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NATIONAL ASSOCIATION FOR THE PREVENTION OF TUBERCULOSIS
78 the
fatty anaplastic variety already described and deeper-staining cells in acinous formation. Humerus.-The left humerus through its whole length.
removed and The marrow was obviously hyperplastic throughout, of a deep redpurple colour containing a few small pale patches. A microscopical section of one of these pale patches showed large, fatty, and lightly stained carcinoma cells, identical with those found in the lung and was
sawn
lymph-glands. Right axillary fold.--Since the tissues in this region were so much hardened and thickened, a microscopical
section was made to determine if carcinomatous involvement of the lymphatics, as a direct spread from the lung adherent to the chest wall, had taken place. This was plainly shown to be the case, and was the cause of the solid oedema of the right arm and chest. DISCUSSION
Icterus gravis in the newborn and acute haemolytic ansemia at any age, may both show a slight increase in red-cell fragility ; but I can find no reference to any disease, other than acholuric jaundice, in which a considerable increase in red-cell fragility is described. In acholuric jaundice it is the characteristic feature and commonly reaches 0-7 per cent. saline. The chief interest in this case of proved leuco-erythroblastic ansemia associated with carcinomatosis lies in the fact that it resembled acholuric jaundice so closely, even to the high degree of fragility of the red cells. Fragility tests done on two subsequent cases of leuco-erythroblastic anaemia, with carcinomatous deposits in the bones but no jaundice, gave normal results ; but Vaughan and Harrison
(1939) have found slightly increased red-cell fragility in two cases of leuco-erythroblastic anaemia How far the associated with myelosclerosis. associated tuberculosis affected the blood-picture in the case here described it is impossible to say. As for carcinoma of the lung starting in an old tuberculous focus, that is well known ; but I have no knowledge that the reverse process has ever been described. It appears that in this case the implantation of the carcinoma on the site of the old tuberculous focus awakened its activity. The dense adhesion of the lung at this part to the chest wall was evidence of a lesion of long standing. It is possible that some cases of so-called acquired acholuric jaundice may really be unrecognised cases of leuco-erythroblastic ansemia. At any rate this case shows the importance of excluding the latter disease by a thorough search of the body for a primary malignant growth and by radiography of the bones for secondary deposits, whenever a diagnosis of acholuric jaundice, largely based on increased redcell fragility, is unsupported by a history of previous attacks of jaundice in either the patient or his relations. It was fortunate that this case revealed its true nature before splenectomy was performed.
My thanks are due to Dr. Norman Hill for permission to use the clinical notes of his patient. REFERENCES
Vaughan, J. M., and Harrison, C. V. (1939) J. Path. Bact. March, p. 339.
Whitby, the
L. E. H., and Britton, C. J. C. (1937) Disorders of Blood, London, p. 266.
MEDICAL SOCIETIES NATIONAL ASSOCIATION FOR THE PREVENTION OF TUBERCULOSIS AT the twenty-nfth annual conference of this association, held in Belfast from June 29 to July 1, with the Marchioness of TITC]EIFIELD, the president, in the chair, a discussion on the
General Administration of Tuberculosis Schemes opened by Alderman E. H. RICKARDS, J.P., who divided the administration of a tuberculosis scheme into four sections. (1) Discovery and diagnosis: there were, he thought, still too many people in whom the early stages of the disease remained undetected owing to the difficulty of persuading some people to submit to examination and owing to the was
lack of propaganda whereby general practitioners might be made acquainted with the existing facilities. (2) Treatment: there were few administrative difficulties here except insufficient accommodation to meet the long waiting-list of some authorities. (3) Isolation and prevention: much success had followed the use of shelters and separate sleeping accommodation, education in hygiene, and rehousing schemes. (4) Care and aftercare of the patient and his family: the funds of care committees could not rise to every type of assistance necessary, and difficulty was often met in the case of the young bread-winner discharged from sanatorium as fit for " light work," because light work was almost unobtainable. So far no serious effort had been made to find suitable work for these patients, and he suggested the setting up of workshops in connexion with a sanatorium at which discharged patients could be profitably employed for regulated hours.
