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JOINT MEETING OF ORTHOPEDIC ASSOCIATIONS

A JOINT meeting of the orthopaedic associations of theEnglish-speaking world was held in London from June 30to July 4. This congress was opened by H.M. QueenELIZABETH the Queen Mother, who presented jewels ofoffice, the gift of the British Orthopaedic Association,to the presidents of the visiting associations from theUnited States, Canada, Australia, New Zealand, andSouth Africa. During the week there were demonstrationsat London hospitals and many social events ; and at theclose visitors dispersed to visit provincial orthopaediccentres.

At the congress dinner on July 3, attended by some 800people, Sir HARRY PLATT, speaking of The Guests, welcomedparticularly the representatives of the Brazilian, Dutch,Swedish, Portuguese, and other orthopaedic associations,which if not English-speaking were English-reading andEnglish-writing. Mr. IAIN MACLEOD, the Minister of Health,who responded, said that the link between so many participantsof different country, politics, colour, and religion was thatthey really cared that there are sick and broken people.Dr. FREMONT CHANDLER, in proposing the toast of Ortho-paedic Surgery, spoke of the practical usefulness of theconference, and Sir REGINALD WATSON-JONES, the chairman,described it as a great event in the history of orthopaedics.He hoped, incidentally, that on their visits to other partsof England, and to Scotland, Ireland, and Wales, the guestsfrom abroad would take the opportunity of seeing to whatextent the medical profession has become regimented.

" Wemay not think much of our head gardeners," he remarked," but at least they have not pulled up the unofficial Englishrose and planted rows of tulips." The conference had,he believed, shown that what holds together the Common-

wealth and the United States is the pursuit of truth withno political bias.The final toast, The English Language, was proposed by

the MARQUESS OF READING, who quoted Bismarck’s sayingthat the most important thing in the world is that the peopleof America speak English. Today Bismarck might say thatthe most important thing is that the English peoples speakAmerican ; but, after all, language was a living growth, andeven the well of English undefiled might be the purer for afew tablets of American chlorine. We might be a poorcountry but we had a rich language : indeed, he regardedthe 13 volumes of the Oxford Dictionary as a sort of linguisticFort Knox in which is stored away-unseen, unused-the wealth of the English-speaking world. Basic, or debased,English might help the foreigner ; but English withouteffort would never do for Englishmen. We had a languagerich and subtle, resonant and strong : let us not condemnit to anemia. Lord Justice BIRKETT, responding, said thatEnglish, with its flexibility and its words from every languageunder the sun, can deal with every situation. He agreedthat it should not be afraid of importations, and he acknow.ledged our debt to America for such expressive inventionsas sobstuff, sky pilot, highbrow, tenderfoot, and loungelizard. But with the vitality of living speech we must seekalso lucidity and grace-the one to make our thoughts plain,the other to make them memorable. Illustrating fromShakespeare what C. E. Montague called the " glamorousprestige of words in high company," he described it as ourduty to welcome every importation that will live by itsvitality, but also to regard ourselves as trustees. The Englishtongue was one of the bonds between the nations that use it;and in such bonds, he felt, lies the chief hope of the world.Some of the papers read at the congress are sum-

marised below.

Traumatic Dislocation of the HipMr. E. A. NICOLL (Mansfield) said that in 144 cases of

traumatic dislocation of the hip the incidence of asepticnecrosis of the femoral head was 10%. If the incidencereported from other sources varied, this was becausenecrosis was often confused with traumatic arthritis.The two conditions were very different. Necrosis was avicious process ; radiographic evidence, always presentwithin two years of injury, preceded clinical features.Traumatic arthritis was a common, relatively benigncomplication of later development and slower course.Necrosis was commoner in children than in adults becausethere was absolutely no anastomosis across the epiphysealcartilage-plate to make up for the interference with theblood-supply to the femoral head caused by retinaculardamage. It might therefore be reasonable to carry outprophylactic drilling of the cartilage-plate after disloca-tion in childhood, but if so there was no point in blockingthe new channels with bone grafts. Half the cases ofnecrosis were associated with delayed reduction or

repeated attempts at reduction, so early recognition andgentle management were obviously essential. Prematureweight-bearing was also dangerous ; 20% of patientsallowed to take weight within a month of injury developednecrosis, whereas the incidence was only 71/2% whenwalking was delayed. But even prolonged abstentionfrom weight-bearing would not facilitate reconstructionof a normal head, once necrosis was established, bycreeping substitution ; the revivification process wastoo slow to prevent cartilage degeneration and massivecollapse. The over-all incidence of necrosis was not highenough to justify routine prohibition of weight-bearingfor more than eight weeks ; but every case must beexamined radiographically every three months for twoyears. If radiographic evidence were seen managementwas a difficult problem, for disability might be trivialdespite the most alarming appearances. Of 15 cases ofnecrosis only 6 required operation (2 arthrodeses and 4displacement osteotomies) ; the remaining patients hadtrivial symptoms and were all working.

