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430 which in return are often adopted widely for the common good. CtTSHiNG always insisted, however, that the freshness of these young branches must not obscure the primary function of general medicine and surgery, with its role of support and linkage, both in training and in treatment. The necessary balance in outlook is one that can be achieved only through inspired clinical leadership, not by administra- tion, and CuSHiNG’s own life is an example of that inspiration. He showed that the specialist can and should have an influence far beyond his own sphere, and should add to the strength of the parent stock, instead of taking it away. And incidentally his qualities of mind and heart made him what he always wanted to be-a good doctor to his patients. Annotations CARE OF THE CHILD AFTER POLIOMYELITIS WHEN children leave hospital after a bout of polio- myelitis, nicely booted and callipered, is there any more to be done 1 The parents can be told that there is a chance of further recovery of muscle power up to 18 months after the onset of paralysis ; and that, later on, an arthrodesis, transplantation of tendons, or sympa- thectomy may diminish the patient’s disability. It is also worth discussing how they themselves propose to treat the child in his daily life, for much depends on this. It is sensible to guide a crippled child towards intel- lectual and artistic activities, but the over-ambitious parent should be reminded that, though her offspring may become a Roosevelt, he can easily be strained beyond his capacity and be additionally disabled by anxiety ; or, particularly at a boarding-school, he may develop a disproportionate envy of his athletic colleagues which may haunt him beyond his schooldays. Physical recreation should be discussed with the parents; for it is common to meet crippled children, or adults crippled in early life, whose incapacity has never been questioned because of their outward appearance, so they finally do not know what they cannot do, what they are afraid to do, and what they have never acquired the habit of doing. Exercise also has important social and symbolic values, apart from its physical benefits, and there are dangers in a purely intellectual life. Many normal children feel insecure, and a lower-limb palsy may turn a phantasy of insecurity into reality. Confidence can be restored by games in which balance is controlled mainly by other muscles than those of the legs. Diving involves poise in the air by means of trunk and neck muscles. - The legs -are of minor importance, particularly in diving off a spring-board, and any child who can hop or jump a few inches can enjoy this sport. Bicycling in fairly flat country can be performed by a child with one or even half an active leg, provided that a light machine, with a three-speed gear and a fixed wheel, is used. Horse-riding, for those who can afford it, is more a matter of balance than of leg-grip and is within the capacity of many apparently disabled older children. The physical exercise of power is also missed unnecessarily by some of these children. If shoulder muscles are weak, a golf shot of fair length can still be made with wrists and forearms. Municipal golf-courses and artisans’ clubs are scattered over Britain, though more thickly in the north. Six or seven years is probably the best age for a child to learn to swim, but four-year- olds can be taught, even ii their legs are paralysed. Leg action is essential in the breast-stroke but of minor importance in the crawl, and swimmers such as Arne Borg obtained nine-tenths of their propulsive power from the arms. An exercise suitable for those with one weak upper or lower limb is jujitsu. One of the principles of this art is that the opponent, though rendered incapable of doing injury, should not himself be injured. Its moral value is considerable, and instructors can be found in clubs in most large towns. The overt aim in all these activities should be that of achievement rather than competition, for failure in competition is more likely to dishearten the partially paralysed than the fit. Esthetics must not be neglected. A case of polio- myelitis should be reviewed at intervals, when perhaps a walking-iron which was helpful and unobjectionable on rough fields may be discarded while going to school through town streets under the eye of other children. A night splint alone may be sufficient to prevent a drop- foot from contracting after the first year of the disease. An early promotion to long trousers can make a small boy the envy of his friends and hide a withered limb of which he is more conscious than he seems. A padded stocking or padded shoulders for a fourteen-year-old girl are more justifiable artifices than lipstick. One cannot dogmatise about individuals of different character who resemble one another only in having weakness of one or more muscle groups. But it may be said that the mental effects of poliomyelitis often outweigh the physical and are no less amenable to prevention and treatment. DANGERS OF GLOVE POWDER TALC granuloma is now a recognised late complication of operation wounds, though few surgeons would be prepared to diagnose it clinically. A more serious result of contamination of the peritoneum with glove powder has been described by Roberts 1-granuloma of the fallopian tubes, producing sterility. This disastrous result of an otherwise uncomplicated operation had not previously been recognised because the symptoms are not very severe and may take several years to appear ; and when the tubes are examined histologically the similarity to tuberculous granuloma is close enough to confuse the diagnosis. Several of the tubal lesions described by Roberts had previously been diagnosed as tuberculous, and only the detection of doubly -refractive material in the sections revealed their true nature. Roberts has raised the question whether some cases diagnosed histologically as tuberculous endometritis may not also be silicious granuloma, since the talc may pass via the fimbriated ends of the fallopian tubes to the endometrium. The long latent period between the original operation and the detection of the granulomata is well illustrated by the history of the seven cases reported by Roberts. Each patient had had a previous appendicectomy. Two patients came under observation on account of swelling of the scar, one 12 and the other 11 years after operation. The scars excised resembled keloids, and were nodular on section. Histologically the mass in each case was composed of multiple follicles containing giant and endotheloid cells. Numerous small anisotropic particles were demonstrated with the polarising microscope. These were intimately related to the giant cells, which were in the main grouped around them, and their silicious nature was established by microchemical methods. The five other cases in Roberts’s series all had granulomatous changes in the fallopian tubes, and histological examination revealed the same intimate relationship of anisotropic particles to-giant cells, the particles sometimes being actually inside the cells. Appendicectomy had been performed in these cases 2, 17, 10, 8, and 11 years before the pelvic operations. Only one of the patients had become pregnant after the appendix operation, and this single pregnancy had ended in abortion. All the women were married and were apparently sterile. Their symptoms suggested a low-grade pelvic inflammation. 1. Roberts, G. B. S. Brit. J. Surg. 1947, 34, 417.
