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PREGNANCY AND TUBERCULOSIS

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944 overstrain, and brings the patient to the doctor, is as follows : (a) pain with active and passive move- ments, especially on performing hard work ; (b) I localised pain over the semilunar on the dorsal and palmar aspects, mostly on hyperextension, but also on hyperflexion, and on pulling the hand or jarring it longitudinally; (c) swelling of the soft parts, mostly on the dorsal spect; (d) limitation of movements in all directions ; (p) sometimes crepitation; (f) some- i times shortening of the whole wrist joint. Together with these symptoms there is loss of power in the hand, and sometimes muscular atrophy. The X ray i picture in the early stages may be normal; later the characteristic changes consist in alteration of the structure, showing disturbance of the laminae, with i areas of density and opacity, arranged in patches or in stripes. The whole bone is compressed proximo- distally, like an impacted fracture. The proximal surface is irregular and less rounded, and often shows I projecting particles. The bone may be divided into two or more pieces, or one corner may be cut off by a cleft. The other bones may be displaced. The I . diagnosis of a typical case can usually be made with- out difficulty on the clinical appearances once these are recognised, but in the early stages the condition cannot be distinguished from a contusion, and usually is diagnosed as such unless an X ray is taken at a later date. In Prof. Sonntag’s series, after the first few cases were recognised, the remainder were diag- nosed clinically in the out-patient department by the assistants and students. The condition can be diagnosed from fractures, dislocations, tuberculous affections, and osteo-arthritis by the X ray. Con- tusion and distortion give similar pictures, but can be distinguished by the fact that in the semilunar disease the disability continues much longer and tenderness is limited to the semilunar. The prognosis cannot be definitely stated without further and longer observations on more cases, but it can be said from the present experience that the prognosis respecting cure and function is very doubtful. The condition is usually chronic, and often leads to true osteo- arthritic changes. It is also not known how many slight cases cure themselves, but when once X ray changes are demonstrable it is likely that the dis- ability will persist for years, if not for ever. Treat- . ment is still uncertain. Conservative measures appear to give the best results ; in the early cases treatment as for contusion ; in the late as for osteo- arthritis. Operative removal of the bone has been carried out, but so far has not been uniformly satis- factory in relieving the symptoms. ETCHER AND SURGEON. THE etchings of Sir Francis Seymour Haden have recently been reproduced and published in one volume, under the editorship of Malcolm C. Salaman, a collection which should have a special interest for members of the medical profession. It is but seldom that distinguished service to the science of medicine is combined with outstanding work in any field of art, yet in the late Sir Francis Seymour Haden there were united a surgeon and an artist of renown. During his medical student days, part of which were spent in Paris, Haden devoted much of his spare time to study in the art schools, less from any artistic inclination than with the object of training hand and eye for surgical work. In after years he laid stress on the importance of such a training for medicine, saying, ,, " How much sooner would the eye accustomed to I’ observe and estimate closely differences of colour, aspect, weight, and symmetry, learn to gauge their aberrations as the signs which make up the facies of disease ; how much better the hand, trained to pourtray them accurately, be able to direct with precision and safety the course of the knife ? " Among his fellow practitioners Haden was noted for an instinctive power of diagnosis, which was attributed often to