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NORTH-WESTERN TUBERCULOSIS SOCIETY
1077 for. The results, however, with virulent strains were better than those of antitoxic serum. The new drug uleron was said to be better than sulphanilamide in and gas-gangrene infections, though striking cure of gas-gangrene had been reported with sulphanilamide. Other workers had made a preliminary clinical report on 9 cases of infection by Type III pneumococcus where improvement had been attributable to the drug. Results on Types I and II had been disappointing, but those of a derivative of diamino-diphenyl-sulphone were a little better, recovered mice being immune. A large proportion of mice were saved by sulphanilamide given at the time of the infection and a small dose of serum given 18 hours afterwards. Cases of pneumonia might therefore be given sulphanilamide
NORTH-WESTERN TUBERCULOSIS SOCIETY
staphylococcal one
-
AT a meeting of this society in Manchester on Oct. 28th Dr. GEORGE JESSEL gave a presidential address on
Radiology at a Tuberculosis Clinic began by describing the methods he had employed
He for the last fifteen years at the Eccles clinic which served an area with a population of about 367,000, containing five dispensaries. He used a single-valve apparatus and gave exposures of one-tenth of a second at four feet. With such an apparatus uniform chest skiagrams of good quality could be produced. Screenin the interval before the administration of serum if ingswere done onlyin connexion with artificial pneumothe typing could not be done at once. The bactericidal thorax refills and were seldom used for diagnosis. effect in the blood in vitro largely depended on the lateral and oblique positions he could obtain using By presence of the leucocytes. the desired information in doubtful nearly always Dr. MAURICE MITMAN described clinical trials of and cases, preferred this to stereoscopy. He used proseptasine, a benzyl sulphanilamide, in scarlet paper films regularly, and thought them valuable for fever and erysipelas. These indicated that the routine re-examination and artificial pneumothorax drug was easy to give, of low toxicity, strikingly refills. The cost of these films was about half that of successful in erysipelas, and relatively ineffectual in celluloid films, but he preferred the latter for scarlet fever. diagnostic purposes. Mr. GEORGE DISCOMBE reported on about 100 It could be argued that radiological methods were cases of complications due to streptococcal infections only when the physician found ordinary necessary treated with sulphanilamide, benzyl sulphanilamide, clinical methods insufficient, but where physical signs and a few of the soluble preparations of prontosil. were absent or slight, valuable time might be lost in No serious toxic effects had been observed. Mild an attempt to discover the undiscoverable, and X ray cyanosis, sulphaemoglobinsemia, and methaemo- examination would often reveal distinctive shadows globinsemia had been noted. Severe hsemoglobinaemia when there were no signs. Moreover the regular did not appear on low-residue diets and liquid paraffin, use of radiography helped a physician to check his and methsemoglobinaemia might be counteracted by physical signs and enabled the course of a case to be methylene-blue. The pigment was completely inert followed accurately. Where the interval between towards oxygen and so had little effect. The worst pneumothorax refills was one week or longer, screencyanosis appeared in patients who had recently ing should be done before each refill, and the appearundergone an operation. ances recorded on a diagram. Skiagrams should be Prof. ARTHUR GREEN, F.R.S., explained the effect of taken after refills for record purposes every 6-8 weeks, these drugs as possibly due to their differential action but the intervals could be varied. In 1933 Dr. Jessel on the cells of the microbe and the cells of the host. had pointed out that failure to use radiography in cases Dr. E. P. PouLTON summarised an investigation of suspected fracture ranked as negligence, and in which the titre of the streptococcal infection in had suggested that a similar view would soon be taken each case was measured by the Guy’s Hospital in cases where there were reasonable grounds for technique of antistreptolysin titration. The condi- suspecting tuberculosis. This suggestion had been tions were chiefly erysipelas and various forms of fulfilled by a recent decision of the Court of Appeal Prontosil in Connolly v. Rubra (see Lancet, 1937, 1, 1006). rheumatism and rheumatoid arthritis. seemed to have some value in the acute stages. HaemoRadiography might nevertheless be abused and too lytic streptococcal infection was more often asso- much reliance might be placed upon it by those ciated with other diseases than was generally imagined who had not troubled to learn or utilise the timehonoured methods of examination. The disadvan-e.g., abdominal actinomycosis and B. coli pyelitis. Dr. J. C. HOGARTH gave some clinical details of tages that came from reluctance to use X rays were the 355 scarlet fever cases mentioned by Dr. Mitman. (1) the longer time usually needed to reach a diagnosis, and (2) the tendency to play for safety and to diagnose The CHAIRMAN observed that there was no doubt non-existent tuberculosis. Radiography was, moreabout the potency of these drugs or their permanent place in therapeutics. It was for the profession to over, particularly useful in the differentiation of chest discover their limitations and dangers. All the conditions. On the other hand it could not be relied speakers had worked with them from the beginning upon to provide by itself an accurate diagnosis, and often the information it supplied was equivocal ; and had described first-hand research. indeed in some respects radiography had tended to make the diagnosis of chest diseases more difficult, MIDLAND MENTAL PATHOLOGICAL SOCIETY.