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THE ARCHES OF THE FOOT
1199 lions. About half an hour before our arrival one of his natives had run in saying that there was a lion The farmer got his rifle and followed near the house. the native. In the bush about 100 yards away he The woman had saw a tawny body and fired at it. been draped in the usual square of orange coloured calico. Natives are seldom in error about animals, and one can understand the farmer’s action on the native’s statement and on seeing the tawny object crouching in the bush. But had we not arrived just at the right moment the farmer might have had difficulty in defending his position. Europeans in the bush are quite likely to mistake domestic animals, and even man, for game. Not so very long ago a boy shot his sister in mistake for an antelope. The old hunter’s maxim " never shoot unless you can
enough of the animal always obeyed. * * see
to
identify
it"
is
not
*
I wonder how many of my readers have ever shot a monkey. I did once, and never, never again ! I was in a canoe paddling up a river with my brother. A native with us pointed out a monkey in a tree above us. Quite instinctively I fired and hit it in the chest-lower than I aimed. The monkey fell some distance and then caught at a branch. It tried to stuff some leaves into its wound, and it cried just like a child in fearful pain. I was completely unnerved, so that every one of five shots I nred at it to end its agony and its dreadful crying went wide. I had to hand the rifle to the native to finish the monkey ; my brother refused the job.
CORRESPONDENCE AIR-BORNE INFECTION IN OPERATING THEATRES To the Editor of THE LANCET
SiR,-The paper by Dr. S. T. Cowan in your issue of Nov. 5th and your leading article on the same subject arouse recollections of Lister’s early work on the problems connected with wound treatment. It the conviction of the existence of air-borne infection which led Lister to devise the carbolic spray. One of the younger school of neuro-surgeons was so impressed with this risk during the long
was
exposure so often necessary in neurological operations that, in 1933, he actually borrowed an old carbolic spray, which I had in my possession, and used it in a series of cases in the hope that the antiseptic vapour might sufficiently sterilise the atmosphere in the vicinity of the operation area. The apparatus was a portable steam spray, which had been regularly used by my old teacher Rutherford Morison until 1891, when the method was discarded. I lent it to my young friend, and it is interesting to think of it coming into its own again after so long. The proved risk of air-borne infections suggests the necessity of keeping the operation area covered as far as ever possible, and I feel sure that it will ultimately be proved that the use of gauze soaked in a weak antiseptic, such as 1 in 5000 biniodide of mercury, will serve this purpose and will not be found harmful to the tissues. I am. Sir. vmrrs faithfiillv-
G. GREY TURNER. British Postgraduate Medical School, Hammersmith, London, W., Nov. 9th.
THE ARCHES OF THE FOOT To the Editor of THE LANCET SiR,-It is a pity that English orthop2edic surgeons do not abolish the term " flat-foot " for conditions that are pathological. It must be very confusing for a foreigner to realise what we mean when we find a surgeon claiming that a flat foot is a normal condition, and in the next paragraph will discuss flat-foot as a disability. It is quite time, as I pointed out over forty-five years ago (Walsham and Kent Hughes, "Deformities of the Foot"), that we ceased to describe longitudinal and transverse arches of the foot. T. S. Ellis (" The Human Foot ") applied the term semi-dome," which fits in much more accurately with the anatomy and function of the foot. I was glad to see McMurray adopted the term semi-dome " but later on still mentions the talus as a key-stone. Ellis’s whole point is that the talus has neither the position nor the shape to perform such a function. I am one of those happy individuals "
blessed with
a
foot with
a
low arch, and
though
it is
not considered a handsome object it has carried me well for 74 years through all kinds of athletics and
manual labour. A pathological flat-foot seldom occurs in such a foot. The foot with a high arch causes most of the aches and pains and instability. The heads of all my metatarsals touch the ground. This frequently is not the case in a high-arched foot which is often a genuine cavus with loss of dorsal flexion and some contraction of plantar muscles and ligaments. I think the original anatomist to describe the longitudinal and transverse arches must have taken this type for his description. The low-arch type seemed to me common among bare-footed Japanese, Batavians, and Australian aboriginals. The frequency of foot trouble in military Germany is easily explained by overstrain of youth. Adolescents require leisure and not over-exercise, and as Ellis pointed out, the military position is stupid. We should stand and walk with feet straight and not
heavy
