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could develop a gangrenous appendix with a large local abscess quite silently without pain or vomiting. An analogy to this is the way in which a mastoid can develop silently under the influence of sulphonamide therapy. This danger should always be remembered. Fifthly: This case illustrates the extraordinary power of a lung riddled with " holes " to heal provided the walls of the cavities are not too rigid, as is so often the case in phthisis. Even in phthisis it is well reeognised 1hat healing of small cavities does frequently occur without apposition bY pneumothorax. Had, however, the cavity with the fluid level shown in film No. 1 been a tuberculous cavity of the same size there would have been little hope of its responding to treatment without some collapse measure. Abscess cavities must have a much greater natural tendency to heal, and an apparently hopeless looking x-ray picture result in what may be considered a perfect result, (see film No. 2) without even any scarring of the lung, at least not such as is apparent radiologically. In conclusion, while it would appear that penicillin w~ll in the future render obsolete much of our previous views about staphylococcal septiemmia (for example, the author has h a d r e c e n t l y under his care a case of staphylococcal septiceemia and purulent meningitis and a case of pneumococcal meningitis, both treated successfully with penicillin), at the same time there seem to be a number of points in this case of more than ordinary interest and t!~erefore worth recording.

PRECAUTIONS TAKEN AGAINST TUBERCULOSIS IN A STATE SCHOOL. By DoRo'rIIY PRICE. N the year 1933 fifty-five pupils in a Dublin boarding school were examined for tuberculosis by Dr. T. G. Hardman and the writer. Every pupil had a tuberculin test, followed by both chest and abdominal radiograph. The results of this investigation were incorporated in articles published in this JOURNAL (1934). For the past eleven years I have been trying to prevent the develop~ ment of the more serious forms of tuberculosis amongst .the pupils of this school. The scheme followed since 1933 is simple. Each pupil is tuberculin-tested on entry, and, if the reaction is negative, at subsequent annual inspections, and finally at the end of the last term. In the event of any illness or debility in a negative pupil during the interval between examinations, the test is repeated. After the final test at the end of the last school year, I give the leavers a short talk about tuberculos~s, and the significance of their tests is explained. Positive reactors are told that they have passed through their primary infection, have healed, and are in a strong position to withstand further infection if exposed, but in the event of any doubt to have another x-ray examination at any time. Negative reactors are warned to get themselves re-tested at intervals, and if they feel run down at any time. From 1933 to 1940 a single test was employed (percutaneous Hamburger ointment). Since 1941 two tests have been used (percutaneous Dublin Moro ointment followed in negative cases by Mantoux 1 in 100

I

FIG. 1. F i l m t a k e n early in illness, showed a n u m b e r o f cavities; these do n o t show up well on t h e plate, except for one i n d i s t i n c t l y seen a t L. base. This was easily seen on original film as a distinct cavity with fluid Ievel.

FIG. 2. Taken 2{ years later, shows complete healing of cavities; no s c a r r i n g nor evidence of original lesion can be seen.

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intracutaneously). All positive reactors get a chest x-ray and exhaustive clinical examinations. To date, only one pupil had at entry a film suggestive of activity; she was dealt with. The entire domestic staff have been tuberculin-tested and positive reactors x-rayed. The matron is tested annually, and members of the teaching staff have volunteered for chest films. These precautions make us feel quite certain that there is no person inside the school walls who could possibly infect the pupils with tuberculosis. Our aim has been tile early detection of primary tuberculosis, followed by adequate treatment. ]3y curing the disease in the primary stage we hope to prevent the development of the more serious form~ of tubereulosis both at the time and in the years ahead. All cases of primary infection during the past eleven years have had a pulmonary focus, except one case of cervical adenitis. The rate at which the negative reactors in this school contract their primary infection appears to be normal, and such as usually occurs amongst the healthy general population; several infections were traced by the six weeks' incubation period to a contact during holidays at home. The incidence of positive reactors both on entry and on leaving is low compared with recent surveys made in ]gire. Details of results: Pupils te~ted. 1933-1944. Total 172. ,Entry aged 14 yrs. Girls Boys 150 negative 134 16 22 positive (12-7%) 22 0 Leavi~.g aged 18 yrs. 119 negative 106 13 53 positive (30"8%) 50 3 It may be seen that 31 pupils changed from negative to positive during their school sojourn, i.e., acquired primary tuberculosis. The Prophit Survey in London have adopted the convenient w o r d " conversion " to describe this altered allergy. 'Analysis of 31 " Conversion " Cases. 16 showed nothing clinically or radiologically ; they had no treatment beyond a watchful eye. 7 showed slight ill-health; they remained at school, but had extra rest for a period of six months. 6 were definitely ill, positive radiograph (4 had erythema nodosom). After a month in hospital, they rested at home, losing from 3 to 12 months' school work. 1 had cervical gland tuberculosis, chest negative; shm~t period of home rest. 1 died. Moved to hospital one week after developing primary tuberculosis, she went straight on to acute miliary tuberculosis, and died two months later. A member of her family was found go be suffering from unsuspected open phthisis. En~ic~,ncy of Tests. For seven years we used one test, but since 1941 we have employed two, thus bringing the figures into line with other surveys. Of nine cases

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negative to percutaneous and positive to intraeutaneous tuberculin, eight had negative radiographs and one was doubtful.

Pupils fully tested.