-The and it was still the man behind the gun, and not the seventh general meeting of this society was held at the University of Birmingham on Oct. 28th, with Sir gun itself, that counted most. Gilbert Barling, the present, in the chair. Dr. F. A. Some said that X ray examination should only be Pickworth read a paper, entitled a New Outlook on the made by a whole-time radiologist, who would not be Physiology and Pathology of Mental and Emotional biased by clinical knowledge of the case. Nowadays States, in which he endeavoured to correlate capillary however many radiologists asked to be supplied with irregularities in the brain with mental disorder in the information of patients referred to them. Conpatient. Dr. P. Bacsich read a paper on rapid and simple methods of demonstrating Nissl substance, myelin sheaths, sistently accurate diagnosis of chest diseases depended on assessment of all the available evidence, and and nerve-fibres in consecutive sections of the same material. there was no a-priori reason why the physician making
1078 the diagnosis should be biased by clinical examination, A radiologist any more than by radiological who had no clinical experience and was not regularly engaged in clinical work had an insecure foundation for his reports. The tuberculosis officer or physician, who was regularly radiographing his own cases, was constantly checking both his clinical findings and the appearances in the skiagrams, and so obtained a good working knowledge of the value of both. In sparsely populated districts’it would, of course, be uneconomical to provide an X ray apparatus for each dispensary ; but the ideal method was for a member of the tuberculosis medical staff to act as radiologist. A second man should be available as deputy, but it was neither necessary nor desirable for every medical officer to practise radiology. Where an outside radiologist was preferred or had to be employed, the nearer he was to the clinician the better. Where payment was made per capita there was grave risk that, in the effort to secure economy, the amount of radiology would be unduly restricted. In the past thousands of pounds had been wasted by the occupancy of beds for the tuberculous by non-tuberculous cases, and most of this loss could have been avoided by a relatively small expenditure on X ray work. In his own unit the cost per skiagram had been worked out at 9s. 6d. This included depreciation, based upon an estimated life for the apparatus of ten years, as well as a proportion of the cost of staff salaries, rent, heating, lighting, and cleaning. No credit had been allowed for screenings to the number of 500-600 a year. Granted the existence of an X ray apparatus and suitable staff, the cost of each skiagram fell with an increase in the number taken, but a wise discretion was necessary if the best use was to be made of the time and energy of the staff, having regard to their other duties.
findings.
’
HUNTERIAN SOCIETY AT a meeting held at Apothecaries’ Hall on Nov. 1st, with Mr. D. C. NoRRis, the president, in the chair, this society discussed the position of the
General Practitioner in
Midwifery meeting was " That
the proposition before the general practitioner should not be excluded from the practice of midwifery." Dame LoursE McILROY pointed out one or two reasons why general practitioners were indispensable to a national midwifery service : No one else could The
be summoned in an emergency, or knew so well the intimate circumstances of the patient or possessed her confidence so completely. No one could so well carry out preventive measures ; the family doctor was the first line of defence. She criticised the wholetime service on several grounds. It was uneconomical, she declared, to administer any public service, and it would never be possible to accommodate every parturient woman in hospital. Mass-production methods, moreover, were not suitable for the expectant mothers of the country ; they needed individual attention. There was no continuity of supervision between many antenatal clinics and the maternity service : in hospital the mother met a different group of doctors and nurses and had to begin all over again. While the whole-time medical staff were pledged to secrecy, their clerical assistants were not. Any clerk might disclose the admission of a patient for an illegitimate birth or an abortion, and the patient had therefore no feeling of confidence in the
