A COMMUNITY TUBERCULOSIS SURVEY

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 The tilt test is now possible in the laboratory. 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 radiography. Altogether 120 cases of pulmonary tuberculosis 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 postoperative 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 in the

much more 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

opening

overlying skull;

difficult problem is presented by

but

a

an

1 Norsk Mag. for Laegevidensk. February, 1937, p. 224.

undertaken. For these deeper abscesses E. A. Kahn1 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 endothermy 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 deficiencies 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 physician 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 Wolbarst2 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 arsphenamines 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 permitted to the patient with persistently positive serum tests after prolonged and intensive treatment provided 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 There 4-5 years before procreation is considered. 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 examination with repeated tests over a period of several 2

1 J. Amer. med. Ass., Jan. 9th, 1937, p. 87. L. (1936) Brit. J. ven. Dis. 12, 229.

Wolbarst, A.

’