Dr. MARCUS J. STEWART (Memphis), from an experienceof 128 cases of dislocation and fracture-dislocation of thehip, did not believe that age, method of fixation, or timeof weight-bearing had any influence on the outcome.The important factors were the severity of the initialtrauma and delay in reduction. Because the urgency ofreduction in determining the quality of the result wasto be reckoned in hours, dislocation was more of an

emergency than many a compound fracture or abdominalcondition. But, quite apart from vascular disturbance,an important cause of necrosis was the molecular changein structure of the head produced by the impact ; thefact that the time of onset of necrosis was exactly thesame-17 months-whether open or closed methods ofreduction were employed suggested that the die was castfor or against necrosis at the time of injury. When therewas coincident sciatic nerve injury and the radiographshowed large separated bone fragments exploration shouldbe done ; for the nerve might be transfixed.

In the discussion of these two papers Dr. PAUL B.MAGNUSON (Washington) confirmed that minimal clinicalfeatures might accompany severe radiographic changesof necrosis ; the plane of flexion-extension at the hiphabitually used by the patient could be smooth andpainless, though the surgeon was able to demonstratethat other ranges were blocked and painful. Revascu-larisation of a dead head could be accelerated by partialresection of the subjacent neck, bringing up the shaftand transplanting the great trochanter downwards.

Mr. JAMES PATRICK (Lanarkshire) thought a cleardistinction between necrosis and arthritis was not made

sufficiently often. The stigma of necrosis was collapseof the head, and this might occur abruptly after monthsof apparent radiographic normality.

Dr. J. M. EDELSTEIN (Johannesburg) agreed that theinitial damage to the head was often concealed andtherefore an unfavourable prognosis could sometimes bemade, but never a favourable one. The only conceivableshort cut to good function in severe established necrosismight be the use of a prosthesis for the femoral head.

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Mr. K. H. PRIDIE (Bristol) admitted no essentialdistinction between necrosis and arthritis. Massivenecrosis was recognisable as such ; but minor focalnecrosis invisible in the radiograph could initiate spread-ing reactive changes and degeneration of the overlyingcartilage which was in fact post-traumatic arthritis.

The Arthritic HipDr. FRANK ST]INC]a]FIFI.D (New York) opened a dis-

cussion on the indications for the various operations forosteo-arthritis of the hip. Sound arthrodesis was

painless and satisfactory ; and he aimed to obtain it bycombining joint erasion, metallic internal fixation, andan ilio-trochanteric bone graft ; some 20% of cases

developed pseudarthrosis, but half of these were satis-factorily fused at a second operation. Arthrodesis was

preferable in young patients, in manual labourers, inunilateral disease, in old septic hips, and when patientswere uncooperative. Cup arthroplasty had not givendependably good results ; some limp was universal,and the range of movement tended to diminish after thefourth year. It was more suitable for the middle-agedsedentary person with bilateral disease who could berelied on to work almost religiously at postoperativeexercises. Coxa valga and a shallow acetabulum werealso points in favour of arthroplasty-an operation whichdid not preclude subsequent revision or arthrodesis. Old

patients did not stand cup arthroplasty well, and herethe use of the Judet prosthesis was better. This pro-cedure was easier and less shocking, with rapid reable-ment, and was valuable for aseptic necrosis ; but it hadno place with young patients and the late results wereunknown.

In discussion, Mr. ALEXANDER LAw (London) thoughtthat the high incidence of pseudarthrosis and backacheafter fusion favoured arthroplasty, which was no morelikely than arthrodesis to cause old sepsis to flare up.His impression was that the Judet operation gave a verymobile hip initially which subsequently tightened up,and he questioned the durability of the prosthesis ifused for young patients. Follow-up of a series of bilateralcases treated by insertion of a cup on one side and anacrylic head on the other would be very instructive.

Mr. JOHN CHARNLEY (Manchester) described his

technique for arthrodesis of the hip, in which a centraldislocation was produced, the femoral head entering thepelvis. The resulting bone block made rotation andlate adduction deformity impossible, so there was noneed to fix the knee postoperatively. Even a fibrous

ankylosis was sound under these circumstances, but henow made bony fusion certain by applying springcompression via a transfixing screw. All his patients hadclinical fusion at six weeks and were back at work inthree to four months-a remarkable record. The balanceof opinion against fusion was due only to the irregularityof its success in the past ; when bony ankylosis couldbe routinely produced within a few months withoutsecondary back or knee strain the indications for

arthroplasty would be fewer.Dr. ARTHUR STEINDLER (Iowa) was opposed to any

irreversible operation on the hip-joint unless the com-pelling symptom of pain had been carefully analysed asto its source. Pain of purely synovial origin could clearup if the synovial pathology were reversible, as it oftenwas.

Treatment of Tuberculous HipMr. THOMAS KING (Melbourne) described the advan-

tages of allowing adduction deformity to occur duringconservative treatment of tuberculous hips in adults,and then performing Brittain’s ischiofemoral arthrodesis.The operation was much easier with a short ischiofemoralinterval, and a stout graft (he preferred the fibula) couldbe used without fear of breakage ; he added an arthro-desis nail fixed to a plate on the outer aspect of thefemur so as to dispense with plaster fixation.

