FRACTURE CLINICS

92

that

they may develop a benign first infection. FRACTURE CLINICS Logically the argument would lead to the personnel THE great majority of all fracture cases are of a sanatorium being treated like a herd of T.T. treated at hospitals, and the responsibility for the cattle and the positive reactors eliminated. But efficient treatment of fractures has in recent the facts at our disposal do not support this line come to lie very heavily on the conscience of of reasoning, although admittedly there is some years hospital staffs. After conference between reprediscrepancy between the observations on nurses sentatives of the British Medical Association and and similar surveys of other groups such as native the British Hospitals Association a questionnaire miners in South Africa and students in the United was sent out to discover how far the hospitals States. It is significant that Dr. MARIETTE did had the principle of segregation of fracture accepted not at first tuberculin-test his nurses because he cases in special departments under the charge of thought they would all be positive ; yet when a qualified team of surgeons. The answers received routine tests were made in 1932 the proportion of from fifty-one hospitals are tabulated in a memonegative reactors was 48 per cent. randum (No. 104) recently published by the In this country the Joint Tuberculosis Council Central Bureau of Hospital Information. These has just published a memorandum based on show that the principle has been accepted and is material collected from 38 hospitals and sanatoria. being acted on in forty-one hospitals; The usual age at which probation nurses are already three others have the scheme under consideration, accepted is, it seems, 18 years, and in view of the seven have considered and rejected it. The size special susceptibility to tubercle of adolescent of the hospital and the numbers of fractures females the Council deprecates the practice in for treatment influence the replies. certain areas, where there is a shortage of candi- attending A small hospital, even though accepting the prindates, of reducing the age of entry to 17. Hours ciple of placing the whole fracture service under of work varied from 48 to 77 per week, the average in bones and joints, obviously control of a for probationers being about 60, a somewhat longer is not in a specialistto position appoint " a team of wholeperiod than that recommended by the College of time assistants "-to quote the wording of the Nursing. At present only about half the insti- questionnaire. The Royal United Hospital at tutions circularised make a routine X ray examinafor instance, with 190 beds, agrees to the tion of their nursing staff ; the Council recom- Bath, appointment of a specially qualified head of the

mends that the staff should be thus examined at least once a year wherever nurses are exposed to tuberculous infection. No mention is made in the Council’s memorandum of tuberculin tests, but Dr. PETER EDWARDS4 has just published a small series from the Cheshire Joint Sanatorium which On appears to support HEIMBECK’S findings. staff 54 nurses were the Mantouxjoining hospital positive and 11 negative; of the latter group 2 developed tuberculosis, both within three months. An investigation on a larger scale is being carried out under the Prophit Trust. The practical issues raised by these observations are momentous. It appears that whereas a few decades ago tuberculous infection was almost universal, by the time adult years were reached, this is no longer the case. The great diminution in the number of open cases of tuberculosis, the gradual education of the public in matters of hygiene, in particular as regards spitting in public, and the provision of clean or pasteurised milk have conspired to make tuberculous infection less frequent in youth. No doubt the reduced risks of infection achieved in these ways have contributed to the fall in the mortality-rate, but at the same time the dangers of infection in early adult life seem to have become more serious than they were in THEODORE WrLraMS’s time. Doctors and nurses who come into close contact with open cases of tuberculosis will either have to be chosen from amongst the . positive reactors or to undergo some form of inoculation to make them tuberculin-sensitive. As the proportion of negative reactors rises the dangers of one spouse infecting the other must also be expected to increase. 4

Tubercle, December, 1936,

p. 101.

fracture service, but answers " numbers insufficient " to the suggestion of appointing a team of whole-time assistants. Others answer " Yes, but not necessarily whole-time," or words to that effect. From the account of the Cardiff municipal accident service, which we print on page 107 of this issue, it will be seen that with an average of 100 cases under treatment it has been found possible to retain a resident assistant surgeon, chosen specially for his knowledge of fractures, by combining the work of the fracture clinic with certain hospital work outside it. The hospitals were asked to give an opinion as to the usefulness of a whole-time salaried officer of the almoner type whose duties would be to keep the records of cases. The practice varies considerably. In some cases the records are kept by the registrar, in others by the massage sister; frequently a part-time clerk is employed. It is obviously a waste of the surgical assistant’s time for him to write notes, answer in his own hand letters from general practitioners, and be responsible for the filing of records, when all this can be done at his dictation, and more efficiently done, by a clerk. The fact that much tedious clerical work has been imposed on the medical staff no doubt explains why records are not available at so many hospitals. Several hospitals stated that the reluctance on the part of the general surgeons to give up their fracture work was an obstacle in the way of placing all fractures under the control of one experienced specialist. Out-patients may be referred to a particular surgeon who wishes to deal with them himself. Nevertheless a large number of the hospitals consulted were of opinion that all ambulant fractures

93

should attend the

special department throughout

their treatment--this not so much to take fracture treatment out of the hands of a general surgical staff who are often quite competent to deal with it, but to remove the responsibility from

casualty officer, who rarely is. The hospital at Southend-on-Sea provides that case specifically sent to one of the fracture any general surgeons may be treated by him, but he the young

new

is invited to refer it to the fracture clinic.

