POLIOMYELITIS

903 23 chest clinics and survey units of the Bureau of Tuberculosis, these criteria were satisfied in 20 cases. With 1 exception, the patients were between 19 and 31 years of age. 10 patients were negative to 1 mg. of Old Tuberculin, and 1 was negative to 0-01 mg., while 4 were 1 case no test was made). positive to 001 mg. and 4 to 1 mg. (in 18 patients had bilateral, and 2 unilateral, involvement. Paratracheal-gland enlargement was seen in 7 patients. In 11 patients who could be reviewed at sufficiently frequent intervals, complete disappearance of glandular enlargement All of the was observed in from ten weeks to nine months. patients studied for a mean period of five years have remained m good health, without evidence of recurrence or other visceral involvement.

During the last few years, only 3 cases of apparently asymptomatic hilar lymphadenopathy have been discovered in the Hull district by means of mass miniature radiography. These cases are being kept under Dbservation, and if the numbers warrant it, they will be reported in

detail later.

more

Here, then,

are some

of the

to be answered : in there Great Britain ?

questions

(1) How many of these cases are How many of these have (a) no symptoms ; (b) erythema nodosum (excluding obvious cases of primary tuberculosis) ; and (c) clinical and histopathological evidence of sarcoidosis. ? (2) What is the age and sex incidence, and the reaction to tuberculin ?

(3) Is there any seasonal incidence (as in erythema nodosum) ? (4) Why is the condition so much commoner in Scandinavia? (5) Has this geographical difference any relation to the later age at which primary tuberculous infections tend to occur or to the more general use of B.C.G. in Scandinavia ? (6) -Are some of these asymptomatic cases forme fruste sarcoidosis ? (7) What virus

bacterial infections can give rise effects ? 18) What is the true value of the Kveim test ? or

to

tuberculin-neutralising

LASAR DUNNER R. HERMON. CIRCUMCISION OF THE NEWBORN a real danger of serious bleeding from disease of the newborn if circumcision is ca,rried out at birth, as reported in your annotation last week ? This danger may well have been the reason for iitual circumcision being delayed till the eighth day of life. DAVID MORRIS.

SIR,—Is there not

hæmorrhagic

ACRYLIC PROSTHESES

SIR,—In recent months a number of Judet acrylic prostheses have had to be removed from patients because of mechanical failure. These failures may be due to one or more of the following factors : (1) unsuitability of the materials employed ; (2) design ; (3) manufacturing methods ; (4) sterilisation procedures ; (5) position of insertion of the prosthesis and fit of the acrylic head in the acetabulum. In collaboration with Mr. J. M. Zarek, fn.D., of the faculty of engineering, King’s College, University of London, experimental work is being carried out, the results of which it is hoped may shed some light on the cause of these failures. The number of cases to which we have access is naturally limited. It would be of the greatest assistance if surgeons and pathologists who remove from a patient any prosthesis (which may or may not be broken) either at operation or post mortem, would be kind enough to send it to me at the Plastics Research Unit, Institute of Orthopaedics (University of London), Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex. The following information is required :

(a)

A brief with the

preoperative

not

required.

(c) (d)

It is hoped that all those interested in this problem will cooperate, as an investigation of this kind can only be of value if as many as possible of the failures aie

investigated. JOHN T. SCALES. POLIOMYELITIS

SiR,,-Your leading article of Jan. 10 several letters from orthopaedic surgeons not surprising, as this leader exaggerated recent views on treatment put forward by

has provoked ; and this is somewhat the various people

including myself. would, however, make

a special plea to my orthotheir to muscle widen pædic colleagues thoughts resting and the avoidance of deformity. The motor pathways in the spinal cord terminate in a pool of neurones, and each tract neurone communicates with If, say, half of these cells many anterior horn cells. are destroyed, the connections of this neuronal pool have to become extensively reorganised, and it is

