A COMMUNITY TUBERCULOSIS SURVEY
1
643 complete knowledge of the various characteristic reaction patterns of the body musculature on tilting becomes available, the same exact diagnosis of labyrinthine lesions will be obtainable clinically as is now possible in the laboratory. The tilt test is simple, and the reactions elicited by it seem to merit study. A COMMUNITY TUBERCULOSIS SURVEY WITH the support of the Norwegian National Association against Tuberculosis, Dr. G. Hertzberg has recently conducted a community survey of two rural parishes in Norway. Thanks to preliminary propaganda and the provision of adequate facilities for expert examinations, he succeeded in netting about 59 per cent. of the whole community, between five and six thousand persons of all ages being tuberculin tested (Pirquet and Mantoux) and the positive reactors being further examined by the sedimentation test as well as radiologically. The radiological examinations consisted of screening and, when its findings were positive or ambiguous, of radiography. A portable radiological outfit enabled Dr. Hertzberg to screen some 200 persons daily at the rate of 30 to 40 per hour, and hustling though this rate was, comparisons of the findings showed that screening was but little inferior in accuracy to radio- graphy. Altogether 120 cases of pulmonary tuber- culosis were recognised as such for the first time by this comb-out, and in as many as 90 of these cases the disease was caught at an early stage. It was not a little remarkable that 7 cases of pleurisy with effusion were discovered in persons unconscious of being ill. The cost of this survey worked out at about 7000 kroner, or about ls. 3d. per head. It may be noted in passing that such community surveys are at present being conducted systematically in Finland by its National Association against Tuberculosis which has recently equipped itself with 11 portable radiological outfits. Dr. Hertzberg’s stimulating and instructive demonstration is likely to be repeated many times in many places. CEREBRAL ABSCESS THE treatment of a cerebral abscess is perhaps the hardest task of the neurosurgeon. Accuracy in localisation, good judgment as to the moment for operation, and critical and untiring attention to post- operative details are essentials for success. It is widely accepted that radical operation should be deferred if possible until the acute inflammatory reaction has subsided, and until a firm abscess wall has formed. During this process, however, the intracranial pressure may rise sufficiently to endanger life, and various procedures have been recommended to tide the patient over this period, based on simple paracentesis of the liquefying area of brain. Opinions differ about the correct course to adopt when a well-localised abscess has formed. Total enucleation is practised by some surgeons ; others prefer to drain the abscess through a small opening in the skull so as to avoid a fungus cerebri. If the abscess is quite superficial, success usually follows drainage through an adequate opening in the overlying skull; but a much more difficult problem is presented by an abscess lying more deeply in the hemisphere. Operation here carries a grave risk of infection of the superficial healthy brain and of the overlying leptomeninges, whereas with a superficial abscess, the leptomeningeal spaces are obliterated by adhesions before operation is 1 Norsk Mag. for Laegevidensk. February, 1937, p. 224. undertaken. For these deeper abscesses E. A. Kahn 1 recommends a modification of the King technique, relying on a two-stage operation to allow the abscess to migrate nearer the surface, and to obliterate the pia-arachnoid spaces by adhesions. The abscess is located by exploring with a blunt needle, without piercing the wall. A wide opening is made in the skull immediately over it and the dura freely incised. Iodoform gauze is packed over the exposed brain and the incision is left open. The second operation is carried out several days later, when the endo- thermy loop is used to remove the fungus which has formed. The abscess, which will be found flush with the skull, is opened and its cavity packed with gauze. The intracranial pressure gradually extrudes the remains of the abscess and the packing. Three of four cases treated in this manner recovered ; Kahn reports these cases in detail, which makes his paper the more interesting. VENEREAL DISEASES AND MARRIAGE IMPROVED means of recognising latent venereal infections have served rather to expose past