Dr. ANDREW TRiMBLE said that any such scheme must concern itself both with the care and cure of the patient and with the prevention of a further spread of the disease, for the decline in mortality was due more to the limitation of infection than to
He outlined the development and progress of cures. anti-tuberculosis measures in Belfast (where the death-rate had dropped by 67 per cent. from 1914 to 1938), put in a plea for a periodic review of any scheme, and suggested certain lines along which fresh endeavour might be directed, such as a study of the whole individual as a social unit, the cultivation of the health
in
habit, and the training of school teachers recognising suspicious signs of oncoming disease.
Dr. W. L. YELL looked upon the tuberculosis as the foundation of all schemes ; hence the choice of a tuberculosis officer and nurse were of prime importance. He maintained that patients with early pulmonary, bone, or joint tuberculosis and those in an advanced stage of pulmonary disease should be given prior claim to institutional treatment, the intermediate group being best catered for by the colony system, which should be more generously subsidised. Dr. Yell then referred to the success of a small maternity unit at one of the Essex sanatoria to which patients are admitted six weeks before term and retained for three to six months after delivery. This, it was hoped, would banish many of the dangers attached to parturition in tuberculous women.
dispensary
Dr. P. W. EDWARDS, in a paper on Arrangements for Artificial Pneumothorax said that, before an artificial pneumothorax was induced, the operators should make sure that there were adequate facilities for carrying on the treatment. These facilities he divided into " essential" and
79 progress to more serious manifestations. There were now more tuberculin-negative adolescents in the community than thirty years ago, and as a result more people were becoming infected for the first time relatively late in life. In Eire, for example, only 11 per cent. of healthy girls of 14 in the country gave a positive reaction. She thought there was a connexion between this and the high death-rate in the 15-25 age-group, and she asked for more consideration to be given to the negative reactor. Mr. A. R. FOSTER, headmaster of the Belfast Royal Academy, attacked the present-day system of education as fostering the spirit of mental cruelty. He illustrated his points by recounting a day in the life of an average pupil aged 16, in which the child was compelled, by his teachers during the day and his parents in the evening, to expend a sum total of physical and mental energy that would make the day’s work of a coal-heaver " look like a pleasant afternoon in the garden." He preferred quality rather than quantity in academic learning and thought that these deficiencies in our educational system were predisposing factors to tuberculosis. Alderman P. ASTINS, J.P., drew attention to numerous gaps in the present legislative framework and the need for amending such legislation so as to make the local authorities responsible for many social activities now only permissive. He laid particular emphasis on the need for adequate rehabilitation of a patient when he left sanatorium, and he suggested that the state could profitably reserve a proportion of its lighter jobs for such people, as indeed it did already for the disabled ex-Service man. Dr. W. M. MACPHAIL gave an account of the occupational training at Burrow Hill Sanatorium colony. Unfortunately there was not time for details, he said that about a third of the patients stayed at the colony the full length of time, and these had little difficulty in finding suitable employment in after life. Dr. LLOYD RUSBY distinguished between the tuberculous and the catarrhal type in a contact community and suggested that more research should in future be devoted to a study of the constitutional factor with the object of early recognition of susceptibility rather than the established disease. Dr. BANSZKY described the modern technique of photographing the fluorescent-screen imaged This had a bearing on the question of mass radiography, for a permanent record could be obtained for 2d.
