Hector Kay Lecture, May 19.1999, St Petersburg Fl.

Hugh G. Watts, M.D.


I want to thank you all for the honor and privilege of speaking to you this morning. Let me start by speaking of Hector Kay. I think 1 am the first Hector Kay Lecturer who did not personally know the man. But I know what he represented. He was the champion of the idea that children with limb deficiencies are best treated by a clinical team. ACPOC is the fruition of that ideal. The fact that I am the first Hector Kay Lecturer who did not know him personally tells you that our organization has grown older. Bob Fielden, our distinguished president, has recognized that we are changing. With this in mind, he asked me to give this lecture with the following instructions... "Talk to us about the present and future of ACPOC. Give us some direction as to which roads to follow to maintain, not only the viability of ACPOC, but of Children's care into the next millennium".

Bob wants me to be a soothsayer. I thought of consulting the fortune tellers of the National Inquirer but had second thoughts when I read about the aliens soon to invade our brains. I figured that I would just have to wing it myself.

While Bob asked about "roads to follow" (showing a mid Western land-based point of view) my bias is not to roads, but to the sea. So that is where I looked to for my metaphors.

When I told my wife that I would be talking about sailing, it put me in mind of an old joke. (I know it's an old joke but I'll tell it to you anyway.) A clergyman was having some difficulty coming up with a subject for his Sunday sermon. Finally, he decided that he would talk about the importance of sex in marriage. It turned out that his wife was unable to hear his sermon so at dinnertime she asked him "What was your sermon about this morning Dear?" Since his wife was rather a prude, he felt a bit embarrassed so he told her that he talked about sailing as a metaphor for religion. The next day while out shopping the clergyman's wife ran into a parishioner who gushed to her "What an absolutely marvelous sermon her husband had given the day before". The clergyman's wife replied. "Well I'm surprised, since he knows so little about it. He's only tried it twice. The first time he got sick to his stomach and the second time the wind blew his hat over his eyes and he fell off."

Back to our lecture... We are on a journey across vast seas. To where? Where do we want to be in 2025?

I have no doubt that ACPOC will be there in 2025 (as will many of you). But if we don't ask the question "Where do we want to be" we may end up like Christopher Columbus... When he set out, he didn't know where he was going; when he got there, he didn't know where he was; when he got back, he didn't know where he had been (For those of you who are not surgeons, this is what we say about some of our colleagues who have floundered through an unfamiliar operation.)

What is needed for a successful voyage? The important elements are...

  1. Goals that are Shared by the Entire Crew;
  2. A Spirit of Adventure;
  3. Good Navigation and
  4. A Seaworthy Ship with Stalwart Crew:

Let us examine these... in reverse order. How seaworthy is our vessel, the good ship ACPOC? How stalwart our crew? Our strength is our unique shared interest in the child who needs a prosthesis or orthosis. We are multidis-ciplined. Nowhere else is there such strength and coordination of the many disciplines needed for good care of our patients.

But now let us look more closely at some of our weaker points:

1.
Are we multidisciplined enough? We are low on involvement with our consumer organizations. Many of you have individual connections for example with the Amputee Coalition, but as an organization our ties are weak. They need to be strengthened.

There are other specialists who are underrep-resented. Rehabilitation engineers and those interested in Mobility and Seating; Nurses, Social Workers and Clinic Coordinators. We need to plugs those gaps.

2.
We are a small organization and probably always will be. Yet we have a big task. Should we work to become bigger? I think not. Our concerns are very focused and searching for a larger group of people with lukewarm interest will not make us mightier.

But we could be stronger if we involved those of our members who are non-attenders. Look at the back of your programs sometime. Examine the list of Teams. You will see many who are seldom, if ever, participants at out annual meetings. They are glad to have their names on the membership list since that gives them an official status as specialists. For them it is a marketing ploy. Do we let them continue this free ride? We are particularly low on involved physicians. We have lost the old guard of enthusiast, experienced orthopedic surgeons: Leon Kruger; Les Myer; Bob Tooms to name a few. And Keith Van-denBrink has moved to his farm. And there are others of us who are getting long in the tooth.