his disciplined sense of vision. Haden continued his practice as a surgeon until 1887. He pursued the art and study of etching mainly as a relaxation from his professional work, but it is his etchings which form the chief memorial of his life. He first exhibited in the Royal Academy in 1860 under the pseudonym of " H. Dean," but in 1864 he signed his work in his own name. In 1880 he founded the Society (now the Royal Society) of Painter- Etchers, whose president he remained till his death in 1910. In 1905 his distinction was recognised abroad by honorary membership of the Institut de France, the Academic des Beaux Arts, and the Société des Artistes Francais. He gained the Grands Prix at the Expositions Universelles at Paris in 1880 and 1900. Though at first treating art as a hand- maiden of medicine, Haden became, not merely a doctor with an interest in the beaux arts, but a great artist. He shared with Whistler, his brother-in- law, the claim to being one of the finest etchers of his day, and it is mainly to his work and enthusiasm that the revival of etching in this country is due. It is interesting to note that some of Haden’s early drawings appeared in the pages of THE LANCET. In 1862 a report on surgical instruments shown at the International Exhibition of that year was given in our columns, illustrated by accurate drawings. Many of these engravings were from Haden’s burin, and though they could hardly claim, on grounds of the subject, inclusion in a collection of his artistic studies, nevertheless they possess value as showing one manner in which Haden employed his skill to medical ends. PREGNANCY AND TUBERCULOSIS. FOR almost a generation our attitude towards the combination of pregnancy with pulmonary tubercu- losis has largely been determined by the aphorism, credited by Osler to Dubois, that the woman threatened with pulmonary tuberculosis may bear the first accouchement well, the second with difficulty, the third, never. With rather halting logic, this aphorism has often been the excuse for the induction of abortion. The revolt against this course was started a few years ago by Prof. Forssner, of Stock- holm, and of late his plea in favour of conservative treatment has found much support. Two of the most recent publications on this subject may briefly be referred to. In the annual report of the chief tubercu- losis officer for Belfast for the year ending Dec. 31st, 1922, there is an instructive analysis of the result of pregnancy in 1375 tuberculous women. It was found that tuberculosis was not a very active cause of premature birth, and that among the 6-3 per cent. of the patients who miscarried, other causes than tuberculosis may have been at work. With regard to the effect of pregnancy on the clinical course of tuberculosis, it was found that, unless the disease was in an acute or advanced stage, the normal course of pregnancy was not disturbed. The second publica- tion referred to is a paper by Dr. A. Scherer,l of Magdeburg. His analysis of 8520 definite cases of pulmonary tuberculosis in women of the child-bearing age showed that in only a small fraction could pregnancy be convicted of playing a sinister part in the propagation of the disease. In 103 cases the interruption of pregnancy had been advised, but only in 72 cases had this advice been followed. The remaining 31 women objected, partly on religious grounds, to this procedure, and they served as controls to the 72 cases in which the experiment of interrupting pregnancy was carried into effect. Only in 19 of these 72 cases did sacrificing the child prove beneficial or at least harmless. As for the 31 women who refused interference, as many as 22 not only went to term, but gave birth to living children, and when the mothers were examined some time later, they were still in comparatively good health. The lesson of Dr. Scherer’s investigations is that pregnancy which occurs frequently at short intervals may, indeed, be injurious as far as tuberculosis is concerned, 1 Beitr. z. Klin. d. Tuberk., 1923, lxvi., 234.
Transcript
Page 1: PREGNANCY AND TUBERCULOSIS

