I am afraid that the title of this short paper of mine is not sufficiently explicit, but I had some difficulty in choosing a title at short notice which adequately expressed what was in my mind. Most of us who have seen service overseas have come back firmly convinced of the necessity for team work where such is possible, and also of the necessity for our work to be more developed on special lines than it has been in the past if we desire to achieve two objectives, and they are, firstly, an improved service for the community and, secondly, the attainment of a higher degree of knowledge and efficiency for ourselves. The day has gone when the medical practitioner could hope to keep himself abreast of progress in all branches of professional activity, whether medical or surgical, and it seems to me that Orthopaedic Surgery, or that branch of Surgery which deals with the prevention and treatment of Deformities, whether such be congenital or acquired, must be treated as one requiring treatment by us in New Zealand as a special branch of Surgery. The knowledge which has been brought back to New Zealand by the various Officers of the New Zealand Medical Corps who have had special training in the United Kingdom in Orthopaedic work, and especially in the application of the various methods of treatment grouped under the heading of Physio-Therapy should continue to be made use of for the benefit of the civilian population of the country after the present pressing requirements of the returned disabled soldiers have been satisfied, and it is with this object I am venturing to address you this morning.

ln the past it has been difficult to attain good results in the treatment of deformities owing to a variety of reasons, the chief of which are:

1. The length of time taken and the continuity of supervision necessary to obtain good results. Many of these patients can not be kept sufficiently long in hospital owing to demands on beds, and those belonging to the poorer sections of the community cease to persevere with treatment in very many instances, with results disastrous to the patients’ chances of cure.

2. The inevitable tendency of many Deformities, after apparently successful treatment, to relapse unless kept under close and skilled observation.

3. The difficulty in the past which has existed in procuring appliances and proper splints for these cases.

4. The great difficulty which has existed in procuring efficient Physio-Therapeutic treatment. As you know, properly qualified masseuses or masseurs have been few and far between, and an atmosphere of semi-quackery had developed, especially regarding the electrical part of treatment, which was difficult to combat.

5. The fifth reason has been the very small number of surgeons qualified to treat these cases with success.

No branch of Surgery, in my opinion, is more difficult than that relating to Deformities, for, apart from the knowledge and judgment required in determining the type of operation required for any particular case, a very great deal has to be done in supervising and carrying out special work both before and after operation—e.g., all branches of physiotherapy, viz., baths, massage, electricity, gymnastics, S.R.E., and also special plaster work, splintage, etc. If a Surgeon can not give his whole attention to the pre and post-operative special treatment required for Orthopaedic cases and in ensuring that his cases get it, he is committing a surgical crime in operating at all. The difficulties which have been with us in the past can now, in my opinion, be overcome if we make proper use of our opportunities. As you know, efficient Orthopaedic centres exist at the Military Hospitals at Christchurch, Trentham, and Auckland, in the Military Wing of the Dunedin Hospital, and at the Military Hospital at Rotorua, and the staff and equipment of these centres should become part and parcel of our civil hospital organisation and not allowed to disappear as military hospital activities cease. This can be effected, I believe, in the following ways:–

1. As you are aware, a large number of masseuses have been trained here in New Zealand during the past two years at Dunedin, and latterly at Christchurch, Rotorua, and Trentham. They have been trained under close skilled medical supervision and the general standard attained has been satisfactory. As military work ceases, I consider, these masseuses should be stationed at every hospital in New Zealand, according to number of beds, size of district, etc. There they will be able to be of inestimable service in carrying out treatment in all types of recent injury, in dealing with the remote effects of injuries, and in applying the various kinds of Physio-Therapeutic treatment of many acute and chronic medical cases. They will, of course, act on the instructions of the various medical men concerned, and should also be available for work outside the smaller hospitals, should their time not be fully employed in hospital. In the past, as I have said before, Physio-Therapeutic treatment in New Zealand has been too much in the hands of the partially-trained individual, who has invested it in many places with the halo of mystery which so many of the public like and apparently desire. Now medical men will have the opportunity of dealing with masseurs who have been accustomed to working with medical men and who do not wish to do otherwise.

2. The difficulty of obtaining proper splints and special surgical appliances, which previously in New Zealand has been a very real one, can be overcome by the civil hospitals concerned taking over the splint shops, equipment, and staff and carrying on for themselves, the smaller hospitals in their districts, and for individual medical men. The splint-makers concerned are highly skilled men whose services must not be lost to the community. Two of them received a very special and thorough training at the M.O.H. at Shepherds’ Bush, and the result of this training is reflected in the character of the work, which you will have an opportunity of seeing in another room in the building during the week. Meanwhile, and pending the taking over of the workshops, it is proposed that in these shops splints, special appliances, etc., are to be made for any civil hospital or private practitioner requiring them. A circular has been prepared and is in process of distribution showing the way to get these splints and the prices which will have to be paid. This arrangement has been made possible by the Director-General of Medical Services and the Director of Vocational Training. Unfortunately the procedure which a private individual has to go through to get these splints is unnecessarily cumbersome, but nothing less complicated could be arranged, despite the best endeavours of the Director of Vocational Training and myself. In New Zealand we are prone to talk of red tape as though it were an exclusive possession of the authorities in the United Kingdom, but I can assure you that some departments in New Zealand have nothing to be ashamed of in comparison. An exhibition of splints, etc., is now being held in one of the rooms in this building, and it is hoped that everyone will take advantage of the opportunity thus presented of seeing the nature of the work which can now be done in New Zealand.

