1222

its effects to those of the effervescing bath. Britishspas are therefore the most tonic in the world, and,if suitably utilised for preventive and curative treat-ment, are well adapted to the chronic ailments andinfections of our own country, such as catarrh, tuber-culosis, and rheumatism. Among modern methodsrequiring development at home, Dr. Fox specifiedthe utilisation of the British eliminative waters, theemployment of various forms of effervescing baths,and the external treatment of young subjects by saltwaters. New knowledge had been acquired of thephysical properties of various waters : the patientinvestigations of a few devoted workers, like Winter-nitz and his pupils, had borne much fruit; new lightwas constantly being shed by physiological discovery(to a large extent in England) ; and last, but notleast, the systematic instruction that had been givenfor 20 years in continental countries, in the schoolsand at the spas, had resulted year by year in attract-ing to the study of waters and baths a group ofscientific workers. These and other causes, Dr. Foxconcluded, had transformed the position which thisgroup of physical remedies occupied in our materiamedica, and entitled them to an assured and essentialplace in the future. ____

REST OR EXERCISE IN THE TREATMENT OF

PULMONARY TUBERCULOSIS?

ON June 4th there was a general meeting of thatverv live body, the Society of Superintendents ofTuberculosis Institutions, at 122, Harley-stieet, whena paper was read by Dr. E. E. Prest on the Treatmentof Pulmonary Tuberculosis bv Graduated Labour.The paper was a criticism of this treatment, and theSociety had invited Dr. Marcus Paterson to reply.Othermembers joined in the discussion which followed,and it was remarkable in this that many, if not most,of the speakers had themselves suffered from pulmonarytuberculosis. It is not often that, at a medicalmeeting, the discussion of the treatment of a certaindisease is conducted by its victims, and it would bedesirable if this practice were to be more commonthan it is. It would, for example, be remarkablyinstructive if the subjects of venereal disease were tojoin in a debate on its suppression, although theorganisers of such a debate might experience somedifficulty in recruiting speakers. On the presentoccasion it was a significant fact that most of the

Ispeakers who pleaded for prolonged rest in the treat- ment of pulmonary tuberculosis had been perilouslyclose to, or within the limits of, the third stage of thedisease, while the advocates of exercise and graduatedlabour were for the most part able-bodied persons orex-patients who had had but a fleeting, Turban-Gerhardt-first-stage taste of the disease. Indeed, theinfluence of pulmonary tuberculosis on the opinionsof individual speakers was so characteristic that, aseach person spoke, it was possible to form a com-parat.ively accurate estimate of the extent to whichhe or she had suffered from tuberculosis. Thisgrouping of the speakers naturally suggests thatwhile exercise may be very beneficial to personssuffering only slightly from tuberculosis, and toothers who are quite immune to it, rest is the mostimportant remedy for those whose disease is advanced.One of the chief criticisms directed against graduatedlabour in sanatoriums was concerned with itseducational effects. It was pointed out that the fitterthe patient, the more graduated labour lie was given,and that there was a serious risk of patients drawingthe erroneous conclusion that, the harder the workthey were set, the fitter they would become. At thepresent time, with sanatorium treatment lasting onlythree or four months, the most important rule of thesanatorium is its educative work, and it would bedeplorable if patients were to leave these institutionswith the impression that rest is bad because they seethe worst cases kept in bed and the earliest casesexercised. One of the speakers who dwelt on theeducational functions of the sanatorium in thisconnexion, ventured the caustic suggestion that had

Dr. Paterson Kept Ths hrst-Stage patients in IJCtA and

set his third-stage patients to navvying, more of hisold Frimley patients would be alive. For he wouldhave taught his patients by practical demonstrationthat first-stage cases ultimately prosper on a regimenof prolonged rest, while there is nothing like excessiveauto-inoculation for speeding the third-stage patientto his end. In surmming up the chief points of thisdebate, both Dr. Paterson and Dr. S. Vere Pearson,the Society’s President, remarked that the differencesof the two camps were not perhaps as marked andirreconcilable as the opinions of the enthusiasts ateither extreme might suggest. Both remedies havetheir legitimate sphere of usefulness, and, as Dr.Paterson insisted, whether a lung be rested by anartificial pneumothorax or exercised by navvies’work, careless technique and supervision may pro-duce but a sorry caricature, stultifying intrinsicallyvaluable methods. Dr. Pearson suggested that whilerest was suitable during the stage of toxaemia,exercise might be beneficial when toxaemia had ceased.No objection was raised to this perfectly soundgeneralisation, but who can say when the toxaemia oftuberculosis has disappeared ? It is surely one of themost difficult questions to answer, but in insisting onthe superiority of the rectal method of taking thetemperature over the oral and axillary methods,Dr. Prest pointed the way to the readiest method ofdistinguishing between active and inactive, toxæmicand non-toxæmic tuberculosis. Until such laboratorymethods as the rate of precipitation of the erythro-cytes, the W’ildbolz auto-urine tests and others haveproved themselves trustworthy, the physician would dowell to use his clinical thermometer as the chiefarbiter between complete rest and graduated exercise.

SUPPURATIVE THYROIDITIS OR LYMPHANGITIC

ABSCESS?

IT has hitherto generally been taught that mostsuppurative conditions in the lower anterior triangle ofthe neck originate in the thyroid gland-i.e., beginas a thyroiditis. In the Schue-izerische medizinischeWochenschrift for May 3rd, Prof. P. Clairmont, of theUniversity Surgical Hospital in Zurich, throws out thesuggestion that in many cases the thyroid has little ornothing to do with abscesses in this position, and thatthey are often due simply to inflammation in thelymphatic vessels in the triangular space bounded bythe main blood-vessels of the neck as they run underthe sterno-mastoid muscle, by the median portion ofthe omohyoid muscle, and by the middle line of theneck. He has recently observed three cases, theclinical picture of which was remarkably uniform andwell-defined. In every case a unilateral swellingappeared at the anterior margin of the sterno-mastoidin the lower part of the neck. In two cases suppura-tive thyroiditis was diagnosed, and in the third it wassuspected, before the operation. This showed theabscesses to be unconnected with the thyroid gland andto be situated between one lobe of the thyroid andthe mid-fascia of the neck. Microscopic examinationof the wall of one of these abscess cavities showed it toconsist of granulation tissue, and within none of theseabscess cavities were lymphatic glands found. Thiscondition must be distinguished from diffuse phlegmonof the neck ; the type of abscess to which Prof. Clair-mont refers is, indeed, well defined anatomically.The prognosis is as good as for lymphangitic abscessesin the limbs, and after free escape of the pus has beenprovided by incision, the temperature usually fallsrapidly to normal, and uneventful recovery follows.One of the cases recorded was that of a lad, aged 16,who experienced a stabbing pain in the right side ofthe throat while eating blackberries. A few days latersevere pain and dysphagia set in, and he could swallowfluids only with difficulty. A swelling in the neckunder the jaw extended downwards, the temperaturerose to 39.6° C., and he could neither speak norswallow. Later a diffuse swelling appeared in theright, lower, anterior triangle of the neck, being