TUBERCULOSIS SOCIETY.

285 six infants who showed all the signs he had enumerated typical of fibrosis. The root shadows were only slightly increased. There was a definite contrast between the physical signs and the X ray picture in the two conditions, and another important distinction SOCIETY. was the high percentage of negative Pirquet reactions in cases of fibrosis. It had sometimes been suggested AT a meeting of this Society, held on Jan. 14th, that the tubercle bacillus might start the process and Dr. JAMES WATT, the President, in the chair, Dr. then die out or give rise to a peribronchial tubercuC. D. S. AGASSIZ read a paper on the losis. He thought this sequence might occasionally take place, but probably not often, and it was Differential Diagnosis of Non-Tuberculous Fibrosis difficult to see why the fibrosis should increase. The of the Lungs. His experience of this condition, he said, was confined presence of cyanosis was also suggestive of fibrosis rather than of peribronchial tuberculosis. It had to cases in children, and he wished to draw attention to some points in the differential diagnosis which were been shown that one-third of the lung area must be nllt sufficiently stressed. The incidence appeared to involved to produce cyanosis, and it was impossible be greatest in children of from 5 to 10 years of age. to believe that one-third of the alveoli could be There was no evidence of a familial tendency. A history affected and yet give rise to no increase of root shadows. of an antecedent attack of broncho-pneumonia or The after-history of the cases was also important. whooping-cough was commonly met with. The most In a series of 50 cases of fibrosis, no less than 48 were constant symptom was cough, which recurred still alive after three to four years, and all of these especially in the winter and was accompanied by were at work. Lastly, there was the question of little or no sputum. When sputum was present it was post-mortem evidence, which was suggestive, though tenacious and mucopurulent. There might be a good not yet conclusive. He had had one or two postdeal of dyspnoea, which, however, appeared to cause mortem examinations on cases which had died of comparatively little distress. Haemoptysis was rare, fibrosis, and sections examined microscopically showed but cyanosis was frequently present and was of some no signs of tuberculosis. Other diseases, said Dr. Agassiz, in conclusion, importance. Clubbing of fingers occurred in about two-thirds of the cases. The physical signs varied might also sometimes cause difficulty in diagnosis. with the extent of the disease. The cardiac impulse Chronic bronchitis was uncommon in children ; the chest tended to become emphysematous, and the was displaced ; vocal fremitus might be diminished There was no disbut was always present. Auscultation showed the percussion note hyperresonant. Pleural effusion could be breath sounds to be diminished ; dry, leathery, creak- placement of the heart. exploring needle. Thickened pleura ing rates were usually present but were very incon- diagnosed by the stant. The temperature charts might either show a might present some difficulty, but in any case the slight pyrexia of at most 101° or 102° F., which would condition was probably always present to some extent In broncho-pneumonia fall in a day or two and would not be accompanied in fibrosis of the lung. diagnosis might not be possible during the height of an by increased respiration, or they might show a attack. temperature rising sharply to 102° or more, remaining D.iscussion. elevated for a week or so, and being accompanied or In 90 cent. The PRESIDENT said that he found it difficult to get 50. rate of 30, 40, per bva respiratory of these cases the Pirquet reaction was negative, over the fact of a negative Pirquet in so many cases. while it was a curious fact that in 10 per cent. the If Dr. Agassiz were right, it meant that about oneWassermann reaction was positive. Radiography 1third of the children that were being sent to sanatoriums was of great importance in cases of non-tuberculouswere being sent unnecessarily. What happened to fibrosis. The cardiac shadow was often displaced. 1these children afterwards ? They ought to turn into 1 cases of bronchiectasis, but he doubted whether Shadows were to be seen at the root of the lung and typical radiating from it, varying from slight streaks to dense 1they did so, and whether there were enough cases striations. The diaphragmatic shadow was irregular, of bronchiectasis to go round. and " peaking " would often be found on the inner Dr. G. T. HEBERT said that he had followed up two-thirds of the diaphragm, being probably due tosome of these cases of fibrosis for 10 or 12 years. He The root-shadows and basal shadows had often been struck with the physical well-being adhesions. might be more marked in one lung, but were usually
Medical Societies.

TUBERCULOSIS

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large number of adult patients who had been diagnosed as tibrotic, and after some years tubercle bacilli had been found in the sputum of a certain number of them. Dr. P. A. GALPIN said that he had come across a cases in which there had been repeated attacks of broncho-pneumonia with a history of cough but a paucity of symptoms and a good general condition. Such cases, giving abundant physical signs but few symptoms, were probably non-tuberculous. There seemed to be here some analogy with cases of bone disease.—tuberculosis contrasted with sclerosis of the bone. The tendency to destruction was greater in tuberculosis, while the tendency to sclerosis was greater in pyogenic conditions. The final test in both groups must be pathological. Dr. C. F. PEDLEY said that at one time he used to receive cases unlabelled. Nearly all these were associated with a nasopharyngeal condition. As a school medical ollicer, he hardly ever diagnosed tuberculosis ; a nasopharyngeal catarrh was usually present. Dr. T. R. ELLIOTT agreed with the lecturer that a large number of cases were wrongly diagnosed as tuberculous. In Shropshire lie had had cases with enlarged mediastinal glands in which there was definite fibrosis at the root of the lung. He wondered whether the fibrosis in such cases was congestive, due to pressure from the enlarged mediastinal glands. A history of contact with tuberculosis was an important point in the diagnosis, as was also a peculiar smell of sweat associated with tuberculosis. Dr. BRAND thought that the fibroid type of tuberculosis was uncommon in children under 15 He years of age, owing to the lack of resistance. believed that bronchiectasis began at a much earlier Fibrosis age than the speakers appeared to think. merely represented the reaction of the tissues to a bacterial agent ; it was symptomless and signless. Every degree could be present up to an extreme fibrosis causing interference with blood-vessels, alveoli, and bronchi. He also was a believer in the theory of Dr. Agassiz, and had no ditficult,y in looking upon tliese cases as non-tuberculous. He thought that a child who had pulmonary fibrosis plus bronchiectasis had very little chance of getting through to adult life without being notified several times over as suffering from pulmonary tuberculosis. Dr. F. R. WALTERS said that the points of difference between the two conditions seemed clear in children, but diagnosis was not so easy in adults. Dr. C. ROPER said that he had met with a large number of persons suffering from miner’s phthisis, and was convinced of the widespread existence of non-tuberculous fibrosis, although it might happen sometimes that tuberculosis was engrafted upon it later on.

