RICKETS 9 midwifery, avoidance of prolonged irritations, hot foods, etc.

The hereditary factor and matrimony may well be borne in mind. 2nd Curative (in the order of importance): 1. Early surgery. 2. Radium. 3. Electro-coagulation. 4. Serums. Early surgery is possible only if people are educated to pay due regard to early suggestive symptoms and potential lesions. Cancer is curable in SO per cent of cases when surgery is done while the disease is still local. It is 100 per cent incurable where it has developed far enough that the diagniosis can be definitely made without thorough examination; though surgery and other measures may be employed to prolonig life. If every person with a possible cancer could be taught to seek competent advice immediately upon the appearance of suggestive-or even suspicioussymptoms or lesions, nearly all could be cured. This is especially true of the outside cancers. An increasing number of cases are being cured by electro-coagulation, X-ray and radium; but it must be understood that these are largely adjuncts. Our chief hope at present lies in eradicating the disease while it is still localized. Rickets THE SURGICAL TREATMENT OF THE CHRONIC DEFORMITIES OF, WITH EMPHASIS ON BOW-LEGS AND KNOCK-KNEES* BY ROSCOE C. GILES, M.D., Chicago, I11. We must not lose sight of the fact, in presenting a paper on the surgical treatment of rickets, that rickets is and will always remain primarily a disease best treated by medical therapy. While there are miany problems which remain to be solved witb regard to its etiology and its pathogenesis, preventive medicine has made rapid strides in the alleviation of the morbidity and mortality of this disease, to say nothing of the prevention of deformities which offend the aesthetic sense and interfere with locomotor efficiency. Our object is to present for your consideration, and to stimuate interest in, a method of treatment available in correcting a great group of deformities in civil life which are unsightly and incapacitating. especially at a time when we hear so much of reconstruction surgery.

In reviewing the literature of this subject, one is struck by its meagerness and secondly by the fact that many of the operative procedures are old and to date have not been improved upon. We ai-e indebted to the English for most of our knowledge of the surgical treatment of rickets, possibly because of the prevalence of this disease in England. So prevalent was rickets in England that W. Goebel made it a subject of a remarkable treatise. in which he dubbed rickets "Die Englishe Krankheit," a synonym which has persisted to this clay. In the pre-antiseptic and pre-aseptic age, for many years it was customary to treat the deformities of rickets solely by mechanical appliances of *Read before the Louisville meeting of the National Medical Association, August, 1921. various sorts. A few surgeons on the Continent, bolder than their fellows, had attempted open operationi usually with disastrous results because of infection. With the advent of Lord Lister and his teachings, interest in surgical interference was revived. It was at this time that a group of English surgeons took recourse in operative treatment with a large measure of success. Dr. William John Little of London, in 1842, wrote a book of principles for surgical treatment, many of which hold good to this day. MacEwen of Glasgow, a contemporary, described his classical technique for supracondylar osteotomy, a technique which as yet has not been improved upon and one which has remained the standard. StatisticS-Of 42,124 cases tabulated by Taylor of the Hospital for the Ruptured and Crippled of New York, 15 per cent of the cases tabulated were rickets or the deformities of rickets, and these cases constituted one fifth of the total number of orthopedic cases. One half of these cases were for bow-legs or out-knees, one fourth were knock-knees or in-knees and the rest were anterior tibial curves, rachitic spines, pigeon breasts, etc. Taylor states that the cases were largely among the Italians, Negroes, Russians and Polish Jews, possibly because of unhygienic surroundings, improper feeding and especially prolonged lactation even in the latest stages of pregnancy. Before discussing any of the operations in detail,

