1180

condition is clearly improving, the patient is mentallyalert and ambulatory, and the c.s.F. is showing steadysigns of improvement. Usually this requires three to sixmonths. Intrathecal therapy is then stopped, butintramuscular therapy is continued. Lumbar punctureis done weekly. If the c.s.F. deteriorates, the lumbarpuncture is repeated ; and, if this deterioration is con-firmed, intrathecal treatment is begun again on alternatedays. If, however, the c.s.F. remains unchanged and theclinical condition is good, further intrathecal therapy iswithheld. When it is clear that without intrathecaltherapy the C.S.F. is still returning to normal, the weeklylumbar puncture is discontinued. At this stage, providedthere is no radiological evidence of miliary tuberculosisand no other reason, such as pulmonary tuberculosis orbone tubercle, which merits intramuscular streptomycin,then intramuscular therapy is also stopped, and thepatient goes home. He returns in a month for furtherlumbar puncture, and continues to do so until the c.s.F.is normal. If at any time headache or vomiting occurs,he reports back to hospital immediately.

Until C.S.F. normality has been achieved, the outlookremains uncertain, and relapse is an ever-present danger.Only 1 case in this series has relapsed after attaining anormal C.S.F., although another such case has been seen.Although occasional patients may recover on intra-

muscular streptomycin alone (one of our earliest patientsremains well after four years), there is universal agree-ment that intensive intrathecal treatment is essential,but there is considerable difference of opinion on twopoints : the amount of streptomycin to be given in anyone intrathecal dose, and the frequency of injections.Amount of streptomycin to be given in a single dose.-

The dosage we used (adults 0-1 g., children aged 5-140.05 g., children aged less than 5 years 0-025 g.) is

generally used in this country, but in America and insome Continental centres the tendency has been to usesmaller doses. The purer preparations of streptomycinproduced today cause little irritation when introducedinto the subarachnoid space, and the only toxic effect ofsignificance is upon the 8th nerve. Loss of vestibularfunction probably takes place in all the patients whoreceive frequent intrathecal injections of streptomycin,even if the dosage is much smaller than the scale above.None of our patients is known to have recovered thisfunction once it has been lost, yet the only disabilitynoticeable is when moving in the dark. Deafness remainstherefore the only important toxic effect. This was

present in 4 of 67 survivors (6%), but it is impossible toknow whether streptomycin or meningitis was the mainfactor in these. This relatively low incidence of deafnesssuggests that the dosage is not too high. (The greatmajority of patients received only streptomycin ; only afew received dihydrostreptomycin.)

Frequency of intrathecal injections.—The recent

tendency in most centres has been to give daily intra-thecal injections for many weeks, whereas we havecontinued with a short course of daily injections followedby a long course of alternate-day injections. Formal

comparison of our results with those of other centres isimpracticable. For such a comparison to be of valuethe degree of selection of cases must be stated, the stateof the patients before treatment comparable, the follow-uplong, and the clinical and c.s.F. findings in the survivorsdescribed. Further, the number of cases must be verylarge, or the effect of even important advantages intreatment may not be apparent. This is because in anyseries there will be cases, such as those already describedabove, which seem to do well under almost any system ;there will also be cases in which irreversible neurologicalchanges, best shown by encephalography (Lorber 1950),are already present at the start and make cure hopeless.Differences in the effectiveness of different treatments of the

remaining cases therefore tend to be diluted or obscured.

In series u, of 119 patients 58 (50%) recovered; andof these at least 69% achieved normal c.s.F. If late

: cases are excluded, there are 87 patients of which 55i (63%) recovered, at least 40 of these (73%) having

normal c.s.F. These results compare favourably withthose of other series, such as those listed by Cathie andMacFarlane (1950) and Illingworth and Lorber (1951),

! and we conclude that the scheme we have used is atleast as effective as any other available for comparison.

SUMMARY

The results of treatment of 146 patients who developedtuberculous meningitis between August, 1947, andNovember, 1949, are described.Treatment was by streptomycin alone in 141 of the

146 patients and followed a uniform schedule in most cases.There are 69 survivors, most of whom are free from

meningitic symptoms or sequelæ, apart from ataxia inthe dark ; 48 have a normal c.s.F. ; 4 have subsequentlydeveloped tuberculous osseous lesions.The results of pregnancy during or after tuberculous

meningitis are cited in 6 cases.The fluctuating course taken by many cases under

treatment is emphasised ; recovery may eventuallycome after many months of continued severe physicaland mental illness. Decerebrate rigidity, however, hasin our experience proved invariably fatal.A suggested scheme for streptomycin treatment is given.Obviously so large a series treated in five hospitals has

called for an unusual degree of cooperation from many people,whose assistance so freely given it is a pleasure to record.Successive house-physicians and registrars gave invaluablehelp. Especial thanks are due to Dr. George Brewis andDr. C. Neubauer, at Walkergate Hospital, Dr. George Davison,at Newcastle General Hospital, and Dr. C. A. Green, of thedepartment of bacteriology at the Royal Victoria Infirmary.The physicians, radiologists, and pathologists at the hospitalsmentioned and at the Fleming Memorial Hospital for SickChildren helped with various cases, and Mr. G. F. Rowbothamand Mr. J. Whally gave the surgical treatment. Prof. SirJames Spence and Prof. F. J. Nattrass exercised a generalsupervision and gave constant encouragement.