We are competing with other organizations for the time of busy orthopedic surgeons. We must work at attracting their attention. This may mean considering a change in our meeting-time away from that selected by POSNA. POSNA, the Pediatric Orthopedic Society of North America met just this past Sunday till Wednesday in Orlando. Most ACPOC orthopedic surgeons are also POSNA members. Many feel that they cannot give up ten consecutive days away from their work.

In some respects, the juxtaposition of the POSNA and ACPOC meetings worked this year in our favor. If you look around, there are a large number of the younger orthopedic surgeons at our meeting today. However, I seriously doubt that following the 2001 meeting in Cancun, Mexico that we will have much of an orthopedic turnout for ACPOC. I don't know what will happen next year between Banff and Vancouver. Regardless, I think that we need to give very careful consideration to how we fit together with POSNA. Why should we consider changing? Why not POSNA? Their organization is five times larger and has a longer history. And frankly... they don't have a problem. We do.

We need a lot of young blood. Getting young blood will require active recruiting and encouragement by the more senior of us in the organization. We need to do this in a planned and vigorous way.

Orthopedic surgeons in the past had more training in the non-surgical aspects of musculoskeletal care. With that training came an interest in rehabilitation which, sadly, is not as prominent today. We need to replace that faded interest in rehabilitation in other ways. The education committee has worked hard to set up a course aimed at Orthopedic Residents. This effort has culminated in a course to be held in Atlanta in August of this year, and we are particularly in debt to our colleagues at the Atlanta Scottish Rite Hospital for their work and willingness to put this on. I expect that Colleen Coulter-O'Berry was a major tornado in the process.

But we need to do more. We need to be able to prove that it is in the best interests of the children we treat that Orthopedic residents need more training in rehabilitation in general and Prosthetics and Orthotics in particular. We need to infiltrate the AOS, (the Academic Orthopedic Society) to get the message to the heads of the residency programs. That will not be easy, but needs to be done. If they are convinced, they will be able to convince the Orthopedic Board of Examiners. If the Board is convinced, they will make any lack of knowledge on the part of Orthopedic Residents the cause of great discomfort when they go to take their exams.

While ACPOC had its beginnings as a group of Orthopedic Surgeons, we have been parochial in not encouraging Physiatrists and other physicians who have a special interest in our field. We need to change that. We will gain strength by cooperation not competition.

So much for the physicians. In the fairly near future, we will start loosing some of the most influential contributors in our other specialty fields: Physical Therapy, Occupational Therapy, P&O. I won't name names. That might offend them rather than compliment those I'm thinking of. They may think, that I think, that they are old cronies like myself. But we must be looking to foster the junior members in these fields. Again, this needs to be done in an active, planned and vigorous way.

Like most of the old timer orthopedic surgeons, I bemoan the lack of knowledge in Prosthetics and Orthotics demonstrated by Orthopedic Residents, the Physical and Occupational Therapy Schools are also seriously at fault. Most schools of Physical Therapy currently have little or no formal teaching in Orthotics. This slack has been taken up by central fabrication Orthotic businesses who give courses around the country of dubious scientific virtue. Many young PT's have become slaves of those businesses, and are convinced that the various orthoses, especially for children with Cerebral Palsy, have merits which have not been demonstrated scientifically. I believe that this has been a major contributor to the rancor that is all too frequently seen between PT's and Orthopedic surgeons across the USA. To combat the problem, the Education committee needs to look at this part of the problem as well, and see if there are ways that PT and OT institutions can be made aware of this deficiency.

