on for several weeks it will be found that the skin is ready to yield under further manipulation and still more correction can be made. It is at this point that open section, an operation connected with the name of DOCTOR A. M. PHELPS, is so frequently made. Judging from my own observation, covering the treatment of several hundred cases, of which more than thirty were the feet of adults varying from forty-three years of age downward, open section is never necessary in the infant or child, and is seldom required even in the adult. In fact, I am disposed to make the statement that it is a practice which should be condemned. It makes a large, open wound on the inner border of the foot, following which sloughing of the

anterior lips of the wound is not entirely unknown. Under the most favorable circumstances this immense gap could but fill in with cicatricial tissue. Very important structures, such as the blood-vessels and nerves, are recommended to be freely cut and, as a result, interference with the future growth and development of the foot ensues. If the step were really

necessary in order to correct the deformity, even these baneful effects might have to be tolerated. Seeing, however, that rectification most complete can be effected in the vast majority of cases, even in men and women in adult life, without making open incision, it seems a natural and logical claim to say that the open incision should be avoided. I do not believe that it is necessary in five per cent even of the persons over twelve years of age. The illustrations which I show here today fully bear out this contention. One photograph which I pass around is that of a young man who presented himself about twelve years ago, having double club-foot. (Figure VI.) I operated upon one foot, making the open incision. While waiting for healing to occur I began stretching the shortened structures of the other foot. Finding that I was making good headway I completed the rectification in that way. He was then a boy of about ten years of Successful replacement was effected in both feet, and he returned to his home, leaving in my own mind and in the minds of my surgical associates the impression that it was a very excellent result, and greatly surprising his family and friends at home. A short time ago he came to live in Toronto, and called at my office, at which time I had this photograph taken. It will be seen that, although rectification was most complete at the time, the one foot is now shorter; that contraction has occurred at the cicatrix, and that the development of the leg and foot is less than that of the other side. From observations I have been able to make in the intervening years, all of which tend to confirm the statement which I have here made, I am inclined to emphasize the position which I have just taken, namely, that "open incision" in the treatment of club-foot is not necessary, and as an operative procedure should be abandoned, except in a very small proportion of patients.

age.

If replacement cannot be made readily with the hand in the first part of the operation, that is in the correction of the deformity of the foot per se section of the plantar fascia is more commonly indicated than any other operative procedure whether it be in the child or adult. In making this section the inner border of the plantar fascia very near to its point of attachment to the os calcis should be carefully defined by the fingers, and the tenatome introduced at that point should be carried directly toward the bone until it is felt to reach that part. Then it is passed along the surface of the bone under the plantar fascia and the cutting is done by a sawing motion while the fascia is put upon the stretch. Through the same incision, and without removal of the knife, the long plantar ligament may be reached and cut. The deformity of the foot will be found to yield greatly after this cutting is done. At the point here described one enters behind the arteries and extensive hemorrhage may be avoided. If the obstruction appears to be much more toward the inner border of the foot the tendon of the tibialis posticus may be cut subcutaneously, which operation should always be done just below and anterior to the internal malle

olus. It is reached here with greater safety than at a point generally described for this purpose above the malleolus. The next obstruction most likely to need attention is the internal lateral ligament or its anterior part, the calcaneo scaphoid ligament. The tenotome may be so introduced as to pass parallel to the artery. and extensive section be made without causing much hemorrhage. In the vast majority of cases this proves to be quite sufficient use for the knife. Manipulation with the hand, or with a wrench specially designed for the purpose, will now effect very complete

replacement of the foot. The hand of the surgeon is the much better instrument except in the adult, where the resistance to correction is very great. In these latter the wrench may be required so that more force may be applied.

The dressing of the foot is an important matter. Absorbent cotton laid on evenly should be used freely, so that the plaster dressing applied may be put on tightly without risk of causing abrasion. While the plaster

is setting, the foot should be held in a position as nearly approaching complete correction as possible. Great care should be exercised that the pressure is an even one, otherwise abrasions or sloughs may be caused. In this work success may be attained only by the use of very fresh, active plaster of the best quality. The best webbing material to be employed in making bandages is the ordinary book-muslin. When a dressing has been applied in this manner it should be left on for a period varying from two to six weeks. At the end of that time one or two days should elapse after the removal of the dressing before a second one is applied, during which time the collection of old epithelium, et cetera, should be removed from the foot by bathing.

