in the succeeding 20 years it The age of death was also considerably later. was 45. There was need for continuous investigation and fuller training of men on modern lines. Sir HENRY GAUVAIN said that the treatment of nonpulmonary tuberculosis had largely been neglected owing to lack of opportunity. The average period of treatment usually accorded to such cases in hospital was one month, whereas it was recognised that cases. of pulmonary tuberculosis required about two years. Surgical tuberculosis should no" longer be considered as a local condition only. The "soil" was very important, and very largely influenced dissemination of the disease. Conservative treatment-by which was meant the adoption of all measures capable of increasing resistance-should be practised in preference to radical treatment, which was designed to remove the local manifestations. Conservative treatment meant suitable climate, fresh air, personal hygiene, and proper diet. While undergoing treatment proper occupation was necessary, and this should be of a kind to suit the particular class of case. A certain amount of discipline was also a necessity. Cases of surgical tuberculosis could be divided into three classes-those which required absolute rest in the recumbent posture, subacute or chronic cases, which needed immobilisation of the affected part to allow of repair and to prevent deformity, and a class where support only was required. Heliotherapy was of value in some cases, which showed reaction to it by pigmentation.
Excessive reaction must be avoided, and the patient should gradually be acclimatised to the treatment. Surgical treatment might be necessary for special complications such as tuberculous abscess or sinuses. Spontaneous opening of abscesses should never be allowed, as sinus formation was Instead of incision the part should be sure to follow. immobilised, and the abscess aspirated. By so doing, use was made of nature’s barrier in the form of muscular aponeuroses and fascise. The good results following treatment along conservative lines were strikingly demonstrated by figures from the special hospital at Alton. Mr. JOHN FRASER agreed with the efficacy of conservative methods in the treatment of surgical tuberculosis. He advocated, however, in addition, early operation in certain classes of cases, especially in early tubercle affecting the cervical glands, and where there was a focus of disease in a, bone near a joint. In infants also, early operation might be desirable in some cases where it would be undesirable in older children. Extremely bad social conditions might also make operative interference more necessary. Professor G. L. GULLAND emphasised the importance of goodwill on the part of the patient in making treatment a
j,
success.
Dr. I. STRUTHERS STEWART dealt with certain aspects of sanatorium treatment which were at present unsatisfactory, and urged the necessity for development and coordination of research. Sir DAVID WALLACE referred particularly to tuberculosis of the genito-urinary tract. Dr. LOGAN TURNER spoke of the frequency of laryngeal tuberculosis and of its influence on the prognosis in cases of phthisis, showing that the mortality was very appreciably increased. Dr. FERGUS HEWAT referred to irritable heart as an important systemic manifestation in certain cases, and also of the necessity for repeated examination of the
sputum.
Dr. GEORGE MACKAY and Dr. W. G. SYM dealt with tuberculous infections of the eye.-Professor F. M. CAIRD, Mr. C. W. CATHCART, and Dr. CHALMERS WATSON also spoke.
MANCHESTER MEDICAL SOCIETY. Psychotherapy. A MEETING of this society was held on March 3rd, Professor R. B. WILD, the President, being in the chair. A discussion was introduced by Professor T. H. PEAR in a paper on Psychological Analysis. By psychological analysis, he said, is meant here " any .
whereby the nature and relationship of the causes responsible for the patient’s (mental) condition are determined, and the condition removed by the rearrangement and readjustment of these causes."1 The term is wider than psycho-analysis; the latter should be reserved to describe that method which owes its inception to Sigmund Freud. The present discussion attempted to describe the nature and uses of psychological analysis (of which psychoanalysis is one example) in the diagnosis and treatment of method
what are known as the "functional nervous disorders." Of these disabilities there are two kinds, often, but not always, sharply distinguished from each other : (a) conversion hysteria; (b) the anxiety neuroses. These two types of disorder may be symptomatic of different kinds of mentality in a patient, and the cure may necessitate different methods of treatment. The thesis here put forward is that though psychological analysis is only one method in psychotherapy; it is (a) sometimes the only method which will be ultimately successful; because it is (b) the only 11 radical " method. The different psychological processes involved in the methods known as suggestion, persuasion, and analysis were then discussed and compared. Reference was made to the view taken of the differences between these disorders by Dr. Bernard Hart. It was pointed out that the meaning attached to the word " suggestionis usually extremely vague, and that though probably suggestion enters into treatment both by persuasion and analysis, it can be theoretically distinguished from them. The definitions of suggestion and persuasion, given in the article quoted above, In conclusion, it was pointed out were further discussed. that the adoption of all methods of psychotherapy, and in particular of the analytic method, assumed a knowledge of the technique and of the psychological processes underlying them. Emphasis was laid upon the necessity of training medical students in the future to understand and to discriminate between the uses of these various methods. The following took part in the discussion: Professor E. S. REYNOLDS, Dr. D. E. CORE, Dr. S. HERBERT, Dr. A. V. STOCKS, Dr. S. R. WILSON.
1
Bernard Hart, " The Methods of Psychotherapy," Proc. Roy. Soc. Med., vol. xii. (Section of Psychiatry), pp. 15-34.