hospital. Psychology was nowhere more important than in conditions affecting the reproductive functions; the family doctor was a friend and adviser to whom the mother would tell her intimate anxieties and worries, but this valuable relationship was absent from the whole-time service. It was unfair to say that the general practitioner was incompetent to deal with midwifery practice, and to compare his skill with that of the professor who had an expert staff and modern equipment. The clinic should help the family doctor and make him part of its scheme. One London borough maintained a " flying-squad " which the general practitioner could summon, and allowed him to follow his patients into hospital. Dr. W. H. F. OxLEY declared that, although he in charge of a large maternity service, he was and always would be a general practitioner. After an ineffective campaign, lasting ten years, to reduce maternal mortality, most of the administrators and the public had come to the conclusion that the man to be blamed was the general practitioner. Three or four years ago the Minister of Health had appointed two of the higher members of his hierarchy to make " a " field investigation in an area where the mortality had been exceptionally high. They had at length published a beautiful report 350 pages long, written in perfect English and full of statistical tables. The only factor they had been able to incriminate had been the weather. They had therefore immediately taken the line of least resistance and blamed the general practitioner more than he had ever been blamed before, and had recommended that the local authority should be empowered, in consultation with the local medical profession, to see that the best local skill was available for women who required it. This meant that the mother should have only that medical skill which was thought to be best by the medical officer of health and two or three of the local profession, and that the average general practitioner should be prevented from coming to help the midwife. Nothing could be more unfair than that the medical officer of health should be able to take away from a general practitioner his existing right to practise midwifery among the working classes, but this would happen if the Midwives Act, 1936, was the success which all hoped it would be. was
SOME FIGURES FOR RECOVERY
The Ministry of Health was one of the greatest sinners in promulgating false statements. One of the worst of these was the figure for maternal mortality, which was exaggerated by 10 or 15 per cent. through the inclusion of abortion deaths. It was 3.81 per 1000, and ought to be 3. The recovery rate was therefore 99.7 per cent. In a condition in which the whole of the woman’s metabolism was vitally changed, and which was beset with pitfalls, this was a marvellous figure, and the credit for it was due to the general practitioner. Of the remaining 0-3 per cent., only half, or 0.15 per cent., of cases were considered by the Maternal Mortality Committee to be preventable, and then only when the woman did what she was told, the midwife obeyed her rules, and the general practitioner never made an error and always had a good specialist, ambulance service, and hospital behind him. Given all those conditions, the general practitioners might increase the recovery figure from 99-7 to 99-85 per cent.-a superhuman approach to perfection. Premature use of forceps was extremely rare, but some local authorities quite illegally refused to pay more than 10s. for a night and 5s. for a day visit if the doctor did not put on forceps. Only if
NORTH-WESTERN TUBERCULOSIS SOCIETY
staphylococcal one
-
AT a meeting of this society in Manchester on Oct. 28th Dr. GEORGE JESSEL gave a presidential address on
Radiology at a Tuberculosis Clinic began by describing the methods he had employed
He for the last fifteen years at the Eccles clinic which served an area with a population of about 367,000, containing five dispensaries. He used a single-valve apparatus and gave exposures of one-tenth of a second at four feet. With such an apparatus uniform chest skiagrams of good quality could be produced. Screenin the interval before the administration of serum if ingswere done onlyin connexion with artificial pneumothe typing could not be done at once. The bactericidal thorax refills and were seldom used for diagnosis. effect in the blood in vitro largely depended on the lateral and oblique positions he could obtain using By presence of the leucocytes. the desired information in doubtful nearly always Dr. MAURICE MITMAN described clinical trials of and cases, preferred this to stereoscopy. He used proseptasine, a benzyl sulphanilamide, in scarlet paper films regularly, and thought them valuable for fever and erysipelas. These indicated that the routine re-examination and artificial pneumothorax drug was easy to give, of low toxicity, strikingly refills. The cost of these films was about half that of successful in erysipelas, and relatively ineffectual in celluloid films, but he preferred the latter for scarlet fever. diagnostic purposes. Mr. GEORGE DISCOMBE reported on about 100 It could be argued that radiological methods were cases of complications due to streptococcal infections only when the physician found ordinary necessary treated with sulphanilamide, benzyl sulphanilamide, clinical methods insufficient, but where physical signs and a few of the soluble preparations of prontosil. were absent or slight, valuable time might be lost in No serious toxic effects had been observed. Mild an attempt to discover the undiscoverable, and X ray cyanosis, sulphaemoglobinsemia, and methaemo- examination would often reveal distinctive shadows globinsemia had been noted. Severe hsemoglobinaemia when there were no signs. Moreover the regular did not appear on low-residue diets and liquid paraffin, use of radiography helped a physician to check his and methsemoglobinaemia might be counteracted by physical signs and enabled the course of a case to be methylene-blue. The pigment was completely inert followed accurately. Where the interval between