3.
Another weakness is that ACPOC has many members who cannot afford to come to the meeting frequently enough. More often it is the younger therapists and researchers. They have to convince their parent organizations, or their grant funders, that their involvement is vital. These institutions have become very tight fisted. We need to explore ways to make it cheaper for them to attend. Perhaps we need to ask those wealthy physicians for a greater share of ACPOC's costs, or ask more from those teams who use the ACPOC name as a credential without participating in the activities. Perhaps that means raising dues while lowering the registration costs. Could we convince corporations (especially those in the rehabilitation fields) to sponsor individuals?

4.
ACPOC doesn't have much money. And probably never will.

Should we try to change this? Should we go out and try to raise money? I think that in a very small organization like ours, such an effort is unrealistic.

We need to stand back and recognize what these "limitations of size and wealth" bring and to work within them.

For example, we cannot directly fund research in any meaningful way. How can we stimulate research if we can't pay for it? We can provide advice concerning what we see as major needs and deficiencies. The Research committee needs to canvas the members for ideas.

In addition... Can we not help each other with grant writing? Grant writing is both a talent and a learned skill. Some of you have had a great deal of experience and success in your grant writing. Others are painfully naive. I am reminded of an event where Dr. Michael Sussman (who is the Chief of Staff of the Shriners Hospital in Portland, and a very successful grantsman) talked to a group of us at a Shriners Surgeons meeting. He offered his time to review our grant applications prior to their submission. He offered to advise us how better to succeed. Perhaps several experienced ACPOC members could be dragooned into a similar activity.

I should modify what I said before about raising money. Young people need seed money. There is a catch 22 in doing research. You need some preliminary results before a granting institution will give you money. But you need money to get some preliminary results. It's rather like a bank... where you have to prove to them that you don't need the money before they will lend you any. $5000 would go a long way to get someone started. Do we have it in our budget? Perhaps... we will have to ask our treasurer. More likely not. Our president should designate several persuasive members to go out and see if someone in the corporate world would be willing to provide the money for one or two small grants available each year to be designated for young investigators in our organization.

Another consequence of being a small organization and one without huge financial backing... How do we make enough noise? How do we let others know we are there so we can make changes for the better? We can't afford to lobby financially on behalf of our patients. So I suggest that we do as we did when we were kids and threatened by a bully. Hide behind a big guy. Use the powerful organizations... the American Academy of Pediatrics for example. They are a very strong organization that successfully lobbies on behalf of children. The American Academy of Orthopedic Surgeons, the O & P Academy, and the PT and the OT Academies are other possible sources of assistance.

To do that means that we have to get dedicated ACPOC members meaningfully into their organizational structures. I think of Dr. Michael Goldberg, a pediatric orthopedic surgeon from Boston, who as a member of the American Academy of Pediatrics, became one of their leaders and was able to promote issues which were important to the Pediatric Orthopedic Society... a society that was too small itself to provide strong influence on its own.

While POSNA is not a large organization the way the American Academy of Orthopedic Surgeons is, it is the central most powerful organization in the world of pediatric orthopedic surgeons. We should think about some ways in which we can grab onto their coat tails. POSNA, by converse, should be convinced that we, ACPOC, represent the central force for children's prosthetics and orthotics, and have them turn to us, rather than to the Prosthetics Committee of the AAOS which seems to have become stuck on adults and done nothing of value for the children.

On the same topic of being heard... should we court people of influence in the various disciplines present here? I think we should. All of you know people in your specialty who seems to have a unique talent for influencing others. Search them out. Get them involved in OUR activities. One ploy is asking them to give talks at our meetings. They are usually flattered to do so, and once introduced to what we do... they may become excited by what they see Let us turn to Navigation:

Good navigation requires that you know your starting point. A time-honored adage in navigation is that "You don't know where you are, unless you know where you started from". Last year's lecture on The History of ACPOC was important. But we are loosing the "Old Timers" who lived the history. And oral history fades. We need a written legacy to pass to those coming along. Like rowing... we move ahead, looking backwards.

