WORLD HEALTH ASSEMBLY
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IN ordinary radiography the sharpest definition isobtained by placing the film as close as possible to theobject that is being radiographed, and the X-ray tubea good distance away from the object-hence the term" teleradiography." By moving the film away from theobject a radiographic enlargement can be obtained,but use of an ordinary X-ray tube with a focal spot1-0 sq. mm. for making such an enlargement entails a lossof definition. However, with a focal spot 0-3 sq. mm.- i.e., practically punctiform-and with both the X-raytube and the film 24-30 in. from the body (and onopposite sides thereof) definition is remarkably good.Bronchograms taken by this method, which the Frenchcall " radiographie en gros plan" (a term borrowed fromthe cinematograph trade), have been exhibited in Paris,1and some excellent examples have been published.2Part of the secret of such bronchography is to use,as the radio-opaque medium, a mixture of ’Lipiodol’and either sulphanilamide or pure talcum powder, whichfills the bronchial tree slowly and leaves on the bronchialwall a thin layer that shows up the smallest folds ofmucosa. Apart from bronchography twofold radiographicenlargement can be applied to the lungs with advantage,both rendering the details much clearer than in ordinaryradiographs and making more transparent the shadowsof the intervening ribs. It is therefore especially usefulin depicting miliary lesions and scars ; but in the studyof cavities tomography still reigns supreme.
Radiographic enlargement must not be confused withphotographic enlargement ; the former enlarges the
X-ray shadows before they are fixed on the film, whereasthe latter enlarges the picture already fixed on thefilm and therefore enlarges also the emulsion grains ofthe film and any flaws in it. Barclay 3 got over thisdifficulty in photographic enlargement of X-ray films byusing film emulsions of very fine grain ; but such longexposures were necessary that the method, though usefulfor depicting histological specimens, proved unsatisfac-tory for routine radiography of patients.Now it is suggested by Layani et awl. that the two
methods of enlargement, radiographic and photographic,should be combined. These workers first obtain threefold
enlargements by direct radiography and then makethreefold photographic enlargements thereof, thus obtain-ing ninefold enlargements altogether, examples of whichthey publish.
1. Pierre-Bourgeois, Lacourbe, R., Rémy, J. Bull. Soc. méd. Hôp.Paris, 1953, 69, 225.
2. Pierre-Bourgeois, Lacourbe, R., Delos, J., Rémy, J. Sem. Hôp.Paris, 1953, 29, 1193.
3. Barclay, A. E. Micro-arteriography. Oxford, 1951. See alsoLancet, 1951, i, 1006.
4. Layani, F., Fischgold, H., Perles, L. Bull. Soc. méd. Hôp. Paris,1953, 69, 8.
TREATMENT OF LYMPHŒDEMA
IN lymphoedema there is chronic swelling of the
superficial soft tissues, owing to accumulation of extra-cellular fluid rich in protein. This may arise as a con-
genital, and rarely familial, disorder in which a sponge-like lymphangectasia distends the soft tissue ; or it
may follow damage to the lymphatic system by recurrentstreptococcal infections (elephantiasis nostras strepto-genes), surgical intervention, or filarial or neoplasticdisease. Often, however, no cause can be found in
young women in whom there develops a progressive,painless, firm cederna of the lower limbs-a disturbancetermed lymphoedema praecox.The treatment of the lymphoedematous leg in the
early, and often reversible, stages of the swelling is byfirm support, preferably by a rubber bandage over a
lisle stocking. Foot hygiene must be strict, and everyeffort made to eliminate recurrent streptococcallymphangitis and interdigital fungus infections. Too
often, however, the surgeon finds a massive limb which,in addition to its mechanical and cosmetic disadvantages,is recurrently attacked by a hæmolytic streptococcalinfection.
Many ingenious operations have been designed toincrease the drainage of lymph from the subcutaneoustissues, either into the deep tissues or into the abdominalwall. All have proved disappointing. Operationsdesigned, not to repair the physiological disorder butto excise as much as possible of the abnormal tissue,have proved more successful. The original Kondoleonoperation has been modified by Sistrunk,l Homang,2Macey,3 and others. In principle, these proceduresconsist in a staged excision of the thickened abnormaltissue between the muscle or the deep fascia and theskin. The skin is widely undermined for exposure andfinally turned back on the denuded muscle or fasciaas a graft. These operations should not be undertakenlightly, for the blood-loss and traumatic shock may begreat and skin healing is often tardy, and subsequentrecurrence of the swelling and streptococcal cellulitisare not uncommon.
