tuberculosis

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(1) A shoulder-ioint should be ankylosed in the abducted positionto upwards of 80° with a little forward inclination of the humerusand slight internal rotation at the shoulder-joint. The scapula isthus given free movement and the arm can be brought to the side.the lower angle of the scapula rotating inwards. This is greatlyaided by gravity. But if ankylosis has taken place with the arm atthe side and the scapula in its normal vertical position functionwill be greatly impaired, as it will be found impossible to abductthe arm through more than a very few degrees.

(2) The best position for ankylosis of the elbow depends a gooddeal on the man’s work. For most purposes it is probably best tohave the forearm flexed at rather less than a right angle with theupper arm. If rotatory movements are also lost the best positionfor the forearm is in fairly complete pronation. A forearm fixed insupination, especially with an ankylosed elbow, is in a very badfunctional state.

(3) The wrist is best ankylosed either straight or slightly dorsiflexed.A flexed wrist means a hand with a somewhat weakened grip.

(4) The hip is best ankylosed in slight abduction with full oralmost full extension. Walking can then be performed by aswinging movement of the pelvis.

(5) The knee should be ankylosed in full or almost full extension.There is sure to be considerable atrophy of the,thigh on theaffected side, but the calf will not be atrophied unless from someother cause, and may even be increased in circumference becauseof the extra work put upon it.

(6) The ankle should be ankylosed at right angles. It is obviousthat a fixed ankle-joint, with the foot pointing even a little down-wards, is a cause of considerably greater inconvenience than one inwhich the rectangular position is maintained. The disability isaccentuated if a hallux rigidus is also present on the same foot.

A flail joint is almost always a cause of greater dis-ability than an ankylosed joint. This applies to theupper limb. In a lower limb amputation may be theonly possible form of treatment, but instances of thiscondition are not often seen at pension boards.Jlovements.-The examiner should, of course, know

the normal limits of movement of the various joints.For example, pronation of the forearm is a movementwhich is not quite so complete as is often imagined;probably it is frequently tested for in the wrong way,and rotation at the shoulder takes place and deceivesthe examiner. The movements of the two limbs shouldbe compared; the elbows should be firmly applied tothe flanks and flexed at a right angle, and the manshould be directed to pronate both forearms slowly andfully; then rotation at the shoulder will not take place.If a man does not seem to be able to pronate at all, oronly a very little, direct him to bring the palm of hishand to the back of his neck. He requires semi-

pronation to achieve this movement, and it may befound that in this way he can do more than he thoughthe could.

If two distal phalanges are missing from a finger theremaining phalanx may appear, quite wrongly, to have alimited range of flexion. The gap left seems to deceivesomewhat. Normally the proximal phalanges can be flexedalmost, or quite, to a right angle with the metacarpals.Whether phalanges are lost or not, the movements at thefour inner metacarpo-phalangeal joints should be testedtogether and not separately. If tested separately a limita-tion of flexion may be described which does not really exist.The estimation of grip by percentage is a very difficultproposition, and is very often guessed at quite wide of themark.In examining for joint movements of the lower limbs the

trousers and pants should not be left on. In testing forflexion of the hip in the dorsal position the sound hip mustbe fully extended and the sound thigh kept in firm appositionwith the couch, otherwise the limitation of flexion, if any,may be considerably underestimated on account of thepelvis tilting forward, the lumbar spine becoming lessconcave backwards. Examiners frequently describe gratingin the knee-joints when there is nothing pathological aboutthem. A certain amount of friction between the patella andthe condyles of the femur is quite normal.

Sensibility.-In testing for anaesthesia the general distribu-tion of the main cutaneous nerves must be borne in mind.Not unusually the examiner merely asks the man if he feelsa touch in certain places ; this is not sufficient, for a manmay feel a touch less acutely than he ought to do. Thecorresponding parts on the two sides must be tested in asimilar way.

The Question of Treatment.Treatment should not be pressed on a man if the

relief gained must of necessity be small or the resultdoubtful, especially if the man’s economic position willcause him difficulty. If the case will certainly beimproved by treatment the man should be advised tohave it; if there is no hurry from the point of viewof ultimate result it is often well to recommend post-

ponement (to suit the man’s economic convenience)provided that treatment is not too long delayed. Largepensions naturally cannot be paid to men who may becured or improved.A good working rule is as follows. If in doubt,

recommend the man for expert advice, with a viewto treatment if deemed advisable. In cases of ankylosis.of joints in bad position operation for rectification andre-ankylosis, or even formation of a false joint, mustbe considered. With a flail joint, and if operation has.already been decided against on expert advice, thesupply of a suitable apparatus must be thought of.Where a nerve has been divided or destroyed and ifnerve suture has failed, a sufficient time having elapsedto test its possibilities, tendon transplantation maystill be feasible, or even arthrodesis might be indicated.Other examples might be added.