towards oxygen and so had little effect. The worst pneumothorax refills was one week or longer, screencyanosis appeared in patients who had recently ing should be done before each refill, and the appearundergone an operation. ances recorded on a diagram. Skiagrams should be Prof. ARTHUR GREEN, F.R.S., explained the effect of taken after refills for record purposes every 6-8 weeks, these drugs as possibly due to their differential action but the intervals could be varied. In 1933 Dr. Jessel on the cells of the microbe and the cells of the host. had pointed out that failure to use radiography in cases Dr. E. P. PouLTON summarised an investigation of suspected fracture ranked as negligence, and in which the titre of the streptococcal infection in had suggested that a similar view would soon be taken each case was measured by the Guy’s Hospital in cases where there were reasonable grounds for technique of antistreptolysin titration. The condi- suspecting tuberculosis. This suggestion had been tions were chiefly erysipelas and various forms of fulfilled by a recent decision of the Court of Appeal Prontosil in Connolly v. Rubra (see Lancet, 1937, 1, 1006). rheumatism and rheumatoid arthritis. seemed to have some value in the acute stages. HaemoRadiography might nevertheless be abused and too lytic streptococcal infection was more often asso- much reliance might be placed upon it by those ciated with other diseases than was generally imagined who had not troubled to learn or utilise the timehonoured methods of examination. The disadvan-e.g., abdominal actinomycosis and B. coli pyelitis. Dr. J. C. HOGARTH gave some clinical details of tages that came from reluctance to use X rays were the 355 scarlet fever cases mentioned by Dr. Mitman. (1) the longer time usually needed to reach a diagnosis, and (2) the tendency to play for safety and to diagnose The CHAIRMAN observed that there was no doubt non-existent tuberculosis. Radiography was, moreabout the potency of these drugs or their permanent place in therapeutics. It was for the profession to over, particularly useful in the differentiation of chest discover their limitations and dangers. All the conditions. On the other hand it could not be relied speakers had worked with them from the beginning upon to provide by itself an accurate diagnosis, and often the information it supplied was equivocal ; and had described first-hand research. indeed in some respects radiography had tended to make the diagnosis of chest diseases more difficult, MIDLAND MENTAL PATHOLOGICAL SOCIETY.-The and it was still the man behind the gun, and not the seventh general meeting of this society was held at the University of Birmingham on Oct. 28th, with Sir gun itself, that counted most. Gilbert Barling, the present, in the chair. Dr. F. A. Some said that X ray examination should only be Pickworth read a paper, entitled a New Outlook on the made by a whole-time radiologist, who would not be Physiology and Pathology of Mental and Emotional biased by clinical knowledge of the case. Nowadays States, in which he endeavoured to correlate capillary however many radiologists asked to be supplied with irregularities in the brain with mental disorder in the information of patients referred to them. Conpatient. Dr. P. Bacsich read a paper on rapid and simple methods of demonstrating Nissl substance, myelin sheaths, sistently accurate diagnosis of chest diseases depended on assessment of all the available evidence, and and nerve-fibres in consecutive sections of the same material. there was no a-priori reason why the physician making
1078 the diagnosis should be biased by clinical examination, A radiologist any more than by radiological who had no clinical experience and was not regularly engaged in clinical work had an insecure foundation for his reports. The tuberculosis officer or physician, who was regularly radiographing his own cases, was constantly checking both his clinical findings and the appearances in the skiagrams, and so obtained a good working knowledge of the value of both. In sparsely populated districts’it would, of course, be uneconomical to provide an X ray apparatus for each dispensary ; but the ideal method was for a member of the tuberculosis medical staff to act as radiologist. A second man should be available as deputy, but it was neither necessary nor desirable for every medical officer to practise radiology. Where an outside radiologist was preferred or had to be employed, the nearer he was to the clinician the better. Where payment was made per capita there was grave risk that, in the effort to secure economy, the amount of radiology would be unduly restricted. In the past thousands of pounds had been wasted by the occupancy of beds for the tuberculous by non-tuberculous cases, and most of this loss could have been avoided by a relatively small expenditure on X ray work. In his own unit the cost per skiagram had been worked out at 9s. 6d. This included depreciation, based upon an estimated life for the apparatus of ten years, as well as a proportion of the cost of staff salaries, rent, heating, lighting, and cleaning. No credit had been allowed for screenings to the number of 500-600 a year. Granted the existence of an X ray apparatus and suitable staff, the cost of each skiagram fell with an increase in the number taken, but a wise discretion was necessary if the best use was to be made of the time and energy of the staff, having regard to their other duties.
findings.
