837

days later, on Dec. 22, the child was discharged home stillslightly ataxic but reacting normally to his parents andfeeding well.

All the urine was collected from the time of diagnosis-i.e.,thirty-six hours after the onset of coma-for seventy-two hours.In the first twenty-four-hour specimen 56 mg. of phenobarbi-tone was found ; in the second 13 mg.; and in the third 10 mg.Metabolites of the drug were not detected.Follow-up.—Seen on Jan. 2, 1956, the child was well ; in

fact his parents complained that he was sleeping badly.

Discussion

This child received a large dose of phenobarbitone(about gr. 55 in divided doses in thirty-six hours) andwas in coma for at least thirty-six hours before treatmentwas begun. Since his respiration did not become

depressed, he might well have recovered without activetreatment.The fact that he was fat, may have been to his advan-

tage. It is known that some of the short-acting bar-biturates-e.g., thiopentone-are absorbed from theblood-stream by fatty tissue (Goodman and Gilman

1955). The fact that respiration was not affected in thiscase suggests that a similar mechanism may applyto phenobarbitone.The small amounts of phenobarbitone found in the

urine can be explained by the lapse of time beforecollection was begun and the amount which must havebeen metabolised (Goodman and Gilman 1955).Unless respiration is depressed, the use of amiphenazole

as well. as bemegride seems unnecessary, although it hasbeen. recommended (Shulman et al. 1955).- Bemegride does not appear to be toxic. The chief

danger in its use seems to lie in failing to realise that it

may have to be given for -a ""long time. The patient’scondition is liable to ’regress if the dose is reduced

prematurely. This was well shown in the present case,where bemegride had to be given for eighty hours. Forthis reason it seems more sensible to mix it with theintravenous transfusion fluid in the bottle rather than toinject it intermittently.

’

SummaryA case of phenobarbitone poisoning in a child aged

14 months is reported. Phenobarbitone had beenadministered for thirty-six hours by mistake for suc-

cinylsulphathiazole.On admission the child was deeply comatose, but his

respiration and circulation were not depressed.He was treated successfully with 2827 mg. of beme-

gride, mixed with a convenient intravenous transfusionfluid, given continuously for eighty hours.We wish to thank Dr. T. Stapleton, who was in charge of

the case, for advice and encouragement ; Prof. A. Neubergerfor help in the diagnosis and for the chemical analyses ; andDr. Keith Mant, Dr. T. A. B. Harris, and Dr. T. E. Oppefor advice.

REFERENCES

Bingle, J. P., Whitwam, J. G. (1955) Brit. med. J. i, 1340.Buckman, J. (1955) Ibid, ii, 203.Goodman, L. S., Gilman, A. (1955) The Pharmacological Basis c

Therapeutics. London.Harris, T. A. B. (1955) Lancet, i, 181.Holten. C. (1955) Ibid, ii, 619.Montuschi, E., Wickenden, P. D. (1955) Ibid, i, 622.Perinpanayagam, M. S. (1955) Ibid, ii, 620.

— Nicholls, G., Osmond, J. D. (1955) Brit. med. J. ii, 912.Shaw, F. H., Simon, S. E., Cass, N., Shulman, A., Anstee, J. R

Nelson, E. R. (1954) Nature, Lond. 174, 402.Shulman, A., Shaw, F. H., Cass, N. M., Whyte, H. M. (1955) Bri

med. J. i. 1238.Webb, J. W. S. (1955) Ibid, ii, 56.

Medical Societies

BRITISH ORTHOPÆDIC ASSOCIATIONTHE association’s spring meeting was held at Gleneagles

on May 3-5, under the presidency of Mr. PHILIP WILLES.

Conservative Treatment of Spinal TuberculosisMr. J. P. JACKSON (Harlow Wood) discussed 89 cases of

spinal tuberculosis, reviewed not less than two years aftertreatment, which had consisted of immobilisation on a frameor plaster bed and streptomycin 1 g. and y-aminosalicylic acid18 g. daily for ninety days. 3 patients had died, all from

meningeal or genito-urinary infection. Amyloid disease andsepsis were no longer problems, and sinuses closed more

readily, although five had persisted and one new sinus haddeveloped under treatment. Posterior fusion by tibial graftswas usually undertaken when the lesion was quiescent, andof these 3600 proceeded to anterior fusion also ; anteriorfusion had occurred in 46° of cases which had not been

operated on but gave no certain guard against relapse, whichensued in 11% of’ such cases. The relapse-rate after surgerywas, however, only half that where no operative fusion hadbeen performed. Abscesses were not opened routinely, butit was found that only 24% of those with persistent abscessesproceeded to bony fusion. Mr. Jackson concluded that

general treatment was still necessary ; conservative treatmentwith three months’ chemotherapy gave 21% unsatisfactoryresults, but total duration of treatment was shorter and

mortality was reduced. Posterior grafting was well worthwhile.Mr. ROBERT ROAF (Liverpool) remarked that chemotherapy

is now given usually for nine to twelve months, and that wehave learnt how fallacious the interpretation of radiographscan be in assessing quiescence.