I

beyond

that the only effective method of getting the best out of this reorganisation is through the patient’s determined and repeated attempts to move the muscle groups which appear to be paralysed. This provides a physiological explanation for the well-known fact that it is the patients who try hard who recover most. I would submit that the current orthopaedic practice of discouraging activity in weak muscles for several months is likely to lose the opportunity to retrain the spinal connections in the optimum direction, and that under such methods the disconnected neurones of the spinal tracts are likely to be diverted more to muscles which are strong than weak, as the patient’s spontaneous movements in bed are likely to be directed first to the movements he can make. It is for such reasons that I and others advise early active movements to the weak and important muscle groups, which the patient practises himself after being shown how to do it. There is no substitute for the patient’s will to move a muscle as far as the central nervous system is concerned. Fear of muscle fatigue after the acute stage has passed is quite unreasonable to the neurophysiologist, and simple muscle measurements easily confirm the harmlessness of deliberately induced fatigue in weak muscle groups at this stage. Mr. Hyman (April 25) reports a remarkable case he in saw 1949, in which paralysis spread 5 weeks after the acute illness. However, his conclusion that this was due to the patient exercising too much is hardly justifiable. It is more probable that the patient had a second infection with another strain of the virus. Relapsing cases occasionally occur ; but the second bout of paralysis very rarely, if ever, occurs at an interval of more than a week after the first has ceased to spread ; it is for fear of this second spread that complete rest and heavy sedation seem to be so desirable for the first 2-3 weeks of the acute illness. It is conceivable that this period of 2-3 weeks should be prolonged a little if other cases like Mr. Hyman’s are reported ; but apart from his case, existing evidence suggests that complete rest for 2 weeks is long enough.

probable

Department

of

Neurology,

Radcliffe Infirmary, Oxford.

and

postoperative case-history actual or estimated weight of the patient. Personal details which might identify the patients are

can be seen. These will be returned. Details of method of sterilisation and, if possible, information on whether the prosthesis has been sterilised on a number of occasions. The prosthesis.

(b) All radiographs in which the prosthesis

in

W. RITCHIE RUSSELL.

SIR,—I have been interested in the question of exercise poliomyelitis since the 1947 outbreak, when I began

tentatively

to encourage active exercise

during

the third

904 in the isolation hospital here. Encourthe results, I introduced heat and the muscle relaxant drugs to relieve spasm, and by the end of 1949 I had no hesitation in beginning not only passive movement but active exercise as soon as pyrexia; had subsided. Final proof of efficacy could be obtained only by comparing- patients so treated with themselves as they would have been if otherwise treated-a manifest impossibility. I have certainly had a lower.than-average , incidence of contractures, and an impressive proportion of my patients have been discharged to their homes, requiring only outpatient physiotherapy and remedial exercises to complete their treatment. I have had no case in any way corresponding to that reported by Mr. Hyman. I have,-however, tried to follow a policy of asking no muscle- or group of muscles to bear disproportionate strain. So long as the patient is in bed this is easy, for no limb can be called on to do more than raise its own intrinsic weight, and if the muscles cannot raise the limb from the bed they do not even have to bear that weight. In other words, they are not asked to carry a load until they have shown themselves capable of making a reasonable attempt to do so. When the patient gets out of bed, the case is altered and the legs are at once called upon to support the weight of the whole body, even if they are not ready to do so. I cannot help suspecting that this may have been the determining factor in Mr. Hyman’s patient, and that the golden rule, especially in dealing with enterprising schoolchildren and other impatient people, is to keep them strictly in bed, except for tank exercises, until there is evidence that the muscles of the legs are ready to make at least a fair attempt to carry out their normal duties.

week in

patients

aged by

Myland Hospital, Colchester.

JOHN D. KERSHAW.

AUGMENTING KNEE-JERKS

SIR,—However

"