944

overstrain, and brings the patient to the doctor, isas follows : (a) pain with active and passive move-ments, especially on performing hard work ; (b) Ilocalised pain over the semilunar on the dorsal andpalmar aspects, mostly on hyperextension, but alsoon hyperflexion, and on pulling the hand or jarringit longitudinally; (c) swelling of the soft parts, mostlyon the dorsal spect; (d) limitation of movements inall directions ; (p) sometimes crepitation; (f) some- itimes shortening of the whole wrist joint. Togetherwith these symptoms there is loss of power in thehand, and sometimes muscular atrophy. The X ray ipicture in the early stages may be normal; later thecharacteristic changes consist in alteration of thestructure, showing disturbance of the laminae, with i

areas of density and opacity, arranged in patches orin stripes. The whole bone is compressed proximo-distally, like an impacted fracture. The proximalsurface is irregular and less rounded, and often shows Iprojecting particles. The bone may be divided intotwo or more pieces, or one corner may be cut off bya cleft. The other bones may be displaced. The I .

diagnosis of a typical case can usually be made with-out difficulty on the clinical appearances once theseare recognised, but in the early stages the conditioncannot be distinguished from a contusion, and usuallyis diagnosed as such unless an X ray is taken at alater date. In Prof. Sonntag’s series, after the firstfew cases were recognised, the remainder were diag-nosed clinically in the out-patient department bythe assistants and students. The condition can bediagnosed from fractures, dislocations, tuberculousaffections, and osteo-arthritis by the X ray. Con-tusion and distortion give similar pictures, but canbe distinguished by the fact that in the semilunardisease the disability continues much longer andtenderness is limited to the semilunar. The prognosiscannot be definitely stated without further and longerobservations on more cases, but it can be said fromthe present experience that the prognosis respectingcure and function is very doubtful. The conditionis usually chronic, and often leads to true osteo-arthritic changes. It is also not known how manyslight cases cure themselves, but when once X raychanges are demonstrable it is likely that the dis-ability will persist for years, if not for ever. Treat-

. ment is still uncertain. Conservative measures

appear to give the best results ; in the early casestreatment as for contusion ; in the late as for osteo-arthritis. Operative removal of the bone has beencarried out, but so far has not been uniformly satis-factory in relieving the symptoms.

ETCHER AND SURGEON.

THE etchings of Sir Francis Seymour Haden haverecently been reproduced and published in one volume,under the editorship of Malcolm C. Salaman, acollection which should have a special interest formembers of the medical profession. It is but seldomthat distinguished service to the science of medicineis combined with outstanding work in any field ofart, yet in the late Sir Francis Seymour Haden therewere united a surgeon and an artist of renown. Duringhis medical student days, part of which were spent inParis, Haden devoted much of his spare time to studyin the art schools, less from any artistic inclinationthan with the object of training hand and eye forsurgical work. In after years he laid stress on theimportance of such a training for medicine, saying, ,," How much sooner would the eye accustomed to I’observe and estimate closely differences of colour,aspect, weight, and symmetry, learn to gauge theiraberrations as the signs which make up the facies ofdisease ; how much better the hand, trained topourtray them accurately, be able to direct withprecision and safety the course of the knife ? "Among his fellow practitioners Haden was noted foran instinctive power of diagnosis, which was attributedoften to his disciplined sense of vision. Hadencontinued his practice as a surgeon until 1887. He

pursued the art and study of etching mainly asa relaxation from his professional work, but it is hisetchings which form the chief memorial of his life.He first exhibited in the Royal Academy in 1860under the pseudonym of

" H. Dean," but in 1864 hesigned his work in his own name. In 1880 he foundedthe Society (now the Royal Society) of Painter-Etchers, whose president he remained till his deathin 1910. In 1905 his distinction was recognisedabroad by honorary membership of the Institut deFrance, the Academic des Beaux Arts, and theSociété des Artistes Francais. He gained the GrandsPrix at the Expositions Universelles at Paris in 1880and 1900. Though at first treating art as a hand-maiden of medicine, Haden became, not merelya doctor with an interest in the beaux arts, but agreat artist. He shared with Whistler, his brother-in-law, the claim to being one of the finest etchers of hisday, and it is mainly to his work and enthusiasm thatthe revival of etching in this country is due. It isinteresting to note that some of Haden’s early drawingsappeared in the pages of THE LANCET. In 1862a report on surgical instruments shown at theInternational Exhibition of that year was given in ourcolumns, illustrated by accurate drawings. Manyof these engravings were from Haden’s burin, andthough they could hardly claim, on grounds of thesubject, inclusion in a collection of his artistic studies,nevertheless they possess value as showing one mannerin which Haden employed his skill to medical ends.

PREGNANCY AND TUBERCULOSIS.

