TUBERCULOSIS SOCIETY.

1305 Lieut.-Colonel R. H. ELLIOT stated his emphatic for more belief that trachoma was responsible blindness in India, Persia, Afghanistan, and China than all other eye conditions put together ; and he maintained that nothing like enough was being done by the Government to realise the necessity of grappling with the problem, especially in the earlier stages. For trachoma, if treated properly from the start, should never cause blindness. He heartily agreed with Colonel Kirkpatrick on two important points he had discussed : firstly, as to the great value of magnesium sulphate treatment of the conjunctiva; secondly, as to the ballooning of the conjunctiva, which had proved a most useful manoeuvre both for diagnosis and treatment. Colonel S. P. JAMES inquired if Colonel Kirkpatrick from his experience did not consider it important that trachoma should be made compulsorily notifiable in England.-Lieut.-Colonel KIRKPATRICK agreed as to the necessity that the condition ought to be notifiable as an infectious disease ; and Lieut.-Colonel ELLIOT advocated a further step-namely, that all doubtful cases should be notified, whether definitely ’, diagnosed as trachoma or not. An Early Portuguese Contribution to Tropical Medicine, by Dr. CARLOS FRANA, Collares, Portugal, which had been translated by Professor Clifford Dobell, was submitted in the translator’s absence by Dr. BAGSHAWE for publication in the Society’s Transactions. The subject was of considerable interest in the history of medicine, dealing as it did with the rlrst mention of some of the tropical diseases, ascribed to certain Portuguese physicians in the sixteenth and seventeenth centuries. The references included an account of cholera, by Garcia da Orta (1583) ; of yellow fever, by Ferreira da Rosa (1694) ; also descriptions by travellers, who were not medical men ; of scurvy, by Joao de Barros (1552) ; of the cholera epidemic of 1543, by Gaspar Correia ; and of Dermatophilus penetrans, in the production of what is now commonly known as " Chiggers," by Gaspar Affonso (1596). Mention was also made of a work of the sixteenth century containing a clear account of the part played by insects in the transmission of framboesia tropica (yaws), written by Gabriel de Souza, a Portuguese colonist of Brazil, in The account given by this shrewd observer 1587. of the sixteenth century had waited over three centuries for verification by the work of Castellani, who in 1907 demonstrated experimentally that the house fly (Musca domestica) could transmit the spirillum, Treporzerraa pertenue, of yaws. It was rightly claimed, therefore, that the name of? Gabriel de Souza was one which should henceforth figure in the history of Tropical Medicine.

TUBERCULOSIS SOCIETY. A MEETING of this Society was held on June 6th at the Margaret Street for Consumption, London, when a paper was read by Dr. NATI-IAN

Hospital

RAW, M.P., President of the Society,

on

What we do NOT Know regarding Tuberculosis. He said that in spite of an enormous amount of research work by many of the greatest clinicians and scientists of the day there still remained great uncertainty and lack of knowledge on several fundamental and crucial Tubercle bacilli were divided into three points. types, originally all of a common species-human, bovine, and avian. The avian did not infect man and so could be disregarded. Just as the bacilli of tetanus and dysentery selected special organs, so the human and bovine tubercle bacilli attacked different parts of the human body. Speaking generally, Dr. Raw said that the human bacilli attacked the lungs and larynx, whereas the bovine attacked the alimentary system and the lymphatic glands. How and at what exact time a person became infected with pulmonary tuberculosis was still a matter of uncertainty, and how long the bacilli had the power to remain latent before acute symptoms developed7was

