ORTHOPEDIC DEFORMITIES 
OF 
EARLY CHILDHOOD. 
BY 
CHARLES F. STILLMAN, M.D., 
NEW YORK. 
Reprinted from The Ammmo**' JauntrxL OBSTiarcnwc and Diseases 
of Women and Children, Vol. XV., No. IV, October, 1882. 
NEW YORK: 
WM. WOOD & CO., PUBLISHERS, 56 & 58 LAFAYETTE PLACE. 
1882. ORTHOPEDIC DEFORMITIES 
OF 
EARLY CHILDHOOD. 
BY 
CHARLES F. STILLMAN, M.D., 
NEW YORK. 
Reprinted, from The American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XV., No. IV., October,‘1882. 
NEW YORK: 
W1I, WOOD & CO , PUBLISHERS, 56 & 58 LAFAYETTE PLACE. 
1882. ORTHOPEDIC DEFORMITIES 
OF 
EARLY CHILDHOOD. 
BY 
CHARLES f. STILLMAN, M.D., 
New York. 
Paper No. II. 
Inversion of the Feet. 
This condition may be either local or general. Local inver- 
sion is limited to the foot, and is not dependent upon malposi- 
tions of the knee or hip joints. It is associated with and caused 
by a weakened condition of the external supports of the ankle; 
the patient pointing the toes inward and turning the foot under 
thus walking upon the outside of the sole (Fig. 1). 
In walking, the gait is often a shuffle, due to the fact that 
the anterior portion of the foot is not well lifted from the 
ground, the muscular power being deficient. 
The treatment consists in augmenting the power of the mus- 
cles by electricity, rubbing, etc., and providing a proper appa- 
ratus to keep the foot in its normal relations with the leg with- 
out restricting the natural motions of the ankle, which are 
fiexion, extension, and lateral movement. 
It is conceded by all authorities that flexion and extension 4 
Stillman : Orthopedic Deformities 
of the foot are both performed by the ankle-joint; but the move- 
ments of inversion and eversion are variously assigned to the 
astragalo-calcaneoid and mediotarsal articulations, it being as- 
serted with positiveness that the ankle-joint, being a true hinge- 
oint, is thereby rendered incapable of any lateral movement, 
whatever. And yet that it does, to a limited extent, take place 
in this joint is apparent if the supports of the joint are allowed 
to relax, and the weight of the body is removed. 
Let the reader cross one leg over the opposite thigh so that 
Fig. 1. 
the foot becomes perfectly relaxed. Now, deline the sides of 
the astragalus and os calcis under the malleoli with linger and 
thumb of one hand, and with the other grasp the foot, and roll 
it under freely. The astragalus will be felt to move just under 
the internal malleolus, and by the exercise of a little force the 
foot, as a whole, can be turned under almost to a right angle 
with the leg, the astragalus seeming to project almost to a level 
with the internal malleolus; while a depression can be fell 
under the external malleolus. This rolling of the foot upon its 
horizontal axis, with inversion, seems to take place partly in of Eaydy Childhood. 
5 
the ankle, partly in the astragalo-calcaneoid articulation, and 
secondarily in the articulation of the head of the tibula with 
the tibia. 
Lateral movement cannot take place in the ankle, however, 
unless the joint be relaxed externally ; but when this is done, the 
hinge character of the joint is destroyed, and it is converted 
into a 7novable joint by the release of the outer surfaces of the 
articulation from contact with each other, thus allowing an ex- 
tent of motion which is entirely impossible if the pressure be 
so sustained that the joint cannot be relaxed in its outer por- 
tion. 
When, from undue muscular power, a misstep or other 
accident, the ankle becomes suddenly turned under while 
supporting the weight of the • body, the surfaces of the 
outer part of the articulation become suddenly separated; 
while those of the inner part are jammed abnormally together. 
The joint is then rendered temporarily incapable of sustaining 
such weight, and grave injuries to the articulation are apt to 
result; the most frequent being common sprained ankle, and 
one of the lesions of which is the wrench sustained by the pe- 
ronei muscles, one of whose functions seems to be to brace the 
foot at such an angle as to allow it to receive the weight of the 
body in a comfortable or advantageous position; this weight 
and the muscular power together locking it firmly in position 
until it is again relaxed or unlocked by being lifted from the 
ground, the weight of the foot then acting to relax the 
joint. 
The prevailing opinion, that lateral motion in the ankle- 
joint is impossible, is partially correct since it does not take place 
in the locked condition of the joint, but in the unlocked condi- 
tion, when the foot is rolled under, it would seem that lateral 
movement is not only possible, but that it actually takes place 
in the joint to a limited extent every time a step is taken, and 
the foot lifted and set down in position to receive the weight of 
the body to the best advantage. 