ludicrous " the traditional methods of

augmenting the knee-jerks may appear, they are certainly preferable to the method suggested by Dr. Hirschowitz (April 25). If, for example, a patient has a one-sided partial paralysis of his lower-limb flexors, then when he pushes into the bed, the degree of reciprocal inhibition of the extensors so produced may, and probably will, produce a spurious inequality of the knee-jerks. This is one of the reasons for insisting on complete relaxation where possible, however tedious it may be to obtain. BARBARA SIMONDS. TRICHOMONAS VAGINITIS have been interested in the recent articles and SIR,—I letters on trichomonas vaginitis. While supporting Mr. McCullagh’s laudable plea (April 4) for the " gap " seat in lavatories, I think he is being rather hopeful when he says that we could expect cases to be reduced by 90% if the gap seat were universal. For the last four and a half years I have been in practice in North-east India and East Pakistan, where the Eastern squatting position is universal ; and in my experience the prevalence of trichomonas infestation there is almost as great as it is in this country. Gonorrhoea, of course, is the main cause of infective vaginal discharges, but trichomonas runs it a close second. I am of the opinion that transmission is mainly venereal, with perhaps a small percentage of cases caused by infective clothing. During routine prostatic smears, of which we perform very many in a busy outpatient hospital practice, I have come across two instances of Is it not Trichomonas vaginalis in the resting phase. in male the in the that the seminal parasite possible lodges vesicles or the prostatic ducts without causing any symptoms, and that it multiplies and causes symptoms only in the favourable medium of the vaginal secretions ?’?

observations on husbands of infected women series of non-infected couples as controls might give a convincing answer to the vexed question-is this mainly a venereal or a non-venereal disease, and, if venereal, can any treatment be directed at the husband as well as the unfortunate wife ? J. T. PATRICK.

Perhaps

with

a

’

THE GAP SEAT

SIR,—The correspondence (April 4 and 18) about the value of the gap seat brings back old memories to me, for it was I who first thought of it in 1905. I was at that time R.M.O. at the Lock Hospital for Women, Harrow Road. We then had the old type of oval lavatory seat ; and though the lavatories themselves were labelled syphilis and gonorrhœa, I soon found that the patients, disregarded the labels and used them indis’ criminately, leaving obvious signs of use on the front sections of the seats. Cross-infection between gonorrhœa and venereal warts certainly occurred, and probably trichomonas also; and I was so worried by this that in the top ward I had a section of the front of each oval cut out and rounded off, thus making a horseshoe-shaped seat. It was one of those things that once thought of seemed surprisingly The hospital architect saw it, gave it his obvious. approval at once, and had the lavatories in all the wards similarly treated. I thought no more of it after I left Harrow Road until some years later when I began to find it was being supplied to other hospitals ; and I have never until now troubled to claim any credit for it-it seemed so simple. But undoubtedly it is a definite hygienic improvement and probably should be made compulsory in all public It also has the advantage that the seat lavatories. need not be lifted by men. Dr. Hudson (April 18) suggests that it would be even better still to use the squatting platform one finds in Turkey and the Near East. That certainly is true, but we are so conservative in this country that his advice is extremely unlikely to be followed. So may I still recommend my gap seat, at any rate until something better is invented !

J. JOHNSTON ABRAHAM. CHLORAMPHENICOL BY INJECTION

SIR,—In your annotation last week entitled " Good Sense about Antibiotics " you say that " chloramphenicol is not suitable for intravenous, intramuscular, or intra. thecal injection." May I point out that the antibiotic has been successfully administered by each of these A solution of chloramphenicol in aqueous routes ? dimethylacetamide has been widely employed 12 both intravenously and intramuscularly. _ A number of reports 34 have appeared on the intramuscular use of an aqueous_ suspension of microcrystalline chloramphenicol. As chloramphenicol readily penetrates the blood-brain barrier; intrathecal injection is not usually necessary, but as an adjunct to oral therapy it has been considered desirable, on occasion, to use this means of rapidly raising the cerebrospinal fluid level. Intrathecal injec. tions, in the form of sterile aqueous solutions, have been well tolerated.6 Medical Service Department, Parke, Davis & Co. Ltd., Hounslow, Middlesex.

C. BEAVEN

W., Preisser, W. G., Ross, S., Burke, F. G., Rice, E. C. Antibiotics, 1951, 1, 63. 2. Moseley, V., Baroody, W. G. J. S. Carolina med. Ass. 1951, 47, 1. Orr, W.

157. 3. Harb, F. W., Simpson, W. G., Wood, C. E. J. ven. Dis. Inform. 1951, 32, 177. 4. Ross, S., Rice, E. C., Burke, F. G., McGovern, J. J., Parrott, R. H., McGoVern, J. P. N. Engl. J. Med. 1952, 247, 541. 5. Kekwick, A. Lancet, 1952, ii, 630. 6. Anderson, K. F., Ellis, F. G. Brit. med. J. 1951, ii, 1067.