The former included an experienced thoracic surgeon, an X-ray equipment physician, for screening and taking pictures, and a suction apparatus for trocar and cannula. The " desirable " facilities included a rapid gas-replacement apparatus, an operating-theatre for internal pneumolysis and phrenicectomy, and a quick method for sterilising needles in bulk. Dr. B. R. CLARKE computed that 50 per cent. of all patients with open pulmonary tuberculosis required a pneumothorax. He regarded the induction as often a matter of urgency and deplored the lengthy wait for accommodation that was often encountered. He emphasised the need for experience in spacing refills and preferred frequent small refills controlled by screening. Since the main object of a pneumothorax was to bring about the lasting cure of the patient, the mental and physical reaction of the patient to the treatment should be constantly studied. Dr. BRENDAN O’BRIEN considered the control of carriers to be the most important point in the prevention of tuberculosis, and this could be effected only by early diagnosis and adequate treatment. There was a tendency to use the artificial pneumothorax as a substitute for sanatorium treatment, whereas they should be complementary, and he was "
might
desirable."
a
opposed to inducing a pneumothorax preliminary period of observation.
without
a
In the discussion that ensued Dr. GEORGE DAY that tuberculosis officers and others with of pneumothorax patients would be provided with facilities for screening and radiography. This was not universal at the present time, with the result that the lung was either too much collapsed or there was a risk of the pneumothorax being lost.
hoped charge
On the second day, with Sir PERCIVAL HORTONSMITH HARTLEY in the chair, Dr. GEORGE JESSEL, opening a discussion on ’ Tuberculosis in the Adolescent said that the adolescent and young adult population had not participated in the continuous decline in the tuberculosis death-rate from 1901 to 1909, but that from 1933 onwards a steady fall had been noticed. After mentioning the possible predisposing factors that had been investigated by other workers, such as shortage of food, fatigue, work, and worry, he concluded that, apart from shortage of food, which the Registrar-General thought significant in explaining certain periods of arrested fall, no single factor was responsible. With regard to treatment the outlook had become more favourable, but treatment must be applied early. Rest was the most important item, and artificial pneumothorax was useful in suitable On the preventive side the examination of cases. contacts should be compulsory and universal. One examination was not enough ; they should be kept under observation for at least five years. Dr. F. S. HAwrtrrrs cited the figures for Wales as showing the highest incidence of the disease to be in the adolescent age-group, and to account for this he invoked poor housing and poor food, the anxiety of finding a job, and the struggle to retain it. Certain symptoms should be regarded as danger signals, such as a constant succession of colds, aphonia, lassitude, a failure to gain weight, and amenorrhcea. Treatment should be prompt and prognosis guarded, especially in young women, and an annual radiographic examination of all persons between 14 and 21 was desirable if prevention was to be ensured. Dr. D. S. PRICE said that the primary infection of childhood should not be regarded as benign, for it
but
a
,
film.
Dr. J. B. McDouGALL opened a discussion on Architectural Problems from the points of view of the medical superintendent, who was satisfied if administration was made easy ; of the patient, who should be encouraged by social and recreative amenities to look upon the institution as his temporary home; and of the rate-payer, whose main interest was the cost. He held little brief for the present tendency to erect sanatoria at an enormous expense. To illustrate his point he cited the recently constructed hostel at Preston Hall, which satisfied the most exacting demands and cost less than :S200 a bed. Mr. B. LUBETKIN (whose paper was read in his absence) discussed the influence of modern materials and constructive methods on the design of tuberculosis institutions. Light and air were essential, and he favoured cross-ventilation throughout. He advocated 1. See Dormer, B. A., and Collender, K. G., Lancet, June 10, 1939,
p. 1309.
