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TUBERCULOSIS
509
Conferences TUBERCULOSIS FROM A CORRESPONDENT
THE 15th conference7of the International Union Against in Istanbul on Sept. 14-18, was 1200 doctors from more than 60 countries. The list of subjects discussed is impressive:
Tuberculosis, held attended by about
chemoprophylaxis, B.c.G. vaccination, atypical mycobacteria, relapse after medical and surgical treatment, indications for surgical treatment, new antibacterial drugs, health education, the role of the public-health nurse, rehabilitation, and acquired immunity to tuberculosis. The main impressions from attending these meetings and from talking " in the lobbies " are that there is still a vast amount of tuberculosis in the world, and that we still have much to learn about the disease. There is a wide gulf in the outlook between doctors from the more technically and socially advanced countries and those from the poor and economically under-developed ones. To the one group the more interesting questions may be rare infections with mycobacteria other than tubercle bacilli and important but relatively small differences between certain regimes of treatment: to the other group the important topics are more likely to be how tubercle bacilli themselves are to be detected and how any regime of treatment at all can be given to the millions requiring it. The first group may tend to look askance at any measures of detection and treatment that do not meet the scientific standards they would require in their own countries-though it was clear that these standards are not uniformly high. The second group may possibly feel that their own urgent problems of improvisation seem too little understood by the more fortunate.
Some indication of these trends was given in a discussion of proposals put forward by Dr. Johan Holm, of W.H.O., for trying to reduce and finally eradicate tuberculosis. That trained technicians could be trusted to read X-ray films as normal or abnormal was not generally acceptable, though no alternative was suggested to enable more tuberculosis to be detected in countries without enough doctors to do the work. The suggestion that all people with abnormal X-ray shadows thought to be tuberculous should be treated by anti-tuberculosis drugs, by mass-production methods without further attempts "
"
diagnosis, was severely criticised-certainly on good grounds in some respects. But has any other feasible suggestion been put forward to deal with the millions of tuberculous patients living with hunger and poverty, too few hospitals and tuberculosis clinics, too few doctors and nurses, and no hope of cure ?
at
That we have still much to learn about tuberculosis well shown in the discussion on B.c.G. It is now generally accepted on incontrovertible evidence that this vaccine can produce protection against disease. There are, it appears, still a few who question this; but they have perhaps not considered the evidence critically. Recent studies of the Medical Research Council have shown that in Britain a high degree of protection of
was
adolescents persists for B.r.G. vaccination was
at a
least 61/2 years. Ten years ago highly controversial subject in
the time when mass-vaccination campaigns were being carried out in many parts of the world. Now it is an accepted public-health measure in Britain; but at the same time doubt is growing, in at least one country where such campaigns began many years ago, whether it is locally as effective as it was expected to be. Such doubts do not by any means imply that B.c.G. vaccination should be discontinued as a mass preventive measure; they merely indicate that there is still much to be discovered about immunity in tuberculosis and that the scope for further research is immense.
this country
at
smaller way, the discussions on new drugs and relapse brought out the deficiencies in our knowledge. Is cycloserine, for instance, as highly effective as some speakers claimed, or as little effective as others suggested ? What really is the necessary duration of chemotherapy to prevent relapse in different categories of patients ? Is failure of chemotherapy caused only by inefficient drug regimes and irregular drug taking, or is it unavoidable in some cases, beyond both the skill of the physician and the control of the patient ?
In
a
About 40 doctors from Great Britain attended the conference, and this country was well represented in the discussions. But there are less than 20 individual British members of the International Union Against Tuberculosis, compared with approximately 250 in France. Great Britain is undoubtedly making important contributions to the elimination of tuberculosis in the world through its own research and the example of its own practice. But it might be wondered whether we support international work sufficiently. As less of our resources of money and knowledge are required to fight our own battle against tuberculosis, should we not be giving more to help others fight theirs ?