In a written comment Mr. H. A. BRITTAIN (Norwich)said that he disliked the use of metal in tuberculousjoints, could see no need for a nail and plate when theessence of his operation was osteotomy-displacementwithout fixation, found his original tibial graft moreeasily vascularised than a portion of fibula, and notedthat extreme adduction was usually associated with

enough flexion to bring the sciatic nerve dangerouslyforward into the operation field.

Dr. D. M. BOSWORTH (New York) did an arthrodesisas soon as he made the diagnosis, so there was no timefor adduction to develop ; nail fixation could carrytuberculosis into the pelvis. Late adduction was onlycompatible with ischiofemoral fusion when the head andneck had not been destroyed.

Mr. G. PARKER (Middlesbrough) had for several yearsbeen allowing adduction to occur and performingBrittain’s operation in those tuberculous hips in childrenlikely to require fusion, with excellent results. ButMr. MICHAEL WILKINSON (Black Notley) deplored anyroutine adoption of such a programme ; for, in his hands,chemotherapy combined with subtotal synovectomy inearly cases gave mobile hips with good function ; andthe opportunity to do this, once lost, was irretrievable.

Osteoid Osteoma

Mr. JOHN GOLDING (London) reviewed the charac-teristic features of osteoid osteoma. Continuous boringpain might be accompanied by local- swelling, and

operation revealed the cherry-red, highly vasculartumour lying within sclerosed bone. The tibia was thecommonest site, but obscure lesions in the spine or hipmade diagnosis difficult and radiographic evidence wasnot always available. The typical widespread regionalsclerosis was a reaction to the vascularity of the tumourof the kind often seen in relation to angiomata of bone.The disease was self-limiting after a course of severalyears; so, while easily accessible lesions should beremoved, radiotherapy should be employed for othersites rather than attempted radical extirpation.

Dr. H. H. YOUNG (Rochester, Minnesota) said thatfemoral lesions could cause sciatica simulating discprolapse. Pain was too severe to justify waiting forspontaneous regression. Dr. J. R. MOORE (Philadelphia)classified the disease into cortical, cancellous, and sub-periosteal varieties ; juxta-articular lesions could mimicacute arthritis.

Mechanism of Gait

Prof. JOHN SAUNDEBS (San Francisco) gave an accountof an investigation into the mechanics of normal gait.Human locomotion was an exceedingly complex processto analyse ; Nature’s object was the translation ofthe body through space with the least expenditure ofenergy, its centre of gravity describing a sinusoidalpathway of low amplitude with a horizontal as well as avertical excursion, and making a figure of eight in twodimensions and a spiral curve in three. The majordeterminants of normal gait could be deduced by com-paring human progression with that of a simple compassmodel. The centre of gravity of such a model passedthrough a series of high arcs with sharp deflections andextravagant energy expenditure. The body modifiedthis by means of pelvic rotation, which reduced therequired range of flexion and extension at the hip ;by pelvic tilt ; by knee flexion on the weight-bearing sidebetween the extension which began and ended the stancephase of gait ; by providing subsidiary arcs at forefoot,heel, and knee ; and, finally, in the horizontal plane, itlimited the wide sweep of the compass model by meansof normal femorotibial angulation. All these devicescombined to make the legs 21/2 times longer functionallythan they were in reality, and to limit the excursion of thecentre of gravity to the confines of a 2-in. cube.

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Dr. VERNE T. INMAN (San Francisco), collaborator inthis research, had studied the energy expended in raisingand lowering the centre of gravity during locomotion bymeans of force plates-horizontal platforms supportedon bronze pillars-the deformation of which was elec-tricaUy recorded. The resulting oscillograms were

obtainable from one or both legs and recorded bothvertical stress and lateral shear. Force-plate studiesconfirmed the sinusoidal path of the centre of gravityand demonstrated the extra expenditure of energynecessitated by pathological conditions. High heels,like fused ankles, caused little change, though accom-panied by increased knee flexion and pelvic roll ; but thefixed knee required more energy output. The below-knee amputee was relatively normal from this point ofview, but a thigh amputation required 27% greaterenergy expenditure ; such a patient in effect walked5 yards to another man’s 4, and this must be consideredin supplying an artificial limb to a cardiovascular invalidafter amputation. Energy was also expended in walkingin producing oscillation of the legs, two-thirds derivingfrom the foot and ankle and one-third from the hipmechanism ; the knee merely absorbed and dissipatedenergy, and patients with a fixed knee or long leg plasterhad a greater hip excursion than normal.

In discussion, Mr. PHILIP WILES (London) said thatsuch fundamental studies might help in assessing thevalue of a proposed operation such as arthrodesis. Dr.BECKETT HOwORTH (Connecticut) said that the higherthe heel the nearer was the functional approximationto the Symes amputation because of obliteration of anklefunction and shortening of forefoot leverage. The

quadriceps mechanism was the first to fail in leg strain.