abducted. In taking antero-posterior sections through the cuneiform bones and cuboid, I tried to demonstrate (Walsham and Kent Hughes) that the weight of the body was transmitted through the medial portion of the foot, and that the lateral portion of the cuboid was cancellous and contained no compact bone, proving Ellis’s contention that the lateral part of the foot was not meant to transmit weight. That is why I have always raised " the waist to the sole " by a leather - arch beneath the insole, instead of raising the inner border of the foot in early fallen arches. We want to tilt back the talus and calcaneus into their proper position and not merely to throw the weight upon the outer border of the foot. Collapse and spread of the foot anteriorly is surely a very real entity and in my opinion frequently precedes tilting of the talus and calcaneus medially. Pain is due to stretching of ligaments and not nipping of nerves. Real metatarsalgia is due to passing of a digital nerve directly under the head of a metatarsal bone. I have only seen some half-dozen cases, four of which I proved by operation. If you place your fingers under the heads of the metatarsals when a patient is standing up, you will get evidence of the amount of weight transmitted to each bone. I cannot agree with Mr. Bruce and Dr. Walmsley about the production of clawed toes. Even in postparalytic cases I found upon dissection that the interossei and lumbricales were hypertrophied, in Duchenne’s argument some instances enormously so. arose from the fact that he failed to get response to electrical reactions which was natural under the circumstances. The prevalence of flat-foot is largely A person with due to a shortened tendo Achillis
1200 diminished dorsal flexion and walking with foot abducted soon tilts his talus and calcaneus medially
with the utmost freedom to a downward limit of range which is always further than it appears, unless deliberately tested. I would like to assure Dr. Spence that I have a genuine admiration for the thoroughness of his work on this subject, and the unusual fairness with which he has stated his results and the various criticisms of the treatment he uses. I think, however, that he has accepted from his surgical colleagues certain anatomical misconceptions. If I am wrong in this 1 is easy to prove me so on the human body. it I am, Sir, yours faithfully, DENIS BROWNE. Queen Anne-street, W., Nov. llth.
moves
and starts the whole business of breaking down the mechanism of the foot. I have no exact figures but I have a general idea that at least 20 per cent. of people have some diminution of dorsal flexion. T am. Sir. vours faithfullv. WILFRED KENT HUGHES. Melbourne, Oct. 29th. PULMONARY NEW GROWTHS To the Editor of THE LANCET
SiR,-Mr. R. C. Brock in his Hunterian lecture
(Nov. 4th, p. 1041) refers to the 9 cases of benign new growths of the bronchus described by the late AGRANULOCYTOSIS FOLLOWING TREATMENT Dr. A. J. Scott Pinchin and one of us (H. V. M.). Since WITH M. & B. 693 reporting these 9 cases we have had a further 5 To the Editor of THE LANCET cases at the bronchoscopic clinic of the London Chest Hospital, bringing the total to 14. These SiR,-The following case may be worth recording were found during the examination of 330 malignantbecause I think agranulocytosis associated with the new growths, thus reducing their relative frequencyadministration i of 2-(p-aminobenzenesulphonamido) from 6 (as previously reported) to 4-3 per cent. B. 693) has not been previously _pyridine (M. & Mr. Brock advises against the use of diathermyreported. in the treatment of these growths, pointing out the A primipara, aged 36, developed pyrexia twentydifficulty of controlling the diathermy point. Wefour hours after labour-which had been terminated think that this difficulty is satisfactorily overcome by forceps delivery and manual removal of the if the diathermy is accomplished under vision by placenta, associated with extensive laceration of the means of the telescopic bronchoscope. We have lower genital tract. There was nothing significant in treated half of our cases in this manner and have her past history. On admission thirty-six hours post partum she had signs suggestive of pelvic peri. given some of them several applications of the tonitis. Repeated blood cultures yielded StreptocoCC1!8 diathermy without ever having encountered a severe viridans. This organism along with Bacillus coli was haemorrhage or other ill effects. Indeed, when we also grown from the vaginal swab. have removed some growths piecemeal, we have There were at first no definite signs of endocarditis, had occasion to attempt to control the haemorrhage but treatment with M. & B. 693 was commenced at After three days the temonce (6 grammes daily). by the application of the diathermy current. blood culture was fell and one negative perature We are. Sir. vours faithfullv. The fever however, obtained. recurred, quickly H. V. MORLOCK, while she was still taking the drug and streptococci E. H. HUDSON. Harley-street, W., Nov. 9th. reappeared in the blood. Treatment was disconIMPERFECT DESCENT OF THE TESTIS To the Editor of THE LANCET an addendum (Lancet, Oct. 29th, p. 987) paper by Dr. Scowen and himself Dr. Spence expresses disbelief in my statement that testes which can be felt in the inguinal region are all in a space which I have called the " superficial inguinal pouch " between the muscles and the fascia of Scarpa ; and not, as we were all taught, in the inguinal canal. There are two questions that occur to me. (1) Where does Dr. Spence consider that a