1941-1944. (More and Mantoux 1 in 100). Total 64. Entry aged 14 yrs. Girls Boys 56 negative 53 3 8 positive (iz'5%) 8 0 To date aged 16-18 yrs. 44 negative 41 3 20 positive (31%) 20 0

Summary. O~e hundred and seventy-two pupils, aged 14 to 18 years, have bee~ tuberculin tested in the past eleven years. Eighty-six have had chest x-ray films. Thirty-one have passed through the primary infection of tuberculosis in school; of these one died in a very short time, and the remaining thirty are very well today. A follow-up reveals that not one of the positive entrants has developed tuberculosis, nor have any of the thirty " conversion " cases; two of the negative leavers developed early phthisis four to five ve~rs after leavin~ school.

BOOK REVIEWS. Old Age : Some Practical Points in Geriatrics. B y T ~ E v o ~ H. HOWELL. Lewis. 4 / 6 T h i s little b o o k is c o m p o s e d o f a series o f s t u d i e s m a d e b y t h e a u t h o r w h e n a c t i n g as Medical Officer to t h e Chelsea P e n s i o n e r s , s i x o u t o f t h e t e n c h a p t e r s b e i n g r e p r i n t s o f articles c o n t r i b u t e d t o v a r i o u s m e d i c a l journals, I n t h e first c h a p t e r it is p o i n t e d o u t t h a t t h e s u b j e c t o f geriatrics is likely to b e c o m e of i n c r e a s i n g i m p o r t a n c e in t h e f u t u r e . A t p r e s e n t a b o u t 10 p e r cent. o f t h e p o p u l a t i o n c o n s i s t s o f m e n o v e r s i x t y - f i v e a n d w o m e n o v e r s i x t y y e a r s of age ; b u t in t h e B e v e r i d g e s c h e m e it is e s t i m a t e d t h a t b y t h e y e a r 1971 t h e p e r c e n t a g e o f people of t h e a b o v e m e n t i o n e d ages will h a v e riecn to t w e n t y . E a c h c h a p t e r c o n t a i n e d in t h i s b r o c h u r e is t h e r e s u l t o f direct clinical o b s e r v a t i o n , a n d m a n y o f t h e f a c t s a n d o p i n i o n s q u o t e d s h o u l d p r o v e of value, especially to y o u u g m e d i c a l p r a c t i t i o n e r s ; m o s t m e n o f experience will be f a m i l i a r w i t h a l m o s t e v e r y t h i n g t h a t t h e b o o k c o n t a i n s , b u t n e v e r t h e l e s s will find it agreeable to h a v e t h e i r v i e w s a n d conclusions co1~Cu~ed. O n e n o t e s w i t h p l e a s u r e t h a t t h e a u t h o r is entirely o p p o s e d t o t h e u n n e c e s s a r y u s e o f s u c h s t i m u l a n t s a s c a m p h o r in oil, a d r e n a l i n , a n d t h e like, for d y i n g p a t i e n t s , a n d o n e is also g l a d to see t h a t h e r e g a r d s a falling blood p r e s s u r e in a p a t i e n t o f a d v a n c e d y e a r s as a s i g n o f ill-omen. S o m e o f h i s t h e r a p e u t i c s u g g e s t i o n s are r a t h e r o n t h e heroic side, as, for e x a m p l e , 30 g r a i n s of chloral h y d r a t e c o m b i n e d w i t h 30 g r a i n s of b r o m i d e for i n s o m n i a , while h i s s t a t e m e n t t h a t a raised blood sedim e n t a t i o n r a t e in t h e a b s e n c e of a n i n f e c t i o n m a y b e r e g a r d e d as s u g g e s t i n g t h e presence o f a n e o p l a s m is o f interest. T.G.M. The Venereal Diseases. B y $. M ~ m ~ . Macmillan. 21]-. T h i s w o r k is d i v i d e d i n t o four p a r t s : first gonorrhcea, t h e n syphilis, t h e n o t h e r venereal diseases a n d finally t e c h n i q u e . U n d e r t h e last h e a d i n g we w e l c o m e t h e note--brief as it i s - - o n t h e social aspect, w h i c h is o n l y n o w receiving t h e a t t e n t i o n t h a t t h e q u e s t i o n m e r i t s . W e feel s u r e t h a t in s u b s e q u e n t e d i t i o n s t h i s will be d e a l t w i t h m o r e

f~ly. I t s p e a k s well for t h e thorough-ross a n d u p - t o - d a t e - h e s s o f t h e a u t h o r t h a t we s h o u l d find m e n t i o n o f penicillin in t h e t r e a t m e n t o f gonorrhcea. N a t u r a l l y , o n e c a n n o t e x p e c t t h i s to be dealt w i t h e x h a u s t i v e l y . W e t h i n k it e v e n m o r e i m p o r t a n t t h a t t h e d a n g e r of r o u t i n e t r e a t m e n t of gonorrhoea b y penicillin s h o u l d be e m p h a s i s e d as e a r l y a s possible. I t c a n n o t be o v e r - s t r e s s e d t h a t , for t h e p r e s e n t , penicillin s h o u l d be r e s e r v e d for eases of s u l p h a - r e s i s t a n t g o n o r r h c e a ; t h i s w o u l d help to a v e r t t h e possible d a n g e r o f m a s k i n g a coincident s y p h i l i t i c i n f e c t i o n b y l e a v i n g t h e q u e s t i o n o f t h e i n t r o d u c t i o n o f penicillin a c o m p a r a t i v e l y late t r e a t m e n t in gonorrhcea. T h e r e is n o t h i n g in t h e w a y o f t r e a t m e n t a d v i s e d hero to w h i c h e x c e p t i o n could b e t a k e n . T h e s e axe all o r t h o d o x , carefully sot out, a n d follow in t h e m a i n t h e r o u t i n e