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STATISTICAL PRESENTATION OF RESULTS OF TREATMENT
985 who is not in the habit of consuming large quantities of infected raw milk, being generally a reliable indication of active infection with brucella. Whenever possible blood cultures should be taken and incubated both in air and in an atmosphere of 10 per cent. CO2, While, however, the causative organism can generally be recovered from patients with melitensis infections, the proportion of abortus cases yielding positive blood cultures is much lower-probably of the order of 15 per cent. Recent studies reported by Huddleson, Johnson, and Hamannin Michigan suggest that, even with the use of blood cultures and serum agglutination tests, a certain number of definite eases of undulant fever are being missed. They have therefore been exploring the use of two other tests in diagnosis-the allergic skin reaction and the opsono-cytophagic index. The latter reaction is carried out by incubating 0-8per cent. citrated whole blood with a thick suspension of brucella for half an hour at 37° C., making films, counting the number of ingested organisms in 25 leucocytes, and recording the results on a percentage scale. For the skin reaction a special nucleoprotein is used. In susceptible but uninfected persons both these tests are negative. In infected patients the skin test is positive and the cellular index negative or low. Immune subjects have a positive skin test and a high cellular index. On the basis of these two tests these investigators apparently feel justified in making a diagnosis of undulant fever even in the absence of agglutinins in the blood-serum. But the method is still far too much in its infancy to be used for routine purposes. Indeed, experience of other fevers affords but little hope that estimation of the bacteriotropins developing as the result of infection are likely to be of much value in the diagnosis of active disease. It has yet to be shown that definite cases of undulant fever with a persistently negative agglutination reaction are at all common. Many positive reactions are undoubtedly missed by use of an unsuitable bacterial suspension, and by failure to put up a sufficiently wide range of dilutions. Zone phenomena are by no means infrequent, and unless dilutions extending from 1/20 to 1/2560 are prepared, occasional cases will undoubtedly be reported as negative. While there is every reason to explore fresh methods of detecting brucella infection, particularly in children, the actual diagnosis of undulant fever in the absence either of a positive blood culture or a positive agglutination reaction must for the moment be deprecated. It is better to leave a fever undiagnosed than to label it on insufficient evidence with a specific name, and thus prevent any further inquiry into its real causation. STATISTICAL
PRESENTATION
OF
RESULTS
OF TREATMENT
"STONE dead has no fellow" is an old saying that is particularly applicable to the assessment of operative success-or lack of success. The survivalrate of cancer patients, for instance, treated surgically or by radium, measured over a period of years, is the only sound criterion of success, and is now being widely adopted. A similar measure has been used to determine the effects of sanatorium treatment of tuberculosis. On the other hand, it is obvious that the survival-rate presents only one aspect of the result of treatment. Survival does not necessarily denote a freedom from disability, and in conditions which only rarely lead to death it is freedom from disability which is the important criterion. The difficulty is to secure an adequately objective measure 1 Amer. Jour. Pub. Health, September, 1933, p. 917.
of freedom from disability. In a study published on p. 999, Dr. H. V. Prynne, the chief medical officer to the Post Office, suggests that such a measure is available for the Post Office staff (numbering nearly a quarter of a million) in the accurately recorded sickness records. For instance, investigating a series of gastric and duodenal ulcer cases, operated upon in different ways, he finds that the average sick-rate per year per employee for disorder of the digestive system was 12 days after gastro-enterostomy, 22 days after suture, 29 days after excision. Taken at their face value, the figures suggest a considerable advantage to the patients treated by gastro-enterostomy. But were patients treated in these various ways actually in pari materia before they were relegated to the different operative groups ?‘ It must, at the least, seem unlikely; it is not even recorded whether or not any of the operations were undertaken at a critical time, for example, following perforation, and the relative advantages thus become difficult to interpret. Another example that may be cited from Dr. Prynne’s paper is the result in 17 cases of exophthalmic goitre of treatment by thyroidectomy. Of these, 12 are reported to have had no recurrence of the condition in periods varying between one and ten years. On the other hand, the average sick-rate for all conditions per year per officer was nearly 29 days, of which 11.6 were due to recurrence of exophthalmic goitre and 5.4 to nervous and heart symptoms probably associated with the condition of exophthalmic goitre. The operation in a number of cases has failed to prevent recurrence, but to deduce therefore that it has been valueless would hardly be justifiable. We do not know, and obviously can never know, how such cases would have fared, and what their sick-rate would have been if they had not been submitted to operation. A more clear-cut issue is presented in the effect of operation on the knee in cases of semilunar cartilage injury. Of 43 non-operation cases 63 per cent. incurred further sick absence due to the old injury or to further accidents to the knee, while of 42 cases operated upon only 24 per cent. incurred further sick absence for similar reasons. It is clear that, in spite of the limitations suggested above, the objective measure of success proposed by Dr. Prynne deserves close consideration by such medical industrial workers as have the sickness statistics of their patients