Stars to guide us... Roy Porter of the UK, a Professor of the Social History of Medicine said that "The historical record (of medicine) is like the night sky: we see a few stars and group them into mythic constellations. But what is chiefly visible is the darkness"

Because of the darkness, we particularly need stars to guide us. That brings us back to developing our young leaders. In all of the fields represented here. Not only do we need to encourage them early on with responsibilities on the ACPOC Board and its committees for example, we need to encourage them to write. They may be smart. They may be good but they need to write if others are to recognize the talents and use them as guides. They are all busy and writing may be far from the top of their list of most important tasks. They need to be pushed.

We need to involve the young talent. Our committees do not have a mechanism to require rotation of members. That needs to be changed so that more members participate in the committees. That way we will be developing the leaders that we will need in the years ahead.

A Spirit of Adventure How to engender excitement? I don't have an answer... except to infect each other whenever we're together. Perhaps more communication between meeting via the Internet would keep our juices flowing. Gene Banziger's good work on the Newsletter might be enhanced with an on-line discussion group or List Server. That will take a lot of time from an interested computer junkie. Surely we have one amongst us.

Let us turn our attention to Goals. This is a central issue:

Are our goals shared? You want to sail to Tahiti but I want to sail to the Galapagos Islands. Will that work? Obviously not. How do we minimize the problem? We need to talk about it! Not just at the Board meetings nor just in a Long Range Planning committee but in the general meetings with time for involvement, questions and discussion. We need to do it often, not just once every 5 or 10 years. I applaud Bob Fielden's recognition of this need and his use of this Hector Kay lecture as a forum among all the members to stimulate us to look more directly into our future.

We would all agree that we are interested in... The Care of Children with prosthetic and orthotic needs; The Teaching of the principles of this care; Research to make things better and Communication with anyone who will listen.

We are still confused about the role of TEAMS in our organization, versus the part to be played by individuals. Once again at our Board meeting Wed evening the issue was debated. The program yesterday was an ample demonstration of the vitality of the team concept and the importance of the many roles that need to be played if our children are to be well served. I believe we are the only organization where teams are the central members. This provides no role models, and we tend to wander at times. We should invite individuals to feel welcome and be full participants. But the TEAMS must remain central.

What GOALS might we be overlooking? I would like to mention several things. Obviously they represent my personal biases and interests. None-the-less, it is my laundry list for you to look at as a starting point. Make your own lists and talk about them amongst yourselves. Then let the members of the Board know. This is an organization of its members. You have to let your Board know what you want.

So here's some of the things on my list...

1.
Are we adequately focused on the most relevant issues? This group's earliest beginnings were meetings of the Amputee Clinic Chiefs. It was started as an organization of orthopedic surgeons directed to the better care of children with missing limbs who needed prosthetic care. When Leon Kruger reorganized us into ACPOC we widened our mandate to include children with orthotic needs. Yet truly, orthotics in this organization has been the neglected sister. If we look at the need, there are many more orthoses used than prostheses. If you look at our programs, there are many more talks devoted to prosthetics. We need to make an effort to include more orthotic problems in our programs.

If we look at prosthetics, there are many more users of lower extremity prostheses than upper. Again, our programs have been more commonly directed to the upper extremities. Children are incredibly tolerant of most anything you put on their lower extremities. Should this blind us to an interest in making things better? Are all the lower extremity prosthetic issues solved? Are partial foot problems gone? I have no doubt that some of the high tech feet popular with many amputee athletes can improve their function. The urge to be high-tech has lead to their wide spread use in non-competing children. Do they improve function enough in children in their regular daily lives for us to push the payers to foot the bill? Maybe so. Then let us prove it and use them. If not, we should not become slaves to the latest technology. We must be fiscally responsible if we want third party institutions to pay for items that we know are necessary for the children.

2.
"Outcomes": Realities not Hype "Outcomes" has become an "In" term. If you use term "outcomes" in the title of your paper it almost ensures acceptance for publication. But we need more than "in" terms.