defi- ciencies than to simplify the standards by which the cure may be determined. The difficulties are such that the most careful investigation does not remove all uncertainty, and the subsequent marriage of the infected patient is never without risk to the marital partner. In permitting marriage the physi- cian takes a very serious decision and his natural anxiety is sometimes interpreted by the patient as an admission that the particular disease is incurable. In fact this view is held by many laymen and by some medical men with regard to both syphilis and gonorrhoea. In a review of this difficult and important subject Wolbarst 2 expresses his opinion that there is nothing inherently incurable in these diseases but that they often remain uncured through the fault of the practitioner, of the patient, or of both. For his own patients with syphilis who wish to marry he demands rigid standards which include 2-3 years’ continuous combined treatment with the arsphena- mines and with bismuth, followed by 1-2 years’ close observation with periodic examination, both clinical and serological, to exclude recurrence. Tests of the cerebro-spinal fluid must be negative a year after the cessation of the treatment. Marriage is per- mitted to the patient with persistently positive serum tests after prolonged and intensive treatment pro- vided there is no clinical evidence of neurosyphilis and tests of the spinal fluid are negative. Wolbarst ’ throws doubt on his own criteria of cure, however, by advising that observation should continue for 4-5 years before procreation is considered. There must be evidence that during this period the infected patient has remained clinically and serologically negative and has not transmitted the disease to the partner in marriage. He advises that the prospective mother should receive antisyphilitic treatment throughout pregnancy, irrespective of which marriage partner was previously syphilitic, and if both man and wife have been infected, he would have them both permanently sterilised, even though treatment may seem to have been fully successful. All patients who have had syphilis are urged to undergo a brief course of treatment once or twice yearly throughout life as an " insurance against recurrence." To exclude latency of gonococcal infection Wolbarst demands searching clinical and bacteriological exami- nation with repeated tests over a period of several 1 J. Amer. med. Ass., Jan. 9th, 1937, p. 87. 2 Wolbarst, A. L. (1936) Brit. J. ven. Dis. 12, 229.
Transcript of A COMMUNITY TUBERCULOSIS SURVEY
643
complete knowledge of the various characteristicreaction patterns of the body musculature on tiltingbecomes available, the same exact diagnosis of
labyrinthine lesions will be obtainable clinically as isnow possible in the laboratory. The tilt test is
simple, and the reactions elicited by it seem to meritstudy.
A COMMUNITY TUBERCULOSIS SURVEY
WITH the support of the Norwegian NationalAssociation against Tuberculosis, Dr. G. Hertzberghas recently conducted a community survey of tworural parishes in Norway. Thanks to preliminarypropaganda and the provision of adequate facilitiesfor expert examinations, he succeeded in nettingabout 59 per cent. of the whole community, betweenfive and six thousand persons of all ages beingtuberculin tested (Pirquet and Mantoux) and the
positive reactors being further examined by thesedimentation test as well as radiologically. Theradiological examinations consisted of screening and,when its findings were positive or ambiguous, of
radiography. A portable radiological outfit enabledDr. Hertzberg to screen some 200 persons daily at therate of 30 to 40 per hour, and hustling though thisrate was, comparisons of the findings showed thatscreening was but little inferior in accuracy to radio-graphy. Altogether 120 cases of pulmonary tuber-culosis were recognised as such for the first time bythis comb-out, and in as many as 90 of these casesthe disease was caught at an early stage. It wasnot a little remarkable that 7 cases of pleurisy witheffusion were discovered in persons unconscious of
being ill. The cost of this survey worked out atabout 7000 kroner, or about ls. 3d. per head. It
may be noted in passing that such communitysurveys are at present being conducted systematicallyin Finland by its National Association againstTuberculosis which has recently equipped itself with11 portable radiological outfits. Dr. Hertzberg’sstimulating and instructive demonstration is likelyto be repeated many times in many places.