NASAL SINUSITIS IN CHILDHOOD Do children often have infected nasal sinuses ? Opinions differ. In the United States when a child has an upper respiratory infection the diagnosis is almost as likely to be sinus suppuration " as " tonsils and adenoids." On the other hand HAJEK of Vienna, in his classical work " Nasal Accessory Sinusitis " written in 1926, reported that he had seen only 4 cases of antral empyema, proved by puncture, in children between the ages of five and twelve, and said that " the fantastic reports of some American authors are to be regarded with great scepticism as their methods of examination give us no assurance of the reliability of their results." In this country the general opinion seems to be that the disease is not very common, although within the last ten years it has been realised that it is commoner than was previously supposed; there is also an impression that in children sinusitis is usually transitory with a tendency to recovery. Mr. JAMES CROOKShas now published the results of an important investigation which he has made at the Hospital for Sick Children, Great Ormond-street, from which it appears that the disease is far more frequent than is usually believed, and less likely to clear up spontaneously. His material falls into two groups. In the first both antra were aspirated in 100 children while undergoing tonsillectomy. This routine was chosen for four reasons : the patients were suffering from an upper respiratory complaint, possibly due to antral infection ; the puncture could readily be done while they were under the anaesthetic ; it was desired to prove if it was true or not that removal of tonsils and adenoids usually cleared up an antral infection; and, finally, children with a temporary infection from a " cold " would be automatically excluded. Any antrum containing pathological matter was to be subjected to aspiration again six months later. Of these 100 children, 24 were found to have pus or mucus in an antrum (6 of them in both antra), and in only 9 of these were the antra clear at the end of six months ; in other words, 15 per cent. had chronically infected antra. Their average age was seven years. The fluid sucked from the antra was examined bacteriologically by Dr. A. G. SIGNY in all the 100 cases, and it is remarkable that, of those antra that contained neither pus nor mucus, only about half were sterile. Mr. CROOKS does not explain this anomaly, but says that it seems "

reasonable to suppose that the great

majority of healthy ahtra are sterile, though it is not accurately known how often a healthy sinus contains a few organisms. Some ofthe antra that still contained muco-pus after six months were sterile, as were 3 containing muco-pus at the first puncture ; it has been observed that organisms may die out in a long-standing abscess such as a pleural empyema, and this may presumably also happen in a nasal sinus. The pneumococcus was the organism most often found in these children. The second group is composed of children who presented clinical evidence of antral disease. Detailed investigation was stopped when their number reached 76, making with the first group a total of 100 cases ; but many more cases have since been explored and in the last two years mucus or pus has been washed out of the ahtra of over 500 children at the hospital. The sexes were equally divided, and the average age of the 76 was seven and a half, the youngest being two and a half and the oldest twelve ; 42 were under seven. Of the total, 37 could be classified as cured, in 35 by antral lavage at an average of between two and three washings and in 2 by intranasal antrostomy; of the remainder 26 were improved, but 13 were no better, though 4 of them had antrostomy. Any or all of the accessory sinuses may become diseased, but the antra were chosen as the subject of this investigation because they are much the most often affected, and because examination of the other sinuses is far harder in children. Many interesting details about the diagnosis, symptoms, and results are given. Mr. CROOKS thinks that, apart from proof-puncture, radiography is the most accurate means of diagnosis. Nasal obstruction is frequently severe, and he believes that the " adenoid facies " is more often the result of sinusitis than of adenoids. As a cause of otitis media sinusitis is second only to adenoid infection, and should always be suspected if removal of the adenoids is ineffective. A child suffering from sinusitis is usually in poor health, losing interest in work and play, and becoming morose, ill-tempered, and difficult to manage. On the relationship of sinusitis to infection of the tonsils and adenoids Mr. CROOKS holds that, broadly speaking, such infection is not the common cause of sinusitis in childhood, and that the removal of tonsils and adenoids neither prevents nor cures the condition. He is less certain about the converse proposition and says that arguments both for and against sinusitis as a cause of infection of tonsils and adenoids can be deduced from his figures. His own opinion is that sinusitis is a common cause of inflammation of the adenoids and, to a lesser degree, of the

tonsils. MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY.The annual dinner of this society will be held on

Thursday,

Jan.

and Dr. J. R. 1

Arch. Dis. Childh. 1936, 11, 281.

14th,

at

7.45 P.M., at

the

Florence

Restaurant, Rupert-street, W., when the guests of honour will be Mr. Claud Mullins, metropolitan police magistrate,

Psychology.

Rees, director of the Institute of Medical