80
compactness, with administrative and clerical services centralised and the patients confined to the ground floor. He condemned the use of radiators as heating by convection and preferred the radiant type of ceiling heating with steel pipes through which hot water could be passed. Dr. BLYTH BROOKE said that a tuberculosis dispensary both externally and internally should be one to inspire confidence and create a friendly and homely atmosphere. He outlined the details of lay-out and illustrated his points with a plan of the Finsbury health centre. Dr. E. K. PRITCHARD, with experience of the new health services at Southwark, said that he was not in favour of conditioned ventilation, because it required closed windows and it was sometimes difficult to convince the tuberculous patient that you were practising what you preached. Dr. F. R. G. HEAF thought well of Dr. McDougall’s new hostel in view of the increased general demand for bed accommodation, and Mr. S. LOUTIT said that the designing of a tuberculosis institution should be the job of an outside architect and not of a borough surveyor. ,
NORTH OF ENGLAND OBSTETRICAL AND GYNÆCOLOGICAL SOCIETY a meeting of this society in Newcastle-on-Tyne May 10 Prof. E. FARQUHAR MURRAY, the president, delivered his presidential address, entitled Retrospect, Introspect, and Prospect outlining the main changes in gynaecological practice which had taken place since 1911. Perhaps the most striking change was the development of a sound pathology which took regard of the whole patient. This was exemplified by the alteration in the treatment of retroversion and prolapse. In London in 1911 a third to a half of the laparotomies performed As a conclusion to were for antefixing the uterus. it to was known irreverent juniors prolapse operations as the " all red route." After such a training it was
In obstetrics perhaps the most striking advance he had seen had been the almost complete disappearance of craniotomy and its replacement by caesarean section. Although the universal desire to provide ansesthesia for women in labour was commendable, under the present imperfect organisation of maternity services the idea that every midwife should have a powerful drug or apparatus at her disposal for every As a case was both dangerous and impracticable. matter of fact the vast majority of women passed through labour without any analgesia at all and took no harm whatever. By a judicious administration of the old-fashioned drugs it was possible to ensure a reasonably comfortable labour and a shorter and not intolerable second stage. For most women nature was not so terribly unkind as she was made out. In the teaching of obstetrics one of the faults of the present system was the absence of a senior resident with the necessary standing in hospitals where junior residents were being taught their job. There was also a shortage of posts where men could learn postgraduate obstetrics. With the evolution of maternity services there would be an increased demand for general practitioners with such experience, and in some way this problem of instruction must The provision by most public-health be solved. authorities of a comprehensive consultant obstetric service was commendable, although some places had ignored the doctors and displaced them entirely in favour of whole-time officers. Such a step had the most adverse effect.
AT
on
relief to find that there were many backaches and When he very few retroverted uteri as a cause. came to Newcastle in 1919 he found that ventrofixation had not been done for many years, although numerous papers were still being read advocating it. To the Manchester school belongs much of the credit for establishing that a thorough plastic vaginal repair was sufficient to cure prolapse. During the same period there had been a swing of the pendulum from radical surgery to conservatism. Fortunately the clean pelvic sweeps preferred by those who considered a tidy pelvic basin as of prime importance were less common now. Years ago he had been told by a general practitioner that those who believed in removing ovaries should be made responsible for the patients’ aftercare. The replacement of hysterectomy by myomectomy in suitable cases was another instance of the same change in outlook. On the other hand, much of the conservative surgery practised had been unsound-e.g., the performance of salpingostomies without proof of any patency between the tube and the uterine cavity. Hormone therapy certainly was one of the main bulwarks of conservatism, but he wished there were a more satisfactory method of testing the preparations before the market was flooded at great expense to the
NEW INVENTIONS A SYRINGE FOR SIALOGRAPHY
IN several cases I have experienced difficulty with the usual syringes in injecting Lipiodol into thesalivary ducts prior to sialography, and I have therefore designed the new type shown in the figure.
a
hospitals.
This syringe, which is made by John Bell and Croyden, has rendered the technique of injection more precise and less irksome for both the patient. and the operator.
--
-
HAMILTON BAILEY, F.R.C.S.
AN ELECTRIC UVIOMETER
Henry Allday and Sons of 19, Warstone Lane, Birmingham, 18, have designed their new A-T " uviometer on the principle of the photoelectric photographic exposure meter, the scale being calibrated directly in units of erythema dosage. The apparatus is easily portable, being some 5 in. long by 3t in. wide and 2 in. deep. It is said to be Messrs.
"
sensitive to radiations of between 2800 and 4000 the glass filter absorbing most of the radiations within the visible spectrum. If this is so it will register only the therapeutically valuable rays of a mercury-vapour lamp. It should be useful for comparing the emission of different sources of ultraviolet light or for estimating the deteriorationof a lamp after long use. The uviometer costs 15 guineas.
