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INFORMATION ABOUT VENEREAL DISEASE
496 that rubella in the first month was especially teratogenic, the malformation-rates in surviving children being 17%, 17%, and 8% for the first, second, and third months respectively. But Lundstrom points out that infection in the first two weeks after the last menstrual period is, in reality, preconceptional; at that time rubella is probably not teratogenic, and his figures therefore imply a higher rate for malformation in the first two weeks after
conception. In neither series, unfortunately, was the intelligence of the children adequately studied; this is now being investigated in Sweden. But 7% of first-trimester-rubella children, compared with 2% of the controls, showed some delay in acquiring the skills of sitting and standing without support. Moreover, at the follow-up examination, 10% of the rubella children, but only 2% of the controls, were found to have a head circumference more than two and a half standard deviations below the mean value related to height. As in other series, the birth-weights of many of the rubella children suggested immaturity; 36% of those with malformation and 12% of those without (but only 3% of the controls) weighed less than 2500 g. at birth. The birth-weight of 10% of the rubella children lay between 2000 g. and 2500 g., compared with only 1 % of the controls; this was the greatest disparity noted for any weight range. Comparison of the rubella immature with the control immature children was interesting, though limited by the rather small number in the second group. The rubella immature had a longer gestation period, a lower incidence of complications in pregnancy and at delivery, and a lower stillbirth-rate and neonatal deathrate. But a higher proportion of the rubella group were still undersized at the time of the follow-up examination. Among the children of Swedish women exposed to, but not contracting, rubella in pregnancy there was no increase in the frequency of malformation; this was true whether or not the mother had already had rubella before the exposure. Of a group of 251 women exposed to rubella in the first four months of pregnancy who were treated with convalescent y-globulin, the disease developed in 6 (2%). Of the children born of these pregnancies, 3 (1%) had rubella-syndrome defects; but only 1 of these 3 was born to a mother who had contracted rubella in spite of the prophylaxis. Among the 245 mothers who did not contract rubella the abortion-rate and stillbirth-rate were normal; of the 229 liveborn children, only 2 had malformations which could be attributed to rubella. Like the findings reported by Lock et al.3 from the United States, these appear fairly satisfactory. It is difficult to estimate how many women would have contracted rubella if not protected with y-globulin. YOGA
YOGISclaim that they can control essential bodily functions such as the heart-rate. In 1935 Brosse investigated this question in one Yogi, and reported her findings eleven years later.4 While the subject attempted to arrest his heart-beat, a single-lead electrocardiogram (E.C.G.) and a pulse-wave recording were taken; these revealed progressive decrease in the electrical potential, and apparent cessation of the heart-beat for a time. This same Yogi has since been reinvestigated along with three others.55 Electrocardiographic, digital plethysmographic, and 3.
Lock,
F.
R., Gatling, H. B., Wells, H. B. J. Amer. med. Ass. 1961, 178,
711. 4. Main Currents in Modern Thought, 1946, 4, 77. 5. Wenger, M. A., Bagchi, B. K., Anand, B. K. Circulation, 1961,
24, 1314.
tracings were made on a portable electroencephalograph. During attempts to stop or slow the heart, each subject adopted a similar manoeuvre-breath-holding, usually in inspiration, with forcible contraction of abdominal and other muscles against a closed glottis to increase the intrathoracic pressure. In Brosse’s subject (who permitted only limited investigation of the method he employed) this procedure produced some change in potential of the two E.c.G. leads, but the heart-sounds other
still present on auscultation. In two of the other there were changes in the potential of the E.C.G. without any evidence of cardiac arrest. The fourth subject had claimed only that he could slow his heart, and he produced bradycardia with the development of nodal rhythm and some change in potential. These results are in accordance with Anand and Chhina’s earlier report 6 that no cardiac arrest was demonstrable on the E.c.G. Dr. Brosse’s original observation of apparent cardiac arrest on a single-lead electrocardiogram was probably an artefact due to the decreased electrical potential subsequently demonstrated under these circumstances. Many of the associated observations - inaudible breath-sounds, impalpable arterial pulse, and obstruction to the venous return-were probably due to the Valsalva or reversed Valsalva manceuvre which the were
subjects also
Yogis employed. INFORMATION ABOUT VENEREAL DISEASE
CONCERN about the increasing incidence of some venereal diseases has led the Standing Advisory Committee of the Central Health Services Council to review the problem in a bookletwhich has been distributed to all general medical practitioners taking part in the National Health Service. The venereal-disease service was established in 1916, and since then clinics staffed by specialists in venereology have been attached to the outpatient departments of most large general hospitals in the United Kingdom. Venereal disease as defined by statute comprises only syphilis, gonorrhoea, and chancroid; but the clinics deal with all conditions transmitted by sexual intercourse and with some other non-transmissible conditions, so that patients who attend are no longer severely stigmatised as " v.n. patients ". One of the most important functions of the clinic is to act as a centre for investigation, advice, and reassurance of individuals who are anxious but may well be free from infection. In 1960, 130,130 patients attended clinics in England and Wales for advice, but only 37,927 of these were found to have statutory venereal disease. The principles which originally governed the operation of the clinics have been maintained; attendance is entirely confidential, and patients are entitled to attend without doctors’ letters or other introduction. Treatment remains free even to the extent that no charge is made for drugs. Promiscuity, by which venereal disease is spread, is regarded as a symptom of social or marital maladjustment, and many clinics now have skilled almoners or socialservice workers one of whose duties is to assist with difficulties arising from unstable marriages, unwanted pregnancies, homosexuality, and venereophobia. The main problems at present are gonorrhcea and the disease, or group of diseases, commonly called nonAnand, B. K., Chhina, G. S. Indian J. med. Res. 1961, 49, 90. See Lancet, 1961, ii, 90. 7. Venereal Disease Service. Prepared by the Standing Medical Advisory
6.