SIR,-In
to
"
a
retractile" testis is when it is above the pubis ; in the canal or in the " superficial inguinal pouch " ? (2) Do the testes which he considers to be in the inguinal canal vary in palpability with the contractions of the abdominal muscles ? This seems to me a simple sign to show whether they are beneath the external oblique tendon or not, but I have never found a testis that gave it. The type of testis which causes all the misunderis that common one which I have called the standing " emergent," when the testis runs in and out of the canal. It is almost invariably out of the canaland consequently palpable-when the patient walks into the consulting-room ; it is quite invariably in it when he is lying on his back under an anaesthetic. To understand this type it is necessary to experiment before operation in feeling it move suddenly from palpability outside the external ring to complete impalpability within it, and to confirm these findings by dissection. Dr. Spence shows that he has not understood my idea of this when he talks of palpable testes being held in the canal by dense adhesions. What is held is the tunica vaginalis and the hernial sac ; in the serous space within them the testis
tinued for two days, but then recommenced with larger doses (8 g. for two days). This time, however. the temperature did not fall, and when a leucopenia was detected on the 18th day from the beginning of the illness administration of the drug was at once discontinued. A systolic murmur soon developed and in spite of vigorous treatment with sodium Pentnucleotide and transfusion of defibrinated blood, the patient died on the 26th day. At post-mortem fresh vegetations were found on the tricuspid valve. There was no evidence of old endocarditis. The results of leucocyte counts were as follows:Leucocytes PolymorphoDate nuclears. 9400 Normal 2200 41 per cent. ,, 29th 1200 8 " 30th .. 1600 2 Oct. lst 2200 0 3rd " 6th 2400 0-5 " Treatment byM. & B. 693; Sept. 17th to 24th and from Sept. 27th to 29th. .
per e.mm.
Sept.25th
..
..
..
..
..
..
..
..
..
The total drug dosage was 54 g. given over a period of 11 days. It is, of course, impossible to be sure that the agranulocytosis in this patient was due to the drug and not to the very severe streptococcal infection,
but in view of the now well authenticated association of this blood condition with sulphonamide preparations (which I have summarised in your issue of Nov. 5th, p. 1044) its occurrence may well serve as a warning of a potential danger in connexion wilb this nearly related drug. Tam. Sir.
vonrs
faitl1fnllv.
F. D. JOHNSTON. Queen Charlotte’s Isolation Hospital,
Hammersmith, W., Nov. 14th.
enough of the animal always obeyed. * * see
to
identify
it"
is
not
*
I wonder how many of my readers have ever shot a monkey. I did once, and never, never again ! I was in a canoe paddling up a river with my brother. A native with us pointed out a monkey in a tree above us. Quite instinctively I fired and hit it in the chest-lower than I aimed. The monkey fell some distance and then caught at a branch. It tried to stuff some leaves into its wound, and it cried just like a child in fearful pain. I was completely unnerved, so that every one of five shots I nred at it to end its agony and its dreadful crying went wide. I had to hand the rifle to the native to finish the monkey ; my brother refused the job.
CORRESPONDENCE AIR-BORNE INFECTION IN OPERATING THEATRES To the Editor of THE LANCET
SiR,-The paper by Dr. S. T. Cowan in your issue of Nov. 5th and your leading article on the same subject arouse recollections of Lister’s early work on the problems connected with wound treatment. It the conviction of the existence of air-borne infection which led Lister to devise the carbolic spray. One of the younger school of neuro-surgeons was so impressed with this risk during the long
was
exposure so often necessary in neurological operations that, in 1933, he actually borrowed an old carbolic spray, which I had in my possession, and used it in a series of cases in the hope that the antiseptic vapour might sufficiently sterilise the atmosphere in the vicinity of the operation area. The apparatus was a portable steam spray, which had been regularly used by my old teacher Rutherford Morison until 1891, when the method was discarded. I lent it to my young friend, and it is interesting to think of it coming into its own again after so long. The proved risk of air-borne infections suggests the necessity of keeping the operation area covered as far as ever possible, and I feel sure that it will ultimately be proved that the use of gauze soaked in a weak antiseptic, such as 1 in 5000 biniodide of mercury, will serve this purpose and will not be found harmful to the tissues. I am. Sir. vmrrs faithfiillv-