Angstrom units,
fatty anaplastic variety already described and deeper-staining cells in acinous formation. Humerus.-The left humerus through its whole length.
removed and The marrow was obviously hyperplastic throughout, of a deep redpurple colour containing a few small pale patches. A microscopical section of one of these pale patches showed large, fatty, and lightly stained carcinoma cells, identical with those found in the lung and was
sawn
lymph-glands. Right axillary fold.--Since the tissues in this region were so much hardened and thickened, a microscopical
section was made to determine if carcinomatous involvement of the lymphatics, as a direct spread from the lung adherent to the chest wall, had taken place. This was plainly shown to be the case, and was the cause of the solid oedema of the right arm and chest. DISCUSSION
Icterus gravis in the newborn and acute haemolytic ansemia at any age, may both show a slight increase in red-cell fragility ; but I can find no reference to any disease, other than acholuric jaundice, in which a considerable increase in red-cell fragility is described. In acholuric jaundice it is the characteristic feature and commonly reaches 0-7 per cent. saline. The chief interest in this case of proved leuco-erythroblastic ansemia associated with carcinomatosis lies in the fact that it resembled acholuric jaundice so closely, even to the high degree of fragility of the red cells. Fragility tests done on two subsequent cases of leuco-erythroblastic anaemia, with carcinomatous deposits in the bones but no jaundice, gave normal results ; but Vaughan and Harrison
(1939) have found slightly increased red-cell fragility in two cases of leuco-erythroblastic anaemia How far the associated with myelosclerosis. associated tuberculosis affected the blood-picture in the case here described it is impossible to say. As for carcinoma of the lung starting in an old tuberculous focus, that is well known ; but I have no knowledge that the reverse process has ever been described. It appears that in this case the implantation of the carcinoma on the site of the old tuberculous focus awakened its activity. The dense adhesion of the lung at this part to the chest wall was evidence of a lesion of long standing. It is possible that some cases of so-called acquired acholuric jaundice may really be unrecognised cases of leuco-erythroblastic ansemia. At any rate this case shows the importance of excluding the latter disease by a thorough search of the body for a primary malignant growth and by radiography of the bones for secondary deposits, whenever a diagnosis of acholuric jaundice, largely based on increased redcell fragility, is unsupported by a history of previous attacks of jaundice in either the patient or his relations. It was fortunate that this case revealed its true nature before splenectomy was performed.
My thanks are due to Dr. Norman Hill for permission to use the clinical notes of his patient. REFERENCES
Vaughan, J. M., and Harrison, C. V. (1939) J. Path. Bact. March, p. 339.
Whitby, the
L. E. H., and Britton, C. J. C. (1937) Disorders of Blood, London, p. 266.
MEDICAL SOCIETIES NATIONAL ASSOCIATION FOR THE PREVENTION OF TUBERCULOSIS AT the twenty-nfth annual conference of this association, held in Belfast from June 29 to July 1, with the Marchioness of TITC]EIFIELD, the president, in the chair, a discussion on the
General Administration of Tuberculosis Schemes opened by Alderman E. H. RICKARDS, J.P., who divided the administration of a tuberculosis scheme into four sections. (1) Discovery and diagnosis: there were, he thought, still too many people in whom the early stages of the disease remained undetected owing to the difficulty of persuading some people to submit to examination and owing to the was
lack of propaganda whereby general practitioners might be made acquainted with the existing facilities. (2) Treatment: there were few administrative difficulties here except insufficient accommodation to meet the long waiting-list of some authorities. (3) Isolation and prevention: much success had followed the use of shelters and separate sleeping accommodation, education in hygiene, and rehousing schemes. (4) Care and aftercare of the patient and his family: the funds of care committees could not rise to every type of assistance necessary, and difficulty was often met in the case of the young bread-winner discharged from sanatorium as fit for " light work," because light work was almost unobtainable. So far no serious effort had been made to find suitable work for these patients, and he suggested the setting up of workshops in connexion with a sanatorium at which discharged patients could be profitably employed for regulated hours.
