THE PREVENTION OF DEFORMITY.* JOHN PRENTISS LORD, M. D., Omaha, Neb. The cure of disease has always received greater attention from doctors and patients than has its prevention. We are somehow spurred on to our best and supremest efforts in meeting the emergencies of illness and accidents. We seem to lack the wisdom and foresight necessary to live up to the full measure of our knowledge in disease prophylaxis. In comparison the prevention of deformity has been less studied because of its lesser scope. The causes, mechanics, and pathology of deforming diseases are less well understood and much less considered than relief and cure measures after deformity has taken place. Just as our ideal is for disease prevention, so should our aim be to prevent deformity. An acquired deformity is too frequently a reflection upon the medical advisor. Men unqualified to pass judgment are often too pessimistic or are possibly indifferent; and parents discouraged and ignorant spend too much

*Read before the Medical Society of the Missouri Valley, at Colfax, Ia., September 18, 1914.

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time both in inaction and with irregulars and incompetents. The dangers of delay and the effects of growth upon the production and establishment of deformity are not foreseen by ignorant and indifferent parents. Neither are they fully understood or appreciated by many practitioners. existence of an extreme acquired deformity, represents some one's ignorance and neglect. The causes of congenital deformity are too obscure and obviously so remote as to render a discussion of their prevention manifestly unprofitable in this paper. The early correction of congenital deformities, however, forestalls some of its more exaggerated types, and thus fixed forms may be lessened and even prevented. Neglected deformity, usually means an increasing and greater deformity. Early treatment and correction therefore together with measures to prevent recurrence is the burden of this paper. Many deformities may be fully corrected early, which if allowed to exist for years may be quite impossible to overcome completely, and some are utterly refractory. Congenital club foot treated early is amenable to complete correction, and with suffi

ciently prolonged after care, results are practically perfect in the vast majority of cases. This period of after observation and care however, is absolutely essential to insure full restoration of contour and perfect function. This period should be one or two years. Thus the exaggerated later types of this deformity may be positively forestalled.

Close supervision is imperative to prevent the acquirement of deformity following infantile paralysis. Besides the usual treatment splints or braces have a distinct place in maintaining the limbs in the normal or over-corrected positions necessary to maintain, to minimize, or prevent the deforming effects of habitual malposition or faulty posture.

It is important that the muscle balance of a paralyized leg and foot be determined and adjusted by tendon interference, silk ligaments, arthrodesis, or other means to lessen the tendency to malposition and the consequent deformity. Of course a proper appreciation of the value and application of these various procedures must be obtained to insure that degree of success so necessary to satisfactory results. Months and years of supervision are sometimes necessary to preserve the balance to insure the permanence of the results previously obtained; and subsequent operative or corfective measures are sometimes required.

The contractures, and bone, and joint deformities from birth paralysis should be foreseen, guarded against by muscle stretching, apparatus and supports, before the inevitable extreme conditions, resultant upon spastic contractures, are developed. Early tendon transference, as of the biceps to the quadriceps rectus, may correct the contractions at the knees. Lengthening of the tendo Achilles will relieve the equinus. The division of the rectus tendon at the anterior superior spine of the ilium, will do much to lessen the marked lordosis, inevitable after years of forward pull upon the pelvis. To divide the adductors at their pelvic origin will also prevent the marked scissor legs or knock knees. The later cases after marked deformities, the operation must be more formidable and the after treatment greatly prolonged. The latter consists in massage, exercises, plaster, or splints, possibly braces, and muscle re-education.

A legion of deformities may be lessened and prevented by improved general and individual treatment of fractures and dislocations. It would be necessary to recite many don'ts to do justice to the list of precautions to observe to avoid in greater de

gree the imperfect, and too frequently lamentable results from fracture treatment. Radiography is doing much to dispel the self-complacency and over-confidence of tyros who await the end results of their treatment to be really certain of their work. Few really serious or doubtful cases involving joints or the larger and more important bones, should be treated without this aid. And when it cannot be made use of the doctor should be exempted from its exactions. The anatomic corrections now more frequent are serving to lessen deformities. The mastery of non-union and the bridging of bone defects by the use of bone grafts are still further giving modern methods the mastery. Time precludes details of discussion and allusion to cases.

To prevent the deformities of rickets the condition must be early recognized and appropriate treatment instituted. observation that the recumbent position is seldom resorted to, to prevent these frequent extreme deformities. The majority could easily be minimized by a keener scent for the ordinary signs and early effective treatment established.