V-nail Fixation for Fractured Neck of FemurMr. A. W. FOWLER (Bridgend) recommended V-nail fixation

for trochanteric and basal fractures of the neck of the femur.This was a modification of the " low nail " operation describedby Brittain in 1942. A V-nail (actually a clover-leaf Kuntschernail with half of the lateral leaves shaved down) providedfixation based on three solid points-the dense bone of thehead, the upper end of the medial cortex of the shaft, andthe outer cortex at the point of penetration. He permitted

weight-bearing after eight weeks, and earlier in stable fractures.This admittedly experimental method was mechanically soundand cheaper and more efficient than pin or bladeplate, andit permitted telescoping when necessary, but not coxa vara.

Mr. G. K. McKEE (Norwich) had had similar favourableexperience of the procedure, but remarked that some appar-ently pertrochanteric fractures were really subtrochantericposteriorly, so a nail might split the cortex in this region.He therefore preferred to add to a vertical nail a slotted platewhich would allow some telescoping. ’

Mr. ROLAND BARNES (Glasgow) did not think that thismethod was adequate for the unstable type of fracture,because the comminution of the inner cortex would precludestability and permit varus deformity with danger of the nailbreaking through the head as in other methods.

Internal Fixation for Bennett’s FracturesMr. F. C. BADGER (Birmingham) described his method of

’treating Bennett’s fractures, whereby through a dorsal incisionthe fragment was reduced and fixed by a small screw passedthrough the base of the shaft. No plaster was necessary.The patients were off work on average for three weeks. In13 out of 17 cases the results had been good, the failuresresulting either from the use of too short a screw with laterredisplacement of the fragment, or from a badly placed screw.

Mr. 0. J. VAUGHAN-JACKSON said that he used a small pinand a mid-lateral approach ; in 2 cases the small fragmenthad been found turned over so that the articular cartilagewas apposed to cancellous bone on the major fragment.

Congenital Dislocation of HipMr. J. C. SCOTT (Oxford) reported the interim results of

75 cases of congenital dislocation of the hip treated at Oxfordsince 1949, under the regime devised by Mr. E. W. Somervilleand himself. The cases were treated within what he calledthe " critical period "-from the beginning of weight-bearingto the age of 4. The method consisted in (1) gradual reductionby traction on a special frame, (2) operative removal of thelimbus where this was shown by the arthrogram to bein-turned, and (3) rotation osteotomy to correct anteversionwhen required. He believed that the dislocation was firstanterior and later became superior and then posterior for thehead to lie on the dorsum ilii. He thought that it was usuallythe lesser trochanter that pushed in the limbus ; the secondaryreduction in circulation was responsible for the smallness ofthe epiphysial head and cases of later osteochondritis. The

838

use of the frame was an essential part of their regime ; thehead of the femur could always be brought down but wascommonly left standing out from the acetabulum. 75 opera-tions had been performed and only once had they failed tofind an inverted limbus, which might be very large ; thelimbus could not be everted. The position of subsequentplaster immobilisation depended on the degree of internalrotation required to reduce the head fully ; in 1 case posteriorcapsulotomy had been needed to permit this. Three weekslater a rotation osteotomy was done, leaving the upperfragment unmoved and rotating the shaft to the neutral

position. Five weeks later the patients were left free fromsplintage and early weight-bearing was permitted. The totalduration of treatment had now been reduced to fourteen weeks.Further dislocation had taken place in 3 cases, either becausethe limbus had not been excised or because derotation hadbeen insufficient and further operation was required. Allcases had a range of movement 90% or more of normal.

