1361BRITISH ORTHOPEDIC ASSOCIATION

condition more likely to be promptly recognisedand where is transference of infection more likelyto take place 7 In school with constant wide-awakesupervision by teachers and school nurses in cleanairy conditions, or in a stuffy home with a busymother and a crowd of youngsters below school

age ? 7 I am satisfied that exclusion of children inindustrial areas is an insult to our intelligence andmumbo-jumbo of the worst type.The position is different if you are dealing with an

isolated case of any disease and where the conditionseither of the home or of the locality are such thatcontacts can actually be segregated from otherchildren. But, where the disease is established inan industrial area, pretended segregation of one smallbatch of the thousands of contacts is a waste of timeand money. Variations in susceptibility are muchmore important than variations in the intimacy ofcontact, and no one, medical or otherwise, can

postulate which of two children, one known to beexposed and the other only presumed to be, is likelyto prove the greater danger to his fellows. I realisethat any move to stop indiscriminate exclusion willbe met by public outcry. Exactly the same thinghappened when routine school closure was abolishedand when the modified system of exclusion in measlesepidemics was adopted. All are agreed that boththese measures have not resulted in increased incidencebut have brought cases under treatment at a muchearlier stage. Surely it is time for us as a professionto give an unequivocal lead in this important matter.

Dr. MAURICE MITMAN said that there is no

significant difference in the occurrence of secondarycases when terminal disinfection of the old type isabolished. His views, which he maintained are thecurrent views of administrators of fever hospitals,

. are based on the sources and modes of infection.The vast majority of the inhalation diseases are

contracted by the close proximity of the new hostto the infected person, the transmission of dropletstaking place from one nasopharynx to the other.The effective range of such droplets is relativelysmall and the life of the organism outside the body isrelatively short. Droplets suspended in the air aredispersed by ventilation, and most of the organismsin them die as the result of drying and sunlight, sothat their concentration in the air is rarely sufficientto initiate an attack except in the vicinity of aninfected person.Organisms in droplets and discharges deposited

on inanimate objects are in like manner destroyed bysunlight and drying. Those which remain viableform part of the dust and may be inhaled, but theconcentration is seldom sufficient to result in disease,particularly if the dust has lain for some days. The

viability of the organisms deposited on inanimateobjects is influenced by the organic matter-e.g.,mucus and grease-in which they are embedded.A detergent like ordinary soap and water is thereforea good disinfectant. The efficiency of soap and wateris demonstrated in cubicle and chamber nursing.The hands of an attendant are much more likelyconveyors of infection than inanimate objects andare more difficult to clean, but washing seems to beadequate. In alimentary infections insanitary dis-posal of excreta and unhygienic handling of foodresulting in the contamination of food and drink arethe chief factors. Inanimate objects, except bed-linen, play little or no part. If these views are

correct, persons and not inanimate objects are mainlyresponsible for the spread of disease.

Concurrent disinfection of the discharges from theupper orifices of patients with respiratory diseases,

and of the excreta of patients with alimentarydiseases, is therefore particularly important. Exceptin special circumstances, terminal disinfection needbe simple only: removal of dust by a vacuum

cleaner or damp sweeping ; throwing open the windowsto clear the air ; simple laundering of bed-linen andunderclothes ; exposure of mattresses and topclothes to air and sunlight ; disinfection of utensilsby boiling ; destruction of toys and books by burn-ing ; and scrubbing inanimate objects with soapand water.

BRITISH ORTHOPÆDIC ASSOCIATION

THE annual meeting of this association was heldin Birmingham on Oct. 21st and 22nd under the

presidency of Mr. NAUGHTON DUNN.Mr. H. J. BURROWS read a paper on coxa plana

which was an epitome of the essay for which he hadbeen awarded earlier this year the Robert Jonesmedal and prize of the association. He describedthe essential histology of coxa plana as (a) an atypicalsubchondral necrosis involving lysis of trabeculaeand (b) ingrowth of phagocytic and reparative youngmesodermal tissue. The radiological criterion wasdestruction of trabeculse. Coxa plana could not beregarded as due to complete arterial obstruction, forin lesions resulting from the latter-e.g., asepticnecrosis of the femoral head after subcapital fracture-the normal architecture and texture of the bonytrabeculse were preserved a long time. Arterialobstruction alone did not produce the typical changesand he felt, though he had been unable to prove,that venous obstruction and/or haemorrhage intothe bony nucleus of the femoral head might play animportant part. Infection, though unlikely, couldnot be ruled out entirely as a causal factor.