FOR almost a generation our attitude towards thecombination of pregnancy with pulmonary tubercu-losis has largely been determined by the aphorism,credited by Osler to Dubois, that the woman

threatened with pulmonary tuberculosis may bear thefirst accouchement well, the second with difficulty,the third, never. With rather halting logic, thisaphorism has often been the excuse for the inductionof abortion. The revolt against this course was

started a few years ago by Prof. Forssner, of Stock-holm, and of late his plea in favour of conservativetreatment has found much support. Two of the mostrecent publications on this subject may briefly bereferred to. In the annual report of the chief tubercu-losis officer for Belfast for the year ending Dec. 31st,1922, there is an instructive analysis of the result ofpregnancy in 1375 tuberculous women. It was foundthat tuberculosis was not a very active cause ofpremature birth, and that among the 6-3 per cent.of the patients who miscarried, other causes thantuberculosis may have been at work. With regardto the effect of pregnancy on the clinical course oftuberculosis, it was found that, unless the diseasewas in an acute or advanced stage, the normal courseof pregnancy was not disturbed. The second publica-tion referred to is a paper by Dr. A. Scherer,l ofMagdeburg. His analysis of 8520 definite cases of

pulmonary tuberculosis in women of the child-bearingage showed that in only a small fraction couldpregnancy be convicted of playing a sinister part inthe propagation of the disease. In 103 cases theinterruption of pregnancy had been advised, but onlyin 72 cases had this advice been followed. Theremaining 31 women objected, partly on religiousgrounds, to this procedure, and they served as

controls to the 72 cases in which the experiment ofinterrupting pregnancy was carried into effect. Onlyin 19 of these 72 cases did sacrificing the child provebeneficial or at least harmless. As for the 31 womenwho refused interference, as many as 22 not onlywent to term, but gave birth to living children, andwhen the mothers were examined some time later,they were still in comparatively good health. Thelesson of Dr. Scherer’s investigations is that pregnancywhich occurs frequently at short intervals may,indeed, be injurious as far as tuberculosis is concerned,

1 Beitr. z. Klin. d. Tuberk., 1923, lxvi., 234.

Page 2: PREGNANCY AND TUBERCULOSIS

945

but that interrupting pregnancy is a remedy of

very doubtful value. Another German authority,Dr. Schellenberg, has published in the samejournal statistics supporting the views of Dr.Scherer, and in Germany as well as in France themovement would seem to be gaining ground whichfavours the careful supervision of pregnant womenin a sanatorium or other institution during andimmediately after pregnancy. ;

A PROPOSAL FOR DEVOLUTION.

THE rapid development of our knowledge inpreventive medicine has had and is having a profoundeffect on the administrative side of the public healthservice, as Sir George Newman has pointed out onmany occasions. For example, the reduction ofenteric fever can be attributed to improvement inwater-supply, drainage, sewerage, and refuse disposal,and the control of food, including shell-fish. Stillundefeated enemies from the preventive standpoint.are respiratory diseases, heart and circulatorytroubles, nervous diseases, and cancer. These mustnecessarily be attacked mainly from the personalaspects, and it is these a.spects which have beenraised by Lieut.-Colonel F. E. Fremantle, M.P., ina letter to the Prime Minister published recently.Colonel Fremantle thinks that the time has come for areconsideration of health administration, which willlead to the crystallisation of the views of manypeople. He makes concrete proposals for changes incentral administration which are revolutionary incharacter, being no less than the abolition of theMinistry of Health and the transfer of its powers tothe Office of Works as to housing, Home Office as tolocal government (presumably including Poor-lawwork), and the Board of Education as to its healthfunctions. Colonel Fremantle’s suggestion, broadlyspeaking, is that with the development of our know-ledge sanitary works of the character of water-supplyand sewerage have no longer the importance whichthey had in the past, and that future progress is to befound in " research (under the Privy Council) andpublic enlightenment, which surely should come

-Linder the Board of Education." In considering hisproposals some guidance can be gathered from thelost opportunities of the past. In 1871 Sir John:Simon po’ntecl out that the opportunity of placinga new branch of work-sanitary administration--on a sound basis was spoilt by grafting it on

to an existing department which was bound tobe to its detriment, and it has been abundantlyshown that the association of health work withPoor-law administration was a mistake. ColonelFremantle refers to the need of intelligent use

of the human factor in every department of localor national government, as well as in what, becauseof former deficiencies, have been looked on as