Our focus on children has fogged our vision of what happens when these children become adults and even retirees. We need genuine long run follow up. And when I say "long run" I don't mean 2 to 4 years, or even 10 years, but 20 to 40 years, or more. Efforts, such as that being done now by Mary Clark, should be encouraged and emulated. She has been travelling around the country interviewing adults born without arms to see how they function when they try to be independent.

This brings up one of the major areas of disagreement amongst us here... the extent to which children really use their upper extremity prostheses in the long run. As more information becomes available about the high proportion of congenital upper extremity amputees who discard their prostheses, many are getting discouraged about the wisdom of providing prostheses at all. Before Tony Herring organized the meeting on the Limb Deficient Child last year he was convinced that upper extremity prostheses for the congenital amputee were virtually never needed. Is that really true? Do we assume that the provision of the prostheses is just a necessary psychological process for the child and family to go through, even if they are not ultimately worn? Do we give up on upper extremity prostheses? No! If for no other reason than Sheila Hubbard would shoot us all. Can we do better? Would sensory feedback help? This is an area we need to come to agreement on if we are to help the parents of the children for whom we care. I will talk more about this in a few moments when I discuss the brain.

If we are ever to come up with conclusions of value, we need to share data. Multi-institution trials are a trial. We need to recognize that the problems are more social than scientific. Multi-institution trials tend to collapse under the weight of the attitude... "What's in it for me?" One way to help in this is to recognize that if the other person will help you with your project, then you ought to help her in return when she asks you to participate. We are a small enough group who mostly know each other. We should be more likely to make it work than with larger organizations.

3.
Internationalism: This is a favorite topic of mine, as most of you know.

Are we doing all that we should? We are the Association of Children's Prosthetic and Orthotic Clinics. Nowhere does this say "American Children" or even "North American Children". Should a child in South America or South East Asia be any less important to us? I think we all know that the need is great. I've spoken of it to you before.

Let us look at some specifics. The isolated caregiver. I manage a Discussion Group on the Internet for Pediatric Orthopedic surgeons. One thing that has struck me is the great interest shown by those orthopedic surgeons in some of the most distant countries. For them, the connection may be their only one to people of similar interests. If you are the only pediatric orthopedic surgeon in your city, or even maybe in your entire country, such communication may break the isolation. Why should that be different for someone looking after a limb deficient child, for example in Bangladesh? An Internet discussion group may be useful. This takes work to manage, but surely we can do that.

The isolated care needer. The same can be said for the family from an isolated country who is looking for help for their child. For these Families, having a place on the Internet can be their only source of information. The ACPOC web site, so ably established by Kathy Schroeder (and thanks too for her husband's help) is a beginning. But we don't have an adequate system for responding to people who turn to the ACPOC Web Site. We need a system whereby knowledgeable people can be asked to reply . These people may need to reply directly, or have a referral network to which the requester can be transferred. We need to learn what facilities are out there that available around the world.

Research: I have often quoted an item that came across the Internet a few years ago from the library of the University of California in San Diego. They suggested that we look at the world as if it were a village of 100 people and all the statistics would be represented as the number of actual people rather than as abstract percentages. I would like to quote just one item from that list. If there were such a village... "

one half of the wealth of the village would belong to just six people. All six, would be citizens of the USA."

What about the problems of the other 94 people? Those people clearly do not have the financial resources to set about establishing research programs relevant to them. They are more concerned with finding food to eat. Any research programs set up by those wealthy six people will likely ask questions which are only relevant to those six.

For this reason, I think we should be looking at some research problems which are relevant to those overseas which they don't have the resources to pursue... a foot that is cheap and will last more than a year for example.

Coordination: There are a lot of you who are involved in projects around the world. It would be helpful if our organization set up a mechanism to keep information on who is doing what so other that interested members can participate when time and circumstance allows.