Mr. F. G. ALLAN described the method that heuses for bone lengthening. From an analysis of thelarge series of patients on whom he had performedlengthening operations he concluded that 2 in.

lengthening could be safely and easily obtained,that tibial lengthening was more certain and easierto control than femur lengthening, and that manyof the complications experienced by other surgeonswere due to extensive and unnecessary stripping of theperiosteum and damage to the soft tissue.An operation for calcaneo-cavus was described by

Mr. BRYAN McFARLAND. The essential steps of theoperation are the removal of a substantial wedgeof bone from the posterior third of the os calcis andits insertion into a niche on the dorsal surface of theneck of the astragalus, close to the articular surfacefor the tibia. If the wedge is inserted accuratelyit forms a block to excessive dorsiflexion.A paper on osseous dystrophy following icterus

gravis neonatorum was read by Dr. FRANCES BRAID.Two patients were described who had a diseasecharacterised by (1) jaundice of the familial icterusgravis type at birth with acholia, (2) pathologicalpigmentation of the skin, and (3) a generalised cysticcondition of the bones, which developed some timeafter birth. Dr. Braid said that the bone disturb-ance possibly represented an accompanying develop-mental defect, or it might be secondary to cirrhosisof the liver (present in both patients), which couldvery well have disorganised the storage and utilisa-tion of vitamins.

Mr. T. S. DoNOVAN gave a detailed account offive patients who had suffered from tuberculous

infection of the subgl1tteal bursa. He pleaded for

1362 ROYAL ACADEMY OF MEDICINE IN IRELAND

early excision, because immobilisation of the hipin recumbency had proved ineffective.The pathology of snapping jaw was discussed

by Mr. A. C. ARMSTRONG, who described an operationfor the removal of the torn meniscus. Througha short oblique incision in front of the ear the

zygomatic arch is exposed and in. of it removed

(to be replaced at the end of the operation)immediately in front of the eminentia articularis.This procedure gives a clear view of the anterior andantero-lateral aspects of the joint, and excision of themeniscus is easy. In the two patients on whom theoperation was performed a temporary paresis of thefrontalis muscle developed, but recovery was completein a few weeks.

Dr. J. F. BRAILSFORD showed radiograms of variousbone dystrophies in patients with whom he had beenable to keep in touch from childhood to adult life.He discussed the relationship between epiphysiolysisof the upper end of the femur and renal rickets, anddescribed in detail the radiological appearances in

the " pre-slipping " stage. He regarded infantilecoxa vara as a localised bone dystrophy. Similarbone changes were sometimes seen in cleidocranialdysostosis and in Albers-Schonberg disease.

Mr. SAYLE CREER described 36 patients in whomWO-’6[M’MMC dislocation of one or more toes at the

metatarso-phalangeal joint had occurred-most ofthem in association with hallux valgus and meta-tarsal arch defects. Pes cavus was present in only onepatient. In three there were plantar sinuses leadingdown to the dislocated joints. Mr. Creer disagreedwith Branch’s theory that the dislocation is producedby the interosseous muscles, and he demonstratedin a film that these muscles on faradic stimulationhad an action quite different from that ascribed tothem by Branch. It was therefore concluded thatthe extensor tendons were the dislocating factors(in association with deformities already present).Treatment consists in tenotomies of the extensorsin the early stages. When the dislocation is longestablished, excision of the base of the phalanx is

necessary.

