The Harveian Oration.

1146 midwifery. A former scheme for a one-portal system has so nearly succeeded that careful followers of precedent need not feel that in supporting a movement towards a general combination they are doing anything dangerously experimental. The Universities of Oxford and Cambridge may be ;trusted to uphold the principle that their medical degrees are academic acquirements and not licences to practise. Our belief is that if the University of London and the English ’Colleges can arrive at a basis of agreement, the one-portal

system with its many advantages might be found by all the other

qualifying

bodies to

be the

remedy

for admitted

was

of the future ’’ sanatorium treat.

truly prophetical

mentcombined with

to

likely

measures

prevent

auto-

Dr. WILLIAMS also draws attention to the

inoculations. remarks of SYDHNHAM, and fevers," who, after an

advanced

less

acute

of a

"the great physician of gout giving a rather striking isketch

pulmonary tuberculosis,

of

case

and

cas3,

consilers that

the

describes treatment

"which would suffice would be to abstain froma meat and wine for a few days and to take a balsam of sulphur and anise with sugar in the form of tablets and then a cough mixture of oil of sweet almonds, syrup of maidenhair, and syrup of violets, this tojbe taken off a stick of liquorice." SYDENHAM likewise forecasts the use of active exercise, for he says : "0 all the

difficulties in medical education.

remedies for

The Harveian Oration.

and continued

phthisis, long

horseback bear the bell....... Buk is

delivering the Harveian oration for this year befora the Royal College of Physicians of London Dr. C. THEODORE WILLIAMS chose as his subject one that fully carries out HARVEY’S injunctions to exhrt all Fellows and Members of the said College to search and study out the secrets of Nature by way of experiment." There is probably no one condition that has been more carefully studied in all its aspects than pulmonary tuberculosis-its etiology, pathology, and treatment, both curative and prophylactic, have recaived attention from physicians and scientists for generations. In a masterly and scholarly manner Dr. ’WILLIA1IS considers the progress of knowledge in regard to pulmonary tuberculosis since the time of HARVEY, dwelling more particularly on treatment. If we take a general survey of the therapeutics of the disease since that time, we can conveniently review the principal measures which have been introduced in three periods, the first being reckoned from the earliest date until 1882, when KOCH’S classical experiments determined the causation of the disease by the tubercle bacillus ; the second period extending from then until 1890, when tuberIN

" ague than riding for phthisis. rather fully on the treatment of

journeys

on

no surer a cure

for

Dr. WILLIAMS then dwells

consumption

at the time of

LAENNEC, Louis, JAMES CLARK, and others, in order to

"

culin

was

introduced ; and the third from that time

present.

cases

was

closely connected

with the depressing measures-e.g., and in vogue, and that the disease emetics-then bleeding was not, as has been urged, of an utterly different type from that which now prevails when the duration of life

is much greater. Dr. WILLIAMS also refers to the introduction of cod-liver oil, which, he asserts, has exercised a wonderful effect in the outlook of the disease. After the

discovery

of the tubercle bacillus efforts

the germ

directly by

the

and

means

were

of bactericidal

made to kill

drugs

taken

by

mouth, inhaled, introduced directly into the air passages,

injected

into the veim

or

subcutaneous tissues.

Very

many substances were employed, and although success has been claimed by some observers, in the hands of others satis-

factory results then adopted the soil or,

in

were

not obtained.

which unsuitable

other

were

for

words,

Indirect

supposed

to

measures were

by rendering growth of the bacillus, "increasing the resistance act

the

by

is a vague term which has patient"; received various explanations. Foremost amongst these was the or sanatorium treatment. Dr. open-air measures Nevertheless, WILLIAMS gives a brief history of the movement, which was of

the

this

discovery of the tubercle bacillus the treatment necessarily empirical in character, the true etiology of

Before the was

to the

show that the short duration of life in their

the disease not

having

been

determined.

occasionally there was an interesting rehearsal of future at first elaborated at German institutions. The various phases methods. Noteworthy is an Ejsay on the Treatment and through which the sanatorium method has passed are well of Cure Pulmonary Consumption," by GEORGE BoDIrlGTOv known. BREHMER and DETTWEILER were amongst the In THE LANCET of earliest pioneers, the latter in particular laying stress of Sutton Coldfield, published in 1840. a review on the work in which on the importance of rest. we He established the "Liegepublished Ju’y llth, 1840, w: remarked : "Tae modest and rational preface with which halle system." WALTHER of Nordrach took an opposite t’Y3 author iitrodctces his pamphlet on pulmonary consump- view and enjoined outdoor walks, whilst M. S. tion h 1S s) far influenced us that we shall merely PATERSOr, medical superintendent of the Brompton Hosgive an outline of his principles without expending any pital Sanatorium at Frimley, has evolved a system of portion of our critical wrath on his very crude ideas and graduatedlabour which has been attended by encouraging unsupported assertions ....... The measures, then, which results. Dr. WILLTAMs also comments on the favourMr. BODINGTON assures us have beenuniformly and com- able effect of mountain climate ia suitable cases. The pletely successful in the treatment of several cases of introduction of tuberculin by KOCH once again raised hopes tuberculous consumption ’ are detailed in the following that a specific remedy against tuberculosii had beenfound. 11

passages........ More agreeable or seductive medicaments could not certainly be found in any pharmacopoeia : fresh morning air t) ma’{e th3 patient breathe; g3od wine to brin, doyn his pulse, a good dinner to make him " at, and an opium pill to nuke him sleep." This

