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Are Textbooks Correct?

Textbooks particularly have a curious quality of the sacrosanct.  My colleague Prof. Green was giving a ward round to postgraduates when he was critically questioned by a resident.  The resident was well aware of this professor’s name when he blurted “but in Professor Green’s textbook it says something else, and therefore you are wrong!”

 Jargoneering is one form of misdirection.  The correct English term is jargonizing, but jargoneering has a better feel for me, as it relates phonologically to engineering which implies that it is a deliberate construct rather than a style or inadvertent habit. It seems to penetrate almost every aspect of the para-medical literature.

What possible usefulness does a photograph of an MR scanner have in a book about podiatric surgery?  Likely it has been inserted to give the author credibility by implying “This author is sufficiently qualified, experienced, and entrenched in the medical profession to know all about MR scanners, and to prove it here is a picture”.

I have often wondered whether the authors of textbooks have actually encountered the conditions they talk about and performed the surgery which they describe. The following is an illustration from a textbook of orthopaedic surgery.  I think it prudent to not give credits.

 hallux-hammer-preop-corrected2

This illustration purports to explain the mechanics of a “hammered” great toe.  It is nonsensical of course, because if over action of the extensor tendon was the culprit, the result would be as in my illustration below. 

 hallux-hyperextension

 

 

Matters get worse when the text describes lengthening of this tendon in order to “correct” the deformity.  Since one of the prime functions of the extensor tendon is to straighten the interphalangeal joint, lengthening the tendon (and so rendering it less active) will worsen the deformity, with the risk of a toe which (dangerously) catches on the floor or carpets.

 hallux-post-op-corrected2

 

 

Has the author done the surgery which he advocates? If so, how is it that he does not recognize that his surgery has failed? 

 

The next picture is an incision recommended by the same author. 

dorsal-incision-true2

Linear scars tend to contract if placed axially over a joint, and can inhibit future movement.  This scar will abrade against the shoe, particularly if the clawing of the toe increases.  It does not take much experience of operating on  toes to recognize that transverse incisions heal better, scar better, and better meet the foundation principles of incisions. At worst a curvilinea or zig-zag would be a better compromise. Note how the incision divides the gernerative matrix of the great toe which will cause a permanent deformity of nail growth.

Like many attributions to authority it is widely believed that text books are “correct”. I often hear the comment “Medical books must be correct! It is so important that medical information is exactly right. The authorities must keep a check on things like this. Someone must be ensuring that this information is appropriate.”

Much of human belief rests with illusionary, intangible “authorities” and the etherial “someone-who-must”. It is this misplaced belief in the “higher powers” of administrations and administrators which allows damaging perpetuations of faulty practice, whether economic, societal or in healthcare.

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2 Responses

  1. In your articles you don’t recommend osteotomy surgery to correct a long metatarsal. What would you recommend. I was told by a podiatrist that I had a long 2nd metatarsal that need to be shortened (morton’s toe) and that bunion surgery that I had 20 plus years ago (in my 20s) may have contributed to the toe being too long. I have also developed a small morton’s neuroma between the 2nd and 3rd toe. suggestion is to remove the nerve or decompress it using DEIN or MIND and to shorten the 2nd metarsal.

    • The advice you have been given seems to be the standard jargon (and perhaps not any more meaningful than that).
      I have commented else ware on this site about “Morton’s Toe”, and given reasons why I believe that it is irrational.
      The (again almost universal) attribution of pain under the second metatarso-phalangeal joint (feel carefully, and you will probably agree) to a neuroma is not convincing. “Morton’s Neuroma” has probably also been addressed in the web-site, but to summarize it can only occur in the third/forth web space for very definite anatomic reasons. Incidentally it is not a “neuroma” but an irritative, trauma induced neuritis. It reflects the functional derangement of the foot as a whole, and the treatment is the treatment of other aspect of an “unbalanced” foot. It is difficult for me to justify these assertions without being long winded (and best with illustrations). I will try and assemble a more detailed, and illustrated, post given the opportunity in the future.
      I would not allow anyone to shorten my metatarsal (especially as there is a very rational and manageable alternate explanation), and would not let any foot=and=ankle surgeon meddle with any interdigital nerve in my foot (again because there is a rational and easily manageable alternative)

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