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had done the job without producing ill effects. He

- thought it was important to have a vaccine madefrom the organisms of the first case in an outbreak,.and he believed this would prove more successfulthan stock vaccines.

Dr. A. A. W. PETRIE asked what effect inoculationhad upon the symptomless carrier who kept epidemicsgoing; patients of this kind might show nothingmore than a slightly loose stool on a single occasion,yet they might be passing bacilli in large numbers.Negative findings in the laboratory might be due toa change in the type of bacillus; at Banstead,dysentery had usually been due to Flexner organisms,but in one outbreak a series of negative results hadproved to be due to a Sonne infection, for the cultureof which slightly different technique was needed.Dr. PADDLE, in replying, said that success with

inoculation depended on giving the vaccine as soonas possible after the development of the primarycase. He had had no experience of oral vaccines.In order to get a positive bacteriological result it wasessential to plate the material at the bedside as soon.as a stool was passed, or else to take a rectal swab.It was not easy to give a definite estimate of theduration of immunity ; .he thought that in a minorityimmunity lasted about 4! months ; in most patients itlasted 1-2 years. There was no evidence that patientswere more susceptible during the time they werebeing immunised. Judging by the titre, immunitydeveloped within 3 days of inoculation and reacheda maximum in 7 days ; but McCartney consideredthat immunity was relative and differed from day today and sometimes from hour to hour. If a personencountered a sufficient dose of a virulent organismhe would get dysentery though he had been immunised.He agreed with much that Dr. Martin had said, buthe saw no reason why dysentery should not occur inpatients with a titre of more than 500: were we

justified in supposing that titre and immunity wenthand in hand ’? In a hospital for mental defectivesthe problem was largely one of low-grade " wet anddirty " patients. He thought it quite understandablethat cases due to the W type should appear in

patients inoculated with a ZX vaccine. Thevaccine used at Caterham had contained all the

likely organisms.

LIVERPOOL MEDICAL INSTITUTION

A MEETING of this institution, held on Nov. 18thwith Prof. R. E. KELLY, the president, in the chair,was devoted to

Thyrotoxicosis. Prof. HENRY COHFN said that few subjects weremore appropriate for discussion. Despite the pre-valence of thyrotoxicosis its nomenclature was con-fused, its aetiology was unknown, its treatment wasso irrational as to depend on the most primitive oftherapeutic principles (" if thy right hand offendthee cut it off "), and its prognosis was so uncertainas to shake the reputation of many an experiencedprophet. He doubted if it were possible to define itwith greater accuracy than as " a state of intoxica-tion dependent on the thyroid." The term hyper-thyroidism was inappropriate, for the conditionproduced by continued intake of thyroid extractdiffered from Graves’s disease in showing no changein the structure of the thyroid gland and no exoph-thalmos. Administration of the thyrotropic hormoneof the anterior lobe of the pituitary produced charac-teristic changes in the thyroid : (1) colloid loss ;{2) a change in the epithelium lining the vesicles,

from cuboidal to columnar ; (3) a decrease in theiodine content of the gland itself ; and (4) an increasein the iodine content of the blood and urine. More-over it caused exophthalmos, even in thyroidectomisedanimals, unless the superior cervical ganglia had beenremoved. The effect of thyrotropic hormone, how-ever, was only temporary, for an antithyrotropicprinciple developed in the blood which inhibited thestimulation of metabolism by the thyrotropic hor-mone, though it had no effect on the stimulation ofmetabolism by thyroxine. Normal animal andhuman blood had a slightly inhibitory action on thethyrotropic hormones, but the blood of a patientsuffering from Graves’s disease had none. Recentlythe antithyrotropic principle had been obtained inpowder form, and it was clear that its effect was notdue to iodine. Prof. Cohen had seen many cases of

acromegaly with associated thyrotoxicosis. On theother hand, where the pituitary gland had beenexamined in fatal cases of thyrotoxicosis no grossdefinable abnormality had been observed. Caution,however, was necessary in interpreting these nega-tive findings, because very slight changes might giverise to severe bodily disturbances, as was seen fromthe influence of a minute basophil adenomata of theanterior lobe of the pituitary.An attempt had been made to divide cases of thyro-

toxicosis into two main types: (1) Graves’s disease,associated with exophthalmos and a diffuse hyper-plasia of the thyroid, seen in young patients withdominantly nervous symptoms and subject to spon-taneous remissions and relapses ; and (2) Plummer’sdisease, in which the goitre was nodular and eye signsabsent, seen in older patients with dominantly cardio-vascular signs, and usually more progressive. It hadbeen suggested that the former were more likely tohave a pituitary origin, and the latter to be trueexamples of hyperthyroidism. But while it was

true that typical examples of these two main typesexisted, a very large proportion of cases had featurescommon to both; moreover, even with nodulargoitre, there were diffuse hyperplastic changes inthe non-adenomatous areas of the gland. Theseattempted classifications took little heed of the rateand intensity of action of toxins, and the soil onwhich they were acting.