Traumatic ParaplegiaMr. F. HOLDSWORTH (Sheffield) described his manage-

ment of traumatic paraplegia, based on experience with68 patients with lumbodorsal fracture-dislocation. Therehad been too much pessimism about prognosis in thesecases. The dictum that complete motor and sensoryloss for forty-eight hours indicated irreversible damageapplied only to the cord ; but at the common level of

injury around the lumbodorsal junction the cord con-tained only sacral segments and the lumbar elementswere present as roots, which could recover. Here anyretained power in the legs was an index, not of a sparedcord, but of root escape ; and it was vital to encourageroot recovery by reducing and fixing the spine lesion.Return of control of the hips would allow relativelynormal walking compared with the tripod gait of thecomplete paraplegic. Treatment of the fracture was alsoessential, because angulation interfered with balancewhen reablement began. Radiography was not alwayshelpful in assessing the displacement obtaining at thetime of injury, or the potential instability during nursing.Gross crush of a vertebral body with facets intact was astable lesion and no operation was indicated, even forpartial cord damage unless this was progressive. Thecommon cause of unstable fracture-dislocation withparaplegia was torsion plus flexion, which disrupted thefacets, produced a horizontal slice fracture of the lowervertebral body, and was recognisable clinically by a gapbetween the spinous processes and a local hoematoma.This lesion was so unstable that open operation andinternal fixation by two long plates screwed to the spinousprocesses was required as an emergency. It was thenpossible to turn the patient two-hourly ; plaster bedswere unnecessary, and there were no bedsores, myositisossificans, or stiff joints. In 47 patients treated from theoutset there had been not one bedsore ; and these

patients walked at six months and left hospital in tenmonths, 30 having been operated on. But not I of 21

patients admitted late was out of hospital in under twoyears, and these suffered the complications of classical

management. An indwelling catheter was far betterthan suprapubic drainage.Mr. NicoLL said that Mr. Holdsworth’s policy offered

the only hope to these patients, though the operationwas not always simple. Colonel A. W. SPITTLER(Washington) used the Stryker frame and Foster bed tofacilitate turning ; if operation were done he obtainedfusion by bone grafting.

Dr. LUDWIG GUTTMANN’S experience with 800 para-plegics at the Ministry of Pensions Hospital, StokeMandeville, had led him also to abandon the plaster bedand suprapubic drainage ; but he did not feel that earlyoperation necessarily guaranteed any recovery of func-tion. Reablement began when the patient was firstseen ; even a patient completely paraplegic from waistdown should be at work in seven to twelve months.Dr. PHILIP WILSON (New York) doubted the securityof metal-plate fixation and preferred bone grafting;but Sir REGINALD WATSON-JONES (London) acceptedHoldsworth’s thesis because fixation for nursing purposeswas required only for the few weeks before the spineacquired its own stability.

Fractures of Cervical SpineDr. WILLIAM ROGERS (Boston) described his experience

with 77 cases of cervical fracture-dislocation. Of the 15deaths, 12 were associated with cord injury and 3 weredue to pulmonary embolism. Anterior dislocation wasthe usual cause of quadriplegia, but the severity of thecord injury was not commensurate with the degree ofdisplacement. The most dangerous group were the oldpeople with stiff arthritic necks, and there were somecases of hyperextension injury ; paralysis withoutradiographic evidence of fracture-dislocation was due todisc retropulsion or to hyperextension with infolding of aligamentum flavum. Hyperflexion dislocation couldoccur with complete rupture of all ligaments and yetundergo complete spontaneous reduction. Only a

minority of cervical fracture-dislocations escaped cordinjury ; but in 10% of cases this was acquired afterinjury during transit to hospital, or actually in hospitalfrom careless handling or such manoeuvres as haltertraction or laryngoscopic intubation. When cord damagecame on immediately, death was inevitable. For the

emergency nothing was better than the simple turnbuckledistraction brace, based on shoulders, neck, and occiput;later, skull traction produced complete reduction inmost cases without any hazard to the cord. Most of thefailures with skull traction were in cases of posteriordisplacement and unilateral rotary dislocation.

Mr. V. H. ELLIS (London) agreed that patients whohad succeeded in breaking their necks without corddamage ran a grave risk of acquiring the latter duringtreatment. Once skull traction was in place the patientwas safe ; and because the spine remained unstable hewired the spinous processes and performed bone graftingat the same time. Dr. T. C. THOMPSON (New York)applied skull traction by means of malar fish-hooks, andsuch traction could be weighted unequally to correctlateral shift.