4.
Let us turn our attention to PREVENTION. We should become more proactive in preventing problems. For example traumatic amputations in children. Dr. Mervyn Letts, of Ottawa, Canada, has always been a strong proponent of us having a greater interest in prevention. It was his comments at the Limb Deficiency workshop last year in Dallas, which encouraged us in ACPOC to pursue, with greater vigor, the idea of establishing a database of childhood amputees. By doing so, we could, for example, find out the number of children who suffer an amputation as a result of outboard motor injuries while swimming or water skiing. That way perhaps we could champion better ways to avoid such injuries.

We should do more. Nationally and Locally. Internationally we can start by resisting the proliferation of landmines. As you know, this is a subject of special interest to me and one of which I have spoken to you about. Let me remind you. There are over 100 million landmines buried around the world waiting to maim and kill. And there are another 100 million in storage yet to be laid. This is a moral travesty far, far greater than the recent tragic shootings in a Colorado school, about which the nation has responded to with horror. But bear in mind that the 100 million landmines represent two thousand five hundred Littleton shootings each and every day since the birth of Christ two thousand years ago.

5.
I will get down from my soapbox and move onto Sex. Another of my favorite topics. There is the old saying... "If you're not thinking about sex, your mind is wandering". Our minds have been wandering. We are terribly inhibited by our squeamishness about sex. Do we discuss the problems that amelic children might have with masturbation? "Masturbation?". After all, masturbation, in one form or another, is considered part of normal development. Adult amputees do discuss issues of sexuality amongst themselves. Do the patients we care for suddenly go from childhood to adults overnight on their 21 birthday? Who is going to talk to them on this? Ohh no! Not me! That the other person's job.

It would be wrong of me to imply that none of you take on this responsibility because I know you do. But it should not be an isolated event in a few clinics. The issue is rarely raised at our meetings. The last time I recall hearing the topic discussed at our meeting was about 15 years ago when I raised it. At that time I was denigrated for my lack of imagination when I showed surprise that a quadrimem-bral amelic young man had fathered a child.

Let's move on...

6.
Under served Children:

Because of our beginnings (which were in the management of children with limb deficiencies) we have tended to overlook a number of children with other problems whom we could help. Children who do have special interest organizations such as those with Cerebral Palsy or Spina Bifida get support. However there are others who do not. Children with Arthrogryposis and TAR Syndrome may be born with limbs but those with severe involvement have to function in their lives as if they were amelic.

There are other children, for example those who have Skeletal dysplasias who can use our help and interest. We should broaden our horizons.

7.
The Electronic Revolution: Hype or hope? I have already alluded to the Internet on several occasions. It has its virtues, but also it's problems. We need to differentiate between Information and Facts. Let me turn for a minute to talk about music. What is Music? Music is the organization of sounds into a related and interesting composition which generally pleases the ear. Without proper organization we call a series of Sounds "Noise". By this analogy we can recognize "Information" as the analogue of "Music" while a whole mess of "facts" is really nothing but "Noise". The more unorganized facts there are, the greater the Noise.

I'm reminded of a very intelligent family who came to me for a consultation concerning their son's scoliosis. They had looked up reams of stuff on the Internet about scoliosis. They were very well informed. They had it all printed out in their hands. They were very well informed concerning Idiopathic Scoliosis. However their son turned out to have a Congenital Scoliosis. Virtually all their handful of papers were irrelevant. Worse yet, the Internet just contributed to making them very confused.

We have to help each other and our patients and their families to make the differentiation be- tween information and noisy facts. We have to listen for the Music.

In spite of that warning, we do not want to overlook the great potential that electronic communication has to offer... especially in teaching. It becomes more of an issue for many of our patients who have limited use of their hands and may rely on computers for communication.

We are a small group of experts. Our patients are often far flung even in the USA. Is there a role for tele-medicine. Yesterday we heard an excellent presentation by Ed Biden. Clearly there are some large issues that need to be sorted out before telemedicine becomes widely used.

Perhaps, Mr. President, there are enough ways in which electronic communication will become a staple of our diets that there ought to be a gathering of those interested, and knowledgeable, to make sure that we are kept abreast of the ever changing possibilities.