it is necessary for us to consider some general principles. (1) The deformities of rickets usually reach their peak during the second and third years, the active period of rickets, and become fixed (luring the succeeding stage of bone hardening or10 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION Vol. 14, No. 1 eburnation. (2) There is a natural tendency for some of the deformities to correct themselves in varying degrees, for instance, this tendency is greater in bow-legs than in knock-knees. We have all seen cases of anterior curvature of the tibiae which nature has handled very kindly and with a remarkable degree of success. (3) It is imperative that the cases for operation be carefully selected and that the surgeon take in consideration not only the character, location and degree of deformity together with the age of the patient, but the amount of ossification of the bones involved as revealed by the careful roentgenological examination. It is in the group of cases where nature and non-operative orthopedic treatment have failed that surgery offers the greatest hope. These individuals otherwise would in childhood be forced to be objects of ridicule of their playmates, and in adult life be deprived from activity in many pursuits because of unsightliness or interference with efficiency. The surgical treatment of the deformities of rickets as applied to the long bones, consists in non-operative and operative methods. Non-operative methods consist of surgical appliances of various sorts such as shoes, braces, splints and plaster of Paris encasements. The operative methods for restoring a deformed bone to a normal line of growth by means of intercepting the continuity of the bone and replacing the fragments so as to insure subsequent growth along normal lines are: 1. Osteoclasis; which may be either manual or instrumental; a method by whch the none is fractured without making an openi wound. 2. Osteotomoclasis; by which the bone is partially broken through an open wound and the open wound allowed to heal and the weak bone subsequently fractured and put up in a fixed dressing until a firm union in the new position has occurred. 3. Osteotomy; eitlher simple linear, multiple linear and cuneiform or wedge-shaped, a method by which a compound fracture is produced by means of an osteotome.

4. O8teocampsis; (Wallace Blanchard )-The bending of the bone in young children without complete fracture. In the early stage of rachitic deformities, the persistent use of full length rigid apparatus of iron or plaster will usually correct the deformity. G. Magnus (Therap. Halbmonatsh., 34: 4, Jan. 1st, 1920) has gone one step further in treatment by this method. He utilizes the tendency of an immobolized bone to atrophy and soften in his method of treatment of rachitic deformity. He accomplished this by putting the deformed leg in a plaster of Paris encasement, without an attempt at correction. The child is kept in bed from five to six weeks. When the cast is removed at the end of that time the bone, being soft and pliable, can be straightened under general anesthesia as readily as a wax candle. Another plaster of Paris encasement is then applied for a second period of six weeks, but weilght bearing is now necessary to overcome the tendency to atrophy and should be begun by the tlhird week. In thirty cases, treated by this method, the results have been highly satisfactory. Usually both legs were treated at the same time. In cases where merely the legs were deformed, the cast reached to the ischium. However, when the thigh was affected the pelvis was included in the cast. 0. Stracker (Munch. Med. Woch. 1919) uses correctioni by plaster of Paris encasement, modifying it only to the extent that he counteracts muscle atrophy by means of electrical stimulation which may be carried out through openings in the plaster of Paris dressing. O.teoclasis, by which the bone is fractured withoUt making an open wound, was first introduced by Dr. Nicholas Grattan of Cork, Ireland in 1892 and later popularized by Dr. Wallace Blanchard of Chicago. who in 1900 wrote a paper on "Rapid Osteoclasis for the Correction of Rachitic Deformities of the Legs." The operation was introduced as an attempt to avoid open operation with opportunity for subsequent suppuration. Orthopedic surgeons are agreed that in older cases the fracture of bones is the method of choice and the only method offering any certainty of

results. It cannot be too much emphasized, however, that operation should be deferred until there is X-ray and other evidence that the rachitic process is over and that the osseus structures are normial. In actual practice, the best time for osteoclasis is about the fourth or fifth year, when the bones are in condition for rapid union and still small enough to be broken by the osteoclast. All cases should be followed by plaster of Paris encasement for about five or six weeks. The instrument originally designed by Grattan is the best. It should be used without pads. It is rarely customary in most clinics in which this instrument is used to sterilize the leg because no breaking of skin occurs. Blanchard insists that the whole operation takes not over eight to ten seconds under narcosis. In bow-legs, the deformity is practically always in the bones below the knees atnd they are broken with the single pressure bar on the outside and opposite the apex of the deformity, whether this be in the upper or lower third of the leg or at some intermediate point. In knockknees, a single bar is put on the inside of the femur, usually close above the knees. Blanchard advocates osteoclasis for anterior tibial curves. The evidence he produces in his classical article on the subject. shows that cuneiform osteotomy may shorten the leg one inch whileRICKETS 11 osteoclasis lengthens it one inch. This method of operation is usually valuable up to ten or twelve years of age. It is absolutely necessary, especially in bow-legs, to bend or break the fibula so as to completely correct the deformity. This method has the advantage that it produces the fracture exactly at the point desired; it produces it ra,pidly and without injury to the soft parts. In ten years' service at the Hospital for the Ruptured and Crippled, New York City, there were only two cases of ununited fracture of the leg, and these subsequently healed. There were no cases of fracture of muscular injury and no separation of the epiphysis. Osteotomoclasis has produced excellent results in the hands of Dr. W. Barton Hopkins of Philadelplhia. Osteotomy-the open m,ethod of fracture by miieans of an osteotome, was first practicedl onl the Continenit by Diffenbach, Sartorius, and Louvier.