All braces which are applied at the ankle should, therefore, 
be either pivoted at the side or beneath the foot, or be of suf- 
ficiently flexible material to allow a normal amount of lateral 
motion ; otherwise they embarrass the proper movement of the 
foot. 6 
Stillman: Orthopedic Deformities 
The plan of treatment to be pursued in most cases of local 
inversion, after the physician is satisfied by thorough examina- 
tion of the entire limb that the deformity is purely local, is to 
afford support, and at the same time, by spring power, to en- 
deavor to bring the foot around to its normal position without 
restricting motion. This is accomplished in either of two ways : 
In the first, a jointed outside steel strip is used, attached to the 
bottom of the shoe by a pivot in the “ centre of motion ” of the 
Fig. 2. 
Fig. 3. 
foot, thus allowing lateral motion (Fig. 2), and attached to the 
leg just below the knee by a girth (Fig. 3), which must be 
prevented from slipping by a strip of moleskin adhesive plaster 
buttoned over the girth, or drawn through the buckle, and thus 
fastened securely. A rubber cord or coiled spring of varying 
strength is now added, which passes from the strip to the outside 
of the shoe near the toe (Fig. 3). This cord should not be con- 
nected at both ends until the girth is tirmly fastened to the 
limb, as otherwise the girth will rotate. 
To prevent the foot turning under at the ankle, the steel strip 
is given an outward inclination where it passes under the shoe, 
which converts it into a spring when the brace is buckled t of Early Childhood. 
7 
the limb, effectually preventing the joint from giving way ex- 
ternally. 
A simpler method of treating inversion, and one which pos- 
sesses many advantages for general use, is the twisted spring 
(Fig. 4). It consists of a flat steel strip, jointed at the ankle, 
placed outside the leg only, and extends from a girth below 
the knee to the bottom of the shoe, where it is attached adjus- 
tably. This would merely afford support, were it not bent out- 
ward at the point where it passes under the shoe, thus effect- 
ually supporting the ankle. In addition, however, that part of 
the strip extending from the ankle to the girth is twisted out- 
Fig. 4. 
ward, thus producing an everting spring, which throws the foot 
outward when the girth is fastened around the leg. This evert- 
ing power will be constant, and its form maybe regulated by a 
clamp opposite the tibio-fibular articulation. 
This brace also affords the support which is necessary in 
many of these cases, especially when due to paralysis, and as it 
rarely needs adhesive plaster, is extremely light and easy of ap- 
plication and removal. For children it is especially advanta- 
geous. While the brace is worn, the muscles should be vigor- 
ously stimulated by the means at our command, in order to 
hasten cure; but the use of a proper brace to assist the devel- 
opment of the muscles is the most important element of the 8 
Stillman : Orthopedic Deformities 
treatment. I do not limit myself, or should I recommend the 
reader to limit himself, to these braces alone; but as they are 
applicable to perhaps a larger number of cases than some 
others, they are detailed at length. Yet it will be found that 
certain special cases, which space forbids us to dwell upon here, 
will need the employment of special mechanisms. 
General inversion of a limb (see Fig. 5), or, as it is more com- 
monly called, rotation, is very often met with, either alone, or 
Fig. 5. 
combined with bowlegs, knock-knee, muscular insufficiency, and 
various"deformities and conditions of joints. 
Dr. De Forest Willard, who has bestowed much attention 
upon this subject, states that * this condition and its opposite, 
eversion, so rarely occur without some co-existent deformity, 
that a careful search should be instituted to detect the probable 
cause for such misplacement. If there be disease at the pelvis 
or hip, the inversion is ordinarily due to a rotation at the hip- 
joint; if knock-knee exists, the rotation will be partially at the 
knee, partially at the ankle; and the same is true in bowlegs. of Early Childhood. 
9 
If there is impairment of power in the thigh or leg muscles, 
then the inversion or eversion will he in accordance with such 
deficiency. 
The inversion, in case of knock-knee, is probably due to the 
fact that, the knees being brought close together, the feet are 
widely separated ; consequently, in walking, this too wide base 
of support is sought to be narrowed by bringing the toes 
nearer together. 
Let any one attempt to walk with his knees and feet in the 
position of knock-knee, and he will fully appreciate the truth 
of this statement. With the toes turned outward, progression 
is exceedingly difficult, but with the toes turned inward, the 
feet can be easily carried forward by a swinging motion, in 
which the vastus externus and the peroneals seem to play an 
important part. When associated with knock-knee and allied 
deformities, the treatment of the inversion should be considered 
secondary to the treatment of the deformity; but it will be 
found that each yield more readily to treatment which is 
directed to the relief of both at the same time.” 
Dr. Bradford considers that “ abnormal inversion of the foot 
is due to either a weakness of the external rotators of the 
thigh, permitting an inversion of the whole limb, a relaxed 
condition of the ligaments of the knee, or, more commonly, 
a weakness of the peronei muscles, which are overpowered 
by the tibiales muscles.” In infantile paralysis, he con- 
siders this ‘‘ to be most marked, but the same tendency will be 
seen to a slighter degree in non-paralytic cases.” 
