866 CLUB-FOOT.-THE ACTIVE SUBSTANCES OF THE THYROID.

These indefinite results have led to the explorationof other possibilities in the search for a primary cause.LARIMORE, for instance, regards an avitaminosis asthe basis of chronic ulcerative colitis, and McCARRisoNin 1921 demonstrated injury to the intestinal mucosain animals deprived of vitamins. That chemicalsubstances may play a part in ulceration is well known ;physicians who remember the days before theWassermann reaction made it possible to establish thediagnosis of syphilis will recall the severe ulcerationsof the colon produced by mercurial saturation ofpatients who suffered from obscure affections of thenervous system and other chronic diseases. It ispossible, therefore, that ulcerative colitis may becaused not only by lack of vitamins, but also bychemical substances, of composition at presentunknown, which damage the bowel, their lesions beinginfected and kept active by the otherwise harmlessintestinal flora. In tropical countries the white manhas learned to exercise the greatest care to avoid theuse of contaminated and tainted food, for a lapse maybe followed by swift and severe consequences, but inEngland and temperate climates a lower standard ofhygiene is customary and the food often includes gamethat is high and milk that is stale, whilst meat by nomeans above suspicion is included in stews and made-updishes. It is possible that such frequent insults to theintestinal mucous membrane set up lesions in thelower colon where the intestinal contents lodge in theintervals between defsecation and where ulcerativecolitis usually begins. This is a revival of the oldnotion of "stercoral ulceration," modified to includechemical as well as mechanical injuries to thebowel wall from its contents.

Annotations.

CLUB-FOOT.

11 Ne quid nimis."

FROM line time 01 Hippocrates crup-root nas oeenwell known, and although we cannot be sure that anydistinction was made between congenital and acquireddeformities, the Father of Medicine described a

rational method of treatment for those cases whichescaped the fate of death by exposure, as was generallythe lot in Greece of the infant born deformed. Inanother column we publish a paper by Mr. WilfridAdams of Bristol in which he describes the courseof treatment which he has found successful in30 cases of club-foot in the new-born which havecome under his care. Those who have had the mostexperience of the treatment of such cases will be themost likely to agree with him and approve of hismethods and also will be best able to appreciate theamount of patient perseverance which has beennecessary to secure good results. Mr. Adams quitecorrectly states that no other deformity presents sucha record of failures and incomplete cures. WhenW. J. Little wrote his book on club-foot in 1839 heprobably thought that with Stromeyer’s introductionof a safe method of tenotomy and the treatmentwhich he described, all club-feet would in future becured. Yet we find that 89 years after that bookappeared, failures and relapses are still reproachingus. The method described by Mr. Adams is essen-

tially that of Stromeyer, or-with the exception oftenotomy-that of Cheselden. In this branch ofpractice as in so many others, men are often of greaterimportance than methods, and the more successfullythe surgeon can impress his personality on the motheror nurse so as to induce her to take unremitting careof a case of talipes for some years after birth, the

better will be his results. If eternal vigilance is acondition of the preservation of liberty as Curransaid, it is also a condition of the successful and per-manent cure of club-foot. Mr. Adams confesses to afear of doing too much and turning a club-foot intoa flat-foot. We think that this is a baseless fear andagree with Sir Robert Jones and others that over-correction should be aimed at, for the risk of producingany serious disability in this way is trivial and at theworst a foot that is anatomically flat is better than arelapsed club-foot. In some cases, too, it seems thatthere is no mean, but that for permanence, if the footis not to be varoid, it must be valgoid, for the middleposition is one of unstable equilibrium.

Congenital club-feet are classified by some writersas due either to primary causes affecting the embryoin its earliest stages or to the environment of thefoetus at later stages. Not much is certainlyknown about this, but to surgeons who havetreated many cases of club-foot it is evident thatthere are some in which the original vice of con-stitution persists, so that the foot, however thoroughlycorrected, tends as growth goes on to reassume thevicious form. Weakness of the overstretchedabducting muscles, to which Mr. Adams refers, maybe due merely to overstretching or to a more radicaltendency in the embryo. There is little doubtthat too much was expected of tenotomy for yearsafter Stromeyer’s subcutaneous method was madeknown, and too many surgeons thought that allthey had to do was to divide certain tendons. Inthe method described by Mr. Adams, all the work ofcorrection of varus is done before the tendo Achillisis divided and the subsequent correction of theequinus deformity is comparatively easy. Thehistory of tenotomy is one of isolated successes

followed by no permanent advance. No doubtfailure to occupy permanently the territory gainedby one success was due to lack of cleanliness and tothe prevalence of wound infection. The idea that thetight cord of the tendo Achillis might be divided musthave occurred to many people and some of them musthave seen cases in which tendons accidentally dividedor torn had re-united. Among the " cases " describedby Little in his book is that of Thomas Inglis,M.D., of Glasgow, who had suffered from what wasstated to be talipes equinus congenitus. Before thebeginning of his medical studies, Inglis becameconvinced that the contraction of the tendo Achillisprevented his heel from descending. He com-

municated a suggestion of tenotomy to the familydoctor who discountenanced it. He therefore dividedthe tendon himself-no doubt by open incision, forthere was considerable bleeding. Medical advice wascalled in and the foot put up in extreme equinus sothat the deformity was restored. Fifteen yearsafterwards the tendon was divided subcutaneouslywith a most satisfactory result. Thus Inglis mighthave claimed to be the first surgeon in Great Britainto divide a tendon for the cure of club-foot.

THE ACTIVE SUBSTANCES OF THE THYROID.

FOR some years past, as our readers will remember,Dr. G. Scott Williamson and his colleagues haveadvanced views on the structure and function of thethyroid which are at variance with those mostgenerally accepted. He regards the thyroid as

having a distinctly dual function. On the one handis the accumulation of colloid in the vesicles whichdominate the normal histological picture, on theother the production of a genuine secretion in theadenoid areas of the normal gland and throughoutthe organ in Graves’s disease. The two functions areinterchangeable phases in the activity of the normalthyroid epithelium, and tissue in the secreting phasecan be distinguished and separated from tissue in thecolloid phase by careful examination of slices ofmany normal glands. Evidence is now produced (Jour.Path. Bact., 1928, xxxi., 255) which seems greatlyto strengthen this position. Dr. Williamson, workingwith Dr. Innes Pearse and Dr. Hilda Cunnington,