Adrenocortical Function

Dr. PHILIP WILSON (New York) described a study ofadrenocortical response in orthopaedic patients, as shownby eosinophil-counts. Adrenocortical function mustaffect the outcome of many procedures, and good resultswere often attributed to technique which were really theoutcome of the non-specific stimulus to the pituitary-adrenal axis. Stress eosinopenia was common in patientsadmitted with injuries, infections, and acute low-backstrain ; it was also seen with bone tumours. It was not

seen in patients admitted for elective surgery. Post-

operatively, there was immediate profound eosinopenia(which did not occur during the anaesthesia) followed by arebound, sometimes above normal, on the second to

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fourth day ; failure of this response indicated a dangerouslack of adrenocortical reserve. Protracted eosinopeniawas associated with complications in recovery and wasof some prognostic value.

Prof. J. TRUETA (Oxford) welcomed this work as acorrective to the mechanical-mindedness of orthopaedists ;but eosinophil-counts were so variable that care wasneeded in their interpretation. Dr. BEVERLY RANEY

{North Carolina) wondered if the mechanism of eosino-penia was always the same, for there was some evidencethat it could occur in adrenalectomised animals.

Changes in Lumbosacral RegionDr. IAN MACNAB (Toronto) gave an account of an

investigation into the structural changes seen in a

large number of lumbar spines post mortem. The inter-vertebral discs were maximally developed by the endof the second decade and thereafter aged and degeneratedby inspissation and transformation of the groundsubstance into formed elements. The rate of senescencevaried, and degeneration differed from normal ageingonly in its prematurity and its possible association withtrauma. The changes included radial posterior or

posterolateral annulus tears ; nuclear extrusion ; multiplehaemorrhages giving a brown siderotic disc ; or a massive

single haemorrhage into the nucleus. The entire disc

might become soft and putty-like and extruded beyondthe rim of the vertebral bodies by body-weight. Discdegeneration made segmental intervertebral movementlose its smoothness, and the axis of flexion-extensionpassed backwards to the small articulations, whichsuffered considerably, tending to subluxate in flexionand with an overriding of the facets which might allow

, the inferior articular process of one vertebra to wear ahole in the lamina below. Such overriding could alsobe associated with reversed spondylolisthesis of the

upper centrum and with nerve-root pressure. The

capsules of these small joints became fibrosed, chondrified,or ossified, and loose bodies in the joint cavities couldlock the back in acute lumbago. The radiographicsigns of late disc degeneration were obvious ; at anearlier stage it was necessary to demonstrate abnormalmobility of the upper vertebral body in flexion andextension films. Disc degeneration was not necessarilyaccompanied by disc prolapse, though prolapse wasalways an incident in a degenerate disc. Degeneration wasuniversal and gave rise to radiographic signs ; prolapsewas an accident in a few individuals and might have noradiographic features.Mr. E. F. WEST (Adelaide) discussed the origin and

treatment of spondylolisthesis. Trauma seemed a more

likely cause than congenital ossification defects ; and

progressive displacement was probably rare becauselimited by ossification in the anterior bulge of theassociated disc.

Discussing these two papers, Dr. J. A. FREIBERG(Cincinnati) advised excision of thickened zygapophysealjoint-capsules at operation for sciatica, for they mightbe the sole cause of root pressure. It was difficult toreconcile the bulging disc of senile vertebral osteoporosiswith the progressive inelasticity of disc degeneration.Mr. A. L. EYRE-BROOK (Bristol) doubted the practicalvalue of the numerous radiographic abnormalitiesof the lumbosacral region ; clinical evidence should bethe basis for operation for sciatica, and if no disc prolapsewere found the intervertebral foramen must be explored.

Dr. DONALD KING (San Francisco) found anteriorfusion with a tibial bone graft through an abdominalapproach unsatisfactory in spondylolisthesis ; the graftfractured where it traversed the avascular disc. ButProf. MERLE D’AtjBiGNE (Paris) was very happy withthe abdominal operation ; he replaced the disc with aniliac graft, transfixed the lumbosacral joint with a

large screw, and allowed his patients up in two weeks

without immobilisation. Mr. NoRMAN CAPENER (Exeter)thought that spondylolisthesis might be sometimes dueto stress fracture of the neural arch. Reduction of dis-placement was possible but this always recurred, evenafter grafting. Prof. STEN FRIBERG (Stockholm) saidthat the condition could be due to congenital deficiency,chronic strain, or acute trauma. Congenital causes

certainly existed. The other two types were associatedwith an elongated or a ruptured isthmus respectively.Loss of elasticity was the essence of disc degeneration,and discography with opaque media showed this couldbegin in the ’teens.

The Ischaemic HandDr. STERLING BUNNELL (San Francisco) described

the entity of local ischaemic contracture of the intrinsicmuscles of the hand, due to swelling within tight plasteror vascular injury in the forearm. The intrinsic minus

position of ordinary claw-hand was well known ; buthere there was an intrinsic plus position due to spasmor fibrosis of the small muscles, with metacarpophalangealflexion and interphalangeal extension in the fingersand fixed adduction of the thumb. It might accompanyVolkmann’s contracture or occur independently, andwhen the metacarpophalangeal joints were fully extendedpassively the interphalangeal joints could not be flexed.The hand could not be opened for grasping. Prophylaxisconsisted in avoiding further embarrassment of thecirculation in the hand after injury. Treatment ofthe established condition was by forward stripping of theinterossei along the metacarpals when the muscles hadany residual function, so allowing them to lengthen ;or, when they were fibrosed, tenotomising the lateralbands of the finger-joints. The thumb was dealt withby complete incision of the first cleft, stripping or excisingcontracted muscle and opening the first carpometacarpaljoint ; the functional position of opposition was main-tained with an intermetacarpal bone graft threadedwith a wire and the raw cleft lined with a free or pedicledskin graft.

