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THE SECTIONS. SURGERY.
THE BRITISH MEDICAL ASSOCIATION.
form of the rigid splint was of most service: outside leg-iron, in knock-knee an outside splint or iron, and in lateral curvature a posterior support with lateral plates. At some children’s hospitals it was still recommended that for these deformities the patients should be taken " off their feet"for a year or more. Save for rare complications this was not necessary. All these conditions could be treated successfully on the ambulant plan and thus no interference with the course of education was involved. There was room for much improvement in this department, an improvement that, in Mr. Clarke’s opinion, could only be brought about by arranging for a more systematic scheme cf£ teaching orthopædic surgery in the medical schools.
instruments in flat-foot
THE
BRITISH MEDICAL ASSOCIATION. MEETING AT IPSWICH.
THE SECTIONS. SURGERY.
THURSDAY, AUGUST 2ND. Lateral Curvature, Knock-knce, and Flat-foot. IN the absence of Mr. ARBUTHNOT LANE (London) this discussion was opened by Mr. JACKSON CLARKE (London). After defining the meaning of the terms the scope within which the discussion should be limited was then suggested. It was only when these three deformities were considered as habitual pressure deformities that they could profitably be compared. Thus cases of lateral curvature due to paralysis and instances of knockor consecutive to empyema, &c., knee or of flat-foot due to severe arthritis, need not be considered save for purposes of comparison. By a habitual pressure deformity was meant a deviation from the normal form caused by the force of gravity acting on the ligaments and bones owing to the preponderating use of one to the exclusion of other attitudes. In certain circumstances a habitzial posture was gradually converted into a deformity. As applied to the subjects under discussion Mr. Clarke observed that the majority of cases of lateral curvature arose from faultv attitudes assumed by school-children when sitting at a desk, especially during writing. Knock-knee and flat-foot arose in what Annandale had termed the "attitude of rest," as seen, for instance, in the apprentice who stood with the feet everted and somewhat widely separated. The main point for discussion might be formulated thus: "To what extent do pathological processes enter into the causation of pressure deformities ?The danger in giving names was that they might be misinterpreted. The term "pressure deformity" originated in Germany with Roser and Volkmann and Mr. Clarke thought it was as good a one as could be found ; at the same time he strongly believed that in the vast majority of cases of these deformities there was something more than the force of gravity and a habitual attitude at work. There was, he believed, a pathological predisposing cause to be found in nearly every case at the time of the development of the deformity. Healthy children did not long remain in any one posture. According to Danish
observers about 1½ per cent. of school-children became affected with lateral curvature. According to German observers about 90 per cent. of school children assumed abnormal spinal postures during writing. Why did not more than a fraction of those who assumed faulty attitudes become deformed ? Mr. Clarke had no hesitation in expressing his belief that it was only those who suffered from some abnormal softness of ligament and bone who became affected by these pressure deformities. Slight rickets and an inherited tendency to rheumatoid arthritis were the two chief causes of this diminished resisting-power of the skeleton and ligaments. These same two affections were, he believed, the chief causes of naso-pharyngeal adenoid vegetations which played no small part in the production of deformities of the chest. If this contention were correct the physician could do much towards the prevention of pressure deformities by insisting on a rational diet for children. If all schoolchildren could have an abundance of fresh-i.e., unboiled and unsterilised-milk cases of deformity of this class would be diminished and, he believed, almost abolished. Failing a safe milk-supply raw eggs or raw meat might be substituted. In comparison with this broad prophylactic or medical aspect of the matter the strictly surgical aspect was unimportant ; to the individual patients, however, proper surgical treatment was of the highest moment. Mr. Clarke then reviewed muscular training, instrumental, and operative treatment. Seeing that the majority of the patients who came for treatment during the course of development of the deformity required supervision on an average for a period of two years he found that routine courses of special gymnastic treatment of two or three months’ duration were less effectual than simple exercises devised for each patient and practised at home under the supervision of the patient’s medical adviser. Of
605
some
an
FRIDAY, AUGUST 3RD. of Roentgen Rays in Surgery.