REFERENCES

Cathie, I. A. B., MacFarlane, J. C. W. (1950) Lancet, ii, 784.Illingworth, R. S., Lorber, J. (1951) Ibid, ii, 511.Lorber, J. (1950) Arch. Dis. Childh. 25, 404.Medical Research Council (1948) Lancet, i, 582.

HALLUX VALGUS

PREDISPOSING ANATOMICAL CAUSES

R. H. HARDYM.A., D.M. Oxfd

SATRA RESEARCH FELLOW

J. C. R. CLAPHAMB.A. Camb.

SATRA STATISTICIAN

DEPARTMENT OF ANATOMY, UNIVERSITY COLLEGE, LONDON

HALLUx valgus and the bunion it causes are

responsible for much disability and suffering, especiallyamong women about the age of 50. At the Royal NationalOrthopaedic Hospital in May, 1949, the waiting-listfor Keller’s operation contained the names of 250 people,most of whom had a painful bunion (Hardy and Clapham1951). Treatment of this condition in its advancedstages takes a long time and is not always satisfactory.Almost nothing is known of the aetiology of hallux

valgus. It is supposed to be associated with metatarsusprimus varus, and this has been borne out by measure-ments on Canadian troops (Harris and Beath 1947). A

high correlation has been shown between the degree ofdisplacement of the great toe and the size of the anglebetween the first two metatarsals (Hardy and Clapham1951). But examination of adults has not providedconclusive evidence that either a wide intermetatarsalangle or advancing age are responsible factors.We therefore decided to examine children’s feet for

possible evidence of an anatomical predisposition to

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Fig. I-Distribution of hallux valgus deformity, measured as degrees of displacement of proximal phalanx from metatarsal axis.

hallux valgus. If, for instance, some children have anabnormally large intermetatarsal angle, which does notincrease materially with age, and show increasing halluxvalgus as their age advances, it would be clear that thisangle could be a factor in the causation of the deformity.

METHOD

Using a standard radiographic method, we examinedschool-children from a residential area in Middlesexlying between Harrow, Greenford, and Ruislip.This region is a modern housing district some of whose

inhabitants go daily to central London and others to themany light industrial factories in the district. Of the childrenexamined, the infants (aged 4), juniors (5-10), and seniorgirls (11-15) were all taught in a single conglomeration ofbuildings in South Harrow ; the senior boys were taught atGreenford, about two miles away.In all, 1851 children were examined, but there was aninevitable small wastage of results from various causes.The distribution of sexes was approximately equal, andexcept for the extreme ages (4 and 15) there was a moreor less consistent annual age-distribution.The reliability of measurements on standard radio-

graphs of the foot has been assessed by Venning andHardy (1951). In the present inquiry an exposure ofboth feet was made on a single film to save time andmaterial ; the X-ray tube was placed vertically abovea point mid-way between the first metatarsal heads ata target-film distance of 100 cm. By this method

angular measurements can be made with an expectedaccuracy of ±0.5° (standard deviation). _

RESULTS

For simplicity the findings are given in figuresrepresenting numbers of feet and not of children. -

Position of HalluxIn 3642 feet the mean position of the hallux (measured

as the angle between the axes of the proximal phalanxand the first metatarsal) shows a lateral deflection of120° 5-1°. The distributions for boys’ and girls’TABLE I-DISTRIBUTION OF VALGUS DEFORMITY AMONG

AGE-GROUPS

feet are given separately in fig. 1. There is no significantdifference between the distributions for each sex.* *

If these findings are broken down into age-groups it isobserved that there is a progressive increase of lateraldisplacement of the great toe with increasing age. Thereis no - statistically significant difference between thecoefficient of regression on age for the two sexes (table i).First Intermetatarsal Angle

In 3642 feet the mean angle between the axes of thefirst two metatarsals was 74° 2.1°. The distributionsfor boys’ and girls’ feet are given separately in fig. 2.The means are 7-33° ± 204° in 1815 boys’ feet, and

TABLE II-DISTRIBUTION OF INTERMETATARSAL ANGLE AMONG

AGE-GROUPS

7.55° ± 2-060 in 1827 girls’ feet ; this sex-differenceof 0-22° is statistically highly significant.There is in this case no significant increase of inter-

metatarsal angle with advancing age in boys ; there is,however, such a progressive increase in girls (table II).Displacement of Terminal Phalanx

It has been suggested (Emslie 1939) that some factor(possibly tight shoes) causes a lateral displacement of theterminal phalanx of the great toe. Because of this thepull of the tendon of extensor hallucis longus, insertedinto this phalanx, is transferred to the lateral side of theaxis of the toe. As there is no extensor sheath to fixthe tendon to the metatarsal, each contraction of thismuscle will tend to increase the deformity and thelateral displacement of the tendon. Once this processhas started the lateral displacement of the great toemust, therefore, inevitably increase. This is knownas the " bow-string " effect.

