902

REVIEWS AND NOTICES OF BOOKSPulmonary Tuberculosis

Medical and Surgical 2’reatment. By H. MORRISTON IDAVIES, M.D., M.Ch., F.R.C.S., Medical Super-intendent, Vale of Clwyd Sanatorium, ConsultingSurgeon to University College Hospital. WithChapters on Specific Treatment by L. S. T.BURRELL, M.D., F.R.C.P., Physician to the RoyalFree Hospital and the Brompton Hospital for

Consumption and Diseases of the Chest ; andTuberculosis in Childhood, by W. BURTON WOOD,M.A., M.D., M.R.C.P., Physician to the Cityof London Hospital for Diseases of the Heartand Lungs. London : Cassell and Co. 1933.Pp. 460. 27s.

Mr. Morriston Davies occupies a unique position inthis country, not only as a pioneer worker in thoracicsurgery, in which connexion his name is as well knownabroad as it is at home, but as one who for manyyears has combined the dual role of physician incharge of a sanatorium and thoracic surgeon. Thecombination of these qualifications in one man is

rare, but obviously the physician-surgeon shouldbe peculiarly well fitted to assess the value of treat-ment by ordinary sanatorium methods and thebenefits to be obtained by more active intervention.Mr. Davies’s constant insistence that the effects ofexpectant treatment at a sanatorium should bestudied before surgical intervention of any kind isconsidered will command general approval ; butwhen such methods have failed, the patient may wellbe prepared to accept immediate suffering and therisks inseparable from surgery in the well-foundedhope that surgical interference may lead at any rateto a temporary restoration of health and some prospectof permanent cure. Special interest thus attachesto the author’s descriptions of collapse therapy in allits forms. It is an achievement to have condensedso vast a subject into so small a space ; less than250 pages contain all that the general medical reader,and indeed almost all that the chest physician needknow of every accredited surgical method employedin the treatment of pulmonary tuberculosis. Thereader may feel that some of the operations described,involving three or even more visits to the operatingtheatre, would be a severe strain even on a phlegmaticpatient, and that by the highly sensitive such recurrentmutilations, undertaken as they must be withoutguarantee of success, would be regarded as worsethan death. It is indeed almost with a feeling ofrelief that we learn that some concession to humanfrailty is allowed when the position is at last admittedto be entirely hopeless and " it is time to relax someof the rigours of treatment." Mr. Davies’s care fordetail and therapeutic minutiae of treatment are

very apparent in his sympathetic references to thedying and in his suggestions for the alleviation ofterminal suffering.The golden mean is not easy of attainment. There

are those, and even sanatorium superintendents areof the company, who yield to the spirit of defeatism,and rather than risk the death of a patient will incurno risks in treatment. But as Mr. Davies pointsout, though death from misadventure may thus beavoided, death from disease becomes inevitable.There are also those who lose sight of the ends intheir enthusiasm for the means of treatment,and who appear to be more interested in experi-mental surgery than in the ultimate fate ofindividual patients. In the hands of the former

group valuable lives which might have been saved aresacrificed to the timidity or even to the mentalinertia of their medical advisers. But precipitateintervention or surgical interference in cases beyondthe reach of surgery entails unjustifiable risks in theone case, and aggravation of suffering in the other.And lives are lost which might have been saved.

Dr. L. S. T. Burrell contributes a useful section onspecific therapy, and Dr. Burton Wood has writtenan admirable chapter which describes and illustratesthe various manifestations of pulmonary tuberculosisencountered in childhood.We warmly commend this book, not only to the

attention of special workers in this field, but also tothe general practitioner upon whose advice as to thebest methods of treatment the ultimate fate of thepatient often depends.

The Teaching of SpeechBy G. SIBLEY HAYCOCK. Stoke-on-Trent: Hilland Ainsworth Ltd. 1933. Pp. 302.Tms book, issued by the National College of

Teachers of the Deaf, is made up of three partswritten at different times and approaching the

subject from different angles. The first section, onthe methods for promoting the quality of naturalnessin the speech of the deaf, is the Braidwood prizeessay, awarded to the author in 1928. It is a cleardescription of the ways in which the teacher of thedeaf may induce by cultivation a good voice, resonant,intelligible, and satisfactory as regards speech. Thetask of the teacher is particularly difficult when apupil has to be taught to vary the pitch, and Mr.Haycock rightly points out that in all the methodswhich he suggests the teacher, besides being experi-enced and possessing a good ear and technicalknowledge of the rules’of voice production, must haveimagination and ingenuity. The second section ofthe book is a classification of speech sounds with anexplanation of their production and development.The common faults of voice production are statedas well as the methods for their correction. Thedirections given are precise and elaborate; even

when labial and dental adaptation are required theauthor’s instructions can be followed. The third sec-tion deals with the maintenance of intelligibility andcontains practical suggestions as to how intelligibilitymay be promoted throughout a school career. An

interesting addendum to the first section is a noteon the value of suggestion in the development ofpitch in the voice of congenitally deaf children.The child possesses a larynx and all the accessoriesfor supplying motive power and for increasing thevolume and resonance of the laryngeal note, butcannot produce markedly different tones. The onlyway out of the difficulty, says the author, is for theteacher to act on behalf of the child and devisesuitable exercises for the evocation of tones. Then,and with great perseverance, he must proceed onthe principle of trial and error instructing the pupil toreject the bad results and hold fast to the good.