Mr. Guy PULVERTAFT (Derby) spoke of the need forprolonged after-treatment with this procedure, for therewas a tendency to relapse and re-formation of the lateralbands. Splintage and elastic traction were essential.

Arthroplasty for Congenital DislocationDr. PAUL COLONNA (Philadelphia) described the good

results obtained over twenty years with his operationof capsular arthroplasty for congenital dislocation ofthe hip. His age-limits were 3-6 years for bilateral, and3-8 years for single, cases. The femoral head mustbe brought right down by preliminary traction, a deepcup-(not saucer-)shaped acetabulum made at the originalsite, and the head placed therein with capsular inter-

position. For marked anteversion a supracondylarfemoral osteotomy could be done subsequently. Thefalse acetabulum was left alone and no shelf made ;it filled in spontaneously over the years. Very occasionallya shelf was needed years later for instability.

Dr. ALEXANDER GIBSON (Winnipeg) discussed openreduction of congenitally dislocated hips via the postero-lateral approach. Closed reduction was often satis-

factory to patient and parents for some years, thoughthe radiographs gave the surgeon little cause for

complacency. His operation was less damaging thanmanipulation and so simple as to be the method ofchoice. The superior part of the capsule was incisedtransversely and the medial flap stripped with a thinlayer of bone off the dorsum ilii down to the level of thetrue acetabulum. The femoral head was gently replacedand the medial capsular layer overlapped above thelateral layer, so obliterating the entry of the head intothe joint diverticulum above ; the osteogenic capsularflap contributed to the formation of a good roof withoutany necessity for a shelf.

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In discussion, Sir HARRY PLATT (Manchester) said thatopen reduction could be used as an alternative to closedmethods when concentric reduction was made difficultby soft-tissue anomalies or an over-large femoral head ;but no reconstruction of the acetabulum was neededfor these young children except the occasional makingof a shelf. He was not convinced that operation shouldroutinely replace closed reduction.

Mr. H. J. SEDDON (London) wondered whetherDr. Colonna was using his procedure where other surgeonsmight perform simple open reduction, with or withoutacetabuloplasty. What was to be done with patientstoo old for capsular arthroplasty and too young for anadult type of procedure ? Could a cup or prosthesisbe seriously considered 1 He did Colonna’s operationin this difficult age-group of 8-14 years, but with lesssatisfactory results ; the hips were often very stiffbut were at least in good position for subsequent arthro-desis or arthroplasty. Mr. J. B. COLQUHOUN (Melbourne)said that those who believed that a high proportionof cases could be reduced by manipulation reservedColonna’s operation for their failures, and it was not

surprising that their results were worse than those ofColonna himself, with his more liberal indications.

Scoliosis

Dr. JOHN COBB (New York) discussed the selectionof the fusion area in scoliosis. A mature massive fusionwould maintain the stability of a corrected curve, butthe operation was necessary in less than 5% of idiopathicscolioses. The ideal case was a single stable non-

paralytic non-progressive curve in a patient over 15,in whom correction was desirable and possible. Therewas some confusion as to the meaning of correction,which applied to the angular deformity and did not meanstraightening the whole curve. If, as was usual, thecompensatory curves could not be corrected completelycorrection of the primary curve must not be completeand the accepted principle of always fusing betweenparallel lines was wrong. This was indicated when

side-bending away from the primary convexity did notobliterate the secondary curves, and the area of fusionmust be balanced against the residual uncorrectableangular deformity. When, on the other hand, maximumpermissible correction of the primary curve was notobtainable, the fusion area might be extended beyondthe parallel lines into the secondary curves themselves.

Mr. J. 1. P. JAMES (London) discussed prognosis inidiopathic scoliosis in relation to curve patterns and ageof onset. Onset could be infantile, juvenile, or

adolescent ; and prognosis was worse the higher theapex of the curve.The most benign pattern was lumbar idiopathic scoliosis,

mainly of adolescent origin in girls. Severe angular deformitywas seen in only 9 % ; and the clinical appearance was betterthan the radiograph suggested, the shoulders remaining leveland the ribs unrotated. But late lumbar osteo-arthritiswas the rule, all patients over 35 suffering pain.The primary thoracolumbar curve, again mostly in adolescent

girls, had its apex around Till-12. Severe deformity was nowseen in a third of the cases and most patients had pain inadult life.