DEPRESSION THE gathering held on Sept. 21-26 at Clare College, Cambridge, under the xgis of the Postgraduate Medical School was an occasion of considerable psychiatric significance. Introducing it, Sir AUBREY LEwis pointed to the relative neglect of investigation into the affective disorders compared with schizophrenia. It was a popular error to regard depression as well under control with physical methods, as the work of Norris and others had shown, and it remained a major social problem. In an attempt to break away from traditional Kraepilinian nosology, European workers had developed new concepts; the " unitary psychosis " of the 19th century, for example, had been revived,
particularly by Conrad,
who had
described typical endogenous depression as a prelude to schizophrenia. The diagnostic system of Kleist, the
approach of the existentialists, and the tendency in America for diagnosis to be rejected, all reflected a common discontent, and these trends, although Sir Aubrey doubted their value, could not be ignored by psychiatrists here. Recent work linking anxiety with depression supported the view he had long held against opposition that these conditions and involutional melancholia were united in affective disorder by the common form of sadness. New light on suicide might arise from the frequent association with previous head injury noted in Germany and Finland, and in the biochemical field the retention of sodium, seen in depression, seemed to implicate the pituitary-adrenal axis. Sir Audrey concluded with the observation of Henri Ey that ‘‘ ... it is precisely
Conferences TUBERCULOSIS FROM A CORRESPONDENT
THE 15th conference7of the International Union Against in Istanbul on Sept. 14-18, was 1200 doctors from more than 60 countries. The list of subjects discussed is impressive:
Tuberculosis, held attended by about
chemoprophylaxis, B.c.G. vaccination, atypical mycobacteria, relapse after medical and surgical treatment, indications for surgical treatment, new antibacterial drugs, health education, the role of the public-health nurse, rehabilitation, and acquired immunity to tuberculosis. The main impressions from attending these meetings and from talking " in the lobbies " are that there is still a vast amount of tuberculosis in the world, and that we still have much to learn about the disease. There is a wide gulf in the outlook between doctors from the more technically and socially advanced countries and those from the poor and economically under-developed ones. To the one group the more interesting questions may be rare infections with mycobacteria other than tubercle bacilli and important but relatively small differences between certain regimes of treatment: to the other group the important topics are more likely to be how tubercle bacilli themselves are to be detected and how any regime of treatment at all can be given to the millions requiring it. The first group may tend to look askance at any measures of detection and treatment that do not meet the scientific standards they would require in their own countries-though it was clear that these standards are not uniformly high. The second group may possibly feel that their own urgent problems of improvisation seem too little understood by the more fortunate.
Some indication of these trends was given in a discussion of proposals put forward by Dr. Johan Holm, of W.H.O., for trying to reduce and finally eradicate tuberculosis. That trained technicians could be trusted to read X-ray films as normal or abnormal was not generally acceptable, though no alternative was suggested to enable more tuberculosis to be detected in countries without enough doctors to do the work. The suggestion that all people with abnormal X-ray shadows thought to be tuberculous should be treated by anti-tuberculosis drugs, by mass-production methods without further attempts "
"
diagnosis, was severely criticised-certainly on good grounds in some respects. But has any other feasible suggestion been put forward to deal with the millions of tuberculous patients living with hunger and poverty, too few hospitals and tuberculosis clinics, too few doctors and nurses, and no hope of cure ?
at
That we have still much to learn about tuberculosis well shown in the discussion on B.c.G. It is now generally accepted on incontrovertible evidence that this vaccine can produce protection against disease. There are, it appears, still a few who question this; but they have perhaps not considered the evidence critically. Recent studies of the Medical Research Council have shown that in Britain a high degree of protection of
was
adolescents persists for B.r.G. vaccination was
at a
least 61/2 years. Ten years ago highly controversial subject in
the time when mass-vaccination campaigns were being carried out in many parts of the world. Now it is an accepted public-health measure in Britain; but at the same time doubt is growing, in at least one country where such campaigns began many years ago, whether it is locally as effective as it was expected to be. Such doubts do not by any means imply that B.c.G. vaccination should be discontinued as a mass preventive measure; they merely indicate that there is still much to be discovered about immunity in tuberculosis and that the scope for further research is immense.
this country
at
smaller way, the discussions on new drugs and relapse brought out the deficiencies in our knowledge. Is cycloserine, for instance, as highly effective as some speakers claimed, or as little effective as others suggested ? What really is the necessary duration of chemotherapy to prevent relapse in different categories of patients ? Is failure of chemotherapy caused only by inefficient drug regimes and irregular drug taking, or is it unavoidable in some cases, beyond both the skill of the physician and the control of the patient ?
In
a
About 40 doctors from Great Britain attended the conference, and this country was well represented in the discussions. But there are less than 20 individual British members of the International Union Against Tuberculosis, compared with approximately 250 in France. Great Britain is undoubtedly making important contributions to the elimination of tuberculosis in the world through its own research and the example of its own practice. But it might be wondered whether we support international work sufficiently. As less of our resources of money and knowledge are required to fight our own battle against tuberculosis, should we not be giving more to help others fight theirs ?
DEPRESSION THE gathering held on Sept. 21-26 at Clare College, Cambridge, under the xgis of the Postgraduate Medical School was an occasion of considerable psychiatric significance. Introducing it, Sir AUBREY LEwis pointed to the relative neglect of investigation into the affective disorders compared with schizophrenia. It was a popular error to regard depression as well under control with physical methods, as the work of Norris and others had shown, and it remained a major social problem. In an attempt to break away from traditional Kraepilinian nosology, European workers had developed new concepts; the " unitary psychosis " of the 19th century, for example, had been revived,
particularly by Conrad,
who had
described typical endogenous depression as a prelude to schizophrenia. The diagnostic system of Kleist, the
approach of the existentialists, and the tendency in America for diagnosis to be rejected, all reflected a common discontent, and these trends, although Sir Aubrey doubted their value, could not be ignored by psychiatrists here. Recent work linking anxiety with depression supported the view he had long held against opposition that these conditions and involutional melancholia were united in affective disorder by the common form of sadness. New light on suicide might arise from the frequent association with previous head injury noted in Germany and Finland, and in the biochemical field the retention of sodium, seen in depression, seemed to implicate the pituitary-adrenal axis. Sir Audrey concluded with the observation of Henri Ey that ‘‘ ... it is precisely