3. So far as the cases themselves are concerned, definite Orthopaedic departments should be established at each of our four large hospitals. Skilled Surgeons, skilled Physio-Therapy experts, Nurses, Orderlies well up in all details of plaster work, and Masseuses will all be available and should be used. The policy of concentrating these cases under the care of one or two men at each main hospital will, I am sure, be attended by the procuring of vastly better results than have been possible in the past. So far as patients from country districts are concerned, and especially the remoter districts, I hope that a scheme will be evolved which will provide for the gradual transformation of one of the military hospitals (e.g., King George V. at Rotorua) into a hospital where these cases can be received and treated. The vast majority of the cases will be children, and at a place like Rotorua they can, while receiving proper surgical treatment, also, when possible, be receiving their education and instruction in various handicrafts. The provision of a hospital like this is necessary, as these cases can not be treated properly in the smaller hospitals, and the large hospitals will have quite enough to do in dealing adequately with the cases of their own districts, where to-day many cases are receiving no treatment at all, and one of the first problems to be solved is the way to get into touch with the crippled or deformed child for whom much can be done, who is at present getting no treatment and urgently requires it. I do not think that the objection which will be raised to the taking of these children from their homes will hold good, for I am sure the majority of parents will only be too glad to send these crippled children anywhere, so long as efficient treatment is being provided. In this connection I would draw your attention to the paper by Sir R. Jones in the “British Medical Journal” of 11th October, 1919, in which he showed that in one single district at Home with a population of 671,000, one in every 594 of this number was a crippled child requiring treatment, and although these figures would require modifying for New Zealand, owing to the smaller number of deformities due to Rickets and Surgical Tuberculosis, even then it would seem that we have a very large number of cases hidden in our midst for whom something must be done. Sir R. Jones estimated that one bed should be provided for each 2000 of population; that for New Zealand means the provision of, roughly, 500 beds, so you will see that even for our small country the problem is no inconsiderable one.

It is with the object of stimulating interest in orthopaedic work generally that this short paper has been written.

I am afraid that the title of this short paper of mine is not sufficiently explicit, but I had some difficulty in choosing a title at short notice which adequately expressed what was in my mind. Most of us who have seen service overseas have come back firmly convinced of the necessity for team work where such is possible, and also of the necessity for our work to be more developed on special lines than it has been in the past if we desire to achieve two objectives, and they are, firstly, an improved service for the community and, secondly, the attainment of a higher degree of knowledge and efficiency for ourselves. The day has gone when the medical practitioner could hope to keep himself abreast of progress in all branches of professional activity, whether medical or surgical, and it seems to me that Orthopaedic Surgery, or that branch of Surgery which deals with the prevention and treatment of Deformities, whether such be congenital or acquired, must be treated as one requiring treatment by us in New Zealand as a special branch of Surgery. The knowledge which has been brought back to New Zealand by the various Officers of the New Zealand Medical Corps who have had special training in the United Kingdom in Orthopaedic work, and especially in the application of the various methods of treatment grouped under the heading of Physio-Therapy should continue to be made use of for the benefit of the civilian population of the country after the present pressing requirements of the returned disabled soldiers have been satisfied, and it is with this object I am venturing to address you this morning.

ln the past it has been difficult to attain good results in the treatment of deformities owing to a variety of reasons, the chief of which are:

1. The length of time taken and the continuity of supervision necessary to obtain good results. Many of these patients can not be kept sufficiently long in hospital owing to demands on beds, and those belonging to the poorer sections of the community cease to persevere with treatment in very many instances, with results disastrous to the patients’ chances of cure.

2. The inevitable tendency of many Deformities, after apparently successful treatment, to relapse unless kept under close and skilled observation.

3. The difficulty in the past which has existed in procuring appliances and proper splints for these cases.

4. The great difficulty which has existed in procuring efficient Physio-Therapeutic treatment. As you know, properly qualified masseuses or masseurs have been few and far between, and an atmosphere of semi-quackery had developed, especially regarding the electrical part of treatment, which was difficult to combat.