Slipping of Upper Femoral EpiphysisMr. P. H. NEWMAN reported the results of surgical treatment

of slipping of the upper femoral epiphysis in 39 cases. Theresults were excellent in 23, good in 8, fair in none, and poorin 8. If there was less than one-third-diameter posteriorand less than one-quarter-diameter medial displacement thefemoral head was pinned in situ. Because of the difficultyof insertion into the epiphysis, the danger of damaging itsblood-supply, and the possibility of a subtrochanteric fractureat the point of insertion, he had abandoned the use of aSmith-Petersen nail and used a modification of Moore’s pins.In this first group only 1 out of 19 had a poor result. Ifthe position was unacceptable an attempt to improve it byvery gentle manipulation was made and pins were insertedif adequate reposition was obtained. There were 7 cases inthis group ; perfect reduction was rarely obtained, but inthe single poor result the patient had had a stiff hip beforeoperation. Where closed reduction failed open reduction

through an anterior approach, with excision of a wedge ofbone where necessary, was performed. A pin inserted up theneck ready before the open correction was done could bedriven on immediately the head was reduced, and this pre-vented loss of position during the later stages of the operation.The results had been poor in 3 out of 9. Treatment of thefourth group was by subtrochanteric osteotomy, which lie hadnow abandoned. Treatment in these cases was urgent.Poor results followed avascular necrosis and operations onhips already stiff from delayed diagnosis or prolonged traction.In such cases two months’ physiotherapy to mobilise the hipand improve the local blood-supply was indicated before

operation could be considered.Mr. A. M. RENNIE (Aberdeen) reported his results in

15 cases. Avascular necrosis had developed in 3, and heagreed that operations on stiff hips, which had resulted in2 poor results in his own series, must be avoided.

Dr. E. THOMASEN (Aarhus) had tried to stimulate fusionby drilling across the epiphysial plate, keeping the patienteight weeks in bed on traction without plaster fixation.

Occasionally he had left a Kirschner wire across the platefor a few months as additional fixation. A subcapital wedgeosteotomy with drilling and fixation by Kirschner wires wasreserved for later cases. Avascular necrosis had developed in3 out of 14 cases.

Fractured Neck of Femur Treated by CompressionMr. JOHN CHARNLEY (Manchester) described the treatment

of fractures of the neck of the femur by compression. Withpresent methods a third failed to unite within the first year.He had been using a coarse threaded screw in the femoralhead ; the smooth shaft of this screw passed through a socketinserted into the femoral neck and fixed by a plate to thefemoral shaft. A nut and spring allowed compression to25 lb. The angle was fixed at 120°. Special tools were

required, and while all other movements were prevented thespring maintained compression between head and neck shouldabsorption of the latter occur. The apparatus permittedmeasurement of the degree of shortening taking place in theneck. Cases fell into two groups : one in which extrusion ofthe bolt was seen to cease after three months ; and anotherin which it continued to progress for a year or more. Of33 cases available for study 82% united satisfactorily.

Arthrodesis of HipMr. McKEE reported the results in 50 cases of arthrodesis of

the hip by a lag-screw, reviewed at least two years after opera-

tion. The operation was done through a lateral approach. Afterremoval of the articular cartilage the hip was fixed by alag-screw inserted up the femoral neck and into the ilium.The neck was drilled out to allow the smooth shaft of thescrew free passage when final compression was applied, andit was important to ensure that all the threaded part was inthe ilium. The greater trochanter was removed and used asan iliofemoral graft. In 76% of cases no additional plasterfixation was used. The screw broke in 16%, but in only halfof these did it need to be removed : this complication hadnot occurred in the last 38 cases. There had been 2 deaths,1 from delayed shock and the other from coronary thrombosis.In only 1 case had union failed to take place, owing to oldischaemic necrosis in the femoral head. Final results showed34% excellent, 32% good, and 28% fair.

Knock-knee in Children

Mrs. M. MORLEY reported an investigation into knock-kneein children. In general knock-knee became increasinglycommon and severe up to the age of 31/2 years, after whichit diminished steadily. Sex made no difference to theincidence, but the more severe the knock-knee the greaterwas the weight of the children. No correlation with heightwas found, and valgus ankles and flat-feet (the latter almostuniversal in the very young) diminished with age and wereunrelated to knock-knee. She had failed to find any associa-tion between knock-knee and the age of first walking, theduration of’ breast-feeding, additional vitamins, or the lengthof time spent in bed because of illness.