Thoracic idiopathic scoliosis was usually a right convexitywith a variable apex between T6 and T10; two-thirds of thecases were severe, with marked rib rotation and shoulderasymmetry. The clinical appearance was worse than theradiograph, and an ugly deformity developed when the curveangle reached 70°. In this group the minimum final angula-tion was 50° and the maximum 150°. Half the cases ofadolescent onset and 90% of those of juvenile onset developedsevere curves.

Infantile idiopathic thoracic scoliosis was exceptional in

being mostly in males and usually left-sided. It invariablybecame severe with growth and little could be done to preventthis.

Combined lumbar and thoracic scoliosis comprised two

primary and two secondary curves-the only pattern with

four instead of three curves in all. It was almost as benignas lumbar idiopathic scoliosis.

In treatment, operation was rarely required forlumbar and combined curves, but fusion was necessaryfor severe pain and deformity in thoracic cases. Mr.James had not ,operated on children under 10, but thismight prove desirable in some cases.

In discussion. Dr. CLAUDE LAMBERT (Chicago) saidthat such a classification was not always helpful in

deciding treatment. He did not agree that lumbarcurves never needed fusing, and operation would beindicated for severe progressive deformity even in childrenunder 10. Mr. H. OSMOND-CLARKE (London) spoke ofthe possibility of dealing with scoliosis by controllingvertebral epiphyseal growth.

Sympathectomy for CausalgiaMr. ROLAND BARNES (Glasgow) spoke on causalgia

after injury to major peripheral nerves. The spon.taneous severe persistent burning pain spread beyond theanatomical territory of the nerve concerned, was

exacerbated by physical and emotional stimuli, and wasaccompanied by trophic changes. There were goodreasons for not believing it to be mediated by afferentsympathetic pathways despite the relief afforded bysympathectomy ; nor was there such persistent peripheralvasoconstriction as to support Lewis’s suggestion thatsympathectomy afforded relief by securing vasodilatation.Benefit must be due to interruption of efferentsympathetic fibres which stimulated the nerve-trunkthrough an artificial synapse or short-circuit at the siteof injury, centrifugal impulses causing the peripheralvascular disturbance and centripetal ones the pain.Only this view explained the relief which might follownerve-block distal to the lesion, and the rarity of causalgiaafter complete nerve section. In the arm, preganglionicsection was effective and postganglionic operation_ theusual cause of relapse ; lumbar sympathectomy wasnecessarily mainly preganglionic and the results

satisfactory.Mr. D. LLOYD GRIFFITHS (Manchester) Icommented

that causalgia did, rarely, occur after complete nervesection and in the phantom limb after amputation.Peripheral short-circuits must not be confused withtrue synapses. If sympathectomy did not relieve

causalgia it was because the operation had not beenadequate. But Dr. 1. W. NACHLAS (Baltimore) had foundthat the most extensive sympathectomy might fail torelieve. Not all cases were the same ; the skin mightbe warm or cold, the bone texture normal or porotic.

Skeletal Tuberculosis Treated by IsoniazidDr. DAVID BOSWORTH (New York) gave a breath-

taking account of his experience in treating skeletaltuberculosis with isoniazid (isonicotinic acid hydrazideand its isopropyl derivative). It was premature to

speak with assurance after only eight months’ acquaint-ance with these substances ; but it was already clearthat they could produce remarkable subsidence offever, and also euphoria, weight gain, and relief of pain(the last often independently of any improvement inthe local condition). Sinuses of long duration which hadresisted streptomycin might heal in a couple of weeks,sometimes even while the patient was dying of tuber-culosis. Though the drugs were certainly bacteriostatic,these rapid results suggested a possible action on meso-dermal tissue, as distinct from a suppression of infection;and this was borne out by the benefit they gave incollagen diseases like lupus erythematosus. But therewas no evidence that they had a cortisone-like action;eosinophil and ketosteroid studies did not support thisview, nor indeed the remarkable tendency to woundhealing. Meningeal and cutaneous tuberculosis respondedfavourably ; and a non-specific improvement in pain

85

and function was even seen with rapidly growingmalignant tumours. Toxic manifestations with the

isopropyl derivative included hepatitis and centralnervous system disturbance ushered in by clonus. The

margin of safety in dosage was small; it was best to

begin with a dose of 4 mg. per kg. body-Weight, increasethis until clonus developed, and then come down to asafe level.

In the discussion of this paper there was a generalfeeling that these drugs supplemented, but did not

replace, surgery. Dr. Bosworth had made it clear,however, that patients could be made safe for surgeryat a much earlier date than hitherto.

Orthopaedic Manifestations of LeukaemiaMr. D. LLOYD GRIFFITHS (Manchester) gave an account

of the orthopoedic manifestations of leukaemia, whichseemed to be on the increase in childhood, where it wasnow the sixth commonest cause of death. When theearly stages were aleukaemic, and when the presentinglesion was osseous, diagnosis was difficult without sternal

puncture. The leading symptom might be backache,sciatica, limp, or paraplegia ; so cases might be treatedfor months as tuberculous spines or instances of Perthes’sdisease before the situation became clear. Destructive

(not osteolytic) changes were seen as translucent meta-physeal zones, as focal erosions, or as diffuse painfulinfiltrations ; these changes might reflect an attemptat compensatory extension of red marrow. Extensivebone infarction could occur and would not necessarilyshow in the radiographs, since the disease inhibited thehealing processes which demarcated infarcted areas.