’Ve were unable to measure displacement of theterminal phalanx upon the proximal, because the squat

* The following terminology is used throughout :Not significant" means a probability of the finding being due

to chance of more than 1 in 20 (> 0-05)." Signincant": probability less than 1 in 20 (<0.05).Highly significant": probability less than 1 in 100 (<0-01)."Very highly significant": probability less than 1 in 1000

(<0-001). ’

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Fig. 2-Distribution of size of first intermetatarsal angle.

and irregular shape of the terminal phalanx made it

impossible to determine its long axis either visually orgeometrically. All we could do was to relate the two

phalanges by an arbitrary scheme based on four degreesof displacement (fig. 3).The mean displacement of the terminal phalanx

upon the proximal in 3642 feet was 2-7 =1 0-5 units,and there was no statistically significant differencebetween boys and girls. With advancing age, however,the displacement of the terminal phalanx diminished(table III).Analysis of Observations

In table iv the mean values of the three observationsare compared in four groups-namely, children of 4-5years, and of 14&mdash;15 years, adults suffering from sympto-matic bunions, and a control group of adults. The

similarity between the children and the adult controlssuggests that they are members of the same statisticalpopulation, whereas the degree of hallux valgus and thesize of the intermetatarsal angle in the morbid groupare so clearly in a class by themselves, that they canprobably be regarded as forming an abnormal group,not merely the outlying observations of a normallydistributed population.The figures for children and adult controls show that

the increase in the displacement of the great toe occurslargely before the age of 14, and the increase in inter-metatarsal angle occurs largely after the age of 15.The decrease in the deviation of the terminal phalanxtakes place before the age of 15-i.e., during the timethat the hallux valgus is increasing.There are also individual children showing a degree

of hallux valgus and an intermetatarsal angle welloutside the expected adult range. An expected range

Fig. 3-Distribution of displacement of terminal phalanx of great toe, measured in

arbitrary degrees.

of variation may be laid down for any statistical observa.tion in a given group by taking the mean &plusmn; twice thestandard deviation of the group already studied. Theodds against any individual being found with measure.ments beyond these limits are 20 to 1 ; or, to put itanother way this range is that of the 0-05 probabilitylevel. The expected ranges thus obtained for displace.ment of the great toe and for the intermetatarsal angleare as follows : 4-28&deg; for valgus in adults and 2-22&deg;in children ; 3-15&deg; for intermetatarsal angle in adults

TABLE III-DISTRIBUTION OF TERMINAL PHALANX DISPLACE.

MENT AMONG AGE-GROUPS

and 3-12&deg; in children. There are 11 children’s feetwith hallux valgus >-28&deg;, and 4 feet with intermetatarsalangle > 15&deg;. There is no statistically significant differ.ence between the sexes. The extreme measurementfor hallux yalgus in children was 37&deg; (in a girl of 12),and for the adult controls 36&deg; (in a woman of 38). The

greatest intermetatarsal angles were 22&deg; (in a girl of 5)and 16&deg; (in a woman of 25 and a girl of 19).

DISCUSSION

It seems unlikely from these data that anincreased intermetatarsal angle can cause anincrease in hallux valgus, since hallux valgusshows its greatest increase before the age of14, and intermetatarsal angle after’ the ageof 15. There is no bimodal distribution ofintermetatarsal angle in children whichcould ’lead us to pick out -a group who wouldbe likely to develop symptomatic bunionslater in life. As the incidence of hallux valgusis unknown in the adult population, neitherthe 4 feet in children with an intermetatarsalangle > 15&deg; nor the 11 feet with halluxvalgus >28&deg; can be regarded as premorbidgroups of a

" threshold " variety. In viewof the high correlation (coefficient 0-7)between hallux valgus and intermetatarsalangle in adult controls-still higher in themorbid group--it is difficult not to concludethat they are causally related, but that the

