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at Rochester General Hospital, New York, illustrate howjaundice can follow such injections. During two yearsbetween 1953 and 1955 50 cases of what appeared to beordinary infective hepatitis were seen at that hospital.15 of these patients gave a history of dental injectionreceived between one and six months before the onset oftheir illness, 16 denied such injections, and in 19 casesdata were not available. In a control group of 68 randommedical cases and in a second control group of similarcases matched for age with the 50 hepatitis patients, asimilar history of dental injections was obtained only3 times in each group. The proportion of dental-injectionpatients in the hepatitis group was therefore almost sixtimes that in the,control groups. In further support oftheir view that the 15 people with a history of dentalinjections were suffering from serum hepatitis, Foley andGutheim cite the several clinical features that help todistinguish the two varieties of infective hepatitis, suchas incubation period, type of onset, and mortality. Inall 15 illnesses these points favoured the diagnosis of

homologous-serum jaundice.Those who have investigated the epidemiology of

hepatitis in the past may have failed to appreciate thesignificance of dental injections for two reasons. First,patients, asked about recent injections or other skin-

penetrating operations, almost invariably forget a visitto the dentist unless they are specifically asked about it.Secondly, when a patient gets jaundice after an injectionby his doctor, he will often consult the same doctor ;but a patient is unlikely to tell his dentist about an attackof jaundice that comes on many weeks after his lastdental visit.Further analysis of the data from Rochester suggests

that 30% of cases of infective hepatitis may arise fromserum transmission ; of these, Foley and Gutheim say,two-thirds may follow dental injections. The size of the

sample from which these figures are derived is such thatwe cannot with certainty ascribe to them more than a localsignificance ; but these findings have shown that theremay be a sizeable risk associated with even the simplestdental operation undertaken with faulty sterilisation.Chemical methods of sterilisation of needles and syringesare unreliable and obsolete, and the multiple-dose bottleof local anaesthetic is an invitation to trouble.

1. Olson, D. E., Jones, F. S., Angevine, D. M. Amer. Rev. Tuberc.1953, 68, 657.

2. See annotation, Lancet, 1953, ii, 1347.3. Juhl, J. H., Alt, W. J., Wusserburger, R. J. Amer. Rev. Tuberc.

1956, 74, 388.

BRONCHOGRAPHY OR TOMOGRAPHY ?

IN the treatment of tuberculosis, bronchostenosis andbronchiectasis with a persistently positive sputum are

often regarded as points in favour of resection. Whenresection has been performed after satisfactory chemo-therapy, there has often been little evidence of residualtuberculosis. The frequency of bronchiectasis is variouslyput at from 40 to 80%.’ It is usually seen in long-standing disease, moderate to advanced conglomeratedisease with fibrosis, tuberculous endobronchitis, andbronchostenosis due to pressure from caseous glands.The advent of propyliodone (aqueous ’JDifmcsii ’) over-came the chief objection to bronchography in tuberculosis2and large series of bronchograms have been reported.Propyliodone is readily absorbed and leaves no residue tomake future comparison of chest films difficult, and it isan aqueous solution, so that the risk of granuloma isremoved, rare though it must be even with oily solutions.But it is more difficult to use in outpatients than theiodised-oil type of medium, and flooding of the alveolimay mar the detail in the radiograph. Juhl et a1.3 havecompared 100 bronchograms with tomograms of the samepatients in an attempt to assess the value of tomography indemonstrating bronchiectasis. Diagnosis by tomographywas easiest in the chronic fibrotic type of tuberculosis, in

which 80% accuracy was achieved, and least successfulin early and small lesions. After a thoracoplasty,tomography results also proved disappointing comparedwith those of bronchography. Juhl et al. based the

diagnosis of bronchiectasis on changes in wall thicknessand lumen. When bronchi were thick-walled or broughtinto contrast by surrounding airless lung, and when theylay in the plane of the tomographic section, the diagnosiswas easy ; but when they were seen end on, it was hard.to judge whether there was an increase in calibre. Juhlet al. would recommend tomography for the demon-stration of bronchiectasis only when there are strongcontra-indications to bronchography.

1. Penfield, W., Paine, K. Canad. med. Ass. J. 1955, 73, 515.2. Earle, K. M., Baldwin, M., Penfield, W. Arch. Neurol. Psychiat.,

Chicago, 1953, 69, 27.

SURGICAL TREATMENT OF EPILEPSY

FoR over twenty-five years Prof. Wilder Penfield hasbeen concerned with the surgical treatment of epilepsy.His approach has never been simply that of a surgicaltechnician, and he has made his surgical explorations thebasis for studying the functions of the living humanbrain. For much of this time he has been assisted byProf. Herbert Jasper’s extensive knowledge and imagina-tive application of electrophysiology. The result is a

unique collection of observations, carefully assessed andinterpreted, for which all those who are interested in thefunction of the human cortex are deeply in their debt.Some of the work has been concerned with the details of

surgical procedure-the gradual additions to the technicalexcellence of cerebral surgery, which will, incidentally,give wider opportunity for observation. Other aspectsof Penfield’s work, such as his evocation of " memories "

by cortical stimulation, had a more dramatic qualityand appealed directly to a wider audience than that ofmedicine.From time to time reports on the results of surgical

treatment of epilepsy have come from the Montreal

Neurological Institute, and one of them includes a survey 1of 234 patients treated in 1945-50. All these patients hadpreviously had long and unsuccessful medical treatmentfor their epilepsy. The results are impressive : 45%had their seizures abolished or very largely reduced ;and in a further 20% fits were substantially curtailed.That these figures represent cure rather than temporaryalleviation is shown by the proportion of patients co,m-pletely free from attacks, which varies between 40%and 48% in each of seven postoperative years.The basic cause of epilepsy-what makes a certain bit

of cortex fire off a seizure-has always been of particularinterest to Penfield. Simple damage to brain tissue doesnot explain it, since areas apparently equally damagedmay cause seizures in one patient and not in another.The answer continues to elude us ; but the picture ofdamaged cortex as a stimulus to focal or generalisedepilepsy has been extended by the suggestion 2 thatsome seemingly idiopathic epilepsy is really due to

firing from an area in the inferomedial aspect of the

temporal lobe damaged by compression or ischsemia

during the process of birth. This view still requires widerconfirmation, but much clinical observation tends to

support it, as does the increasing accuracy with whichthe electrical discharge in such seizures is being localised.And the suggestion has certainly opened up considerabletherapeutic possibilities.

In this country at present the surgical treatment ofepilepsy is not widely practised ; but it will inevitablyexpand, and there are signs that it is already doing so.We hope it will be guided by Penfield’s spirit of scientifichumanism : "the clinician must often make the bestcompromise with perfection that he can. He mustunderstand the patient and his hopes before he presumesto decide on treatment. But this is, after all, the secretof the art in the practice of medicine."