Recently Pratt 4 has introduced a further modificationof the Kondolen procedure by which, after preliminaryreduction of the swelling by postural drainage, theskin over the swollen limb is removed with an electricdermatome to a depth of 0-43 cm. This thickness, hebelieves, removes epithelium but not the lymphatic-bearing portion of the skin. After radical excision of all
remaining hypertrophied tissue, the skin grafts are
stitched together and replaced on the denuded muscle.When healing has taken place, bandage support iscontinued. Pratt has done 25 such operations in thelast three years, and in none has the swelling recurred.Unfortunately he does not give details of the types andthe severity of the cases selected. Possibly this skin-
graft technique will find a place in the treatment ofsome lymphoedematous legs, but we need more precisecorrelation of results with aetiology and pathology.
1. Sistrunk, W. E. J. Amer. med. Ass. 1918, 71, 800.2. Homans, J. New Engl. J. Med. 1936, 215, 1099.3. Macey, H. B. Proc. Mayo Clin. 1940, 15, 49.4. Pratt, G. H. J. Amer. med. Ass. 1953, 151, 888.
WORLD HEALTH ASSEMBLY
LAST Monday the sixth World Health Assembly, inGeneva, elected Dr. M. G. Candau, of Brazil, to be thenew director-general of the World Health Organisation.Dr. Calldau is at present deputy director of the W.H.O.regional office for the Americas ; and for two years upto March, 1952, he was assistant director-generalof W.H.O. in charge of the department of advisoryservices.When the Assembly opened on May 5 the delegates
paid homage to the Burmese delegation, composed ofDr. U Ba Maung and Dr. C. C. Po, who were killed in anaircrash near Calcutta on their way to Geneva. Inhis valedictory address to the members, the outgoingpresident, Dr. Juan Salcedo, jun. (Philippines),* drewattention two dangers facing the Organisation—namely,the delay by some countries in the payment of theircontributions, and the cut of nearly half in the U.N.Technical Assistance Funds for W.H.O. Dr. MurchedKhater, minister of health of the Syrian Republic, whois the president of this year’s assembly, spoke of hiselection in these words :
" Has not this election upheld before the whole world theprinciple of equality as between large and small States, anddemonstrated the spirit of true democracy ? ... up to thepresent, no-one from my part of the world had been honouredwith this presidency ; and so, in order that the principles
of social justice might prevail, the great nations, which could,
easily have tilted the balance in whichever direction theychose, stood aside and renounced the presidency in favour ofthe small States.
Dr. Brock Chisholm, the first director-general of theOrganisation, who is retiring on July 21, presented hisreport for 1952,1 which shows clearly how, during histenure, the organisation has acquired stability and howit continues to meet international needs, which are
becoming better defined.Communicable diseases still present new problems,
ever changing with the social and economic developmentof the people. Malaria control remains foremost, but inmany parts of the world, notably in Asia, national govern-ments are taking over and expanding schemes originallylaid down and started by international consultants andteams. On the other hand, in tropical Africa malariacontrol is still in its early days and is attracting more
, and more attention. Tuberculosis comes second on thelist of infectious diseases, and over 38 million youngpeople have been tuberculin-tested and 18 million non-reactors vaccinated with B.C.G. The setting up of theinternational laboratory in Copenhagen for tuberculosisimmunisation research is an important recent develop-ment. The international yaws campaigns seem to besteadily crushing the enemy and bear witness tothe competent planning Qf the general staff behindthem.Education plays an increasing part in the work of
W.H.O., and a total of 1147 fellowships were awardedin 1952. Of these, 487 were for group training ; andW.H.O. organised 26 courses and assisted in 18 more,including those on Engineering Aspects of Public Healthin London, Yaws Control in Bangkok, Anaesthetics inCopenhagen, Nursing Education in Taiwan, and Brucel-losis in Santiago. Of the fellows, 666 were studyinghealth organisation and services, 348 communicablediseases, and 131 clinical and medical sciences and educa-tion. In the organisation and execution of this pro-gramme, as in all W.H.O.’s work, there has .been anincreasing amount of decentralisation to the six regionaloffices. The regional office for Africa, directed by Dr. F.Daubenton, moved from Geneva to Brazzaville inOctober last and, despite recruiting difficulties, has
begun a full programme in which the training of Africandoctors and medical auxiliaries plays a large part. The
flourishing work of the South-East Asia regional office,under Dr. Ct Mani, continues ; here India seems to pro-vide a model for the proper use of international aid andinternational experts. Much good work is also being doneunder very difficult circumstances in Burma, Indonesia,and Thailand.The total assessments of the 71 member countries for
the year totalled just under$9 million. The largest sub-scribers are the United States ($2-8 million), the UnitedKingdom (1-0), and France (0-5). Of the total subscrip-tions, 80% have already been paid, and most of theremainder is due from countries with Communist govern-ments who continue to be " inactive members."An important decision was taken at the Fifth World
Health Assembly, when the increase and control ofworld population were discussed. There was considerabledisagreement on the question of whether this was or wasnot properly a medical problem, and the assemblyultimately decided that no action should be taken. Manydoctors in all countries must regret this decision, butclearly no international organisation can proceed with-out a substantial measure of agreement amongst itsconstituent members.Any public-health report inevitably contains a large
mass of factual data and details of organisation, which1. The Work of W.H.O. Annual Report of the Director-General,