CEREBRAL ABSCESS
THE treatment of a cerebral abscess is perhapsthe hardest task of the neurosurgeon. Accuracy inlocalisation, good judgment as to the moment foroperation, and critical and untiring attention to post-operative details are essentials for success. It is widelyaccepted that radical operation should be deferredif possible until the acute inflammatory reaction hassubsided, and until a firm abscess wall has formed.During this process, however, the intracranial pressuremay rise sufficiently to endanger life, and variousprocedures have been recommended to tide thepatient over this period, based on simple paracentesisof the liquefying area of brain. Opinions differ aboutthe correct course to adopt when a well-localisedabscess has formed. Total enucleation is practisedby some surgeons ; others prefer to drain the abscessthrough a small opening in the skull so as to avoida fungus cerebri. If the abscess is quite superficial,success usually follows drainage through an adequateopening in the overlying skull; but a much moredifficult problem is presented by an abscess lyingmore deeply in the hemisphere. Operation here carriesa grave risk of infection of the superficial healthybrain and of the overlying leptomeninges, whereaswith a superficial abscess, the leptomeningeal spacesare obliterated by adhesions before operation is
1 Norsk Mag. for Laegevidensk. February, 1937, p. 224.
undertaken. For these deeper abscesses E. A. Kahn 1recommends a modification of the King technique,relying on a two-stage operation to allow the abscessto migrate nearer the surface, and to obliterate thepia-arachnoid spaces by adhesions. The abscess islocated by exploring with a blunt needle, withoutpiercing the wall. A wide opening is made in theskull immediately over it and the dura freely incised.Iodoform gauze is packed over the exposed brainand the incision is left open. The second operationis carried out several days later, when the endo-thermy loop is used to remove the fungus which hasformed. The abscess, which will be found flushwith the skull, is opened and its cavity packed withgauze. The intracranial pressure gradually extrudesthe remains of the abscess and the packing. Threeof four cases treated in this manner recovered ; Kahnreports these cases in detail, which makes his paperthe more interesting.
VENEREAL DISEASES AND MARRIAGE
IMPROVED means of recognising latent venerealinfections have served rather to expose past defi-ciencies than to simplify the standards by whichthe cure may be determined. The difficulties are
such that the most careful investigation does notremove all uncertainty, and the subsequent marriageof the infected patient is never without risk to themarital partner. In permitting marriage the physi-cian takes a very serious decision and his naturalanxiety is sometimes interpreted by the patient asan admission that the particular disease is incurable.In fact this view is held by many laymen and bysome medical men with regard to both syphilis andgonorrhoea. In a review of this difficult and importantsubject Wolbarst 2 expresses his opinion that thereis nothing inherently incurable in these diseases butthat they often remain uncured through the faultof the practitioner, of the patient, or of both. Forhis own patients with syphilis who wish to marry hedemands rigid standards which include 2-3 years’continuous combined treatment with the arsphena-mines and with bismuth, followed by 1-2 years’ closeobservation with periodic examination, both clinicaland serological, to exclude recurrence. Tests of thecerebro-spinal fluid must be negative a year afterthe cessation of the treatment. Marriage is per-mitted to the patient with persistently positive serumtests after prolonged and intensive treatment pro-vided there is no clinical evidence of neurosyphilisand tests of the spinal fluid are negative. Wolbarst
’
throws doubt on his own criteria of cure, however,by advising that observation should continue for4-5 years before procreation is considered. Theremust be evidence that during this period the infectedpatient has remained clinically and serologicallynegative and has not transmitted the disease to thepartner in marriage. He advises that the prospectivemother should receive antisyphilitic treatment
throughout pregnancy, irrespective of which marriagepartner was previously syphilitic, and if both manand wife have been infected, he would have themboth permanently sterilised, even though treatmentmay seem to have been fully successful. All patientswho have had syphilis are urged to undergo a briefcourse of treatment once or twice yearly throughoutlife as an " insurance against recurrence." Toexclude latency of gonococcal infection Wolbarstdemands searching clinical and bacteriological exami-nation with repeated tests over a period of several
1 J. Amer. med. Ass., Jan. 9th, 1937, p. 87.2 Wolbarst, A. L. (1936) Brit. J. ven. Dis. 12, 229.