G. GREY TURNER. British Postgraduate Medical School, Hammersmith, London, W., Nov. 9th.
THE ARCHES OF THE FOOT To the Editor of THE LANCET SiR,-It is a pity that English orthop2edic surgeons do not abolish the term " flat-foot " for conditions that are pathological. It must be very confusing for a foreigner to realise what we mean when we find a surgeon claiming that a flat foot is a normal condition, and in the next paragraph will discuss flat-foot as a disability. It is quite time, as I pointed out over forty-five years ago (Walsham and Kent Hughes, "Deformities of the Foot"), that we ceased to describe longitudinal and transverse arches of the foot. T. S. Ellis (" The Human Foot ") applied the term semi-dome," which fits in much more accurately with the anatomy and function of the foot. I was glad to see McMurray adopted the term semi-dome " but later on still mentions the talus as a key-stone. Ellis’s whole point is that the talus has neither the position nor the shape to perform such a function. I am one of those happy individuals "
blessed with
a
foot with
a
low arch, and
though
it is
not considered a handsome object it has carried me well for 74 years through all kinds of athletics and
manual labour. A pathological flat-foot seldom occurs in such a foot. The foot with a high arch causes most of the aches and pains and instability. The heads of all my metatarsals touch the ground. This frequently is not the case in a high-arched foot which is often a genuine cavus with loss of dorsal flexion and some contraction of plantar muscles and ligaments. I think the original anatomist to describe the longitudinal and transverse arches must have taken this type for his description. The low-arch type seemed to me common among bare-footed Japanese, Batavians, and Australian aboriginals. The frequency of foot trouble in military Germany is easily explained by overstrain of youth. Adolescents require leisure and not over-exercise, and as Ellis pointed out, the military position is stupid. We should stand and walk with feet straight and not
heavy
abducted. In taking antero-posterior sections through the cuneiform bones and cuboid, I tried to demonstrate (Walsham and Kent Hughes) that the weight of the body was transmitted through the medial portion of the foot, and that the lateral portion of the cuboid was cancellous and contained no compact bone, proving Ellis’s contention that the lateral part of the foot was not meant to transmit weight. That is why I have always raised " the waist to the sole " by a leather - arch beneath the insole, instead of raising the inner border of the foot in early fallen arches. We want to tilt back the talus and calcaneus into their proper position and not merely to throw the weight upon the outer border of the foot. Collapse and spread of the foot anteriorly is surely a very real entity and in my opinion frequently precedes tilting of the talus and calcaneus medially. Pain is due to stretching of ligaments and not nipping of nerves. Real metatarsalgia is due to passing of a digital nerve directly under the head of a metatarsal bone. I have only seen some half-dozen cases, four of which I proved by operation. If you place your fingers under the heads of the metatarsals when a patient is standing up, you will get evidence of the amount of weight transmitted to each bone. I cannot agree with Mr. Bruce and Dr. Walmsley about the production of clawed toes. Even in postparalytic cases I found upon dissection that the interossei and lumbricales were hypertrophied, in Duchenne’s argument some instances enormously so. arose from the fact that he failed to get response to electrical reactions which was natural under the circumstances. The prevalence of flat-foot is largely A person with due to a shortened tendo Achillis
1200 diminished dorsal flexion and walking with foot abducted soon tilts his talus and calcaneus medially
with the utmost freedom to a downward limit of range which is always further than it appears, unless deliberately tested. I would like to assure Dr. Spence that I have a genuine admiration for the thoroughness of his work on this subject, and the unusual fairness with which he has stated his results and the various criticisms of the treatment he uses. I think, however, that he has accepted from his surgical colleagues certain anatomical misconceptions. If I am wrong in this 1 is easy to prove me so on the human body. it I am, Sir, yours faithfully, DENIS BROWNE. Queen Anne-street, W., Nov. llth.