It reimained for Dr. MacEwe-n of Glasgow to perfect the operation nowv practiced today. I believe it is unnecessary to go into the technique. since it is presented in practically any standard text-book of surgery. In these days of aseptic sturgery, tl:e danger from infection is almost nil; the operative mortality is very low and the results obtained are unifornmly good. It cannot twe too often emphasized, lhowever, that the l)ost-op!rLative treatment is as essential as the operation, and the surgeon is as muchl responsible for the post-operative treatment as for the operation. The case which promrjntod this paper was a case of cuneiform osteotomy of both the tibiae and a supracondylar osteotomy of the femora. The results were most gratifying. The osteotomy may be simple linear, as deseribed by MacEwen, or multiple linear, or cuneiform or we(lge-shaped. The operation is practically bloodless. Occasionally, it is necessary to combine with the operation the subcutaneous tenotomy of the tendo Achilles. It is the experience of most men that multiple fractures can be made at one sitting and( that the subjects bear the operation well. In the series reported by Taylor, there were no infections and no fat emboli. Several new procedures have been put forward1 recently for the alleviation of severe curvature of the lower leg in the region of the lower third, that is for typical deformity in which the lower leg is convexly bent forward and outward. These operationis are based on the fact that the rachitic perostium is unusually firm. C. Springer (Ztschrift. F. Orthop. Chirug. 1920) excises subperiosteally the whole deformed portion of the tibia. The excised piece is then placed in a hand vise and sawed up into discs one cm. thick. The fibula is then broken and the curve straightened. The discs are then laid back in the cylinder of the periostium and held in place by means of forceps and the periostium is closed by means of a silk button suture. The epidermis is sutured and covered with silver leaf and a plaster of Paris dressing with openings for ventilations is applied. This is left on four to five weeks and after six weeks, walking with a protecting covering on the leg may be done. Since the firmness of the rachitic periostium is an essential factor in keeping the segments in place, the operation is only useful for rickets. The pieces

of bone are handled only with instruments, although rubber gloves are worn, and those instruments used in incising are not used again. T. Loeffler (Denit. Med. Woch. 46:1274, Nov. 11, 1920) considers the sawing up of the bone in discs very difficult and the replacement of all of these discs is almost impossible. He therefore breaks up the excised piece of bone in small particles and fills the cylinder of the periostium with "Knochsalat" (bone salad). After four weeks the bone is firm. I am very much indebted to Dr. U. G. Dailey of Chicago, for his very valuable assistance rendered at the time of operation of the case which prompted this review of the literature, and also for the use of his electrical saw. BIBLIOGRAI'HY Osteotomy for rachitic forward curve of femur; Boeckh; Munch. Med. Woch., 67:1095, Sept. 17, 1920. Goebel (W), "Die Englishe Krankheit" (Rachitis and ihre Behandlung). The treatment of rachitic deformities: Brunig; Deutsch Med. WVoch., 46:1438, Dec. 28, 1920. Rachitis and deformities: H. Spitzy, Wien. Klin. Woch., 22 :909, 1919. Blanchard (W) Rapid Osteoclasis for the correction of rachitic deformities of the legs. Tranactions Am. Orthop. Am. Phila. 1900 XIII idem 1901 XIV-453466 idem. Rachitic deformities of the lower extremities F. Trillmilch; Klin-therap. Woch. 20:421, 451, 1913. Rickets: Surgical Aspect: H. B. Robinson; Rep. Soc. Study Dis. Child., 1906-1907, 7:69-71. Osteotomy and osteoclasis in rachitic deformities of the lower extremities; T. Kolliker, Arch. f. kliin. Chir., 1903, 49 :48-51. Taylor, H. L. The Surgery of Rickets; Jour. Am. Assoc. Chicago, 1902. XXXIX. A plhysician who has prescribed Tongaline for -ain-y years sums uip his experience with the prepr-ation in the following statements: 'For all indefinite aches and pains Tongaline is rarely given without the most beneficial results." "Tongaline is always efficient for the relief of paiin resulting from excess of uric acid." "Tongaline promptly rids the system of any and all sorts of poison, making it an ideal eliminant."