5. The fifth reason has been the very small number of surgeons qualified to treat these cases with success.

No branch of Surgery, in my opinion, is more difficult than that relating to Deformities, for, apart from the knowledge and judgment required in determining the type of operation required for any particular case, a very great deal has to be done in supervising and carrying out special work both before and after operation—e.g., all branches of physiotherapy, viz., baths, massage, electricity, gymnastics, S.R.E., and also special plaster work, splintage, etc. If a Surgeon can not give his whole attention to the pre and post-operative special treatment required for Orthopaedic cases and in ensuring that his cases get it, he is committing a surgical crime in operating at all. The difficulties which have been with us in the past can now, in my opinion, be overcome if we make proper use of our opportunities. As you know, efficient Orthopaedic centres exist at the Military Hospitals at Christchurch, Trentham, and Auckland, in the Military Wing of the Dunedin Hospital, and at the Military Hospital at Rotorua, and the staff and equipment of these centres should become part and parcel of our civil hospital organisation and not allowed to disappear as military hospital activities cease. This can be effected, I believe, in the following ways:–

1. As you are aware, a large number of masseuses have been trained here in New Zealand during the past two years at Dunedin, and latterly at Christchurch, Rotorua, and Trentham. They have been trained under close skilled medical supervision and the general standard attained has been satisfactory. As military work ceases, I consider, these masseuses should be stationed at every hospital in New Zealand, according to number of beds, size of district, etc. There they will be able to be of inestimable service in carrying out treatment in all types of recent injury, in dealing with the remote effects of injuries, and in applying the various kinds of Physio-Therapeutic treatment of many acute and chronic medical cases. They will, of course, act on the instructions of the various medical men concerned, and should also be available for work outside the smaller hospitals, should their time not be fully employed in hospital. In the past, as I have said before, Physio-Therapeutic treatment in New Zealand has been too much in the hands of the partially-trained individual, who has invested it in many places with the halo of mystery which so many of the public like and apparently desire. Now medical men will have the opportunity of dealing with masseurs who have been accustomed to working with medical men and who do not wish to do otherwise.

2. The difficulty of obtaining proper splints and special surgical appliances, which previously in New Zealand has been a very real one, can be overcome by the civil hospitals concerned taking over the splint shops, equipment, and staff and carrying on for themselves, the smaller hospitals in their districts, and for individual medical men. The splint-makers concerned are highly skilled men whose services must not be lost to the community. Two of them received a very special and thorough training at the M.O.H. at Shepherds’ Bush, and the result of this training is reflected in the character of the work, which you will have an opportunity of seeing in another room in the building during the week. Meanwhile, and pending the taking over of the workshops, it is proposed that in these shops splints, special appliances, etc., are to be made for any civil hospital or private practitioner requiring them. A circular has been prepared and is in process of distribution showing the way to get these splints and the prices which will have to be paid. This arrangement has been made possible by the Director-General of Medical Services and the Director of Vocational Training. Unfortunately the procedure which a private individual has to go through to get these splints is unnecessarily cumbersome, but nothing less complicated could be arranged, despite the best endeavours of the Director of Vocational Training and myself. In New Zealand we are prone to talk of red tape as though it were an exclusive possession of the authorities in the United Kingdom, but I can assure you that some departments in New Zealand have nothing to be ashamed of in comparison. An exhibition of splints, etc., is now being held in one of the rooms in this building, and it is hoped that everyone will take advantage of the opportunity thus presented of seeing the nature of the work which can now be done in New Zealand.

3. So far as the cases themselves are concerned, definite Orthopaedic departments should be established at each of our four large hospitals. Skilled Surgeons, skilled Physio-Therapy experts, Nurses, Orderlies well up in all details of plaster work, and Masseuses will all be available and should be used. The policy of concentrating these cases under the care of one or two men at each main hospital will, I am sure, be attended by the procuring of vastly better results than have been possible in the past. So far as patients from country districts are concerned, and especially the remoter districts, I hope that a scheme will be evolved which will provide for the gradual transformation of one of the military hospitals (e.g., King George V. at Rotorua) into a hospital where these cases can be received and treated. The vast majority of the cases will be children, and at a place like Rotorua they can, while receiving proper surgical treatment, also, when possible, be receiving their education and instruction in various handicrafts. The provision of a hospital like this is necessary, as these cases can not be treated properly in the smaller hospitals, and the large hospitals will have quite enough to do in dealing adequately with the cases of their own districts, where to-day many cases are receiving no treatment at all, and one of the first problems to be solved is the way to get into touch with the crippled or deformed child for whom much can be done, who is at present getting no treatment and urgently requires it. I do not think that the objection which will be raised to the taking of these children from their homes will hold good, for I am sure the majority of parents will only be too glad to send these crippled children anywhere, so long as efficient treatment is being provided. In this connection I would draw your attention to the paper by Sir R. Jones in the “British Medical Journal” of 11th October, 1919, in which he showed that in one single district at Home with a population of 671,000, one in every 594 of this number was a crippled child requiring treatment, and although these figures would require modifying for New Zealand, owing to the smaller number of deformities due to Rickets and Surgical Tuberculosis, even then it would seem that we have a very large number of cases hidden in our midst for whom something must be done. Sir R. Jones estimated that one bed should be provided for each 2000 of population; that for New Zealand means the provision of, roughly, 500 beds, so you will see that even for our small country the problem is no inconsiderable one.

It is with the object of stimulating interest in orthopaedic work generally that this short paper has been written.