Dr. ANDREW TRiMBLE said that any such scheme must concern itself both with the care and cure of the patient and with the prevention of a further spread of the disease, for the decline in mortality was due more to the limitation of infection than to
He outlined the development and progress of cures. anti-tuberculosis measures in Belfast (where the death-rate had dropped by 67 per cent. from 1914 to 1938), put in a plea for a periodic review of any scheme, and suggested certain lines along which fresh endeavour might be directed, such as a study of the whole individual as a social unit, the cultivation of the health
in
habit, and the training of school teachers recognising suspicious signs of oncoming disease.
Dr. W. L. YELL looked upon the tuberculosis as the foundation of all schemes ; hence the choice of a tuberculosis officer and nurse were of prime importance. He maintained that patients with early pulmonary, bone, or joint tuberculosis and those in an advanced stage of pulmonary disease should be given prior claim to institutional treatment, the intermediate group being best catered for by the colony system, which should be more generously subsidised. Dr. Yell then referred to the success of a small maternity unit at one of the Essex sanatoria to which patients are admitted six weeks before term and retained for three to six months after delivery. This, it was hoped, would banish many of the dangers attached to parturition in tuberculous women.
dispensary
Dr. P. W. EDWARDS, in a paper on Arrangements for Artificial Pneumothorax said that, before an artificial pneumothorax was induced, the operators should make sure that there were adequate facilities for carrying on the treatment. These facilities he divided into " essential" and
79 progress to more serious manifestations. There were now more tuberculin-negative adolescents in the community than thirty years ago, and as a result more people were becoming infected for the first time relatively late in life. In Eire, for example, only 11 per cent. of healthy girls of 14 in the country gave a positive reaction. She thought there was a connexion between this and the high death-rate in the 15-25 age-group, and she asked for more consideration to be given to the negative reactor. Mr. A. R. FOSTER, headmaster of the Belfast Royal Academy, attacked the present-day system of education as fostering the spirit of mental cruelty. He illustrated his points by recounting a day in the life of an average pupil aged 16, in which the child was compelled, by his teachers during the day and his parents in the evening, to expend a sum total of physical and mental energy that would make the day’s work of a coal-heaver " look like a pleasant afternoon in the garden." He preferred quality rather than quantity in academic learning and thought that these deficiencies in our educational system were predisposing factors to tuberculosis. Alderman P. ASTINS, J.P., drew attention to numerous gaps in the present legislative framework and the need for amending such legislation so as to make the local authorities responsible for many social activities now only permissive. He laid particular emphasis on the need for adequate rehabilitation of a patient when he left sanatorium, and he suggested that the state could profitably reserve a proportion of its lighter jobs for such people, as indeed it did already for the disabled ex-Service man. Dr. W. M. MACPHAIL gave an account of the occupational training at Burrow Hill Sanatorium colony. Unfortunately there was not time for details, he said that about a third of the patients stayed at the colony the full length of time, and these had little difficulty in finding suitable employment in after life. Dr. LLOYD RUSBY distinguished between the tuberculous and the catarrhal type in a contact community and suggested that more research should in future be devoted to a study of the constitutional factor with the object of early recognition of susceptibility rather than the established disease. Dr. BANSZKY described the modern technique of photographing the fluorescent-screen imaged This had a bearing on the question of mass radiography, for a permanent record could be obtained for 2d.
