many surgeons that I am quite unable with any degree of certainty to give credit to the originators of the operation. It is so simple, so easily performed, so safe and the result so surprisingly satisfactory I feel that it would be more universally practised if it were more thoroughly understood by the profession. I therefore present for your consideration an exact description of the operation which, in my personal experience, has proved the most useful.

This is an operation for relapsed club-foot, cases that have resisted the ordinary methods of treatment. There is no age limit, no preliminary treatment and no after treatment beyond the time required for the healing of the wound.

First: If necessary, subcutaneously divide the fascia on the inner side of the foot and also the heel-cord; then bring the foot into as good position as possible, using nothing but the hands and being careful not to bruise the tissues.

Second: Make an incision through the skin and superficial fascia just in front of the external malleolus on the outer side of the foot. The skin incision should be perpendicular from the bottom of the foot to just above the bend of the ankle.

Third: With an osteotome remove a large wedge of bone; make the first incision far back, just in front of the fibula. Pay no attention to the periosteum or peronei tendons. Cut the bones completely across and remove everything. Be sure to make the wedge large enough.

The foot can now be brought without force into excellent position, and by giving the anterior part of the foot a quarter turn, its outer border can be elevated. It is vitally essential to the success of the operation that the outer border of the foot be elevated. In order to do this the tarsus is cut completely across to enable the operator to give the anterior foot the quarter turn which elevates the outer border.

It is claimed for this operation that flat clean surfaces of bone are opposed. There is no cavity to fill up. The wound is a clean cut and there is no bruising or mangling of the surrounding tissues. No sutures except skin sutures are required. If the wedge of bone is sufficiently large and the angles of the wedge

are correct, there is no tendency to, or possibility of, a relapse, as every step the patient takes tends to maintain the bone in its

new position.

Personally, I use a light retention splint in preference to a plaster cast. Young children will often walk at the end of two weeks.

The dressing is worn from six to eight weeks, when the patient is ready for an ordinary shoe.

The important thing in this operation is to remove the right shaped wedge of bone. The older the patient, the less liability to relapse. When relapses occur they are easily corrected. Paralytic club-foot is more likely to recur than congenital clubfoot. I have one paralytic club-foot in a very young child which has once relapsed and has been cured by a secondary operation. The foot is now easily held in perfect position by a simple ankle brace and has every normal motion. The brace could be dispensed with by doing a tendon transplantation but the child is so comfortable as she is and the foot is growing so evenly that I hesitate to disturb present conditions. I believe that if I should discontinue the brace and not do a tendon transplantation, this case would ultimately relapse and require a third operation.

In one case, and only one out of thirty, there has been some interference with the growth of the fourth and fifth metatarsal bones of one foot. Whether this was due to the operation described above, why it should occur in one foot and not the other when both feet were operated on, or whether it was due to numerous previous operations of various kinds, I do not know. At all events it does not interfere with the usefulness of the foot.

This operation performed early insures the free, normal use of the foot and the atrophy from disuse is eliminated.

End Results.

It is now twenty years since my first tarsectomy. For the last three and a half years I have done the operation for relapsed club-foot exactly as described above. I have operated in all upon thirty patients, in some cases on both feet. There have been no accidents and all of my patients have been perfectly

satisfied with the result. Three of the feet have relapsed and I was obliged to do a secondary operation. This, I believe, was because I failed to take out a sufficiently large wedge of bone in the first place. One of the feet had to have a secondary operation because I failed to sufficiently rotate the anterior portion of the foot and a sharp point of bone projected toward the sole of the foot. In one of the feet I took out too large a wedge of bone and the patient now suffers from moderate pronation and flat-foot. All of the patients are cured and all have practically perfect functional use of their feet.

I have two or three patients who are doing well but who, I believe, will ultimately relapse and require a secondary operation. This is easily done by opening the old scar and removing a little more bone. They are young children and their parents had so little trouble with the first operation and are so thoroughly sick and tired of shoes and braces that they are quite ready to let me operate again.

DISCUSSION

DR. J. F. O'BRIEN (Hartford): Mr. President: I consider it a privilege to discuss Dr. Cook's paper. We have a great many cases of congenital club-foot that have been neglected in childhood. Heretofore they have been indifferently treated, with the result that there are many relapses. I think Dr. Cook is rather modest about giving credit to himself, because it is due to his efforts that this operation has been standardized. It is now called the Cook operation and I know that Dr. Gibney and Dr. Whitman consider it the operation of choice. In my experience I have always treated these cases with plaster of Paris after the operation but I consider his brace an improvement as a retentive apparatus in walking. If these children were all taken care of in childhood and if treatment were begun within the second week of life, surgical treatment would not be necessary. They can all be cured and many times the lack of treatment is due to the neglect of parents.

