1311THE CHARCOT CENTENARY.

4) the reservoir of the virus, or big game. " I do not

hope for much," he said, " from the labour of theInternational Conference. Such a conference seemsto me to be premature. I cannot believe that itssnorts are likely to advance knowledge, and wehardly know enough at the present time to formulateregulations governing the international frontiers intropical Africa. In my judgment much more is tobe hoped from an inter-colonial conference and fromthe coordinated and sustained effort which it wouldbe in the power of such a conference to ensure."The main difficulty, as he pointed out, which at presentbars the way of progress in the investigation of theravages of the tsetse-fly, is that energy is oftenmisdirected ; first, in that reports from isolated investi-gators frequently omit some essential information andthus do not permit of any inferences being drawn ;and secondly, in that work, admirably conceivedand executed, is often brought to naught by the factthat those who are conducting it go on leave withoutarrangements being made to carry it on. Further,it is sometimes difficult to realise the natural diffi-culties in the shape of marauding big game with whichlonely investigators, inadequately supported by fundsand personnel, have to contend, and Prof. Yorke isemphatic that the only hope of success is by substitut-ing for isolated workers, whether entomologists orpathologists, large and well-equipped commissionshaving real funds at their command. He againurges, as he did five years ago at the first Entomo-logical Conference, that entomological, medical, andveterinary research into the trypanosomiasis problemshould be combined under one central organisation,supported by pooled contributions from all theAfrican colonies interested, with adequate precautionto ensure continuity of work. Only by concentratingenergies can experimental work be undertaken on ascale large enough to determine the relationship of i

fly and trypanosomiasis to game, and to solve thevarious problems enumerated in the report of theGlossina Sub-committee of the Imperial Bureau ofEntomology. Prof. Yorke’s stimulating criticism will,no doubt, receive respectful attention.

THE CHARCOT CENTENARY.A SOCIAL evening of the Royal Society of Medicine I

was held on June 15th at 1, Wimpole-street,in celebration of the centenary of the birth ofJean Martin Charcot. Sir StClair Thomson, thePresident, in his prefatory remarks extended anespecial welcome to several colonial and foreignguests who were present, and read a letter of appre-ciation to the Society from the Académie de Medecineof France. Dr. Farquhar Buzzard, President of theSection of Neurology, then gave a paper on the greatFrench neurologist. After briefly indicating themilestones in Charcot’s life, Dr. Buzzard said anyspectator of the recent centenary celebrations heldin Paris could hardly fail to wonder what manner ofman this Charcot was, who still held, 32 years afterhis death, the esteem, the gratitude, and the affectionnot only of his professional pupils and successors,but of his countrymen at large. At a reception inthe amphitheatre of La Sorbonne, at which thePresident of the French Republic was present, theproceedings were enthusiastically followed by anaudience of between two and three thousand people,the majority of whom were not medical. From allcorners of the earth pilgrims had come to listen andto add to the eulogy of the great neurologist. Itwas, he said, perhaps the most wonderful tributeever paid to any medical man-not as a scientist,not as the author of some epoch-making discoveryconferring lasting benefits on humanity, just a

physician whose work and personality had made animperishable impress on the science and art to whichhe had devoted his talents and his life. And, headded, it would be difficult to visualise our publicand our Government joining so whole-heartedly incommemorating the birth of even a Jenner or a

Lister ; it might be doubted whether any medical

man had ever been to any country what Charcothad been-and still was--to France. He continued :" Here was a man who, having been appointed quiteearly in his career chief physician to a large infirmary,the Salpetriere, spent his life and energies in theservice of the institution with the result that frombeing a building of merely historic and charitableinterest it became the foremost school of neurologyin the world. And yet Charcot has no great dis-covery to his name. The enormous amount ofmaterial which lay ready to his hand and whichillustrated every form of advanced disease he studiednot only in minutest detail, but with the artist’sflair for accurate observation, for picking out essen-tials, and for giving them their due perspective. Inan era devotedchiefly to thecollection ofpathologicalspecimens andclinical observa-tions he was

second to noneof his contem- JJporaries as acollector, and he iexcelled all inhis marvellous ’dgift for marshal-ling the resultsof his labour andfor giving themgraphic presen-tation whetherby pen or byft or uy The Centenary Medallion.word of mouth.

