()ld and Neglected Deformities Following 
Infantile Spinal Paralysis. 
RY 
STEWART LEROY McCURDY, A. M., M. I). 
PITTSBURGH, PA., 
Surgeon to P. C. C. & St. t,. Ky.j Professor Orthopedic Surgery, Ohio Medical University ; 
Orthopedic Surgeon Protestant Hospital, Columbus, Ohio; Member American 
Orthopedic Association; Treasurer Ohio Association of Railroad 
Surgeons; President Ohio Pediatric Society; Mem- 
ber American Medical Association, Etc. 
Read before American Orthopedic Association. 
REPRINT FROM 
COLUMBUS MEDICAL JOURNAL, 
June, 18‘)4. OLD AND NEGLECTED DEFORM!TIES FOLLOW- 
ING INFANTILE SPINAL PARALYSIS. 
Surgeon to P. C. C. <fc St. L. Ry.; Professor Orthopedic Surgery, Ohio Medical Univer- 
sity ; Orthopedic Surgeon Protestant Hospital, Columbus, Ohio ; Member 
American Orthopedic Association; Treasurer Ohio Association 
of Railroad Surgeons; President Ohio Pediatric 
Society ; Member American Medical 
Association, Etc. 
STEWART LEROY McCURDY, A. M., M. D., PITTSBURGH, I’A. 
Read before American Orthopedic Association. 
The orthopedic specialist seldom sees a case of anterior 
poliomyelitis of infants during the acute attack, and he is sel- 
dom* called until marked deformity exists. If a specialist is 
called to consult with the general practitioner during the early 
course of the trouble, it would very naturally be the neurologist 
instead of the orthopede. These cases are found almost every- 
where. In every small town you will find what the local pro- 
fession will say are hopeless incurables, either crawling about 
on their hunkers, or hauled about in carriages, etc., and the 
friends of these unfortunates take it for granted that nothing 
can be done for them. On the contrary, they are the cases that 
are the most promising, and the deformity is the most quickly 
corrected. By this I do not mean to convey the idea that the 
surgeon experiences no difficulty in the cure of this trouble, but 
as compared with other classes of deformities ; for instance, of a 
congenital talipes equino-varus and a paralytic equino-varus of 
ten years’ standing, the latter deformity can be more promptly 
corrected. In the congenital deformity, mechanical treatment 
will generally be relied upon, and the stretching of tendons by 
appliances and holding them in position by the same method, is 
a procedure that requires time. In the paralytic cases, on the 
other hand, mechanical treatment is out of the question, and 
the operative treatment must be resorted to. By the operative 
treatment I do* not mean that in cases of subluxation at the 
knee an osteostomy is always necessary, or indeed is it always 
necessary to do an osteotomy; or in an old case of club foot, it 
is but rarely necessary to remove a wedge-shaped piece of the 
foot, or to enucleate the astragalus. 
The general surgeon is more likely to correct the deformity 
at oue sitting; the instrument maker, in whose hands these 2 
cases very frequently fall, depends upon braces entirely. The 
orthopede fills in the chink between the general surgeon and 
the brace maker, and gives patients the benefit of both of the 
foregoing extremes, and, in addition, bridges the chasm that 
must necessarily otherwise exist. 
It is seldom necessary to destroy the bony continuity of a foot, 
even in the worst cases of talipes, but it is a common occurrence 
for general surgeons to do a cuneiform osteotomy through the 
tarso-metatarsal joint, or to enucleate the astragalus. But'sub- 
Fig. 1 
A. 
B. 
c 
cutaneous tenotomy and a Thomas wrench are generally suffi- 
cient. It is seldom necessary to more than do a subcutaneous 
tenotomy of the ham-string in subluxation dependent upon 
false anchylosis, but the general surgeon would expect to com- 
pletely restore the limb to parallelism at one sitting, regardless 
of the extent of the operation. 
Experience has demonstrated to me the wisdom of making 
haste slowly in the restoration to the normal of joints that have 
been in abnormal positions for years, 3 
Case 1, Fig. A.—M. C., aged 17. When two years old had 
an attack of anterior polio-myelitis with sudden onset, high 
fever, convulsions, etc., after which he was completely paralyzed, 
i. e., paralyzed of both upper and lower extremities. This 
paralysis was continuous until he was about four years of age, 
when he began to have some use of his arms and legs. The 
right arm gained more rapidly than the left, and the left arm 
more rapidly than the lower extremities. When treatment was 
begun, 14 years after the onset, he was crawling around on his 
hunkers, as he had been for all these years except during the 
past two or three when he had been riding in a tricycle. As 
shown in Fig. 1—A, he had an exaggerated talipes equino-varus 
of the right foot, which could not be corrected by manipulation, 
and a subluxation of the left knee at an angle of 45 degrees 
Fig. 2. 