The earlier

results, lowever,

were

disappointing,

but within

modifications of the original substance have been made and tried, and a the present time in one form or another tuberculin is being extensively employed. The modern view of treatmeat by this method recent year’s

numerous

1147 differs considerably from that formulated by KocH. As originally used, tuberculin occasionally produced a stormy reaction, giving rise to dangerous destruction of tuberculous tissue and even setting free tubercle bacilli. It is now found, however, that an immunising response can be obtained without causing a reaction, namely, by using very minute doses, which produce the desired effectstoxic immunity and local hypersemia. The exact technique employed by different physicians varies, as also does the composition of the remedy. Dr. WILLIAMS urges further investigation, but expresses the opinion that such observation should be carried out in a hospital or sanatorium rather than at a tuberculin dispensary. He also refers to the theory of auto-inoculation which has been advanced by A. C. INMAN and M. S. PATERSOV to account for the benefit produced in those patients undergoing treatment by graduated labour. In conclusion, Dr. WILLIAMS discusses the prophylactic measures which have been adopted in the crusade against tuberculosis. That the decrease in the incidence of the disease has been in large measure due to improved drainage,

having sought this modification of its mode of practice is even less disposed to bind on itself fetters of inadequate pay." Lastly, there is a breezy unsigned article entitled, The <&2 per week Income Limit," which claims to speak from inside knowledge. This sharply criticises the alleged action of a committee meeting of the Representatives at Birming-

cubic space, and less overcrowding there can be no The problem of the housing of the workingdoubt. classes is one of the chief elements in the prevention of The education of the masses in the printuberculosis. ciples of cleanliness and ventilation is essential, for

Bill."

more

whole is aware that these principles are necessary for the prevention of the disease a powerful factor for good will have been established. In order to combat tuberculosis two principal achievements are required: the first, to establish immunity against the

if the

population

as

a

by collaboration of the physician laboratory) ; the second to improve not only in large cities but also in sanitary conditions, villages. The remarks of Dr. WILLIAMS in this year’s

disease

(this

must be done

and the worker in the

Harveian Oration will be an incentive to further labours on the part of all those who are genuinely anxious to assist in the conquest of what is still one of the most fatal of maladies.

The National Insurance Bill. contemporary, the St. Bartholomerv’s Hispital .Tu2crnal, publishes this month three articles and a prefatory editorial note, which together amount to a symposium on the National Insurance Bill. Dr. CHRISTOPHER ADDISON, who speaks with the fullest knowledge of the OUR admirable

Chancellor’s intentions tributes

an

well

of

as

his

actions,

con-

article in support of the Bill, and incidentally own attitude towards the vexed question

his

explains of the

income limit.

recently

come

of Direct

Council,

as

forward

Representative

Mr. as a

for

T.

who

has

candidate for the vacant

post

J.

England

and who may be taken

of the British Medical

as

VERRALL, on

the General Medical

speaking

for the leaders

11

ham under the

chairmanship of Mr. VERRALL, and accuses British the Medical Association of giving way on the essential point of the demand for an income limit. The anonymous writer, indeed, suggests that the withdrawal of Sir PHILIP MAGNUS’S amendment and the passing of Dr. ADDISON’S amendment would never have happened unless the Chancellor of the Exchequer had been given to understand that the medical profession had " climbed down" on the question of the income limit. The circumstances narrated for the first time in the third article and the inferences drawn from them would certainly not pass unchallenged if the article were

signature. According to the editor of the St. Barthol’Ont6qV’S Hospital J01!;rnal, the writer suggests that "the bulk of the profession has been kept ignorant of a

supported by

want of firmness

in terms

We

to

an

on

the essential of

an

income limit in the

believe, however, that according

GEORGE there

was never

any intention

on

his

to Mr. LLOYD

part

to agree

income limit.

These three articles seem to us to reveal only more clearly the position of deadlock which we have indicated in our recent surveys of the progress of the National Insurance scheme. On the one hand, the British Medical Association has stated more than once, and now most explicitly,1 that it will not modify in any way the policy which has been formulated by it and approved by the profession. This is the more necessary because one of the original and most vital of the six cardinal points of the Association’s policy has already been set aside by the vote of the House of Commons : we refer, of course, to the demand for a &2 On the other per week wage limit for all insured persons. hand, evidence is daily accumulating that the leaders of the Friendly Societies have no intention of relaxing their demands for the control of the administration of medical benefits. Thus, at the annual meeting of the National Conference of Friendly Societies, which was held last week at Edinburgh, the delegates, "representing over 4,000,000 benefit members of Friendly Societies in the United Kingdom," passed resolutions to this effect, and further resolved that in the event of Parliament not conceding their minimum demands they would recommend the whole of the societies throughout the country strenuously to oppose the passing of the Bill. It seems clear, therefore, that the Chancellor is faced by two ultimatums. Without the support of the medical profession he cannot work his scheme. He has not yet won this support by granting all their demands. Nevertheless, what he has already done to reconcile the medical profession has raisela storm of angry protest among the members of the Friendly Societies, which grows fiercer and more menacing as the Autumn Session approaches. Whatever may be the political results of their insistence, the medical profession at least will not

Association, writes of the present state of qualified approval. Mr. I YERRALL makes the very good point that Mr. LLOYD GEORGE give and the public must be told that the professionnot of the Bill

a

way. 1

Brit. Med. Jour.

Supplement,

Oct. 14th,

1911, p. 394.