At the time of a second dressing, whether in child or adult, the same steps should be taken if the indications call for them. It is seldom, however, that the knife will be required. It will be found, on using the hand, that a large amount of correction can be gained without much trouble.

Nearly always in this way the deformity of the foot can be corrected. in two to four dressings. When the deformity of the foot per se has been fully corrected, or somewhat overcorrected, especially in children, the relation of the foot to the leg, that is to say, the equinus, should be corrected. As a first step in doing this, in most cases, the tendo Achillis should be cut by the insertion of the tenotome at the inner border where the tendon is found to be narrowest. The tendon should be fully separated and correction made until the axis of the foot makes an angle of about eighty degrees with the axis of the leg. Dressing should take place as before, and the foot be retained in this position for a period ranging from three. to six weeks. In nearly all cases, even the most severe, this operative work from first to last should not require more than three months. It may often be completed in about half that time.

After the removal of the last dressing, boots should be made to be worn in the daytime and a night brace to be worn every night. The tendency to relapse is more manifested at night than during the day, because the weight of the body upon the feet as the patient goes about tends to prevent deformity, whereas the bedclothes at night become a factor in increasing the deformity. The night brace may be a very simple structure having a sole plate at an angle of eighty degrees with the line of the leg bars. Into this the foot may be comfortably strapped so as to keep the foot at the angle above named. The character of the boot worn in the daytime is a matter of great importance. The last upon which the boot is made should be in a condition of valgus as above described. The sole and heel of the boot should be made to project in a marked manner toward the outer border and should be made thicker than the sole and heel at the inner border so that the outer portion of the foot may be raised and the foot thrown toward a position of pronation. We are in the habit of having these boots made of three grades, according to the degree of elevation

and projection of the sole and heel. A counter should be placed in the boot at the inner border opposite the head of the first metatarsal so as to prevent in-turning of the foot. By wearing the night brace above described, and boots made in the manner here set forth, the after treatment of the club-foot is made comparatively simple and successful. It will be found that relapse will occur but seldom. It is the duty of the surgeon, however, to see that the patient returns at intervals of a few months in order that he may supervise the use of day boots and night braces. Various other plans for the treatment of club-foot have been advocated. I have found, however, that in following out the line which I have very simply described to you today, success invariably attends the treatment of this deformity, which in general is considered so difficult a one to handle.

NOTE. FIGURES I, II, III, IV, V show the kind of result obtainable in a man thirtyone years of age; FIGURES VII and VIII, in a boy six years of age.

THE RELATION OF THE MEDICAL PROFESSION TO THE DEPARTMENT OF PUBLIC HEALTH.*

BY GUY L. KIEFER, A. B., M. D., DETROIT, MICHIGAN,

HEALTH officer of detroit; lecturRER ON HYGIENE IN THE DETROIT COLlege of MEDICINE.

[PUBLISHED IN The Physician and Surgeon EXCLUSIVELY)

THE administration of public health affairs is a subject with which the practicing physician comes into contact daily and almost constantly, and therefore it has occurred to me that a discussion of this subject would not be out of place before a representative body of physicians in Detroit. It is with this thought in mind that I present for your consideration a few statements which I trust will call forth a lively discussion on the part of the members of this society.

The Department of Public Health is established by a state law and by the statutes therein contained this department has certain duties to perform. In administering the rules which pertain to the prevention and restriction of communicable diseases, the Public Health Department and its executive officer, the health officer, come most closely in contact with the medical practician.

There are a number of statutes relating to the duties of the physician to the Department of Public Health, as for example, Section 4453 ("Compiled Laws"), which says: "Whenever any physician shall know that any person whom he is called to visit, or who is brought to him for examination, is infected with smallpox, cholera, diphtheria, scarlet fever, or any other disease dangerous to public health, he, shall immediately give notice thereof to the health officer of the township, city, or village, in which the sick person may be." According to this section the physician has no choice, "he shall immediately give notice"; but in my opinion he should do more. The family doctor is the counselor of the afflicted persons, he

*Read before the DETROIT MEDICAL SOCIETY.