It is not necessary to go into very elaborate detailwith the cases. A fair estimate of functional disabilityand curability is all that is required. The ideal is totake a wide general view of the case, to know what tolook for, and to do the examination in a systematic anddeliberate way.No pretence is here made of giving anything like a.

full account of the examination of wounded pensioners ;this paper is merely a collection of a few conclusionsarrived at during fairly wide experience of pensionboard work; but in spite of the elementary nature ofthe points discussed, or because of it, I think they maybe found useful on application.

TUBERCULOSIS.

Position of Sanatorium Superintendents under theMinistry of Health.

IN a memorandum dated March 31st the Ministry ofHealth has drawn attention to the special arrangementsto be made on and after May 1st for the provision oftreatment in residential institutions for tuberculousex-Service men in England. Sanatorium benefit ceasingto be included under the National Insurance Acts afterMay lst, it has proved necessary to set out in detail thearrangements made with the local health authoritiestaking over the care of tuberculous ex-Service men. It

may serve a useful purpose at once to focus attentionon one aspect of these arrangements as they affect,superintendents of sanatoriums. Under paragraph 11the following passage occurs :-

" It will also rest with the tuberculosis officer, subjectto the considerations set out in paragraph 17 of thismemorandum, to determine the length of treatment to beafforded to each case admitted to a residential institution.In reviewing from time to time the cases receiving resi-dential treatment the tuberculosis officer should have beforehim, in each case, periodical reports on the patient’s condi-tion and progress from the medical superintendent of theinstitution in which the case is being treated."According to paragraph 17-" The Minister of Health reserves the right to call for the

reconsideration of cases by the tuberculosis officer, and forthis purpose to ask for special medical reports from him onparticular cases, where necessary, and he may afterwardsterminate liability for the cost of treatment of any case-after a certain date."

It appears from these instructions that a tuberculosis.officer may overrule a medical superintendent in theconduct of a case under the latter’s care. The decisionas to the duration of treatment being put into thehands of the tuberculosis officer, it follows that he mayalso, to a certain extent, dictate the nature of thetreatment given in an institution, for time is an

essential factor in the choice of treatment. A medicalsuperintendent may consider a course of specifictreatment for six months or more indicated in a givencase, but knowing that such a course may be arbitrarilyinterrupted at any time, he may attempt nothing morethan palliative tinkering. On the other hand, thetuberculosis officer may continue to keep in a sana-torium patients whom the medical superintendent mayhave found to be unsuited for this treatment; bothsuperintendent and patient may agree on this point,

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yet their wishes may be disregarded by the tuber-culosis officer. Even with free hands, a sanatoriummedical officer is apt to find his work monotonousand to slip by imperceptible stages from the statusof a keen clinician to that of an administrativehack. Robbed of stimulants to initiative and thesense of responsibility conferred by freedom to pre-scribe only what he considers the best treatment, he isbound to feel aggrieved, and if this arrangement is per-petuated, the sanatorium service will not attract the besttype. Yet the successful management of a sanatoriumrequires many and exceptional qualities, and if thisservice comes to attract only second-rate men whosechief qualification is docility, then sanatorium treat-ment will suffer. In Canada this difficulty has recentlybeen thrashed out, and since the inspection of 26 sana-toriums by a board of tuberculosis consultants, thechain of responsibility in such institutions has beenreorganised, so that the medical superintendent shallbe in complete charge, and shall be the sole channel ofcommunication with the governing board, whether it becivilian or departmental. There are, of course, othersides to this question which bristles with administrativedifficulties, but we have dwelt solely on the point ofview of the medical superintendent, because it has not,apparently, been sufficiently studied in the drafting ofthis memorandum, and because the person who mustultimately suffer most from any arrangement, whichfetters the medical superintendent unnecessarily, isthe patient himself.

Conditions .Mistaken for Pylmonrzry Tuberculosis.As a result of a study of 1700 consecutive cases

admitted to his sanatorium Dr. B. Stivelman, of theMontefiore Sanatorium, New York,l indulges in ratheruncomplimentary reflections on the diagnostic skill ofspecialists as well as of general practitioners. It

appears that though no patient could be admittedunless the diagnosis of a general practitioner was con-firmed by at least one specialist, 176, or 10’4 per cent.of the total, were found to be non-tuberculous. In thepast it has sometimes been the privilege of the specialistto lay the blame for faulty diagnoses at the door of thegeneral practitioner, and it is with ill-concealed gleethat the sanatorium physician shows up the frequentmistakes of the consulting physician. The matter is,however, rather one of opportunity than of superiorskill; the consultant sees a patient only once or twice,whereas the sanatorium physician has unrivalled oppor-tunities for weighing at his leisure the evidence for andagainst the diagnosis of tuberculosis. Dr. Stivelmanfinds that chronic bronchitis and emphysema is thecondition most commonly mistaken for tuberculosis ofthe lungs. Other common simulants are mitral disease,neurasthenia, and non-specific diseases of the upperrespiratory tract. With regard to this latter class, heindulges in a digressive thrust at the "...... manyfeverish reports about the great frequency of conjugalphthisis......." It seems that in as many as 15 casesacute affections of the upper respiratory tract werediagnosed as tuberculous because the consorts of thesepatients happened to be tuberculous. " In the light ofcold study it would seem that conjugal tuberculosis isaccidental."