For some years I have made frequent protest against the too frequent and almost general use of the ambulatory treatment of Potts' disease of the spine. The mind of the general practitioner seems (too frequently) in my observation, to run as straight from the diagnosis, to a cast or brace, as the line from the eye of a cartoonist's figure to the object. To avoid deformity and too great destruction of bone, abscess, complications, recurrence, prolonged bed treatment with fixation is imperative. There are exceptions of course, but they should not make the rule. The lesion is too severe, and the issues and consequences too great to be lightly regarded. Prolonged bed treatment will insure the best results whether bone grafting is or is not resorted to. It is probable, however, that grafting in suitable cases will by fixation hasten the healing of the process, and thereby shorten convalescence and lessen the deformity. It may be said, however, that this is not yet universally accepted. Probably a few more years of trial will be required to establish its true worth.

Extensive shortening, following hip disease either from dislocation or great bone destruction, is evidence of bad treatment, and neglect in the majority of cases. Marked flexion deformity is also evidence of somebody's shortcomings. Early diagnosis and a keen appreciation of possibilities, intelligent observation, close surveil

lance, and prolonged after-care, are necessary to minimize these deficiencies, and reduce the numbers of cases that reflect so much discredit upon the treatment and management of hip disease, as now evidenced by those who are blighted for life by its indelible marks.

Weak or imperfect feet require early and systematic observation and treatment in children and adults, not only to prevent their deformity and greater weakness, but to forestall the secondary postural changes the sure outgrowth of these imperfections, notably the changes in the spine, shoulders, chest and abdomen. Visceroptosis is one of the many ulterior results of faulty carriage. The economic loss to the industries the result of faulty feet is becoming recognized. Some hospitals are systematically examining the feet of their nurses. rejection of army recruits on account of flat feet is traditional. Its importance will soon become manifest in the attitude of the trades and other classes of labor. School inspection sure to come and be universally adopted, will do wonders in directing attention to early and incipient deformities. It is already having its effect in quickening parental observation. Baby exhibitions are having the same effect.

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Gymnasium inspection is another check upon the neglect of potential, incipient, and established deformities. Dressmakers now discover more cases of scoliosis in girls than do their mothers. This emphasizes the necessity and importance of periodic, and systematic physical inspection, by trained eyes. Physical inspection, or hygienic inspection, are designations perhaps to be preferred to medical inspection. The word medica. is intolerant to the christian scientists (note in reading the absence of capitals) who have, it has been said defeated medical inspection by their opposition. Whereas a less obnoxious term than the word medical would have vouchsafed their acquiescence to this needed legislation. If we are to secure early this eugenic legislation we should recognize this balance of power, eliminate the non-essential word, harmonize the factions, and attain our unselfish purpose for the common good. The cost of rearing, educating, and rendering efficient the human animal, is too great for us to let pass any measure designed for the improvement of the individual, and which will add to the sum total of human improvement and happiness.

After all our moralizing, our don'ts, generalized cautions and advise, we are face to

ation and praise for their proverbially numerous good qualities-the general practitioners. The all-around doctor is (to be perfectly frank) too much of a composite, to be an all around specialist. The polyglot specialist is an absurdity if not an impossibility. The true specialist is one who does, in a measure at least, recognize his limitations. It has been my observation and experience that the worst cases of neglected and preventable deformity, had passed through the hands of those who had not recognized their limitations, and who had so poor an outlook as to express pessimistic prognoses, and therefore hinder their patients from securing the advantages of special counsel, making possible the greater service which will prevent, rather than render necessary the cure of deformity. City National Bank Building.

have seen

H. WINNETT ORR, Lincoln: I was on the point of discussing the treatment of infantile paralysis when this question was asked. In our experience at the Nebraska Orthopedic Hospital Dr. Lord and I a great many permanently deformed and crippled patients because of the fact that early treatment had been neglected. There has been considerable pessimism in the profession regarding the treatment of infantile paralysis: partly on this account and partly sometimes because of carelessness these children are allowed to drift from a condition of flaccid paralysis of certain muscle groups into one of contracture deformity.

The fact of the matter is that the indications for treatment are perfectly clear as soon as we know that there is any paralysis. The paralyzed muscles must be protected against over-stretching and the unparalyzed muscles must be prevented from contracting. If such measures are not instituted early some contracture deformity is unavoidable.

It is the duty of every physician to recognize this indication and to institute such measures in every case, in fact it is my opinion that every child with a contracture deformity following infantile paralysis is the victim of neglect on the part of some one.

There is another point which I desire to emphasis in connection with the care of these patients. That is that when contracture deformity has developed, the application of a brace not only does not meet the indications but is a waste of time and expense. Forcible correction of the deformity or correction by a suitable surgical procedure must precede the application of braces in every such case.

If braces are applied without such preliminary correction not only is nothing accomplished but the patient is led to delay proper treatment under the impression that as long as he is wearing a brace, something is being done. This applies not only to fixed deformities in infantile paralysis, but other fixed deformities as well.

CHAS. R. WOODSON, St. Joseph: I think that

who are so deservedly entitled to commend

have more residual paralysis as a result of the failure of the physician treating the case to recognize