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

positive to 001 mg. and 4 to 1 mg. (in 1 case no test was made).18 patients had bilateral, and 2 unilateral, involvement.

Paratracheal-gland enlargement was seen in 7 patients. In11 patients who could be reviewed at sufficiently frequentintervals, complete disappearance of glandular enlargementwas observed in from ten weeks to nine months. All of the

patients studied for a mean period of five years have remainedm good health, without evidence of recurrence or othervisceral involvement.

During the last few years, only 3 cases of apparentlyasymptomatic hilar lymphadenopathy have been dis-covered in the Hull district by means of mass miniatureradiography. These cases are being kept under Dbserva-tion, and if the numbers warrant it, they will be reportedin more detail later.Here, then, are some of the questions to be answered :(1) How many of these cases are there in Great Britain ?

How many of these have (a) no symptoms ; (b) erythemanodosum (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 totuberculin ?

(3) Is there any seasonal incidence (as in erythemanodosum) ?

(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 tooccur or to the more general use of B.C.G. in Scandinavia ?

(6) -Are some of these asymptomatic cases forme frustesarcoidosis ?

(7) What virus or bacterial infections can give rise to

tuberculin-neutralising effects ?18) What is the true value of the Kveim test ?

LASAR DUNNERR. HERMON.

CIRCUMCISION OF THE NEWBORN

DAVID MORRIS.

SIR,—Is there not a real danger of serious bleeding fromhæmorrhagic disease of the newborn if circumcision isca,rried out at birth, as reported in your annotation lastweek ? This danger may well have been the reason foriitual circumcision being delayed till the eighth day of life.

ACRYLIC PROSTHESES

JOHN T. SCALES.

SIR,—In recent months a number of Judet acrylicprostheses have had to be removed from patients becauseof mechanical failure. These failures may be due to oneor more of the following factors : (1) unsuitability of thematerials employed ; (2) design ; (3) manufacturingmethods ; (4) sterilisation procedures ; (5) position ofinsertion of the prosthesis and fit of the acrylic head inthe acetabulum. In collaboration with Mr. J. M. Zarek,fn.D., of the faculty of engineering, King’s College,University of London, experimental work is beingcarried out, the results of which it is hoped may shedsome light on the cause of these failures.The number of cases to which we have access is natur-

ally limited. It would be of the greatest assistance if

surgeons and pathologists who remove from a patientany prosthesis (which may or may not be broken) eitherat operation or post mortem, would be kind enough tosend it to me at the Plastics Research Unit, Instituteof Orthopaedics (University of London), Royal NationalOrthopaedic Hospital, Brockley Hill, Stanmore, Middle-sex. The following information is required :

(a) A brief preoperative and postoperative case-historywith the actual or estimated weight of the patient.Personal details which might identify the patients arenot required.

(b) All radiographs in which the prosthesis can be seen.These will be returned.

(c) Details of method of sterilisation and, if possible,information on whether the prosthesis has been sterilisedon a number of occasions.

(d) The prosthesis.It is hoped that all those interested in this problem

will cooperate, as an investigation of this kind can onlybe of value if as many as possible of the failures aieinvestigated.

POLIOMYELITIS

W. RITCHIE RUSSELL.Department of Neurology,

Radcliffe Infirmary,Oxford.

SiR,,-Your leading article of Jan. 10 has provokedseveral letters from orthopaedic surgeons ; and this isnot surprising, as this leader exaggerated somewhat therecent views on treatment put forward by various peopleincluding myself.

I would, however, make a special plea to my ortho-pædic colleagues to widen their thoughts beyond muscleresting and the avoidance of deformity. The motor

pathways in the spinal cord terminate in a pool ofneurones, and each tract neurone communicates with

many anterior horn cells. If, say, half of these cellsare destroyed, the connections of this neuronal poolhave to become extensively reorganised, and it is

probable that the only effective method of getting thebest out of this reorganisation is through the patient’sdetermined and repeated attempts to move the musclegroups which appear to be paralysed. This provides aphysiological explanation for the well-known fact thatit is the patients who try hard who recover most.I would submit that the current orthopaedic practice ofdiscouraging activity in weak muscles for several monthsis likely to lose the opportunity to retrain the spinalconnections in the optimum direction, and that undersuch methods the disconnected neurones of the spinaltracts are likely to be diverted more to muscles whichare strong than weak, as the patient’s spontaneousmovements in bed are likely to be directed first to themovements he can make.

It is for such reasons that I and others advise earlyactive movements to the weak and important musclegroups, which the patient practises himself after beingshown how to do it. There is no substitute for the

patient’s will to move a muscle as far as the centralnervous system is concerned. Fear of muscle fatigueafter the acute stage has passed is quite unreasonableto the neurophysiologist, and simple muscle measure-ments easily confirm the harmlessness of deliberatelyinduced fatigue in weak muscle groups at this stage.

Mr. Hyman (April 25) reports a remarkable case hesaw in 1949, in which paralysis spread 5 weeksafter the acute illness. However, his conclusion thatthis was due to the patient exercising too much is hardlyjustifiable. It is more probable that the patient had asecond infection with another strain of the virus.Relapsing cases occasionally occur ; but the second boutof paralysis very rarely, if ever, occurs at an intervalof more than a week after the first has ceased to spread ;it is for fear of this second spread that complete restand heavy sedation seem to be so desirable for the first2-3 weeks of the acute illness. It is conceivable thatthis period of 2-3 weeks should be prolonged a littleif 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.

SIR,—I have been interested in the question of exercisein poliomyelitis since the 1947 outbreak, when I begantentatively to encourage active exercise during the third