1183

TABLE IV-COMPARISON OF MEAN VALUES IN THE DIFFERENT SERIES

displacement of the great toe is primary and causesthe widening of the intermetatarsal angle.There remains the question : what causes the displace-

ment of the great toe in the first place ?There is in children a marked lateral displacement of

the terminal phalanx upon the proximal ; it is higherin the 4-5 age-group than in the 14-15, higher in childrenthan in adults, and higher in all groups together (exceptthe morbid one) than in the morbid group itself. Atno age is there a significant positive correlation betweenthis displacement and the lateral displacement of thewhole toe-i.e., hallux valgus. It would be possibleto argue that the displacement of the terminal phalanxtipped the balance in the first instance, but was imme-diately obliterated when the proximal phalanx was dis-placed from the longitudinal axis of the first metatarsal.This seems a far-fetched defence of a hypothesis whichcannot well be substantiated without reference to theoccurrence of hallux valgus in the habitually barefoot.Data from barefoot peoples are, in fact, of such crucialimportance in this inquiry that we quote two pieces ofevidence which are of a significance out of all proportionto their numerical size.

Footprints, which give an adequate objective measure-ment of hallux valgus (though of almost nothing else),personally communicated from the north-east Transvaalshow hallux valgus of a fully pathological degree intwo women who had never worn shoes. This conditionis said to be not uncommon among the women of thetribes in that area. HaJlux valgus can therefore occuramong barefoot people, though in what proportionand with what symptoms is not known.A condition of hallux varus is also recorded among the

Annamites of French Indochina (Huard and Bigot 1943,Do-Xuan-Hop 1944). This condition, known as giao-chi, occurs in both sexes and consists of an angulardisplacement of the great toe medially for as much as90&deg;. It is also said to be associated with a widenedintermetatarsal angle.This evidence, slender though it may be, suggests

that the factors influencing the position of the greattoe must be sought elsewhere than in skeletal patternsand ill-designed footwear, though the role of -the latterin producing symptoms is hard to deny. Little isknown of the function of the abductor hallucis muscle,but it is clear that it urgently requires investigation.

SUMMARY

Evidence from standard radiographs of the feet of1851 school-children suggests that the deformity ofhallux valgus precedes widening of the first inter-metatarsal angle.A congenital widening of the intermetatarsal angle may

not be as important in hallux valgus formation as hasbeen thought.

The coefficient of correlation is an expression of the scatterof the plots of two variables on a correlation diagram. Ifthe variables are independent the correlation coefficient willbe zero ; if the relationship is linear the coefficient will be&plusmn;1, the positive sign indicating a rise in the slope of the linejoining the plots of ordinates and absoissse, and a negativesign a fall. Intermediate values of the coefficient indicatethe degree of approximation to a linear relationship. Thecoefficient of regression is an estimate of the slope of theline joining the plots of two variables on a correlation diagram.We wish to thank Prof. J. Z. Young, F.R.S., for his helpful

criticism ; the Shoe and Allied Trades Research Associationfor the grant which paid for the work ; Dr. W. G. Booth,medical officer of health, Area 7, Middlesex County Council,who made the inquiry possible, and his assistant, Dr. D. A.Craigmile ; the headmasters and headmistresses of the schoolsconcerned for their cooperation ; and all others who wereinconvenienced by our inquiry. We are particularly indebtedto Mr. P. Venning, M.S.R., for his radiographic work. Mr. N. A.Barnicot drew attention to the Annamites, and Mr. BancroftClark lent the footprints collected by Mrs. E. Krige innorth-east Transvaal.

REFERENCES

Do-Xuan-Hop (1944) Trav. Inst. anat. Fac. M&eacute;d. Indochine, 8, 1.Emslie, M. (1939) Lancet, ii, 1261,Hardy, R. H., Clapham, J. C. R. (1951) J. Bone Jt Surg. 33B, 376.Harris, R. I., Beath, T. (1947) Army Foot Survey, Ottawa.Huard, P., Bigot, A. (1943) Trav. Inst. anat. Fac. M&eacute;d. Indochine,

2, 51.Venning, P., Hardy, R. H. (1951) Brit. J. Radiol. 24, 18.

ACUTE SORE THROATCLINICAL FEATURES, &AElig;TIOLOGY, AND

TREATMENT

J. M. BISHOPM.B. Birm.

A. S. PEDENM.B. Edin.

T. A. J. PRANKERDM.D. Lond., M.R.C.P.

From the Medical Division, Military Hospital, Tidworth

R. H. CAWLEYB.Sc., Ph.D. Birm.

.. ACUTE, sore throat is common in temperate climes andcauses much loss of working capacity. It is therefore

important to discover a form of treatment which is atonce effective and economical.Some observers have reported benefit from sulphon-

amides, taken by mouth or insufflated into the throat(Freis 1944, Goldman and Kiesewetter 1946), and largequantities of these drugs are used in this way. Other

investigators, however, think that their value has notbeen proved (Rhoads and Afremow 1940, Anderson1949, Macdonald and Watson 1951). Penicillin has givenuniformly good results when administered systemically(Plummer et al. 1945), but is of little value in lozengesor pastilles.