great number of

Reply. Dr. AGASSIZ, in reply, spoke of the after-history of the patients. A certain number of cases, he believed, went on to bronchiectasis ; others in adult life were labelled chronic bronchitis ; some would probably clear up altogether. Lipiodol might throw a good deal of light upon some of these cases. Some probably did develop tuberculosis afterwards. He thought that cervical adenitis undoubtedly did occur in ’ association with fibrosis. Interlobar pleurisy was probably not as uncommon as was sometimes believed, and it might quite well lead to fibrosis. One or two speakers had referred to the comparative rarity of pulmonary tuberculosis in children. About onethird of his own cases had tubercle bacilli in the sputum, and more than these had bacilli in the faeces. He had had quite a number of patients, aged three, who had had positive sputum. Symptoms in fibrosis were undoubtedly less complained of by children. He agreed that chronic nasopharyngeal infectious conditions were extremely common and might very possibly cause fibrosis, and he thought that fibrosis was more common in both children and adults than was usually recognised. The PRESIDENT suggested that tuberculosis officers might help in the elucidation of the question by a careful following up of their cases of fibrosis.

ROYAL SOCIETY OF MEDICINE. SECTION OF DERMATOLOGY. AT a meeting of this Section held on Jan. 20th Dr. J. H. SEQUEIRA, the President, took the chair and Mr. II. S. SOUTTAR demonstrated the USES OF A STEAM-HEATED CAUTERY which has been described by him in THE LANCET.1 The use of heat coagulation, he said, in the destruction of malignant growths often had advantages over their removal by direct surgery. When properly used there was no hæmorrhage, and it was thus possible to deal with fungating masses where the direct control of haemorrhage by ordinary surgical methods was impossible. Provided the heat was applied at a low enough temperature, any degree of penetration could be obtained, and a dense covering of coagulated tissue was formed which allowed the deeper tissues to granulate under ideal conditions of asepsis. These results had usually been obtained by means of diathermy, but it had appeared to him that they could be got more simply and effectively with an applicator maintained at a constant temperature by a current of dry steam. His apparatus consisted of a small boiler in which -LNfeta Fuel" was used as a source of heat. The steam was slightly superheated by being carried

ACTION

AND

"

a flame, and was conveyed by a thick rubber tube to an insulated handle. This terminated in a nozzle on to which applicators of various forms and dimensions could be screwed, and the steam, after passing through the applicator returned by the handle to the discharge tube. The applicator was thus kept at a constant temperature of approximately 100°C., and so long as it was kept in contact with the tissues heat slowly penetrated and produced coagulation ; as the temperature of the applicator was absolutely constant the depth of penetration could be gauged with great accuracy. With large applicators, and on moist tissues. penetration occurred at a rate of about one inch in ten minutes. With small applicators minute defects such as spider nsevi could be destroyed in a few seconds. The range of applicability was therefore very large, and the instrument could be used with equal facility for the destruction of huge masses of fungating carcinorna and for the removal of minute cutaneous defects. The method had been found of peculiar value in the treatment of epithelioma of the skin arising on a scarred surface, e.g., after treatment for lupus and similar conditions by X ray& In such cases excision would leave a widely gaping wound which could only be closed with great difficulty. With the steam cautery these growths could usually be destroyed quite easily under local anaesthesia. and when the slough separated a granular surface was left which was easily covered by epithelium. Mr. Souttar then described and showed a number of cases, most of which were reported in article already referred to. Dr. H. SEMON showed three cases treated by the method. I.—Carcinoma on lupus treated by X rays in 1994. The patient, a man aged 65, had suffered from lupus

directly through

the right side of his face and nose for over ? When he was seen at the Royal Northern Hospital in March 1926, there was a moist fungating tumour itt the midst of a patch of X ray atrophy on the right cheek. The growth had extended deeply into the subcutaneous tissue and through the buccinator muscle. Under general anaesthesia the tumour was scraped away, over a palpating finger placed in the patient’s mouth. This enabled the operator to ascertain that the mucous membrane was still intact. The exposed area was then treated with the steam cautery in its full extent, and for a distance of about half an inch beyond its apparent limits. The lesion healed -completely in three weeks.

vulgaris of years.

This case, said Dr. Sermon, illustrated a over diathermy inasmuch as with

advantage

1 THE LANCET, 1926, i., 805.

notable finger

a