Committee for the Central Health Services Council and the Minister of Health.
497
gonococcal urethritis. Cases of gonorrhoea at the clinics of England and Wales, which amounted to 47,343 in 1946, declined to 17,436 in 1954, but rose in each subsequent year to reach 33,756 in 1960; and the increase is known Cases of non-gonococcal to have continued in 1961. urethritis in males were first recorded in a separate category in 1951 when the total was 10,794 ; it has increased each year, and in 1960 there were 21,971 cases. On the other hand, the incidence of infectious syphilis, which reached a peak in 1946, when 17,675 cases were reported, fell to 808 cases in 1954 and to 704 in 1958. It increased to 984 in 1960; but this remains a small problem by all the standards of the past. ’Only in recent years has it been fully appreciated that vaginal infestation with Trichomonas vaginalis, which is extremely common in women in the reproductive years, is frequently transmitted sexually and that infestation, with few or no symptoms, is common in men. Modern methods of treatment are very effective, but reinfection is almost inevitable unless sexual partners are also treated. Neither patient nor partner should be treated without proper investigation, because of the possibility that other diseases may be
present. For those who undertake responsibility for potentially infected patients without the resources and experience available at venereal-disease clinics, the booklet gives some useful advice. It emphasises that the diseases may be clinically latent, and therefore anyone who has been exposed to possible infection should be examined to exclude it. Transmissible infection is by far the commonest cause of urethral discharge in the male and of vaginal discharge in the female. Symptoms of cystitis, rectal discharge, or lower abdominal pain in a woman may all be due to such a cause. Any genital lesion is suspect, and syphilis should always be excluded. Treatment should never be given before diagnosis, and tests to prove cure are essential. Latent syphilis is the commonest form of the disease and can be detected only by blood tests. Arthritis in young adults may be due to Reiter’s disease, which is believed to be a complication of one variety of transmissible non-gonococcal urethritis. Especially important is the tracing, investigation, and treatment of contacts of infectious patients; for without this any measures for the control of venereal disease must fail. Failure in this responsibility leads to spread of infection, and may lead to reinfection. Patients are often unwilling to assist in this matter, especially men whose wives ought to be examined. Such resistance should be overcome by careful explanation, by tactful insistence, and by perseverance. Some hospitals arrange for sessions to be conducted on other premises than those of the v.D. department, at which patients can have expert investigation while remaining unaware of an association with that department, which inevitably carries some stigma. Control of this serious spread of disease requires a concerted effort by all branches of the medical profession, and the general practitioner has an important part to play. Specialists in other fields also have a considerable responsibility, for patients with these infections commonly present in other departments. The booklet suggests that many problems are best handled by cooperation between the family doctor and a specialist. For those
practitioners who have a particular interest in the personal problems of their patients, clinical assistantships at special clinics offer opportunities for valuable work in this field.