Paralytic ScoliosisMr. J. 1. P. JAMES had attempted to correlate the distribu-

tion of paralysis with the curve patterns in paralytic scoliosis.Of 193 cases, divided into high thoracic, thoracic, thoraeo-lumbar, lumbar, combined thoracic and lumbar, and ’.’ tele-

scopic "

spine, he had chosen the high thoracic, thoracolumbar,and lumbar for special study. When the onset was beforethe age of 5 the curvature usually exceeded 100°, but ifdelayed till after the age of 10 it was usually less than 70°.The high thoracic curve usually started at Tl. In contra-distinction to Colonna he had failed to find any correlationbetween paralysis of the shoulder-girdle or proximal segmentsof the upper limb in this type of curvature. The erector

spinae was usually normal and there was no significantrelationship to abdominal paralyses. He had, however, foundalmost constant paralysis of the intercostal muscles on theconvex side, and in contradistinction to idiopathic curves theribs were not spread on this side but were crowded and hungalmost vertically so that they were obscured by the spine onthe anteroposterior radiograph. A cine-radiographic filmshowed the ribs on the concave side moving well on respirationin contrast to those on the convex side. In thoracolumbarcurves with the apex at Dll or D 12, and in lumbar curves,weakness of the lateral flexors on the convex side was constant.Weakness of the erector spinæ, anterior abdominal muscles,psoas, glutei, or lower limbs was apparently unrelated. The

only other factor that he believed to be significant was gravity.On the M.R.C. scale adequate muscle charting of the trunkmuscles was extremely difficult and of the intercostalsobviously impossible by clinical methods.

Fractures and Dislocations of Cervical SpineMr. F. C. DURBIN (Exeter) discussed 75 cases of fractures

and dislocations of the cervical spine, seen in a ten-year period.12 of these involved atlas and axis and were excluded fromconsideration. The rest were chiefly in young active males,road accidents being the commonest cause. Where paralysiswas absent and there were other serious injuries, the lesionwas easily missed. A fractured spinous process alwaysimplied damage to the interspinous ligament. In these

injuries, if no dislocation was present he advised that radio-graphs in flexion carefully controlled by the surgeon shouldbe taken to test the stability of the spine. In over half thecases with dislocation the cord or nerve-roots were injured.In 26 the cord was injured ; in 15 there was completequadriplegia, and 14 of these patients had died. He recom-mended gradual reduction by skull traction with Crutchfieldice-tong callipers, which were safe and effective if tighteneddaily. The 4 failures of reduction by this method were dueto locked facets, which needed operative reduction. Simpleimmobilisation after reduction was not sufficient ; recurrence

of displacement, as shown by radiographs in flexion, hadoccurred in 8 cases, 3 of them even after six months in plaster,and 2 associated with fractures of a spinous process where

839

no dislocation was present at first. He therefore recommendedopen fixation by wiring the spinous processes and bone-grafting in all such cases ; wiring alone was insufficient.Union was rapid and protection was required for three monthsonly; there had been no deaths in 16 operations.Mr. BARNES said that in these cases he applied both deep

and superficial wiring to his grafts ; this gave such stabilitythat only the lightest collar protection was necessary. He

suspected that cases of’ unilateral locked facets were alwaysirreducible by traction alone and needed immediate openreduction.

Stress Fractures of the Fibula

Mr. M. B. DEVAS, with Mr. R. SWEETNAM, had seen 50 casesof stress fracture of the fibula, all in athletes. All their

patients were already in training, and the chief cause appearedto be running on a hard surface. A ten-day history wascommon, and the usual complaint was of pain behind theankle. In some cases the onset was sudden ; in rather moreit was gradual. A few had noticed local swelling ; this was

always slight, tender, and soft at first and later hard. " Spring-ing " the fibula produced pain. Diagnosis was made onclinical grounds and not from radiographs, in which the

changes were slight even after a month. A fine crack

appeared, often affecting only the lateral cortex, and runningupwards, inwards, and forwards ; the periosteal reaction wasminimal. The scar in the bone might remain visible for years.The majority (29 cases) occurred between 4 and 7 cm.

from the lower end of the bone ; the highest seen was 23 em. up.Two-thirds of the cases had occurred in the winter months,perhaps because at that time official tracks were being savedand training done on roads. They believed that the stresswas due to muscle action each time the ball of the foot struckthe ground ; they demonstrated by special radiographictechnique that static contraction of the calf muscles withoutankle movement caused the upper two-thirds of the fibula toapproximate to the tibia, although the lower part remainedunmoved. Patients must stop all sport until free from painand then take up training gradually. Strapping was usefulbut plaster was definitely contra-indicated. If pain recurredthe patient must again reduce his activities.Mr. NEWMAN remarked that he had seen eases affecting

the upper third of the fibula in parachutists.Mr. McKEE had seen 1 case progress to non-union requiring

excision and bone-grafting.Mr. DEVAS thought that the stress fractures of the upper

third of the fibula in parachutists were of a different natureand were due to repeated relatively severe injuries.

BRITISH INSTITUTE OF RADIOLOGY

Radioactivity in Man and his EnvironmentIN a presidential address on June 24, Prof. F. W.