works of sanitation-water-supply, sewerage-orhousing or hospitals. His use of the word " former "suggests that there is no need for further activity inthese matters. Happy would be the area of whichthis could be said, but even if it were true of thelarge towns, there is much to be done in the vasttracts of county areas before even modest ambitionswith respect to water-supply, sewerage, refusedisposal, and isolation hospitals would be satisfied.These are hardly cognate to the work of the Board ofEducation. We agree with Colonel Fremantle-thatknowledge of prevention of illness and disease hasreached the stage when public enlightenment iR aneven more important factor than it has been at anyprevious time, and for this the community requires acentral department which has preventive measures asits chief function. But the Ministry of Health hassince its inception behaved as though prevention wereits prime object, and though the Ministry might wellbe relieved of certain extraneous duties it must remainthe central department for all health matters. Decen-tralisation of some of the functions of the Ministry canonly be recommended with stringent safeguards forefficiency and economy.

Modern Technique in Treatment.A Series of Special Articles, contributed by

invitation, on the Treatment of Medicaland Surgical Conditions.

XLII.-THE TREATMENT OF THE NEUROTIC.

SOME 40 articles have appeared in this series so far,each and all-with one exception, and that onlyapparent--dealing either with a definite type ofdisease or a definite objective symptom. The moreimpersonal and objective the condition, the simpler isits therapeutic consideration ; specific ailments evokespecific treatment. Nothing could be more objectivethan club-foot, nothing more impersonal than scabiesor pediculosis. By comparison, the physician calledon to discuss the treatment of the neurotic andneurasthenic is doubly handicapped ; he is not surewhether he is dealing with " disease " in the acceptedsense of the word, and as a clinician he is frequently injustifiable doubt as to the reality of the symptoms hemay be invited to dispel. He labours, however, underno misapprehension as to the commonness of nervoussymptoms called neurotic or neurasthenic ; were heprone to minimise their significance or ignore theiruniversality, the rush of patients to the latest pur-veyor of mysterious panaceas, duly chronicled in thedaily press, would remind him of his error. Whateverelse is the matter is uncertain, this is clear, that thereexists an immense amount of nervous ailment, real,exaggerated, or feigned, with which the practitioner ofmedicine should be able to cope, and for the con-tinuance of which he cannot escape a modicum ofresponsibility.

It is unnecessary to indicate with greater particu-larity the nervous symptoms included under neurosisand neurasthenia, and it would be endless were itnecessary. There is no kind or degree of ache or pain,of numbness or other paraesthesia, of fear or depression,of fatigue or ennui, of sensitiveness or apathy, of

anxiety or moodiness, which cannot be set down to" the nerves " and for which relief will not be sought.No pretence is here made to define the landmarks or tospecify their relative importance ; no description canbe given that will be universally applicable ; but thephysician in practice soon learns to separate the

organic cases from the " functional," though here, aswill be indicated later, lies a source of therapeutictrouble.

The Element of Fear.For the successful treatment of the neurotic it is

incumbent on the practitioner to realise in everyinstance that there may exist in the patient’s mind anelement of fear or apprehension. He has not theknowledge that the practitioner has ; he is incapableof interpreting aright the symptoms that have begunto obtrude themselves into conscious notice ; uneasyand concerned, a prey to too facile an imagination,especially if he is, as almost all of this class are,constitutionally sensitive, he seeks advice because he isdominated to some extent by foreboding. He may beafraid of having to relinquish his work, of havingbrought the trouble . on by previous indiscretions, offailure on the part of the practitioner to diagnose hiscondition accurately, of insufficiency in respect of the

treatment that will be suggested-in a word, he longsto be reassured about himself and his symptoms.The physician’s aim, therefore, must be to show by

his investigation and his demeanour that he recognisesthe symptoms for what they are, that he is familiarwith the course taken by such morbid conditions, andthat he is confident a cure’is practicable. He mustnever allow the patient to leave his room on the firstvisit without having taken definite steps to dispelapprehension. In this respect he might take a leafout of the book of the " faith healer " ; if he is true tohis own intellect he cannot, like the latter, facilelydeny the reality of disease, yet his optimistic outlook,and his willingness to take the burden of the patient’s


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