Mr. Haycock, who is superintendent of the LangsideSchool for the Deaf in Glasgow, has for many yearsbeen recognised as one of the foremost teachers ofthe deaf not only in England but in all civilisedcountries, and it is good that he should have placedhis range of practical knowledge at the disposal ofthose concerned. "

903THE DIFFERENTIATION OF NOXIOUS DUSTS

THE DIFFERENTIATION OF NOXIOUS DUSTS

THE LANCET*

Z02VDOVr SA TURDA Y, APRIL 28, 1934

THE medico-legal significance of dangerous dustsin industry is beginning to assume the internationalimportance which it has long deserved. Followingthe report of a committee of experts convened lastyear, a meeting of representatives of governmentsis to be held at Geneva next month with the objectof drawing up a preliminary charter to secure

compensation for those who suffer damage due tosilicosis, one of the most generally recognised formsof hazard. It is unlikely that asbestosis, anotherscourge whose evils have been demonstrated more

recently, will as yet be granted international status.The sequence leading up to’such recognition usuallybegins with private action-i.e., admission by afirm or group of firms conducting an industry thatthe workers in it are liable to a risk. This admissionis sometimes made spontaneously and sometimesunder pressure of local public opinion, and is

generally associated with research into the methodswhereby the risk can be reduced or avoided. Therefollow regulations for the protection of personsemployed in the hazardous occupation and a

scheme of compensation for those affected in

proportion to the damage they have suffered. Thenext stage is the coordination of such schemes inany one country by laws designed to bring thepractice of all employers up to the standard set bythe best, coupled, as in South Africa and in thiscountry under the Medical Research Council, withactive encouragement by subsidy of research intothe cause and possibilities of prevention and cureof the pathological condition engendered by thedust. Only when national conscience in severalcountries has reached a certain degree of sensitivitycan international action be hoped for. This stagehas now been reached in regard to silicosis, but itis clear that other allied conditions will demand

recognition in the future.In the past the only way of establishing the

dangers of inhaling any particular dust was themelancholy one of observing the toll of morbidity andfatality among the workers exposed to it. Nocriteria could be established in advance of this

experience, since the fibrotic process is as a ruleslow to develop. The obvious method of study-the exposure of animals to the dust under the sameconditions as the workers in mines and factories, orthe mimicry or exaggeration of such conditions inspecially constructed dusting chambers-has beenused by Dr. L. U. GARDNER and his staff at SaranacLaboratory for many years with success, and itis evident from his report for 1933, which has justreached us, that development of this work on avast scale is contemplated. This technique, how-ever, has the primary disadvantage that the length

of time during which exposure is necessary is solong as to be measured in years rather than inmonths. There is need for more rapid methods ofdistinguishing potentially dangerous from inertdusts in order that the risk may be recognisedbefore serious damage has been done, and adequatemeans devised and adopted for the protection ofworkers exposed to the dust. Incidentally it ishighly desirable to investigate biologically the

theory recently put forward by Mr. W. R. JONES,D.Sc.,’ that the presence or absence of sericite-asilicate of potassium and aluminium-in a dust isthe factor determining its pathogenicity. His viewis based on his detection, by petrography and bychemical analysis, of the presence of sericite in

lungs of patients dying from silicosis and hisfailure to detect this substance in lungs of mendying from fibroid tuberculosis of the lung whohave not worked in a dusty atmosphere. Hisconclusions are supported by the fact that incertain mines in Australia, and in the Kolar goldmines in India, where silicosis is unknown, nosericite is present, whereas in the Rand mines ofSouth Africa it is present in large proportion. IfDr. JONES proves to be right it will be necessaryto establish the proportion of sericite that makes adust dangerous. Thus for many reasons a morehumane method of diagnosing dangerous duststhan by watching the fate of employees, and a morerapid and certain method than by the use of adusting chamber for animals has long been desired.

In a series of communications bearing on thisproblem published during the last two years Prof.E. H. KETTLE has described experimental methodswhich in his hands have proved more convenientthan dusting chambers for the differential diagnosisof biologically harmful from biologically inert dusts.Of these, the first to be tried was the subcutaneousinjection of a suspension of the dust to be testedinto the flank of a mouse, which subsequentlyreceives an emulsion of tubercle bacilli into thetail vein. Dusts which are known to be activecause local necrosis and a pronounced cellularreaction in which the tubercle bacilli accumulateand multiply; while the inert dusts bring aboutlittle or no tissue reaction and do not favour the

growth of the bacilli. A drawback of the methodis the production of lesions in the subcutaneousrather than in the pulmonary tissues where thedamage occurs in industry, and in recognition ofthis the next step 2 was an attempt to expedite theformation of pulmonary lesions by intratrachealinjection of suspensions of dust. The onset offibrosis was disappointingly slow, so slow indeed asto raise a doubt whether in the absence of aninfective factor it is possible to produce silicosis.When, however, a suspension of even an avirulentstrain of tubercle bacilli was introduced with thedust, the reaction to the infection tended to be sopronounced as to mask the early fibrotic changesdue to the dust. An emulsion of killed tuberclebacilli was then substituted 3 for one of live bacilli,with the gratifying result that using the active

1 Jour. Hyg., 1933, xxxiii., 307.2 THE LANCET, 1932, i., 1190.

3 Jour. Path. and Bact., 1934, xxx., 201.