(Fig. 2). Owing to the fact that the deformities had existed for 
so many years, the bones were held in their abnormal position 
by dense adhesions. The rule to which prominence has been 
given by Phelps, viz.: cut every tissue that offers resistance, be- 
ginning with the tissue that offers the greatest resistance, and 
continue to cut until the foot can be returned to a super-correct- 
ed, or at least corrected position, was observed as nearly as pos- 
sible. Under A. C. F., the tendo-Achilles was first tenotomized ; 
the plantar fascia next, and, finally, the deltoid ligament had to 
be completely severed before the foot could be approximated to 
the normal. The Thomas wrench, or twister, was used to break 
up adhesions and rupture the shortened ligaments about the tar- 4 
sal bones. Great force had to be used with the twister to do this. 
TJie tenotomies were done subcutaneously of course. In divid- 
ing the deltoid ligament, an artery, possibly a continuation of 
the posterior tibial, or at least a considerable branch, was cut, 
but as the cutaneous puncture was about an inch from the point 
of injury to the artery, pressure soon controlled the hemorrhage. 
The astragalus, which had been of course dislocated during all 
these years, could not be reduced, i. e., could not be pushed back 
between the tibia and os calcis. 
Phelps’ open operation occurred to me, but was not de- 
manded, because, had the plantar surface of the foot been laid 
completely open the ligamentous resistance to the return of the 
astragalus would not have been removed. Enucleation of the 
astragalus as practiced by many, and notably Gibney, was con- 
sidered, and would doubtless have been performed but for the 
fear that some detail in cleanliness had been neglected (the 
operation was done at the home of the patient). The foot was 
brought as nearly to a normal position as possible, but was not 
super-corrected by any means, and put up in plaster-of-Paris. 
The skin punctures were dressed with gauze and protective. 
The plaster-of-Paris dressing was renewed once a week, and the 
foot held to the extreme point of correction until the plaster 
was hard. After each adjustment of the plaster the patient suf- 
fered great pain in the joint in the region of the astragalus for 
an hour or so, but he invariably noticed “ something slip ” and 
the pain was relieved. As this slipping occurred after every 
dressing, it was evident to my mind that the astragalus was 
wedging itself back between the tibia and os calcis, and the 
forcible correction maintained thus by the plaster caused the 
soft structures to yield. The success we had in effecting a re- 
duction of the astragalus can be determined by examining Fig. 
i B. This patient was also given massage, electricity by the 
Faradic current, and gymnasium exercises. To carry out the 
latter, two poles twelve feet long were rigged up in his room, 
placed high enough to support his hands and allow his feet to 
rest on the* floor. At first he was given five minutes morning 
and afternoon, and the time was extended two minutes daily up 
to one hour in the forenoon and one hour in the afternoon. Re- 
sult of treatment is shown in Fig. i—C. 
The subluxation of the left knee joint, in case i, Fig. i—A, 
Fig. 2, required tenotomies of the ham-strings and forcible 
breaking up of the adhesions between the bones and about the 
joint. It was impossible to completely correct the deformity 5 
here, as in the case of the foot, i. e., a parallelism could be had 
between the thigh and leg, but the leg was upon a lower plane 
than the thigh. This was due to the fact that the head of the 
tibia did not slip down and forward upon the condyles, but in- 
stead the relationship of these bones was not disturbed. The 
Fig. 3. 
condition that existed is shown in Fig. 3, “ a ” representing the 
condition before correction was tried, and “b” and “c” the con- 
dition as the bones were brought parallel, which, as may be ob- 
served, increases the pressure of the anterior surface of the tibia 
against the condyle of the femur, and thus prevents the head of 
the tibia from gliding forward over the condyles of the femur. 
Immediate reduction of subluxation of the knee joint is 
prevented, 1st—by the adherent patella and synovial membrane 
to the condyles; 2nd—by the impinging of the anterior portion 
of the head of the tibia against the condyles. In cases where 
the ham-strings are not cut, this burrowing in of the bones upon 
each other is much greater, and an immediate reduction is less 
likely to be effected. 