SCOLIOSIS
THE management of any
deformity can be divided into phases-firstly prevention, and secondly correction. Prevention of progressive deformity, especially in growing children, is an important part of orthopaedics and much work has been done on the prevention of progressive scoliosis in children. Stilwell’casts fresh light on this subject because his experiments were performed on monkeys, whereas those reported hitherto have concerned quadrupeds. Stilwell resected the erector spinas muscles, interspinous ligaments, and ligamentam flava, and found that this caused progressive kyphosis and scoliosis, with adaptive changes in the growing bones and distortion of the intervertebral discs. Suppression of growth, or epiphysiodesis, followed in areas which were subjected to excessive compression, whereas where pressure was less than normal the growth of cartilage was accelerated. As a result there was wedging of the vertebral bodies. Stilwell divides the factors responsible for progressive idiopathic spinal deformity in children into the predisposing, the precipitating, and the perpetuating. Even if the predisposing and precipitating factors cannot be eliminated, the perpetuating factors can usually be controlled. An established deformity can be corrected either by direct attack on the primary curve or by creating secondary two
compensatory curves to mask it. Each of these may be attempted either by conservative means-i.e., by different types of splinting-or by operative intervention. Some years ago Allan2 described a spinal jack for the correction of lateral curvature of the spine. More recently Gruca3 described an ingenious system of springs to be inserted on the convex side of the curve in order to correct the deformity. Harrington4 has described his experiences with instruments of his own devising which combine jacking-up the concave side with compressing the convex side. This method has now been used in 129 patients over a period of eight years. He claims that, where his " " operation of spine instrumentation is combined with spinal fusion and long-continued immobilisation, there will be improvement in 84% of cases. Certainly, dramatic improvement can be produced in curves which are still mobile. There are certain technical problems in the introduction of straight rods where lateral curvature is combined with severe kyphosis. Moreover, Harrington gives no details of the aetiology of the various curves he has treated, of the exact types of curve (whether kyphoscoliosis, pure lateral curvature, or lordoscoliosis), or of their preoperative mobility. The procedure which Harrington recommends is fairly extensive, may be extremely difficult, and demands great technical skill. Whether it is applicable to the majority of spinal curvatures or only to a selected few is not yet known; but, in selected patients, it has certainly produced improvement unparalleled by purely conservative measures. The technique has already been employed in some centres in this country, but it should not be regarded as an easy short-cut to the correction of spinal deformity. Indeed, it should only be used by those who have very considerable experience of this type of spinal surgeryat any rate until its exact indications and contraindications have been firmly established. Meanwhile we must await a longer and more complete account of Harrington’s results, with details of the deformities best suited to this treatment. 1. 2. 3. 4.
Stilwell, D. L. J. Bone Jt. Surg. 1962, 44A, Allan, F. G. ibid. 1955, 37B, 92. Gruca, A. ibid. 1958, 40A, 570. Harrington, P. R. ibid. 1962, 44A, 591.
611.
conception. In neither series, unfortunately, was the intelligence of the children adequately studied; this is now being investigated in Sweden. But 7% of first-trimester-rubella children, compared with 2% of the controls, showed some delay in acquiring the skills of sitting and standing without support. Moreover, at the follow-up examination, 10% of the rubella children, but only 2% of the controls, were found to have a head circumference more than two and a half standard deviations below the mean value related to height. As in other series, the birth-weights of many of the rubella children suggested immaturity; 36% of those with malformation and 12% of those without (but only 3% of the controls) weighed less than 2500 g. at birth. The birth-weight of 10% of the rubella children lay between 2000 g. and 2500 g., compared with only 1 % of the controls; this was the greatest disparity noted for any weight range. Comparison of the rubella immature with the control immature children was interesting, though limited by the rather small number in the second group. The rubella immature had a longer gestation period, a lower incidence of complications in pregnancy and at delivery, and a lower stillbirth-rate and neonatal deathrate. But a higher proportion of the rubella group were still undersized at the time of the follow-up examination. Among the children of Swedish women exposed to, but not contracting, rubella in pregnancy there was no increase in the frequency of malformation; this was true whether or not the mother had already had rubella before the exposure. Of a group of 251 women exposed to rubella in the first four months of pregnancy who were treated with convalescent y-globulin, the disease developed in 6 (2%). Of the children born of these pregnancies, 3 (1%) had rubella-syndrome defects; but only 1 of these 3 was born to a mother who had contracted rubella in spite of the prophylaxis. Among the 245 mothers who did not contract rubella the abortion-rate and stillbirth-rate were normal; of the 229 liveborn children, only 2 had malformations which could be attributed to rubella. Like the findings reported by Lock et al.3 from the United States, these appear fairly satisfactory. It is difficult to estimate how many women would have contracted rubella if not protected with y-globulin. YOGA
YOGISclaim that they can control essential bodily functions such as the heart-rate. In 1935 Brosse investigated this question in one Yogi, and reported her findings eleven years later.4 While the subject attempted to arrest his heart-beat, a single-lead electrocardiogram (E.C.G.) and a pulse-wave recording were taken; these revealed progressive decrease in the electrical potential, and apparent cessation of the heart-beat for a time. This same Yogi has since been reinvestigated along with three others.55 Electrocardiographic, digital plethysmographic, and 3.