The former included an experienced thoracic surgeon, an X-ray equipment physician, for screening and taking pictures, and a suction apparatus for trocar and cannula. The " desirable " facilities included a rapid gas-replacement apparatus, an operating-theatre for internal pneumolysis and phrenicectomy, and a quick method for sterilising needles in bulk. Dr. B. R. CLARKE computed that 50 per cent. of all patients with open pulmonary tuberculosis required a pneumothorax. He regarded the induction as often a matter of urgency and deplored the lengthy wait for accommodation that was often encountered. He emphasised the need for experience in spacing refills and preferred frequent small refills controlled by screening. Since the main object of a pneumothorax was to bring about the lasting cure of the patient, the mental and physical reaction of the patient to the treatment should be constantly studied. Dr. BRENDAN O’BRIEN considered the control of carriers to be the most important point in the prevention of tuberculosis, and this could be effected only by early diagnosis and adequate treatment. There was a tendency to use the artificial pneumothorax as a substitute for sanatorium treatment, whereas they should be complementary, and he was "
might
desirable."
a
opposed to inducing a pneumothorax preliminary period of observation.
without
a
In the discussion that ensued Dr. GEORGE DAY that tuberculosis officers and others with of pneumothorax patients would be provided with facilities for screening and radiography. This was not universal at the present time, with the result that the lung was either too much collapsed or there was a risk of the pneumothorax being lost.
hoped charge
On the second day, with Sir PERCIVAL HORTONSMITH HARTLEY in the chair, Dr. GEORGE JESSEL, opening a discussion on ’ Tuberculosis in the Adolescent said that the adolescent and young adult population had not participated in the continuous decline in the tuberculosis death-rate from 1901 to 1909, but that from 1933 onwards a steady fall had been noticed. After mentioning the possible predisposing factors that had been investigated by other workers, such as shortage of food, fatigue, work, and worry, he concluded that, apart from shortage of food, which the Registrar-General thought significant in explaining certain periods of arrested fall, no single factor was responsible. With regard to treatment the outlook had become more favourable, but treatment must be applied early. Rest was the most important item, and artificial pneumothorax was useful in suitable On the preventive side the examination of cases. contacts should be compulsory and universal. One examination was not enough ; they should be kept under observation for at least five years. Dr. F. S. HAwrtrrrs cited the figures for Wales as showing the highest incidence of the disease to be in the adolescent age-group, and to account for this he invoked poor housing and poor food, the anxiety of finding a job, and the struggle to retain it. Certain symptoms should be regarded as danger signals, such as a constant succession of colds, aphonia, lassitude, a failure to gain weight, and amenorrhcea. Treatment should be prompt and prognosis guarded, especially in young women, and an annual radiographic examination of all persons between 14 and 21 was desirable if prevention was to be ensured. Dr. D. S. PRICE said that the primary infection of childhood should not be regarded as benign, for it
but
a
,
film.
Dr. J. B. McDouGALL opened a discussion on Architectural Problems from the points of view of the medical superintendent, who was satisfied if administration was made easy ; of the patient, who should be encouraged by social and recreative amenities to look upon the institution as his temporary home; and of the rate-payer, whose main interest was the cost. He held little brief for the present tendency to erect sanatoria at an enormous expense. To illustrate his point he cited the recently constructed hostel at Preston Hall, which satisfied the most exacting demands and cost less than :S200 a bed. Mr. B. LUBETKIN (whose paper was read in his absence) discussed the influence of modern materials and constructive methods on the design of tuberculosis institutions. Light and air were essential, and he favoured cross-ventilation throughout. He advocated 1. See Dormer, B. A., and Collender, K. G., Lancet, June 10, 1939,
p. 1309.