still unknown. The period of adolescence was undoubtedly a critical period and one in which the infection was stimulated to activity. Pulmonary tuberculosis was caused by the human bacillus in 90 per cent. of cases and was always primary. The remaining 10 per cent. were secondary to a primary infection by the bovine bacillus and were either an extension from the cervical glands downwards to the apex or an extension upwards from the abdomen to the bronchial glands. The problem of the bronchial glands was still unsolved, and whether or not the bacilli live and flourish in the blood stream was still a matter of controversy. Diathesis played an important part in predisposition to tuberculosis, and gouty people were much less susceptible than those of the diabetic diathesis. Tubercle bacilli varied greatly in virulence and to-day their virulence appeared to be much less than it was 50 years ago. The amount of individual resistance to attack and the degree of inherited tendency were still matters of uncertainty. Nomadic tribes were relatively free from tuberculosis, whereas civilised nations were more susceptible; and hence tuberculosis was really a disease of civilisation. Dr. Raw said that introduced into a primitive race it rapidly decimated the population, as this population had neither immunity nor resistance. How did civilised peoples become more or less immune to infection ? Probably because the majority were infected with small doses which protect them against a more massive infection. Only a small proportion of married couples were infected, and this fact might be ascribed to the non-infected mate becoming immunised by contact with the infected mate. There was a strong antagonism between the human and bovine types of the tubercle bacillus, and it had never been found possible to distinguish the two types in the same body. If the body were attacked by the human type and exposed afterwards to the bovine, the latter Calmette had was incapable of causing infection. shown also that it was possible to protect calves and other animals by using attenuated bacilli of the same type. How was infection produced and how long might it remain latent ? The difficulties which arose when we attempted to answer these and other questions showed how little indeed we do know regarding tuberculosis and how much yet remained for research to accomplish. Discussion. Dr. H. B. GIBBINS remarked on the improvement shown by many women suffering from tuberculosis during pregnancy, for which improvement no adequate reason had been adduced, and on the fact that so few cases of the disease showed physical signs of excavitation. Dr. A. SANDISON commented on the association of the colour of the hair with disease and noted that red hair was more commonly met with in the rheumatic diathesis, and black hair in the tuberculous. Such association might be a matter of considerable importance in prognosis, to which aspect of the problem he thought too little attention was paid in general ; the psychology of the patient, his susceptibility to the influence of suggestion in treatment, had also been unduly neglected. Dr. F. HERNAMAN-JOHNSON stated that, so far as the X rays showed, pulmonary tuberculosis always appeared to begin in the hilus glands and to spread therefrom, bandwise or fanwise, towards the apex, which might or might not show signs of being affected. A pure apical tuberculosis was never found without definite signs at the root, though the connexion between them might not, however, be very obvious. Dr. HENRY A. ELLis called attention to the difference in prognosis between man and woman. The proportion of deaths in man grew greater as age increased, whereas the death-rate in woman was highest between the ages of 15 to 25. In regard to the question of immunity he pointed out that, if cases were injected with tuberculin in the pre-tuberculous stage, tuberculosis would not develop in them. Dr. CAMPBELL MCCLURE considered that one of the most hopeful signs of the times was the tendency to leavetheory alone and to concentrate on the tabula-

,

1306 tion of large series of

cases. Two most important OBSTETRICAL AND GYNAECOLOGICAL MONOGRAPHS. questions were (1) diathesis ; and (2) the low death-rate Pelvic Inflammation in IVomen. By JoHrr OSBORN from the disease compared with the high incidence-rate. POLAK, M.Sc., M.D., F.A.C.S., Professor of Dr. JOHN SORLEY thought that some of those Obstetrics and Gynaecology, Long Island College who held views on the production of immunity by London and New York : D. AppleHospital, &c. small infecting doses did not always have the courage 1921. With 2 coloured plates and ton and Co. of their convictions and put these views into prac88 illustrations. Pp. 229..ElIs. tice. It might be possible to produce immunity by THIS monograph deals with the large group of administering small doses of living bovine bacilli to children in milk, but one could not guarantee that diseases peculiar to women which result from septic, disaster might not result, and parents were not gonorrhoeal, and tuberculous infections, and an likely to offer their children for experimentation in attempt has been made to give the accepted pathology, view of this uncertainty. a definite clinical picture, and the treatment. Dr. Dr. ELLIS showed the upper lobe of the lung of a Polak uses the term pelvic inflammation in the wide lion which had died of pulmonary tuberculosis. The sense, since he deals with this condition as it affects whole lobe was one large cavity. The specimen was all parts of the genital tract. The book contains a obtained from the Zoological Gardens through the great deal that is interesting. The author has a very kindness of Dr. C. F. Sonntag. profound belief in the prevalence of gonorrhoea in the female, and considers it a potent cause of pelvic inflammation and of one child sterilitv. He quotes the well-known figures of Noggerath, the

Reviews

and

Notices of Books.

DIATHERMY. Its Production and Uses in Medicine and Surgery.

By ELKIN P. CUMBERBATCH, M.A., B.M. Oxon., London : Wm. Heinemann (Medical Books), Ltd. 1921. 44 illustrations. Pp. 193. 21s.