DR. CARMALT (New Haven): There is nothing to be said in adverse criticism of this operation and treatment; its merits are both theoretical and practical but Dr. Cook and Dr. O'Brien each spoke of these cases being all the result of neglect, and I agree with them entirely. They should never have been allowed to get to the stage depicted in Dr. Cook's illustration, and would not, if the profession were alive to what may be

accomplished in very early life. Dr. O'Brien made use of the expression "to begin treatment within the first two or three weeks”—why wait so long? When I was in practice I was called in consultation a few times, and I emphasize a very few times, by the attending physician immediately after birth; the next day after the accouchement, and in every case that persistent treatment was carried out good was accomplished. To this end two factors are imperative:

I. An intelligent trained nurse or nurses.

2. A mother willing to supplement the work of the nurse, making permanent the endeavors of the surgeon to correct the intrauterine forces. The first few weeks of extra uterine life are the most important in this combat; at this time the bones are, so to speak, soft, and it takes but little force to mould them into their proper shape. This can be best done, at first, by the hands of the nurse; any plaster or bandage is liable to injure the extremely soft and delicate skin of the infant, causing the child to worry and cry. If the nurse will grasp the distorted foot around the heel and instep with her full hand and press firmly and steadily upon the inside of head of the great toe, i. e., at the tarso-phalangeal joint, she will then be employing the same forces Dr. Cook has shown to be necessary with his brace; and if employed at this formative period of the bones it can be done at less cost of time and force than if one waits for the two or three weeks that Dr. O'Brien mentions, and infinitely less than the months and years required if one waits for the time when the deformity has become confirmed, as in the cases requiring Dr. Cook's operation and brace.

This must be done, however, constantly, sleeping and waking, just as later Dr. Cook's brace is applied, and while this may appear to be onerous, the light is well worth the candle. Just think what is this month's light work compared with the distress of mind, in the first place, of the parents seeing this deformity before their eyes all the time, and the subsequent care and expense of operative interference.

One may say, Mr. President, that I am not speaking to the matter of Dr. Cook's paper. He refers to correcting the confirmed deformity; I am speaking of preventing it from becoming confirmed and exaggerated, so that, while not strictly germain to the immediate subject of the paper, it has its place in correcting the deformity at its earliest accessibility, and so far as that goes the two methods are identical. The mechanical principle of each is the same, but he, through neglect of others, is obliged to tackle the problem at a much more difficult, more complicated stage. At the stage I now advocate treatment the mechanical problem is relatively simple, but it requires understanding and persistence, though much less force. I have seen a marked change take place in a week's time and in one the deformity was almost corrected at the end of a month when the nurse left. The treatment by holding the foot with the

hand may be supplemented at intervals by the use of adhesive plaster; this, however, requires great caution and only the old-fashioned moleskin lead plaster should be used, as the Z. O. and other rubber plasters of modern make are sure to irritate and perhaps blister the skin. But even this again requires looking after frequently, daily, and readjusted.

It isn't practicable in a few words at this time to discuss how to apply the plaster; the application must follow the principles indicated by Dr. Cook.

DR. HENZE (New Haven): Mr. President and Gentlemen: Intrauterine pressure is undoubtedly an important etiological factor in club-feet. In the Munich clinic scars were constantly looked for and frequently found upon the dorsal aspect of the deformed feet, these being after the nature of a healed decubitus. In order to remodel the foot it is not only necessary to twist and stretch the ligamentous tissues, but the foot must be kept in an over-corrected position until the deformed tarsal bones have changed their shape. Coincidentally with this the ligaments and tendons adapt themselves to the new conditions. The ability of the patient to voluntarily over-correct the original deformity by pulling taut the tendon of the extensor digitorum longus muscle (producing dorsal flexion and valgus) is a fairly reliable test that these changes have taken place. Many failures are undoubtedly due to the fact that the surgeon does not continue the treatment long enough. Two years should be the minimum time for the patient to be kept under observation. At the last meeting of the orthopedic section at the New York Academy of Medicine, it was shown by Barnett and Zadek that dorsal flexion is frequently impossible without division of the posterior ligaments of the foot in addition to the usual tenotomy of the Achilles tendon. Radiographs taken before and after the division of these ligaments clearly prove the contention of the authors.

DR. E. H. ARNOLD (New Haven): Listening to Dr. Cook's calm and dispassionate statement about club-foot and its treatment, strikes me like the discussion on English spelling simplified, for a club-foot is much like English spelling. I am afraid it is not quite as simple a matter as Dr. Cook would lead you to think. I have not seen any of Dr. Cook's cases eight or nine years after the operation but have no doubt that he has succeeded in curing them all and that they will show up well at that particular time.

I have in mind some of my own cases, however, which did not do quite as well and about the relapse of which I felt quite sore at the time some of them relapsed because they did not follow out treatment. As Dr. Cook says, they are apt to wander from one to the other for treatment. However, occasionally some balm comes to my soul when I see