Gradual and continuous leverage offered the best means for 
correcting the deformity mechanically. After the severe manipu- 
lation and tenotomies, the joint was put up in plaster-of-Paris 
and kept there for about three weeks, or until all inflammation 
had subsided. At this time, very little progress had been made 
toward restoring the normal relations of the joint. A perfectly 
plain splint was used, to which the leg was bandaged, and the 
knee was drawn down as close to the splint as possible, or to 
the tolerance of the patient. This was tightened about every 6 
other day, or as often as was necessary to keep the bandage 
tight. Here, as was experienced after forcible correction of the 
talipes, the patient experienced a slipping or letting loose in 
the joint, and the pain caused by the forcible correction was re- 
lieved thereafter. 
The success we had in the treatment is shown by comparing 
A with B and C, Fig. 1, taken six mouths apart. 
Case 2, Samuel M., aged 17. Had an attack of anterio- 
polio-myelitis at four years of age, resulting in talipes equinus 
in both feet, the right foot being worse than the left (see Fig. 
4 A and C). 
Fig. 4. 
The case came to my clinic at Ohio Medical University, 
Columbus, Ohio, January 12th, 1893, and was sent to the Pro- 
testant Hospital for operation. Operation required tenotomy of 
tendo-Achilles and plantar fascia of both feet, and forcible break- 
ing up of adhesions about the tarsal bones with a Thomas 
wrench. The feet were put up in plaster-of-Paris, and new 
dressings re-applied once a week for four weeks, when the 
patient was able to walk home on crutches. Fig. 4, A. shows 
the right foot before, and B after treatment, and C shows the 
left foot before, and D after treatment. The patient always 
used crutches before treatment, but has no need of them since. 
Recovery practically perfect. 
Case 3, Clarence G., aged nine. When 11 months old he 
had fever and severe convulsions. While yet in his mother’s 
arms she noticed that he was completely paralyzed on his left 
side. He had been able to walk before the attack of anterior 
polio-myelitis, but it was about one year after before he began 7 
to creep and he did not get upon crutches until three years later, 
or when about five years old. For the succeeding four years he 
walked with crutches. (See Fig. 5.) Operation consisted in 
Fig. 5. 
tenotomies of tensor vaginae femoris, fascia, etc., to liberate the 
thigh at the hip joint, and of the ham-strings to correct the snb- 
lnxation and flexion at the knee. The tenotomies were 
done subcutaneously. The patient was put up in plaster-of- 
Paris from the thorax to the heel, and allowed to remain so for 
about two weeks. In order to make the plaster dressing lighter 
and less likely to break over the hip and under the knee, pieces 
of iron were put in over these joints, as is the practice in the 
New York Institute for Ruptured and Crippled. (The case is 
shown in Figs. 5, 6, and 7.) As a retaining splint, shown in 
Pig. 6, after the first few weeks, he wore a Thomas Hip Splint, 
with an outside piece riveted to riugs at thigh and calf, and fast- 
ened to the foot at the heel. It was also necessary to use an 
abduction arm, see Fig. 6, owing to the great tendency to that 
deformity. The patient now has entire control of the hip. The 
brace was cut off at upper end of the double bars, or at thigh 
ring, which removed all support to the hip joint, and the lower 
or knee portion was used. He can walk without crutch or 
cane. 8 
Hilton gives us an anatomical law that the nerve that sup- 
plies a joint, also supplies the muscles that control the motion 
of the joint and the skin which covers the same. The force of 
the law is demonstrated in many pathological conditions, but 
very forcibly in paralytic deformities. When joints are in de- 
formed positions, the trophic nerves distributed to the muscles 
controlling the joint do not perform their function normally. 
When a joint, which has been in an abnormal position for 
years, restored to a normal position, the power of the nerves 
to perform the trophic function is increased, and the muscles 
Fig. 7. 
Fig. 6. 
that have shown no signs of development for years, begin to 
increase in size and strength. A remarkable development of 
muscles was shown in this case, as I have observed in others. 
The rule is that after a plaster-of-Paris cast is adjusted, it 
gets loose in a few days ; but just the opposite condition has al- 
ways been observed in all my paralytic cases. 
1. Tenotomy. 
2. Osteotomy, rarely. 
3. Brismentforce. 
SUMMARY OF TREATMENT. 
Operative : 
Plaster of-Paris and other splints, 
Braces 
Mechanical : 
i. Retentive 
2. Corrective 
' Gymnastics. 
Massage. 
. Manipulation. 
Electricity.