Reverse: Centenaire de la Naissance deIt is not mere J. M. Charcot, 1825-1925.patriotism whichmakes us hesitate to place him beside HughlingsJackson as a deductive philosopher, but we can boastof no physician who, in addition to makng countlesscontributions to scientific knowledge, can comparewith Charcot in his ability to attract students fromall over the world by means of his inspired gift forexposition." To give orientation to Charcot’s lifeand work it must be remembered that he was about20 years younger than Duchenne, of Boulogne, whomight rightly be regarded as the founder of Frenchneurology. Duchenne and Charcot were to Frenchneurology what Laennec and Trousseau were toFrench medicine as a whole. It might almost besaid that Duchenne and Charcot discovered andentered a new field in which a rich harvest lay readyfor the gathering. Dr. Buzzard then gave manyintimate and vivid glimpses of Charcot at home andin hospital, and showed on the epidiascope several-interesting portraits, including the centenary medal-lion, after the design of Mons. F. Vernon, the authorof the Osler plaque. He also showed examples ofCharcot’s skill as a draughtsman and as a caricaturist.A vote of thanks to the lecturer was moved by

Sir David Ferrier, who had himself been a pupil ofCharcot over fifty years ago in the Salpetricre. Hereferred to his master as one who had made an oldpoor-house ward into the most visited and mostfamous clinic in the world. A feature of the eveningwas the display, in the library, of books, documents,and drawings relating to Charcot and his work whichhad been prepared by Mr. Walter G. Spencer, thelibrarian. To his labours Dr. Buzzard paid a

special tribute, and expressed the hope that thevaluable collection which had been assembled mightreach a wider public in some permanent form.

Sir James Berry was among those admitted tothe honorary membership of the Inter-State Post-Graduate Assembly of America on June 4th.

ARRANGEMENTS for the International Congress ofRadiology, to be held in London on July lst to 4th,are now complete. Details of the advance programmewill be referred to in our next issue.

1312 THE TREATMENT OF HAMMER-TOE.

Modern Technique in Treatment.A Series of Special Articles, contributed by

invitation, on the Treatment of Medicaland Surgical Conditions.

CXXVII.—THE TREATMENT OF HAMMER-TOE. IPART II.—OPERATIVE MEASURES.

ONE difficulty in these small operations is that ofaccess. The operation must be done delicately, and adressing applied which maintains complete correctionwithout being cumbersome. To fix the deformed toe,and to hold the toes on either side out of the way, astout fishing gut suture is passed through the pulpyend of each of the three toes. The ends of eachsuture are gathered up in three separate artery forceps,and the toes held rigidly and firmly out of the wayof each other by the assistant. At the end of theoperation, when the dressing has been applied-thetoe-tip being left uncovered ,in order to watch thecirculation subsequently-the retention sutures are

removed. To assist precision and delicacy a rubberbandage should be used as a tourniquet, appliedimmediately above the ankle after the foot has beenexsanguinated by a similar bandage, and is not removeduntil the dressing is dry and set. The best dressing issterile ribbon gauze of the same width as the lengthof the toe, applied directly to the wound (which is sewnup with two or three fine interrupted fishing-gutsutures), and wound around the toe moderately firmlyand closely (but without risk of strangulation), withthick collodion applied as the layers are increased.About a dozen or so layers are requisite, and theretention sutures hold the toes corrected for a fewminutes while the collodion dries. The " splint " isrigid, and the circulation is noted to be satisfactory inthe uncovered toe-tip before the patient leaves thetheatre.The dressing does not shrink subsequently. It is

maintained for two weeks, and then cut off with strongscissors, and the skin sutures removed. A similardressing is applied, and renewed again in anotherfortnight, taking six weeks in all. The patient canwalk a week or two after the operation in this dressing,which is so rigid and small that the walking is harmlessand comfortable. Another advantage of the sealeddressing is the avoidance of the thickening of the jointwhich is liable to persist for many weeks if an ordinarygauze dressing be used.

