ON PRE-TUBERCULOSIS AND PRE-PULMONARY TUBERCULOSIS, AND THEIR DIAGNOSIS IN RELATION TO SCHOOL INSPECTION
This treatment is continued for about three weeks, when a plaster spica is substituted. About 12 weeks after the operation the patient is allowed to put some weight on the foot; but care must be taken to delay this as long as possible on account of the risk of bending at the union. Figs. 1 and 2 show the X ray appearances before and after treatment in this way. A girl, aged 11 years, had 22 inches of shortness of the right leg. She now only has a quarter of an inch and needs no high boot. In
... no high boot. In worse cases the method has been equally successful in reducing the shortening. For instance, in a girl aged 15 years a shortening of 3 inches was reduced to three-quarters of an inch. This made a great deal of difference to her comfort and appearance. This is so far satisfactory even in cases of ankylosis, but it is far more successful when there is some mobility of the hip-joint. One of my patients with considerable deformity improved her condition very much by falling down stairs and breaking her thigh-bone in the upper third. She fell in a sitting position, the right heel coming against the right femur below the great trochanter. This patient was a middle-aged woman, who from want of exercise was excessively stout. She had been sent to me by Dr. O. T. Brookhouse of Bromley, and I had ordered an apparatus, designed to conduct most of the weight from the tuber ischii and the root of the thigh to the heel of the boot. This had afforded considerable relief to the pain at the hip-and knee-joints, which was due to mechanical strain upon these joints in a flexed position. The apparatus was, fortunately, not on when the fall occurred. The fracture was treated by weight extension. The result of the accidental correction of the deformity is very satisfactory. The limb is longer, stronger, and straighter than before the accident, and the pain has almost ceased. The pati 3nt can now walk several miles in comfort. SECRETARY TO THE QUEEN ALEXANDRA SANATORIUM, DAVOS; ETC. IT is essential to realise the practical distinction between (a) the identification of tuberculosis and (b) that of pulmonary tuberculosis. 1,n ahÛdren, much more than in the adult, the prevailing method begins at the wrong end. Their initial tuberculosis is almost invariably pre-pulmonary in clinical date. As I pointed out in a paper read before the Ilford division of the British Medical Association in April, 1909, our ideal should be the recognition of the p7'c-<Mc?'cMMM' stage; but our practical ideal duty is to identify, where it exists, the pre-puZ-l7lonary tubercular stage, that of tuberculosis in possession, although not yet in pulmonary possession. This consideration touches our urgent problems of school inspection. In its all-surpassing object, that of the suppression of tuberculosis, the inspection is a matter not of perfunctory examination but of special skill, for two reasons-(1) the difficulties and the fallacies of pulmonary diagnosis ; and (2) the fact that the methods of pulmonary diagnosis are not only imperfect or even misleading, but too often are on the wrong scent.