ROYAL ACADEMY OF MEDICINE IN

IRELAND

AT a meeting of the section of obstetrics on

Nov. 4th, with Dr. R. M. CoRBET in the chair, a

paper on

Transfusion in Infancy and Childhoodwas read by Dr. W. R. F. COLLIS. He began byanalysing 102 consecutive cases, 64 being in infantsand 38 in older children. In the first group he laidparticular emphasis on the importance of transfusionin the neonatal anaemias, including icterus gravis,hsemolytic anaemias, and anaemias secondary tomelaena neonatorum and other conditions. In acuteinfections he had not found transfusion of any greathelp, but in chronic infection, especially when it wasassociated with anaemia, improvement had been

noticed-e.g., in marasmus associated with empyemain older children. He considered that the directmethod, by which blood was passed direct from thedonor to the baby without citration was less likelyto cause reactions and was more beneficial than theindirect citrate method. At the Rotunda Hospitaland the National Children’s Hospital he used a

Soresi 2-c.cm. transfusion syringe, as supplied by theModern Surgical Supply Company, Brooklyn. Oncelearnt, the technique was extremely simple ; indeed

he had transfused three babies, all weighing less than5 lb., from a single donor, the whole procedure takingonly 35 minutes.

Dr. NINIAN FALKINER showed a colour film ofDr. Collis’s technique.

Dr. R. E. STEEN congratulated Dr. Collis on

having introduced this procedure into Dublin. In

haemophilia transfusion was undoubtedly very useful;it was also good in melaena neonatorum. In thesecases the missing factor was supplied by transfusion.In icterus gravis also transfusion could be of definitevalue. In the secondary anaemias, in which thehaemoglobin but not the red cell count was reduced,he thought that iron was better than transfusion.In conditions where the red cells were more reducedthan the haemoglobin transfusion might be suitable.In septic cases transfusion was certainly not of value.In marasmic children it could be tried, but he wasnot satisfied that it helped. It should always beremembered that there was a slight risk from trans-fusion. Overloading the right heart was a possibilitythat had to be considered.

Dr. G. C. DOCKERAY said that in very youngchildren blood-grouping did not matter. He thoughta Wassermann test should always be done before anydonor for a transfusion was chosen. In the MayoClinic six cases of transmission of syphilis by trans-fusion had recently been reported. The donor shouldalso be asked if he were sensitive to any foodstuff,and his serum should be tested against the patients’corpuscles.

Dr. APTHORP said that the technique used

by Dr. Collis was not very difficult to learn, butthere must be two, or possibly three, assistants whoknew exactly what the method was and how it wasdone. Because of this, it was a method which couldbe used only in a children’s hospital where everyfacility was available.

Dr. A. W. SPAIN thought that there were manyconditions in which transfusion would be of verydoubtful value and would possibly be harmful, givingexamples from his own experience.The CHAIRMAN said that in cases of sepsis trans-

fusion was a two-edged weapon. He had no doubtthere were some cases in which transfusion was

absolutely life-saving-e.g., in uterine infection with-out septicaemia but with profound and rapidlyincreasing anaemia. He had seen three cases inwhich the anaemia was so bad that he was afraid evento examine the patients, and he had also seen casesin which any movement produced tachycardia. Inthis sort of case transfusion made a great difference.In any patient with septicaemia, however, it wasnecessary to be very careful about transfusion, notonly because it might do harm but also because itwas not always easy to get blood which was com-patible. Where there was blood infection it was

necessary to take the most particular precautionsagainst these risks.

Dr. COLLIS, in reply, said that transfusion, like

oxygen, should not be used as a last resort. In casesof rapidly advancing anaemia due to sepsis it was ofgreat help, but it was not appropriate for every possibleoccasion. It was of great value in the hsemolyticanaemias of the new-born; in the general septic groupof cases it was useless except as an adjunct to othertreatment ; in maras mus it was successful only whenthe baby was anaemic. In the ordinary maternityhospital not nearly enough transfusions were done.It was only by the maternity hospitals taking chargeof new-born infants that the infantile mortality-ratecould be reduced.