available. THE VISIT OF PROF. BURGER
THE Semon lecture will be delivered on Thursday, Nov. 2nd, at the Royal Society of Medicine, by Prof. H. Burger, of Amsterdam, his subject being the So-called Associated Paralyses of the Larynx and Pharynx (Multiple Cranial Nerve Palsy). Dr. Burger will deliver the lecture in English ; like so many Dutchmen he is an excellent linguist. It was partly for this reason that in 1909 he was appointed secretary-general of the International Committee for the International Congress of Medicine. In this capacity he acted when the last International Congress was held, under the presidency of Sir Thomas Barlow, in London in the year 1913. Dr. Burger is still the secretary-general, but there seems little prospect of another International Congress for general medicine at present. Our visitor is professor of otolaryngology in the University of Amsterdam. He is a man of many interests. He was Rector Magnificus of his university during the academic year 1927-28, and he has three times been president of the Dutch Medical Association. He is a man of culture and wide interests. On Wednesday, Nov. 1st, at 5 P.M., he will give an
PRESENTATION
OF
RESULTS
OF TREATMENT
"STONE dead has no fellow" is an old saying that is particularly applicable to the assessment of operative success-or lack of success. The survivalrate of cancer patients, for instance, treated surgically or by radium, measured over a period of years, is the only sound criterion of success, and is now being widely adopted. A similar measure has been used to determine the effects of sanatorium treatment of tuberculosis. On the other hand, it is obvious that the survival-rate presents only one aspect of the result of treatment. Survival does not necessarily denote a freedom from disability, and in conditions which only rarely lead to death it is freedom from disability which is the important criterion. The difficulty is to secure an adequately objective measure 1 Amer. Jour. Pub. Health, September, 1933, p. 917.
of freedom from disability. In a study published on p. 999, Dr. H. V. Prynne, the chief medical officer to the Post Office, suggests that such a measure is available for the Post Office staff (numbering nearly a quarter of a million) in the accurately recorded sickness records. For instance, investigating a series of gastric and duodenal ulcer cases, operated upon in different ways, he finds that the average sick-rate per year per employee for disorder of the digestive system was 12 days after gastro-enterostomy, 22 days after suture, 29 days after excision. Taken at their face value, the figures suggest a considerable advantage to the patients treated by gastro-enterostomy. But were patients treated in these various ways actually in pari materia before they were relegated to the different operative groups ?‘ It must, at the least, seem unlikely; it is not even recorded whether or not any of the operations were undertaken at a critical time, for example, following perforation, and the relative advantages thus become difficult to interpret. Another example that may be cited from Dr. Prynne’s paper is the result in 17 cases of exophthalmic goitre of treatment by thyroidectomy. Of these, 12 are reported to have had no recurrence of the condition in periods varying between one and ten years. On the other hand, the average sick-rate for all conditions per year per officer was nearly 29 days, of which 11.6 were due to recurrence of exophthalmic goitre and 5.4 to nervous and heart symptoms probably associated with the condition of exophthalmic goitre. The operation in a number of cases has failed to prevent recurrence, but to deduce therefore that it has been valueless would hardly be justifiable. We do not know, and obviously can never know, how such cases would have fared, and what their sick-rate would have been if they had not been submitted to operation. A more clear-cut issue is presented in the effect of operation on the knee in cases of semilunar cartilage injury. Of 43 non-operation cases 63 per cent. incurred further sick absence due to the old injury or to further accidents to the knee, while of 42 cases operated upon only 24 per cent. incurred further sick absence for similar reasons. It is clear that, in spite of the limitations suggested above, the objective measure of success proposed by Dr. Prynne deserves close consideration by such medical industrial workers as have the sickness statistics of their patients
available. THE VISIT OF PROF. BURGER
THE Semon lecture will be delivered on Thursday, Nov. 2nd, at the Royal Society of Medicine, by Prof. H. Burger, of Amsterdam, his subject being the So-called Associated Paralyses of the Larynx and Pharynx (Multiple Cranial Nerve Palsy). Dr. Burger will deliver the lecture in English ; like so many Dutchmen he is an excellent linguist. It was partly for this reason that in 1909 he was appointed secretary-general of the International Committee for the International Congress of Medicine. In this capacity he acted when the last International Congress was held, under the presidency of Sir Thomas Barlow, in London in the year 1913. Dr. Burger is still the secretary-general, but there seems little prospect of another International Congress for general medicine at present. Our visitor is professor of otolaryngology in the University of Amsterdam. He is a man of many interests. He was Rector Magnificus of his university during the academic year 1927-28, and he has three times been president of the Dutch Medical Association. He is a man of culture and wide interests. On Wednesday, Nov. 1st, at 5 P.M., he will give an