The Use
I
Mr. J. MACKENZIE DAVIDSON (London) gave an account of the recent progress in this direction. He showed that a single skiagram was often very misleading, as the relative position of parts might be completely misrepresented. He now took two photographs with the Crookes’s tube in different positions, about two and a half inches apart. These two pictures differed slightly from one another and they were combined by a Wheatstone’s stereoscope so that. one mental image was obtained in which the relative depths of objects could be distinguished. He had also been able to adapt the stereoscopic method to the fluorescent screen by employing two Crookes’s tubes, which were alternately eclipsed, and the eyes of the observer were correspondingly shut out from a view of the screen. (A demonstration of this important step in stereoscopic radiography was afterwards given by Mr. Davidson.) The Opeo Incision for Clitb-foot, its Indications and Abuses. Dr. A. M. PHELPS (New York) read a paper on this subject. In 1878 Dr. Phelps performed his first operation by open incision on a relapsed club-foot and since that date he had operated on 1650 cases. In the last 700 cases he had not performed a single osteotomy and the mortality of the whole 1650 had been nil. Up to the age of four months it was unnecessary to do more than attempt to straighten the foot by the employment of the surgeon’s hands and the use of adhesive strapping, but if the fourth month had passed and the foot refused to straighten then the surgeon should perform subcutaneous tenotomy, dividing first those tendons which were most tense. The tendo Achillis generally first needed division. It was only after tenotomy had failed that any open operation should be considered. The soft parts. were really responsible for all forms of congenital talipes and the complete division of any restricting band would nearly always suffice for the straightening of the foot. The incision was made on the inner side of the foot from just in front of the internal malleolus to the neck of the astragalus. The foot was then wrenched into an over-corrected position and fixed in that position. The most important structure to divide was the anterior limb of the deltoid ligament. In. most cases the wound filled up with blood-clot which organised. If, however, as occasionally happened, it were found impossible to get the foot straight an osteotomy might be done, the simplest being division of the neck of theastragalus, or, if that were not sufficient, a wedge-shaped piece of the os calcis might be removed. Very rarely indeed it might be necessary to amputate and then Pirogoff’s opera-tion should be performed. The results of the open incision could not be surpassed by any other method of treatment and much time was saved. Mr. JACKSON CLARKE (London) said that he would much like to see the present condition of Dr. Phelps’s earlier cases. He considered that treatment should guide the growth of the foot, and by manipulation with one or two tenotomies it was possible to make any congenital club-foot into a perfect foot in two or three years. Mr. A. H. TUBBY (London) did not consider Dr. Phelps’s operation a good surgical procedure. The scar filling the gap on the inner side of the foot must contract and cause a return of the deformity which would then be irremediable The results of the mechanical treatment were, in his opinion, better than those obtained by any other method. Mr. NOBLE SMITH (London) thought that if all cases. which could be treated by manipulation and tenotomy were excluded none would be left for the more severe operations. He considered that Dr. Phelps’s operation would leave a very inelastic foot. Mr. CHISHOLM WILLIAMS (London) had never seen a case
form of the rigid splint was of most service: outside leg-iron, in knock-knee an outside splint or iron, and in lateral curvature a posterior support with lateral plates. At some children’s hospitals it was still recommended that for these deformities the patients should be taken " off their feet"for a year or more. Save for rare complications this was not necessary. All these conditions could be treated successfully on the ambulant plan and thus no interference with the course of education was involved. There was room for much improvement in this department, an improvement that, in Mr. Clarke’s opinion, could only be brought about by arranging for a more systematic scheme cf£ teaching orthopædic surgery in the medical schools.
instruments in flat-foot
THE
BRITISH MEDICAL ASSOCIATION. MEETING AT IPSWICH.
THE SECTIONS. SURGERY.
THURSDAY, AUGUST 2ND. Lateral Curvature, Knock-knce, and Flat-foot. IN the absence of Mr. ARBUTHNOT LANE (London) this discussion was opened by Mr. JACKSON CLARKE (London). After defining the meaning of the terms the scope within which the discussion should be limited was then suggested. It was only when these three deformities were considered as habitual pressure deformities that they could profitably be compared. Thus cases of lateral curvature due to paralysis and instances of knockor consecutive to empyema, &c., knee or of flat-foot due to severe arthritis, need not be considered save for purposes of comparison. By a habitual pressure deformity was meant a deviation from the normal form caused by the force of gravity acting on the ligaments and bones owing to the preponderating use of one to the exclusion of other attitudes. In certain circumstances a habitzial posture was gradually converted into a deformity. As applied to the subjects under discussion Mr. Clarke observed that the majority of cases of lateral curvature arose from faultv attitudes assumed by school-children when sitting at a desk, especially during writing. Knock-knee and flat-foot arose in what Annandale had termed the "attitude of rest," as seen, for instance, in the apprentice who stood with the feet everted and somewhat widely separated. The main point for discussion might be formulated thus: "To what extent do pathological processes enter into the causation of pressure deformities ?The danger in giving names was that they might be misinterpreted. The term "pressure deformity" originated in Germany with Roser and Volkmann and Mr. Clarke thought it was as good a one as could be found ; at the same time he strongly believed that in the vast majority of cases of these deformities there was something more than the force of gravity and a habitual attitude at work. There was, he believed, a pathological predisposing cause to be found in nearly every case at the time of the development of the deformity. Healthy children did not long remain in any one posture. According to Danish