moves
and starts the whole business of breaking down the mechanism of the foot. I have no exact figures but I have a general idea that at least 20 per cent. of people have some diminution of dorsal flexion. T am. Sir. vours faithfullv. WILFRED KENT HUGHES. Melbourne, Oct. 29th. PULMONARY NEW GROWTHS To the Editor of THE LANCET
SiR,-Mr. R. C. Brock in his Hunterian lecture
(Nov. 4th, p. 1041) refers to the 9 cases of benign new growths of the bronchus described by the late AGRANULOCYTOSIS FOLLOWING TREATMENT Dr. A. J. Scott Pinchin and one of us (H. V. M.). Since WITH M. & B. 693 reporting these 9 cases we have had a further 5 To the Editor of THE LANCET cases at the bronchoscopic clinic of the London Chest Hospital, bringing the total to 14. These SiR,-The following case may be worth recording were found during the examination of 330 malignantbecause I think agranulocytosis associated with the new growths, thus reducing their relative frequencyadministration i of 2-(p-aminobenzenesulphonamido) from 6 (as previously reported) to 4-3 per cent. B. 693) has not been previously _pyridine (M. & Mr. Brock advises against the use of diathermyreported. in the treatment of these growths, pointing out the A primipara, aged 36, developed pyrexia twentydifficulty of controlling the diathermy point. Wefour hours after labour-which had been terminated think that this difficulty is satisfactorily overcome by forceps delivery and manual removal of the if the diathermy is accomplished under vision by placenta, associated with extensive laceration of the means of the telescopic bronchoscope. We have lower genital tract. There was nothing significant in treated half of our cases in this manner and have her past history. On admission thirty-six hours post partum she had signs suggestive of pelvic peri. given some of them several applications of the tonitis. Repeated blood cultures yielded StreptocoCC1!8 diathermy without ever having encountered a severe viridans. This organism along with Bacillus coli was haemorrhage or other ill effects. Indeed, when we also grown from the vaginal swab. have removed some growths piecemeal, we have There were at first no definite signs of endocarditis, had occasion to attempt to control the haemorrhage but treatment with M. & B. 693 was commenced at After three days the temonce (6 grammes daily). by the application of the diathermy current. blood culture was fell and one negative perature We are. Sir. vours faithfullv. The fever however, obtained. recurred, quickly H. V. MORLOCK, while she was still taking the drug and streptococci E. H. HUDSON. Harley-street, W., Nov. 9th. reappeared in the blood. Treatment was disconIMPERFECT DESCENT OF THE TESTIS To the Editor of THE LANCET an addendum (Lancet, Oct. 29th, p. 987) paper by Dr. Scowen and himself Dr. Spence expresses disbelief in my statement that testes which can be felt in the inguinal region are all in a space which I have called the " superficial inguinal pouch " between the muscles and the fascia of Scarpa ; and not, as we were all taught, in the inguinal canal. There are two questions that occur to me. (1) Where does Dr. Spence consider that a
SIR,-In
to
"
a
retractile" testis is when it is above the pubis ; in the canal or in the " superficial inguinal pouch " ? (2) Do the testes which he considers to be in the inguinal canal vary in palpability with the contractions of the abdominal muscles ? This seems to me a simple sign to show whether they are beneath the external oblique tendon or not, but I have never found a testis that gave it. The type of testis which causes all the misunderis that common one which I have called the standing " emergent," when the testis runs in and out of the canal. It is almost invariably out of the canaland consequently palpable-when the patient walks into the consulting-room ; it is quite invariably in it when he is lying on his back under an anaesthetic. To understand this type it is necessary to experiment before operation in feeling it move suddenly from palpability outside the external ring to complete impalpability within it, and to confirm these findings by dissection. Dr. Spence shows that he has not understood my idea of this when he talks of palpable testes being held in the canal by dense adhesions. What is held is the tunica vaginalis and the hernial sac ; in the serous space within them the testis
tinued for two days, but then recommenced with larger doses (8 g. for two days). This time, however. the temperature did not fall, and when a leucopenia was detected on the 18th day from the beginning of the illness administration of the drug was at once discontinued. A systolic murmur soon developed and in spite of vigorous treatment with sodium Pentnucleotide and transfusion of defibrinated blood, the patient died on the 26th day. At post-mortem fresh vegetations were found on the tricuspid valve. There was no evidence of old endocarditis. The results of leucocyte counts were as follows:Leucocytes PolymorphoDate nuclears. 9400 Normal 2200 41 per cent. ,, 29th 1200 8 " 30th .. 1600 2 Oct. lst 2200 0 3rd " 6th 2400 0-5 " Treatment byM. & B. 693; Sept. 17th to 24th and from Sept. 27th to 29th. .
per e.mm.
Sept.25th
..
..
..
..
..
..
..
..
..
The total drug dosage was 54 g. given over a period of 11 days. It is, of course, impossible to be sure that the agranulocytosis in this patient was due to the drug and not to the very severe streptococcal infection,
but in view of the now well authenticated association of this blood condition with sulphonamide preparations (which I have summarised in your issue of Nov. 5th, p. 1044) its occurrence may well serve as a warning of a potential danger in connexion wilb this nearly related drug. Tam. Sir.
vonrs
faitl1fnllv.
F. D. JOHNSTON. Queen Charlotte’s Isolation Hospital,
Hammersmith, W., Nov. 14th.