M. R. C. P.

Tur

author takes the trouble at the outset to

explain the term diathermy, which means the which occurs on the passage through heating through the body of an electric current of special kind. A brief history of the way in which these "

"

currents came into use is followed by the technical features which distinguish both their production and their application to the body in conditions of disease. The subject is a comparatively new one ; the first diathermy machine for medical use was introduced into this country by the late Dr. Lewis Jones in 1909. Dr. Cumberbatch’s work on diathermy is well known to those conversant with the subject ; the author’s particular studies on the rise in temperature of various parts of the body traversed by diathermic currents form the subject-matter of Chapter VI. ; they will repay careful perusal, for they are well-planned experiments. Further experimental work by Dr. Cumberbatch upon physiological lines-for example, the effect of diathermy upon blood pressure, pulserate, and respiratory exchange-paves the way for an appreciation of the medical possibilities of this special form of electric current. One of the most striking features of electrical currents, which alternate with great frequency, is their inability to stimulate the excitable tissues. Until quite recently no explanation of this has been offered, but researches upon this phenomenon have now shown that the power of an electric current to stimulate the excitable tissues depends both upon the strength of the current and upon its duration ; if the latter falls below a certain critical value the current loses altogether the power of excitation. The diathermic currents flow for less than this critical period of time before they reverse and therefore have no stimulating action ; the sensation of warmth which is felt is due to the actual generation of heat within the tissues by these currents. The body can tolerate sufficiently large currents of this kind to allow of a very considerable rise of temperature : herein lies the possibility of surgical applications of these currents, discussion of which forms the concluding chapter of the volume. The book is an excellent one. The subject is dealt with in a thoroughly scientific manner, the descriptions of the various types of diathermy machines at present in use are brief but lucid ; the author has a scrupulous regard for exactness in every detail of his subject. On p. 16 an inversion of sentences occurs which the author will doubtless correct in future editions. The book is illustrated with line drawings and plates which enhance but do not over-balance the letterpress.

accuracy of which

we are inclined to doubt. However, is well known, the proof is difficult to obtain owing to the rapid disappearance of the gonococcus in these cases. Dr. Polak maintains that pyogenic cocci not infrequently persist in the prostate of men who have had gonorrhoea, and that in some cases they are the cause of infection in their wives. Considerable stress is laid upon the frequency of gonorrhœal infection of the mucosa of the cervix, and its treatment by a cone-shaped excision of the affected area is recommended in bad cases. The chapter dealing with gonorrhoeal infection is a very good one, and in the section on treatment great stress is laid on the importance of preventing the upward spread of the disease. In discussing the treatment of cases of puerperal infection the author strongly maintains that local interference is practically always contra-indicated and entirely condemns manual manipulations within the uterus or the use of the curette. In dealing with cases of puerperal pyæmia and general puerperal infection, treatment by sunlight, food, fresh air, repeated small blood transfusions, and general supportive stimulation is advised. Dr. Polak believes that by the repeated transfusions of small quantities-300-500 c.cm.—of citrated blood it is possible to lessen the secondary anaemia,to increase the number of active leucocytes, and to raise the blood pressure. Reliance is also placed on postural drainage by Fowler’s position, proctoclysis, posterior colpotomy, and packing the pelvic cavity with gauze after the method introduced by Pryor. In the radical treatment of cases of salpingitis it is urged that no operative procedure should be undertaken until all acute symptoms have subsided. The case is tested by a blood count and a thorough bimanual pelvic examination. If after this the temperature and the leucocytes are not raised the operation may be performed with safety. Four very interesting cases are quoted in this chapter, in which the streptococcus lay latent in a parametrial exudate for periods varying from five to 15 years, and then gave birth to a general infection. In removing infected tubes Dr. Polak recommends the procedure by which a wedge-shaped portion of the fundus of the uterus, including the pars interstitialis, is resected. Resection of the ovary on general principles, in his opinion, should be discouraged. Dr. Polak’s book is interesting and valuable, and contains a great deal of information based on sound principles and on a wide experience. as

Cœsarean Section. By FRANKLIN S. NEWELL, A.B., M.D., Professor of Clinical Obstetrics, Harvard University ; Obstetrician. Massachusetts General Hospital. London and New York : D. Appleton and Co. 1921. With 53 illustrations. Pp. 210. £1Is. THE operation of Cæsarean section is occupying so large a place in the treatment of many complications of labour at the present time that a methodical review of the operation and its results,