observers about 1½ per cent. of school-children became affected with lateral curvature. According to German observers about 90 per cent. of school children assumed abnormal spinal postures during writing. Why did not more than a fraction of those who assumed faulty attitudes become deformed ? Mr. Clarke had no hesitation in expressing his belief that it was only those who suffered from some abnormal softness of ligament and bone who became affected by these pressure deformities. Slight rickets and an inherited tendency to rheumatoid arthritis were the two chief causes of this diminished resisting-power of the skeleton and ligaments. These same two affections were, he believed, the chief causes of naso-pharyngeal adenoid vegetations which played no small part in the production of deformities of the chest. If this contention were correct the physician could do much towards the prevention of pressure deformities by insisting on a rational diet for children. If all schoolchildren could have an abundance of fresh-i.e., unboiled and unsterilised-milk cases of deformity of this class would be diminished and, he believed, almost abolished. Failing a safe milk-supply raw eggs or raw meat might be substituted. In comparison with this broad prophylactic or medical aspect of the matter the strictly surgical aspect was unimportant ; to the individual patients, however, proper surgical treatment was of the highest moment. Mr. Clarke then reviewed muscular training, instrumental, and operative treatment. Seeing that the majority of the patients who came for treatment during the course of development of the deformity required supervision on an average for a period of two years he found that routine courses of special gymnastic treatment of two or three months’ duration were less effectual than simple exercises devised for each patient and practised at home under the supervision of the patient’s medical adviser. Of
605
some
an
FRIDAY, AUGUST 3RD. of Roentgen Rays in Surgery.
The Use
I
Mr. J. MACKENZIE DAVIDSON (London) gave an account of the recent progress in this direction. He showed that a single skiagram was often very misleading, as the relative position of parts might be completely misrepresented. He now took two photographs with the Crookes’s tube in different positions, about two and a half inches apart. These two pictures differed slightly from one another and they were combined by a Wheatstone’s stereoscope so that. one mental image was obtained in which the relative depths of objects could be distinguished. He had also been able to adapt the stereoscopic method to the fluorescent screen by employing two Crookes’s tubes, which were alternately eclipsed, and the eyes of the observer were correspondingly shut out from a view of the screen. (A demonstration of this important step in stereoscopic radiography was afterwards given by Mr. Davidson.) The Opeo Incision for Clitb-foot, its Indications and Abuses. Dr. A. M. PHELPS (New York) read a paper on this subject. In 1878 Dr. Phelps performed his first operation by open incision on a relapsed club-foot and since that date he had operated on 1650 cases. In the last 700 cases he had not performed a single osteotomy and the mortality of the whole 1650 had been nil. Up to the age of four months it was unnecessary to do more than attempt to straighten the foot by the employment of the surgeon’s hands and the use of adhesive strapping, but if the fourth month had passed and the foot refused to straighten then the surgeon should perform subcutaneous tenotomy, dividing first those tendons which were most tense. The tendo Achillis generally first needed division. It was only after tenotomy had failed that any open operation should be considered. The soft parts. were really responsible for all forms of congenital talipes and the complete division of any restricting band would nearly always suffice for the straightening of the foot. The incision was made on the inner side of the foot from just in front of the internal malleolus to the neck of the astragalus. The foot was then wrenched into an over-corrected position and fixed in that position. The most important structure to divide was the anterior limb of the deltoid ligament. In. most cases the wound filled up with blood-clot which organised. If, however, as occasionally happened, it were found impossible to get the foot straight an osteotomy might be done, the simplest being division of the neck of theastragalus, or, if that were not sufficient, a wedge-shaped piece of the os calcis might be removed. Very rarely indeed it might be necessary to amputate and then Pirogoff’s opera-tion should be performed. The results of the open incision could not be surpassed by any other method of treatment and much time was saved. Mr. JACKSON CLARKE (London) said that he would much like to see the present condition of Dr. Phelps’s earlier cases. He considered that treatment should guide the growth of the foot, and by manipulation with one or two tenotomies it was possible to make any congenital club-foot into a perfect foot in two or three years. Mr. A. H. TUBBY (London) did not consider Dr. Phelps’s operation a good surgical procedure. The scar filling the gap on the inner side of the foot must contract and cause a return of the deformity which would then be irremediable The results of the mechanical treatment were, in his opinion, better than those obtained by any other method. Mr. NOBLE SMITH (London) thought that if all cases. which could be treated by manipulation and tenotomy were excluded none would be left for the more severe operations. He considered that Dr. Phelps’s operation would leave a very inelastic foot. Mr. CHISHOLM WILLIAMS (London) had never seen a case