Sanatorium Benefit in Birmingham.In a Report of a special subcommittee appointed by

the Birmingham Insurance Committee to inquire intosanatorium treatment, some fairly encouraging figuresare published showing the results achieved in Birming-ham by sanatorium and other treatment. Of 1314 insuredpersons recommended for sanatorium benefit in 1914,between 40 and 50 per cent. had died within six years,and of 493 survivors traced, 357, or 72’4 per cent., hadworked steadily since 1914. While these resultq are

better than those obtained in areas where the problemhas been dealt with half-heartedly, they leave room forimprovement. Incidentally the fact is mentioned thata large proportion of these cases received an intensivecourse of tuberculin treatment, one indirect advantageof which was the stimulus it gave the patient to keep

1 American Review of Tuberculosis, January, 1921.

in touch with his medical adviser before and afterresidence in a sanatorium. The facts given in thisReport are a useful antidote to the atrabilious analysesof sanatorium treatment published elsewhere, but itsrecommendations are still more helpful, because theyshow how, with economy of effort, good results may bebettered. In a recent letter to the American Review ofTuberculosis, Professor Fishberg stated that none of thesanatoriums in New York State was fllled. There are

signs that this may shortly be the case in the UnitedKingdom, and when this happens, and our sanatoriumsare no longer choked by advanced cases shoulderingeach other out and robbing the early case of a chanceto attain to permanent cure by prolonged treatment,sanatorium treatment will be a step nearer to the ideal.Towards this consummation the Report points byadvocating the provision of hospital as distinct fromsanatorium beds. The former should provide forcases of tuberculosis complicated by other diseases,such as diabetes, which unflt the patient for thegeneral routine of sanatorium life. Such hospitalbeds would afford a brief respite for workers, whosecareers of useful part-time work are punctuatedat irregular intervals by short periods of impairedhealth. Though beyond the possibility of permanentcure, these patients need but a few weeks’ rest torestore them to part-time working capacity, and thismay be prolonged for many years. The Reportemphasises the value of prevention, and suggests that" It would be wiser and more practicable to removeinfants born into the infected homes of poor consump-tives and bring them up for a few years in healthysurroundings than to remove the consumptive parentfrom the home for the whole period of his infectious-ness." This growing movement in favour of preventingtuberculosis in childhood, instead of patching up thepatient in adult life, is one of the most hopeful signsdiscernible at the present time, but in the van of thismovement there are, unfortunately, enthusiasts likeDr. Harald Sundelius2 who, in saving children fromtheir infected parents, would give a Herod-like touch tothe proceedings.

PARIS.

(FROM OUR OWN CORRESPONDENT.)

Radium for Paris Hospitals.AT a recent meeting of the Conseil Municipal de

Paris it was decided to buy 2 g. of radium for thebenefit of a new radium institute under the supervisionof the Administration of the Assistance Publique, and asum of Fr.2,500,000 has been granted for the purchase.The radium will be delivered to the town authorities bythe Curie Institute, and the capital acquired from thesale will enable scientists working at this institute tocarry out further researches on radium. Mr. P. Mourier,Directeur General de 1’Administration de 1’AssistancePublique, has officially expressed a vote of thanks tothose responsible for the decision of a grant throughwhich many hospital patients will have the benefit ofradium therapy.

Dangers of Radium and X Rays.At a recent meeting of the French Academy of

Medicine Mr. H. Bordier, of Lyons, made an importantstatement concerning the dangers of radium to thosewho manipulate it, dangers which, in his opinion, maybe greater still than those resulting from exposure toX rays. He pointed out that the ill-effects of radiumare revealed by the occurrence of perniciousanaemia resulting from the action of the radiumemanations upon the marrow of the bones, this beingproved by the pathological findings in rats whichhave been exposed to radium emanations. In thecourse of his statement Mr. Bordier mentioned the casesof the nurse and two laboratory assistants reportedby J. C. Mottram. In his conclusion he expressedthe wish that such harmful effects due to radiumemanations should be investigated by the Académie

2 Tubercle, April, p. 321.