8.
The Mind as the Central Controller: Are we overlooking Research because it doesn't seem to be relevant? The past decade was the "Decade of the Brain". Especially over the last few years, there has been an incredible explosion of information on how the Mind Functions. By now, most people have heard about the different roles that the left and right brain hemispheres play. And the importance of the corpus callosum in connecting the two hemispheres. But did you know that men and women tend to use different parts of the brain to solve a mathematical problem? How can the neurophysiologists tell? By PET scans and functional MRIs. PET scanning, Positron Emission Topography is based on the simple idea that for cells to function more actively, they need energy... that is glucose. Cells, which are more active, use more glucose. If you could track which cells are using more glucose you could tell which cells are busier. And indeed, this is exactly what is done. Radioactive glucose is given to subjects and their brains are scanned while the subjects perform a task or a process of thinking. Functional MRI's do not require the use of radioactive glucose and give even better resolution but at this time, they are a great deal more expensive.

In the past, we learned about important areas of the brain by studying the loss of function after disease or trauma destroyed specific parts of the brain. Now the scanning techniques have sharpened the resolution. When a person speaks Broca's area (on the left side of the brain in the Parietal region) "lights up". "Lighting up" is the colloquialism for an area that shows more activity than the surrounding areas of the brain. Interestingly, if you are bilingual from childhood, Broca's area lights up whenever either language is spoken. However, if the second language is learned as an adult, a totally different area is used.

In children who are born deaf and learn to communicate by sign language, they find that when they are, so to speak "talking" with their hands, Broca' s area lights up. Fascinating.

Children who are blind from birth and who learn to read by Braille develop the area in the brain, which represents the index finger tip to a huge size.

By the converse does a child with Arthrogryposis, who has very limited use of the hands have decreased representation in the brain for those hands? I don't know.

We are all aware of children who have amblyopia. .. crossed eyes, who are treated by patching the good eye. The theory (which appears to be born out in practice) is that as a result of the crossed eyes, the brain sees two images, which are not superimposed. The mind finds that confusing. It therefore represses the messages from the less dominant eye. The result of the chronic suppression is that the cells in the occiput which process the non-dominant eye images become defunctioned and eventually can't see. We call that cortical blindness. The eye is capable of seeing images, but the brain does not recognize the images that are transmitted. Does something like this happen following severe birth palsy? There is some evidence to suggest so.

Do children who are born with a limb deficiency have brain representation of the missing part? Or is there a "virtual" representation of the missing part waiting for messages to come, but waiting in vain. So it never adequately develops. Could our children with an absent hand have what we might call cortical blindness of the hand? Might that explain why so many of these children wouldn't use a prosthetic hand functionally? Perhaps like those of us, who have learned our second language as adults, such children must use a different part of the brain with resultant less facility. Can another part of the brain be trained to "take over" when we apply a prosthesis? Does this suggest to you that we need to learn more about how the mind learns new motor skill that are not, so to speak "natural"? Could we screen our patients to find out which ones are likely to use prostheses? I don't know the answers to these questions. Then again, I don't think that anybody else in this room does because the questions haven't been asked, let alone tested. Do you think some of us ought to look into the issue?

Well that's my list...

  • Let me review what we have done during this lecture.
  • I have asked you to plan this mythical voyage with me across uncharted seas.
  • We have looked at our ship, the ACPOC, and found that we are small and definitely not a luxury yacht.
  • We have examined the consequences of these limitations.
  • We have looked at strategies that might be used to make up for these limitations and...
  • We have looked at some goals that we may not be meeting adequately. I have tried to titillate your imaginations about the possible role of the brain.

ACPOC will be there in 2025. However, we cannot drift aimlessly across the water and expect success from the journey.

We must look ahead and plan together if we expect to get somewhere worthwhile. Thank you

Hugh G. Watts, M.D.

Shriners Hospital for Children, Los Angeles, Ca. USA