Lock,
F.
R., Gatling, H. B., Wells, H. B. J. Amer. med. Ass. 1961, 178,
711. 4. Main Currents in Modern Thought, 1946, 4, 77. 5. Wenger, M. A., Bagchi, B. K., Anand, B. K. Circulation, 1961,
24, 1314.
tracings were made on a portable electroencephalograph. During attempts to stop or slow the heart, each subject adopted a similar manoeuvre-breath-holding, usually in inspiration, with forcible contraction of abdominal and other muscles against a closed glottis to increase the intrathoracic pressure. In Brosse’s subject (who permitted only limited investigation of the method he employed) this procedure produced some change in potential of the two E.c.G. leads, but the heart-sounds other
still present on auscultation. In two of the other there were changes in the potential of the E.C.G. without any evidence of cardiac arrest. The fourth subject had claimed only that he could slow his heart, and he produced bradycardia with the development of nodal rhythm and some change in potential. These results are in accordance with Anand and Chhina’s earlier report 6 that no cardiac arrest was demonstrable on the E.c.G. Dr. Brosse’s original observation of apparent cardiac arrest on a single-lead electrocardiogram was probably an artefact due to the decreased electrical potential subsequently demonstrated under these circumstances. Many of the associated observations - inaudible breath-sounds, impalpable arterial pulse, and obstruction to the venous return-were probably due to the Valsalva or reversed Valsalva manceuvre which the were
subjects also
Yogis employed. INFORMATION ABOUT VENEREAL DISEASE
CONCERN about the increasing incidence of some venereal diseases has led the Standing Advisory Committee of the Central Health Services Council to review the problem in a bookletwhich has been distributed to all general medical practitioners taking part in the National Health Service. The venereal-disease service was established in 1916, and since then clinics staffed by specialists in venereology have been attached to the outpatient departments of most large general hospitals in the United Kingdom. Venereal disease as defined by statute comprises only syphilis, gonorrhoea, and chancroid; but the clinics deal with all conditions transmitted by sexual intercourse and with some other non-transmissible conditions, so that patients who attend are no longer severely stigmatised as " v.n. patients ". One of the most important functions of the clinic is to act as a centre for investigation, advice, and reassurance of individuals who are anxious but may well be free from infection. In 1960, 130,130 patients attended clinics in England and Wales for advice, but only 37,927 of these were found to have statutory venereal disease. The principles which originally governed the operation of the clinics have been maintained; attendance is entirely confidential, and patients are entitled to attend without doctors’ letters or other introduction. Treatment remains free even to the extent that no charge is made for drugs. Promiscuity, by which venereal disease is spread, is regarded as a symptom of social or marital maladjustment, and many clinics now have skilled almoners or socialservice workers one of whose duties is to assist with difficulties arising from unstable marriages, unwanted pregnancies, homosexuality, and venereophobia. The main problems at present are gonorrhcea and the disease, or group of diseases, commonly called nonAnand, B. K., Chhina, G. S. Indian J. med. Res. 1961, 49, 90. See Lancet, 1961, ii, 90. 7. Venereal Disease Service. Prepared by the Standing Medical Advisory
6.
Committee for the Central Health Services Council and the Minister of Health.