Excision of Head of Proximal Phalanx, withRemoval of Cartilaginous Base of Middle

Phalanx.Of the several operations that have been advised

from time to time for acquired hammer-toe excision ofthe head of the proximal phalanx, combined with theremoval of the cartilaginous base of the middlephalanx, is to be preferred. No flexor tenotomy ordivision of the flexor capsule is done, and only just asmuch of the head of the proximal phalanx is removedas will enable the toe to be made quite straight onstrong passive stretching into extension. There shouldbe no tension tending to reproduce flexion when theoperation is finished. An ankylosis (arthrodesis) ofthe proximal joint is desired. If the base of themiddle phalanx is left untouched, fibrous rather thanbony ankylosis is likely to result, with some riskof recurrence of the flexion deformity. The dorsalincision is elliptical, of about three-fifths the width ofthe toe, and the redundant skin with the dorsal corn isremoved. There is no need to damage the lateraldigital arteries. If the deformity be severe, the dorsalexpansion of the extensor tendon should be removedwith the elliptical piece of skin ; if not, it may bepreferable merely to incise the tendon longitudinally,to give access to the head of the bone. But theexcision is more difficult to do delicately in this case.The head of the bone is best removed by fine-pointedbone-cutting forceps, and the neck of the bone neednot be fragmented. :1 fine chisel or stout, small knife

is used to denude the base of the second phalanx ofits cartilage. The skin suturing helps to maintainsubsequent correction.

In operating on the congenital type, the proximal orterminal joints are similarly corrected, according tothe site of greater flexion. It is never necessary tocorrect both joints. To correct the adduction androtation of the terminal (one or two) phalanges, theelliptical excision of the skin will be placed somewhatto the outer side of the joint, at the site of themaximum bend. The dorsal expansion of the tendonis removed. In these tiny toes the joint excision isbest done with a small, stout scalpel. The skin woundcan be sutured in such a way as to assist in correctingflexion, adduction, and rotation. Two or three toescan be operated upon at the same time.

Alternative Operations.The alternative operations may be mentioned.

Amputation of the whole second toe in the acquiredvariety is not usually desirable unless its terminal nailportion is grossly deformed, or the toes on eitherside so rigid in their position that there will be nolonger room for the corrected toe in its proper place, orunless, as in neglected cases, lateral corns exist. Theobjection to total amputation is that the frequentlyassociated hallux valgus is liable to increase subse-quently, from pressure of the stocking and want of thepreventive effect of the second toe. Amputation ofthe terminal phalanx alone would in most cases leavean awkwardly dorsiflexed proximal stump. In somecases, however, where the hammer deformity is notgiving trouble from pressure on a dorsal corn, butwhere the nail is thick and distorted, with painfulterminal corn, the terminal phalanx can be amputatedat the end joint, with removal of the bone and nailbed, by the palmar flap method.

Total removal of the proximal phalanx has beenadvocated, leaving a short, stumpy toe which wouldserve to prevent the hallux valgus from increasing, butwith no other function. The writer has no experienceof this method, nor does it appeal to him. In mildercases of acquired deformity, subcutaneous division ofthe flexor tendons and capsule may be done, followedby passive correction and splintage as after the openoperation, but there is some risk of relapse. Flexortendons do not unite after tenotomy, and thus theonly important function of the toes, flexion, is perma-nently lost, which is not the case after excision by thedorsal method.

In any operative method extension contracture ofthe metatarso-phalangeal joint must also be overcomeby subcutaneous division of the extensor tendons,otherwise relapse into flexion at the distally correctedjoint is fostered. After the tenotomy the toe is forcedinto flexion at the metatarso-phalangeal joint, andretained thus in the dressing while the joints of the toeare kept fully extended.

Correction of " Clawed Toes.In the correction of " clawed toes-i.e., those

associated with pes cavus and boot-caused deformities-attention is directed chiefly to the extension of themetatarso-phalangeal joints rather than to the flexionof the distal joints. In pes cavus the toes are dealtwith after the arch has been flattened sufficiently bythe Steindler operation. The various procedures forcorrecting the toes are : (1) Division of dorsal extensortendons and capsules, and tethering the toes down to aslotted and looped sole-plate for four to six weeks,by night and day, followed by active and passiveexercises and electrical stimulation of the intrinsicmuscles. This is the older method, and is liable toresult in relapse after some months. (2) Transplantingthe dorsal extensor tendons into the necks of one ormore metatarsals or into the dorsum of the foot.There are several modifications of this method.(3) Transplantation of the long flexor tendons from theterminal to the proximal phalanges, a method firstadvocated by the writer. The hyper-extension at themetatarso-phalangeal joints is corrected by one orother of these methods, while the flexion of the toe-