’
HUNTERIAN SOCIETY AT a meeting held at Apothecaries’ Hall on Nov. 1st, with Mr. D. C. NoRRis, the president, in the chair, this society discussed the position of the
General Practitioner in
Midwifery meeting was " That
the proposition before the general practitioner should not be excluded from the practice of midwifery." Dame LoursE McILROY pointed out one or two reasons why general practitioners were indispensable to a national midwifery service : No one else could The
be summoned in an emergency, or knew so well the intimate circumstances of the patient or possessed her confidence so completely. No one could so well carry out preventive measures ; the family doctor was the first line of defence. She criticised the wholetime service on several grounds. It was uneconomical, she declared, to administer any public service, and it would never be possible to accommodate every parturient woman in hospital. Mass-production methods, moreover, were not suitable for the expectant mothers of the country ; they needed individual attention. There was no continuity of supervision between many antenatal clinics and the maternity service : in hospital the mother met a different group of doctors and nurses and had to begin all over again. While the whole-time medical staff were pledged to secrecy, their clerical assistants were not. Any clerk might disclose the admission of a patient for an illegitimate birth or an abortion, and the patient had therefore no feeling of confidence in the
hospital. Psychology was nowhere more important than in conditions affecting the reproductive functions; the family doctor was a friend and adviser to whom the mother would tell her intimate anxieties and worries, but this valuable relationship was absent from the whole-time service. It was unfair to say that the general practitioner was incompetent to deal with midwifery practice, and to compare his skill with that of the professor who had an expert staff and modern equipment. The clinic should help the family doctor and make him part of its scheme. One London borough maintained a " flying-squad " which the general practitioner could summon, and allowed him to follow his patients into hospital. Dr. W. H. F. OxLEY declared that, although he in charge of a large maternity service, he was and always would be a general practitioner. After an ineffective campaign, lasting ten years, to reduce maternal mortality, most of the administrators and the public had come to the conclusion that the man to be blamed was the general practitioner. Three or four years ago the Minister of Health had appointed two of the higher members of his hierarchy to make " a " field investigation in an area where the mortality had been exceptionally high. They had at length published a beautiful report 350 pages long, written in perfect English and full of statistical tables. The only factor they had been able to incriminate had been the weather. They had therefore immediately taken the line of least resistance and blamed the general practitioner more than he had ever been blamed before, and had recommended that the local authority should be empowered, in consultation with the local medical profession, to see that the best local skill was available for women who required it. This meant that the mother should have only that medical skill which was thought to be best by the medical officer of health and two or three of the local profession, and that the average general practitioner should be prevented from coming to help the midwife. Nothing could be more unfair than that the medical officer of health should be able to take away from a general practitioner his existing right to practise midwifery among the working classes, but this would happen if the Midwives Act, 1936, was the success which all hoped it would be. was
SOME FIGURES FOR RECOVERY
The Ministry of Health was one of the greatest sinners in promulgating false statements. One of the worst of these was the figure for maternal mortality, which was exaggerated by 10 or 15 per cent. through the inclusion of abortion deaths. It was 3.81 per 1000, and ought to be 3. The recovery rate was therefore 99.7 per cent. In a condition in which the whole of the woman’s metabolism was vitally changed, and which was beset with pitfalls, this was a marvellous figure, and the credit for it was due to the general practitioner. Of the remaining 0-3 per cent., only half, or 0.15 per cent., of cases were considered by the Maternal Mortality Committee to be preventable, and then only when the woman did what she was told, the midwife obeyed her rules, and the general practitioner never made an error and always had a good specialist, ambulance service, and hospital behind him. Given all those conditions, the general practitioners might increase the recovery figure from 99-7 to 99-85 per cent.-a superhuman approach to perfection. Premature use of forceps was extremely rare, but some local authorities quite illegally refused to pay more than 10s. for a night and 5s. for a day visit if the doctor did not put on forceps. Only if