SPIERS discussed the background or natural radio-

activity of Man and his environment.Professor Spiers pointed out that Man has always been

exposed to ionising radiations : in fact, he has alwayslived in a radioactive world. It now seems likely that,at least in geologically recent times, there has been nogTeat change in the radiation intensity to which Manhas been exposed in his environment. But Man has now

begun to produce artificial radioactivity and ionisingradiations in abundance, and Professor Spiers considersit possible, and perhaps likely, that the increase in radia-tion background now taking place will be greater thanany changes in the past.The human body is naturally irradiated in two ways :

by sources of radiation external to the body, whichInclude terrestrial and cosmic radioactivity ; and byinternal radioactivity acquired by the body from air,food, and water. The radiation dose acquired in thisway is known as the " background dose."The main contributors to terrestrial y-radiation are the

members of the uranium and thorium series, together withnaturally occurring radioactive potassium. Swedishalum shale is an example of a particularly highly radio-active rock ; granites are less active, and sedimentaryrocks are considerably less active than granites. Seawater has a low radioactive content ; the equivalent.

radium content of sea water is about 100 times lower thanthat of sedimentary rocks. High radioactivity can occurin mineral waters and well waters. The radioactivity oftap water is much reduced by precipitation methods ofpurification.The natural radioactivity of the air is due to radon

and thoron arising from the escape of these gases fromthe ground. Their local concentrations depend on localatmospheric conditions, as well as wind, rain, dust, and,in the case of buildings, their ventilation and fabric.The radium content of the human body has lately

been established as 0.05-0-32 x 10-9 g. Since there is

only a slight correlation between the body-radiumcontent and drinking-water, it seems probable that themajor source of this radium is food. The other maincontribution to internal radiation is from radioactivepotassium ; the 4OK body content is now established atabout 0.2% of body-weight. Radioactive carbon as 14C,though present, is such a weak &bgr;-ray emitter that itscontribution to radiation dose, compared with radium andpotassium, is negligible.

There are three components of external radiation

background : local -,,-radiation, cosmic radiation, andatmospheric radioactivity.Rock radioactivity is responsible for most of the

external y-radiation background. Higher dose-rates arerecorded inside buildings than in the open air, particularlyif the building fabric contains a high proportion of radio-active material-for example, alum shale in concrete. In

general, wooden houses do not have very dissimilar dose-rates from those in the open air ; brick buildings are inter-mediate between wood and concrete or concrete-shalestructures. The dose-rates recorded vary from 48 to 50m.rad.1 per year out of doors or in Swedish woodenhouses, to 171 m.rad. per year for concrete buildings witha high proportion of alum shale in the concrete.

Cosmic radiation at sea level in Northern latitudescontributes 28 m.rad. per year. This intensity is increasedby altitude, and diminished by absorption in the base-ments of tall buildings.Atmospheric radioactivity under normal conditions

with a radon atmospheric content of 3 x 10-13 curie 2

per litre contributes about 4 m.rad. per year. This issmall ; but if the highest recorded values from Londonof 2-3 x 10-12 curie per litre are used, the y-ray dose is ofthe same order as that from cosmic radiation.The internal radiation background is due to radioactive

potassium primarily in soft tissues, ingested radium inbone, radioactive carbon, and radon and its’disintegrationproducts in air.

40K is the main agent of soft-tissue irradiation and isestimated to contribute 20 m.rad. per year mean dose,the dose-rates to individual organs being determined bytheir potassium content. 14C contributes about 1 m.rad.

per year.Bone dosage is likely to be particularly heterogeneous,

but if 82 m.rem.3 per year is received from sources otherthan radium, and if an osteocyte is 5 (JL in diameter,the radium contribution is estimated to be 39 m.rem.

per year, making a total dose-rate of 121 m.rem. per yearto the osteocyte.The contribution to the internal background radiation

made by radon and its daughter products arising fromtheir inhalation is uncertain, and depends on the assump-tions made. It is probably of the order of 2.0 m.rem. per

1. rad. is a unit of absorbed dose. It is 100 ergs. per gramme.(International Commission on Radiological Protection 1955.)

2. curie is a unit of radioactivity defined as the quantity of anyradioactive nuclide in which the number of disintegrations persecond is 3.700 × 1010. (I.C.R.P. 1955.)

3. rem. is the absorbed dose of any ionising radiation which hasthe same biological effectiveness as 1 rad. of X-radiation withaverage specific ionisation of 100 ion pairs per micron of water,in terms of its air equivalent, in the same region. A dose inrems. is equal to the dose in rads. multiplied by the appropriateR.B.E. (relative biological effectiveness). (I.C.R.P. 1955.)