It was important to recognise that thyrotoxicosisappeared in various guises which obscured theclassical features. The presenting symptoms of" masked " thyrotoxicosis were, in Prof. Cohen’sexperience, mainly: (1) ) cardiovascular disorders,including auricular fibrillation, hyperpiesis, and cardiacfailure ; (2) rapid wasting, especially seen in middle-aged males with a good appetite, often mis-diagnosedas diabetes because of the slight glycosuria so commonin thyrotoxicosis ; (3) diarrhcoa with, rarely, othergastro-intestinal symptoms, occasionally includingintractable vomiting ; (4) psychotic manifestations ;(5) nervous manifestations, of which ophthalmo-plegia and amyotropic lateral sclerosis were the mainbut rare examples. He regarded factors such as

psychic trauma, infections, sex cycles, and reducingcures as activating rather than causative. In hisview estimations of basal metabolic rate were

unnecessary for diagnosis ; all accessory tests, whetherof metabolic rate or electrical impedance, measuredlevels and trends, but more important was the dura-tion of the toxaemia and its effect on tissues, and thiscould be estimated only by clinical observation.Plummer’s work on iodine had revolutionised

the therapy of thyrotoxicosis. But though rest,iodine, and X ray treatment might cure the mildcase in which psychogenic activation played a part, a

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subtotal thyroidectomy, after adequate preparation,was the treatment of choice for the vast majority ofpatients, and should not be delayed. The results incases conforming to the Graves type were perhapsless satisfactory than in those of the Plummer type.All cases should be carefully followed up, and residualor recurrent thyrotoxicosis dealt with immediately.When all was said and done, however, surgery re-mained a confession of failure, and it was to be hopedthat work on the rôle of the pituitary might yield amore rational therapy.

Mr. J. B. OLDHAM said that at present surgicaltreatment was the best we had to offer the patient.The immediate mortality in reputable clinics hadfallen almost to vanishing-point, some 90 per cent.of the patients were rehabilitated, and recurrenceswere rare. It must, however, be admitted that ina proportion of cases the exophthalmos was notcured and mild subjective symptoms remained. InAmerica it was the custom to operate on all cases assoon as a definite diagnosis was made ; but some at leastof the mild cases could recover with medical treat-ment, and in this type of case non-operative treat,ment should be attempted if the patient could affordthe time and money. Mr. Oldham emphasised thatmedical treatment did not mean simply rest andiodine but must be a broad regime, including prophy-lactic, dietetic, hygienic, medicinal, psychotherapeutic,and other measures. Iodine should not be used inthe non-operative treatment of toxic goitre except inan emergency such as thyroid crisis. It was unfor-tunate that many of the profession had the impressionthat iodine in itself was a curative agent ; given afalse sense of security by the temporary benefitsderived from its use, they persevered in non-operativetreatment until the best moment for surgery waslong past. He was convinced that iodine given forweeks or months lost its power to improve the

patient, which meant that its help was not availablewhen it was most needed-at the time of operation.

Mr. Oldham held that almost all cases, exceptearly ones in young patients with primary thyro-toxicosis, should be treated by subtotal thyroidec-tomy as soon as the diagnosis was made. Compli-cations occurred in neglected cases and althoughsurgeons were able to get extraordinarily good resultsin these serious cases that was no excuse for leavingthe patients till they were very ill. For thyroidcrisis he had found the oxygen tent of singular value.During the last four years Mr. Oldham had operated

on 186 cases with 3 deaths. He had used Avertinwith gas-and-oxygen in all but one case, and thiswas the only one in which there were any pulmonarycomplications. He used surgical diathermy for theskin incision and for dissecting up the skin-flaps. Asa rule he did not divide either the platysma or infra-hyoid muscles. In every case in this series a one-stage subtotal resection was done, and it was hisbelief that the less thyroid left behind the less likeli-hood there was of post-operative crisis or residualsymptoms. He found that he was draining fewerand fewer cases as his experience increased and thatthe most perfect scar was given by interruptedeversion sutures of silkworm gut, removed on thesecond or third day after operation. Mr. Oldhamadmitted that he followed the usual habit of givingiodine after operation, but he failed to see the logicof it provided full iodinisation had been producedbefore operation and a sufficient amount of the glandhad been removed.