80
compactness, with administrative and clerical services centralised and the patients confined to the ground floor. He condemned the use of radiators as heating by convection and preferred the radiant type of ceiling heating with steel pipes through which hot water could be passed. Dr. BLYTH BROOKE said that a tuberculosis dispensary both externally and internally should be one to inspire confidence and create a friendly and homely atmosphere. He outlined the details of lay-out and illustrated his points with a plan of the Finsbury health centre. Dr. E. K. PRITCHARD, with experience of the new health services at Southwark, said that he was not in favour of conditioned ventilation, because it required closed windows and it was sometimes difficult to convince the tuberculous patient that you were practising what you preached. Dr. F. R. G. HEAF thought well of Dr. McDougall’s new hostel in view of the increased general demand for bed accommodation, and Mr. S. LOUTIT said that the designing of a tuberculosis institution should be the job of an outside architect and not of a borough surveyor. ,
NORTH OF ENGLAND OBSTETRICAL AND GYNÆCOLOGICAL SOCIETY a meeting of this society in Newcastle-on-Tyne May 10 Prof. E. FARQUHAR MURRAY, the president, delivered his presidential address, entitled Retrospect, Introspect, and Prospect outlining the main changes in gynaecological practice which had taken place since 1911. Perhaps the most striking change was the development of a sound pathology which took regard of the whole patient. This was exemplified by the alteration in the treatment of retroversion and prolapse. In London in 1911 a third to a half of the laparotomies performed As a conclusion to were for antefixing the uterus. it to was known irreverent juniors prolapse operations as the " all red route." After such a training it was
In obstetrics perhaps the most striking advance he had seen had been the almost complete disappearance of craniotomy and its replacement by caesarean section. Although the universal desire to provide ansesthesia for women in labour was commendable, under the present imperfect organisation of maternity services the idea that every midwife should have a powerful drug or apparatus at her disposal for every As a case was both dangerous and impracticable. matter of fact the vast majority of women passed through labour without any analgesia at all and took no harm whatever. By a judicious administration of the old-fashioned drugs it was possible to ensure a reasonably comfortable labour and a shorter and not intolerable second stage. For most women nature was not so terribly unkind as she was made out. In the teaching of obstetrics one of the faults of the present system was the absence of a senior resident with the necessary standing in hospitals where junior residents were being taught their job. There was also a shortage of posts where men could learn postgraduate obstetrics. With the evolution of maternity services there would be an increased demand for general practitioners with such experience, and in some way this problem of instruction must The provision by most public-health be solved. authorities of a comprehensive consultant obstetric service was commendable, although some places had ignored the doctors and displaced them entirely in favour of whole-time officers. Such a step had the most adverse effect.
AT
on
relief to find that there were many backaches and When he very few retroverted uteri as a cause. came to Newcastle in 1919 he found that ventrofixation had not been done for many years, although numerous papers were still being read advocating it. To the Manchester school belongs much of the credit for establishing that a thorough plastic vaginal repair was sufficient to cure prolapse. During the same period there had been a swing of the pendulum from radical surgery to conservatism. Fortunately the clean pelvic sweeps preferred by those who considered a tidy pelvic basin as of prime importance were less common now. Years ago he had been told by a general practitioner that those who believed in removing ovaries should be made responsible for the patients’ aftercare. The replacement of hysterectomy by myomectomy in suitable cases was another instance of the same change in outlook. On the other hand, much of the conservative surgery practised had been unsound-e.g., the performance of salpingostomies without proof of any patency between the tube and the uterine cavity. Hormone therapy certainly was one of the main bulwarks of conservatism, but he wished there were a more satisfactory method of testing the preparations before the market was flooded at great expense to the
NEW INVENTIONS A SYRINGE FOR SIALOGRAPHY
IN several cases I have experienced difficulty with the usual syringes in injecting Lipiodol into thesalivary ducts prior to sialography, and I have therefore designed the new type shown in the figure.
a
hospitals.
This syringe, which is made by John Bell and Croyden, has rendered the technique of injection more precise and less irksome for both the patient. and the operator.
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HAMILTON BAILEY, F.R.C.S.
AN ELECTRIC UVIOMETER
Henry Allday and Sons of 19, Warstone Lane, Birmingham, 18, have designed their new A-T " uviometer on the principle of the photoelectric photographic exposure meter, the scale being calibrated directly in units of erythema dosage. The apparatus is easily portable, being some 5 in. long by 3t in. wide and 2 in. deep. It is said to be Messrs.
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sensitive to radiations of between 2800 and 4000 the glass filter absorbing most of the radiations within the visible spectrum. If this is so it will register only the therapeutically valuable rays of a mercury-vapour lamp. It should be useful for comparing the emission of different sources of ultraviolet light or for estimating the deteriorationof a lamp after long use. The uviometer costs 15 guineas.
Angstrom units,