497
gonococcal urethritis. Cases of gonorrhoea at the clinics of England and Wales, which amounted to 47,343 in 1946, declined to 17,436 in 1954, but rose in each subsequent year to reach 33,756 in 1960; and the increase is known Cases of non-gonococcal to have continued in 1961. urethritis in males were first recorded in a separate category in 1951 when the total was 10,794 ; it has increased each year, and in 1960 there were 21,971 cases. On the other hand, the incidence of infectious syphilis, which reached a peak in 1946, when 17,675 cases were reported, fell to 808 cases in 1954 and to 704 in 1958. It increased to 984 in 1960; but this remains a small problem by all the standards of the past. ’Only in recent years has it been fully appreciated that vaginal infestation with Trichomonas vaginalis, which is extremely common in women in the reproductive years, is frequently transmitted sexually and that infestation, with few or no symptoms, is common in men. Modern methods of treatment are very effective, but reinfection is almost inevitable unless sexual partners are also treated. Neither patient nor partner should be treated without proper investigation, because of the possibility that other diseases may be
present. For those who undertake responsibility for potentially infected patients without the resources and experience available at venereal-disease clinics, the booklet gives some useful advice. It emphasises that the diseases may be clinically latent, and therefore anyone who has been exposed to possible infection should be examined to exclude it. Transmissible infection is by far the commonest cause of urethral discharge in the male and of vaginal discharge in the female. Symptoms of cystitis, rectal discharge, or lower abdominal pain in a woman may all be due to such a cause. Any genital lesion is suspect, and syphilis should always be excluded. Treatment should never be given before diagnosis, and tests to prove cure are essential. Latent syphilis is the commonest form of the disease and can be detected only by blood tests. Arthritis in young adults may be due to Reiter’s disease, which is believed to be a complication of one variety of transmissible non-gonococcal urethritis. Especially important is the tracing, investigation, and treatment of contacts of infectious patients; for without this any measures for the control of venereal disease must fail. Failure in this responsibility leads to spread of infection, and may lead to reinfection. Patients are often unwilling to assist in this matter, especially men whose wives ought to be examined. Such resistance should be overcome by careful explanation, by tactful insistence, and by perseverance. Some hospitals arrange for sessions to be conducted on other premises than those of the v.D. department, at which patients can have expert investigation while remaining unaware of an association with that department, which inevitably carries some stigma. Control of this serious spread of disease requires a concerted effort by all branches of the medical profession, and the general practitioner has an important part to play. Specialists in other fields also have a considerable responsibility, for patients with these infections commonly present in other departments. The booklet suggests that many problems are best handled by cooperation between the family doctor and a specialist. For those
practitioners who have a particular interest in the personal problems of their patients, clinical assistantships at special clinics offer opportunities for valuable work in this field.
SCOLIOSIS
THE management of any
deformity can be divided into phases-firstly prevention, and secondly correction. Prevention of progressive deformity, especially in growing children, is an important part of orthopaedics and much work has been done on the prevention of progressive scoliosis in children. Stilwell’casts fresh light on this subject because his experiments were performed on monkeys, whereas those reported hitherto have concerned quadrupeds. Stilwell resected the erector spinas muscles, interspinous ligaments, and ligamentam flava, and found that this caused progressive kyphosis and scoliosis, with adaptive changes in the growing bones and distortion of the intervertebral discs. Suppression of growth, or epiphysiodesis, followed in areas which were subjected to excessive compression, whereas where pressure was less than normal the growth of cartilage was accelerated. As a result there was wedging of the vertebral bodies. Stilwell divides the factors responsible for progressive idiopathic spinal deformity in children into the predisposing, the precipitating, and the perpetuating. Even if the predisposing and precipitating factors cannot be eliminated, the perpetuating factors can usually be controlled. An established deformity can be corrected either by direct attack on the primary curve or by creating secondary two
compensatory curves to mask it. Each of these may be attempted either by conservative means-i.e., by different types of splinting-or by operative intervention. Some years ago Allan2 described a spinal jack for the correction of lateral curvature of the spine. More recently Gruca3 described an ingenious system of springs to be inserted on the convex side of the curve in order to correct the deformity. Harrington4 has described his experiences with instruments of his own devising which combine jacking-up the concave side with compressing the convex side. This method has now been used in 129 patients over a period of eight years. He claims that, where his " " operation of spine instrumentation is combined with spinal fusion and long-continued immobilisation, there will be improvement in 84% of cases. Certainly, dramatic improvement can be produced in curves which are still mobile. There are certain technical problems in the introduction of straight rods where lateral curvature is combined with severe kyphosis. Moreover, Harrington gives no details of the aetiology of the various curves he has treated, of the exact types of curve (whether kyphoscoliosis, pure lateral curvature, or lordoscoliosis), or of their preoperative mobility. The procedure which Harrington recommends is fairly extensive, may be extremely difficult, and demands great technical skill. Whether it is applicable to the majority of spinal curvatures or only to a selected few is not yet known; but, in selected patients, it has certainly produced improvement unparalleled by purely conservative measures. The technique has already been employed in some centres in this country, but it should not be regarded as an easy short-cut to the correction of spinal deformity. Indeed, it should only be used by those who have very considerable experience of this type of spinal surgeryat any rate until its exact indications and contraindications have been firmly established. Meanwhile we must await a longer and more complete account of Harrington’s results, with details of the deformities best suited to this treatment. 1. 2. 3. 4.
Stilwell, D. L. J. Bone Jt. Surg. 1962, 44A, Allan, F. G. ibid. 1955, 37B, 92. Gruca, A. ibid. 1958, 40A, 570. Harrington, P. R. ibid. 1962, 44A, 591.
611.