Other changes included sheath-like subperiosteal ossifica-tion and, usually in the vertebral bodies, massivesclerosis. Apparent remissions with anti-folic-acid

drugs or A.c.T.H. were only temporary.Mr. JACKSON BURROWS (London) remarked that the

disease was sometimes confused with senile osteoporosiswhen it affected the spines of old people ; but osteo-

porosis did not involve the hands or pelvis, and suchodd points should arouse enough suspicion to justifysternal puncture.

Special Articles

COST OF A RADIOLOGICAL SERVICE

F. PYGOTTM.B. Lpool, D.P.H.,

D.M.R.E.

BADIOLOGIST

W. S. TAYLORM.S.R.

SUPERINTENDENT

RADIOGRAPHER

CENTRAL MIDDLESEX HOSPITAL, LONDON

THE National Health Service has removed the patient’sconcern about the cost of his treatment. Indeed, as acontributor intent on getting his money’s worth, hemay take a pride in the number and variety of testsand examinations carried out upon him, and he is oftenmore impressed by the complexities of his investigationand treatment than by the result achieved. He mayretain for years a feeling of satisfaction and self-

importance arising from a complete overhaul, duringwhich hardly any avenue has been left unexplored by"

scope " or contrast medium. We have reached the

stage when the good specialist may be defined as thedoctor who knows when to stop. Investigations are

not only unnecessarily wasteful but (even more impor-tant) they use materials which in these days are hardto obtain, such as chemicals, X-ray film, drugs, anddressings.

Radiological investigations are the most expensivecommonly carried out in hospitals, and it seemed to usthat all who ask for a; radiological examination to bemade ought to know what it costs in money andmaterials. Accordingly we surveyed the expenditure inour department for the year, April 1, 1950, to March 31,1951. We did not include the costs of buildings, heating,lighting, water-supply, painting, and other expensesdirectly concerned with the structure of the department.Expenditure on these items is of course essential, butit was difficult for us to estimate the sums involved,

TABLE IŇŇEXAMINATIONS MADE IN 1950

Examinations Special examinationsChest 8911 Barium meals ...... 2545Skeletal (general) .. 8148 enemas .... 479Cranial .... 1432 swallows 127Biliary tract 631 Cholecystograms .. 568Alimentary trace 3760 Intravenous pyelograms .. 863Urinary tract .. 1319 Retrograde " .. 59Female generative 805 Encephalograms and ventri-Dental 927 culograms 127Miscellaneous .. 168 _9rteriograms . 70

- Contrast examinations of26,101 lungs, sinuses, and spine 87

Miscellaneous .... 17Tomograms .... _175

5117

especially in a department that had undergone onlyminor structural changes for many years.

THE WORK DONE

The department is a closed one, dealing only withpatients from the different sections of an 800-bed regionalhospital. In 1950, 25,000 patients were examined andthe general scope of the work is set out in table I.

WHAT IT COST

StaffThe staff consists of a whole-time consultant radio-

logist, a senior registrar, and a registrar on the medicalside ; a superintendent radiographer, a senior radio-

grapher, four junior radiographers, and a dark-roomtechnician on the radiographic side ; a clerical staffof four ; two assistant nurses ; two porters ; and a cleaner.The pay-roll of these nineteen people comes to £11,760(including superannuation and national insurance).About 1:100 was spent in arranging transport for radio-graphers on call after normal working hours.

Materials

During the year, approximately 58,000 films of varioussizes were used, costing jE6200. The cost of chemicalsused in the dark-rooms was £ 373 for the year.

Contrast media were a fairly heavy item. Bariumsulphate preparations for gastro-intestinal examinationscost 1:285. Diodone compound for pyelography, intra-cavitary radiography, salpingography, and arteriographycost E291. Iodised oil preparations, used almost entirelyfor bronchography, cost only E60. Pheniodol compoundsfor cholecystography cost E61. Smaller amounts ofcontrast media for other examinations cost £12.

BreakdownsSo far the expenditure was foreseeable. But in any

radiological department mechanical breakdown of plantis fairly common.Though the modern rotating anode tube may survive

30,000-40,000 exposures or even more, a breakdown, whichmeans an expensive renewal, may be expected at any timeafter the lower figure has been passed, and there is alwaysthe possibility of it happening before. The makers usuallyguarantee a minimum of 20,000 exposures and will generallybear a proportion of the cost of replacement below this number.X-ray rectifying valves are also expensive to renew, and

in our experience valve failure in the four-valve X-ray setis 2-3 times more common than tube failure on the sameset.

Mechanical breakdown is also not unusual. It can bereduced by regular inspection and overhaul but it cannotbe avoided.