1952. W.H.O., Geneva, 1953. Pp. 204. 9s. Obtainable fromH.M. Stationery Office, P.O. Box 569, London, S.E.1.
are not easy reading. The difficulty in presenting thiswork in an imaginative way is great, but W.H.O. hasset an excellent example by including many fine photo-graphs of its workers in the countryside, in hospitals,and in laboratories. These add immensely to thevalue of the report, especially for the non-technicalreader.
After six years W.H.O. has a reliable and efficientsecretariat, and an executive board which is capable ofthinking internationally rather than nationally and whichis thus capable of carrying out major international plans.These achievements are in no small measure due toDr. Brock Chisholm’s vision and energy.
1. Jolmson, R. W., Hillman, J. W., Southwick, W. O. J. BoneJt Surg. 1953, 35A, 17.
2. Wilkinson, M. C. See Ibid, 35B, 150.
EARLY SURGERY IN SKELETAL TUBERCULOSIS
IT happens not uncommonly that an important advancein surgery, though long foreseen, depends for fruitionon developments in another field of science. The internalfixation of fractures by metal-an idea that had beencherished since the early days of aseptic surgery-hadto await the development of biologically inert metals. Aparallel situation is seemingly evolving in the earlysurgical treatment of skeletal tuberculosis ; in this casethe accessory is the development of effective antibioticdrugs.Long before the introduction of antibiotics the idea
of a direct surgical attack on a tuberculous focus inbone or joint had seemed theoretically attractive to
orthopaedic surgeons, and such operations were occasion-ally practised. But the results were often discouraging :dissemination of the disease to other organs and theformation of chronic discharging sinuses with secondaryinfection were common sequels. Consequently theattitude of most surgeons towards skeletal tuberculosisbecame strictly conservative, especially in Britain.
Operative treatment was seldom undertaken except inthe quiescent phase of the disease, and even then thesurgeon sought to avoid cutting directly into diseasedtissue.. The introduction of antibiotic drugs-especiallystreptomycin-has led to reconsideration of the possibleadvantages of a bolder policy. Many surgeons nowbelieve that, with the greater security against unfavour-able complications afforded by streptomycin, directoperation on tuberculous lesions of the skeleton mayprove, after all, to be advantageous. Johnson et al.1
suggest that certain lesions can be tackled surgically withimpunity and probably with benefit to the patient ; andWilkinson 2 makes it clear that similar observations arebeing made in Britain. In following up this developmentorthopaedic surgeons must beware lest their enthusiasmcarry them too far. A proper note of caution was struckin the British Orthopaedic Association’s discussion of Pott’sparaplegia, summarised on p. 799. Whatever its localmanifestations tuberculosis is a systemic disease. There-fore constitutional treatment must continue to be thefirst method of attack : to advocate surgical treatmentwithout proper constitutional measures is to courtdisaster.
Johnson and his collaborators emphasise the valueof operation in diagnosis. Important though this maybe, it is mainly in the hope of hastening the healing ofthe lesion that British surgeons are investigating thepossibilities of surgery. So far, early operation has beenundertaken mainly for the thorough evacuation ofabscesses and the removal of tuberculous debris bycurettage, especially in spinal disease. Synovectomy isalso under trial in selected joint lesions. Such operationsshould create favourable conditions for rapid healing ;and in spinal disease drainage of paravertebral abscesseswill help to prevent extension of the infection along the