Dr. ROBERT CooP spoke on the association of

hyperthyroidism with pancreatic disorder. In 1912Cohn and Peiser had recorded 5 cases of inflammation

of the pancreas associated with hyperthyroidism,while Holst, Garrod, and other writers had describedcases of hyperthyroidism in which autopsy revealedatrophy and other lesions of the pancreas. Theassociation of glycosuria with hyperthyroidism wasmoderately common, but not as common as was

sometimes assumed. John (1928) found hyper-glycsemia in less than 10 per cent. of his cases ofhyperthyroidism, and noted that the loss of sugartolerance did not run at all parallel with the severityof the hyperthyroidism. In Dr. Coope’s experiencetrue diabetes mellitus accompanied by hyper-thyroidism was very rare. In the last few years hehad seen three patients suffering from true diabetesmellitus in whom careful examination revealed a realbut quite mild hyperthyroidism. All were under35 years of age. They were given X ray therapy tothe thyroid gland ; two of them, who previouslyneeded 12-15 units of insulin a day to keep them" standardised," were afterwards able to take thesame controlled diet without any insulin, while thethird was enabled to reduce his daily dose from50 to 17 units. But though these patients were" cured " of their hyperthyroidism, they still remaineddiabetics, though of milder degre&; even those nolonger needing insulin could not abandon dieteticcontrol without a reappearance of hyperglycaemia andglycosuria. The disturbance of carbohydrate meta-bolism in this type of case was not due to thyroid" toxicity " ; the hyperthyroidism put a strain on analready weak link, so revealing a tendency, previouslyunsuspected, to diabetes, or making an obviousdiabetes more severe.

Mr. PHiLip HAWE said that the diagnosis of thyro-toxicosis was not always easy, and it was of para-mount importance to exclude cases of neurovascularasthenia, early phthisis, and early mental disease.Some help was to be obtained by noting the effectof iodine treatment on the patient’s condition. Itwas difficult to assess the value of impedance angletests, and although these might replace ordinarybasal metabolic estimations the clinical features ofthe case should have priority in reaching the diagnosis.Although Mr. Hawe favoured the one-stage operationhe had recently, in a few cases with very advancedmyocardial damage, used a two-stage procedure withsatisfaction. Possibly the advantage of a shorteroperation in such cases outweighed the risk of a

post-operative thyroid crisis, which seemed less likelyto occur when a very large proportion of the glandwas removed.

Prof. JOHN HAY said that if objection was offeredto the term " masked " thyrotoxicosis the conditionmight be referred to as " easily missed." In these

patients the underlying thyrotoxicosis was camou-flaged by some more obvious clinical manifestation,such as cardiac irregularity, cardiac failure, or gastro-intestinal disturbance. But as operation was

undoubtedly the most satisfactory line of attackand successful treatment depended on early treat-ment it was of the utmost importance that theatypical form of thyrotoxicosis should be recognisedas soon as possible. Exophthalmos was often absentor slight, and the thyroid was not necessarilyenlarged. Thyrotoxicosis should be suspected whentachycardia was associated with loss of weight(a loss of weight that continued in spite of rest inbed and a good appetite), or when the tachycardiawas associated with a rise in blood pressure and asimultaneous rise in pulse pressure. In thyrotoxictachycardia the mitral first sound often had a sharp,snappy quality that should arouse suspicion. Again,paroxysmal auricular fibrillation or persistent fibrilla-

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tion in the later decades would in itself suggestthyrotoxicosis.

Dr. T. F. HEWER said it was often impossible tooffer any opinion as to the toxicity of a goitre onhistological grounds. Iodine medication before opera-tion altered the histological appearance of an otherwisetypical Graves’s disease and quite often apparentlysimple colloid or adenoparenchymatous goitres wereclinically toxic.

Dr. ROBERT KEMP said that an attempt to dividethyrotoxicosis into the two main clinical groups-diffuse toxic goitre and nodular toxic goitre-seemednecessary when the results of treatment were reviewed.In following-up a group of 90 cases operated on,containing equal numbers of both types, " completecure" was found in 70-80 per cent. of the nodulartoxic group, whereas there were residual symptomsin all but 30-40 per cent. of the diffuse toxic goitres.

It seemed clinically that the toxicosis of nodular

goitres was mainly thyrogenic, corresponding withthe results of administering thyroid substance or

thyroxine ; hence thyroidectomy was fairly rationaland gave good results. On the other hand, the pictureof diffuse toxic goitre resembled experimentally pro-duced " pituitary thyrotoxicosis." Here, where theprincipal mechanism was untouched, operation wasnot likely to be so successful. It was in such cases thatLoeser’s antithyrotropic substance would probably beof great value.

Dr. G. F. RAWDON SMITH emphasised the desira-bility of not refusing operation to patients desperatelyill from one of the complications mentioned by Prof.Cohen ; he gave three illustrations from his ownpractice, in which the patients, though not cured,had been able to resume their ordinary avocationsafter operation.

REVIEWS AND NOTICES OF BOOKS

Control of Tuberculosis in England, Pastand PresentBy G. GREGORY KAYNE, M.D., M.R.C.P.Lond.,D.P.H., Deputy Medical Superintendent, CountySanatorium, Clare Hall, Middlesex. London:Humphrey Milford, Oxford University Press.1937. Pp. 188. 8s. 6d.

A GENERATION has passed since, in 1908, the Statebegan its administrative control of tuberculosis byissuing regulations for the notification of certain

groups of persons suffering from phthisis. The timeis opportune for a survey of the steps taken in thepast and for consideration of the efforts to be madein the future to deal with a disease which still causesa formidable mortality amongst those in the primeof life. Individual enterprise showed the need andbegan the attack on tuberculosis : Bodington in

England opened the first sanatorium, and SirRobert Philip in Scotland began dispensary work atEdinburgh in 1887. Gradually the growing publichealth service was compelled to take a part, butdespite development and some new contributions,the movement lost drive and the ideas on which itwas based were more fully worked out abroad.Dr. Kayne divides his book into three parts, the firstcovering the period before 1908, the second from thatdate up to the present day, while in the third heconsiders the problem now, discussing the meritsand shortcomings of our present methods andthe possibilities for improvement. The last partproperly brings under review not only purelyadministrative but also certain clinical aspects of thedisease. Ample statistical tables illustrate the textwhich is fairly and lucidly set out.

Dr. Kayne has used his tenure of the DorothyTemple Cross Research Fellowship to good purpose,and embodies here the experience he derived fromhis study on the Continent. Though private treat-ment will not be wholly abandoned, especially for

the well-to-do, he forecasts an increasing Statecontrol, for " the preservation of the health of the

population will come to be regarded on the samefooting as national defence or police supervision."He is zealous for the really effective care of thepatient and for thorough investigation of the family :he would not relinquish the control of any patienttill the last tubercle bacillus disappears from thegastric lavage, and the dossier contains the radio-gram of every contact. Group radiography too musthave an important place. While the numbers ofcontacts examined annually hardly exceeds the

number of new cases discovered, and while the useof radiology in dispensaries is still limited, there isno room for complacency though recent years haveshown the beginning of a new phase of energy andenthusiasm. Dr. Kayne thus reflects not discontentalone but also optimism and concentrates the beamin an illuminating and stimulating way. All interestedin tuberculosis in its varied aspects, especially mem-bers of public and private bodies concerned withpublic health, would do well to study its pages,though of course its special appeal is to the medicalreader. The volume is one of the Oxford MedicalPublications and its production maintains the highstandard of that series.

Medico-Legal Aspects of the Ruxton CaseBy JOHN GLAISTER, M.D., D.Sc., Barrister-at-law ;Regius Professor of Forensic Medicine, Universityof Glasgow; and JAMES CoupER BRASH, M.D.,F.R.C.S. Edin., Professor of Anatomy, Universityof Edinburgh. Edinburgh : E. and S. Livingstone.1937. Pp. 284. 21s.THIS record of the conscientious reconstruction of

the Ruxton remains is a classical contribution toforensic medicine. The Ruxton case was the first in thecriminal records of this country in which two separateidentities were established solely by accurate andhighly skilled reconstruction of remains. Identitywas not disputed in the Mahon or Thorne cases, andboth the Voisin and the " trunk murder " remains wereidentified principally by laundry marks. The Crippencase hung on two slender points for identity, and inan American case alone, that of Parkman, is thereany precedent for the magnitude of the undertakingembarked on by Glaister and Brash. To the generalmedical public this lavishly illustrated, quietlywritten book, provides a revelation of modern forensicingenuity. Soft and skeletal tissues, hair, teeth, sex,age, stature, special characteristics, finger nails andprints, feet, identity by super-imposition uponprevious studio or other photographs, are discussedin turn in a manner almost Hunterian in its applica-tion of foundation to argument. When Dr. Glaistersays : "I formed the opinion that-" we soonlearn to expect a judicious mixture of scientificreserve, facts neatly marshalled by an unassailabletechnique, and a conclusion based on sound premises.Here is no witness " for the prosecution," but for thetruth. It is noteworthy that no single point in thescientific evidence given in the case was broughtinto question by the defence, and no opinion refuted.