There is one point upon which too little thought is usually 
given in the treatment of such deformities as we are now con- 
sidering, and that is the thorough examination of the genital 
organs. Inquire of the parents or nurse whether the child has 
the habit of rubbing or playing with its genitals, and this you 
will find to be very often the case. If, on examination, you 
discover any abnormal cause for such genital irritation, as 
phimosis, adherent prepuce", or clitoris, this should be relieved 
before mechanical treatment is attempted, as, in some cases, it 
will obviate the necessity for such treatment. 
Too much credit cannot be given by the profession to Prof. 
L. A. Sayre for the prominence which he has given to this 
subject of genital irritation as an element in the causation and 10 
Stillman : Orthopedic Deformities 
continuance of these abnormal conditions of the lower limbs, 
and the pertinacity with which lie sustains his position. 
There exists much difference of opinion in the profession at 
the present time in regard to the actual value of the operations 
upon the genitals in these deformities; but when a man of 
large experience in this domain of surgery is confirmed in his 
opinion in regard to their usefulness, it is of itself sufficient to 
insure the subject a fair trial as time elapses; and some of the 
cases noticed have so thoroughly borne out his statements 
that I cannot withhold my indorsement as to the value he 
places upon the subject. 
Some of the successful results in cases I have seen are 
marked, and some cases of failure which have come under 
my observation seem to have been due to errors of judg- 
ment as to the degree of importance which the irritation bore 
to the extent of the deformity. In some cases, instead of 
being the cause of the deformity, it is merely a co-existing 
trouble without direct relation to it; and, of course, in such 
the operative procedures for the relief of the irritation possess 
no curative power over the deformity whatever. It appeals to 
the common sense that when an abnormal irritation of these 
parts exists, measures should be immediately taken for its re- 
moval ; for, while the operations can do no possible harm, they 
are productive of cleanliness and other good results to the 
patients, and in many cases are of permanent benefit to the co- 
existent deformity. As to the exact benefit to be derived in 
each individual case, that can only be determined by actual 
procedure, although an approximate opinion may be given 
from the history and general conditions of the case. 
I have in mind, among others, a case of double inversion, 
caused by infantile paralysis occurring in a female child, which 
had steadily resisted all treatment until, in consultation with 
Dr. Geo. F. Slirady, we decided to examine the clitoris, after 
eliciting the fact that the patient was continually rubbing her- 
self ; and we found it hypertrophied, engorged, and bound 
down by adhesions to the surrounding parts, the forcible rup- 
ture of which, under an anesthetic, was followed by prompt 
improvement, and conjoined with mechanical means, by the 
recovery of the patient. 
The following extract from a letter from Dr. Geo. K. Smith, of Early Childhood. 
11 
of Brooklyn, will be found of practical value in this connection, 
and it is therefore inserted here : 
Wm. McC , age four years, colored (see Fig. 6), came under 
my care in the summer of 1879. 
The photograph shows the feet inverted to such an extent that 
he walked on the outer border, and, to a slight degree, on the 
dorsum of each foot. The legs bowed outward. On examina- 
tion, I found the opening in the foreskin so small that it could 
not be drawn back over the glans, and the prepuce was adherent. 
Behind the glans was a quantity of smegma, which could be felt 
by slight pressure with the thumb and finger. I ventured the 
opinion that the malformation of the limbs and the malposition 
of»the feet were caused by irritation at the extremity of the penis. 
I further stated to the father that I believed that if the operation 
Fio. 6. 
of circumcision were performed, the limbs, which were now bend- 
ing beneath their burden, would become stronger, and that nature 
would straighten them without the aid of the costly apparatus 
used by surgeons to accomplish the same result. 
I performed the operation, and in a few months it was plainly 
perceptible that the limbs were becoming straighter, and at the 
end of a year the improvement in this direction was but little less 
than marvellous. About this time, the boy and his mother were 
sent to live with friends out of the. city, and I did not see him 
again. Eight months ago, the father told me one limb was en- 
tirely natural, and the other nearly straight. 
After the presence or absence of genital irritation is deter- 
mined, and, if present, relieved, the question of mechanical 
treatment of the inversion arises. 12 
Stillman : Orthopedic Deformities 
There are three classes of braces which may be used in the 
treatment of general inversion of a limb : rigid force, adjusta- 
ble force, and spring force. Rigid force is produced by a 
metal bar attached to the shoe, and extending along the limb 
to a pelvic band, with appropriate girths and joints between, 
and, in some cases, accomplishes good results. An instrument 
of this class is described by Dr. Bradford, of Boston, as a pair 
of steel rods jointed at the knee and ankle, fastened into the 
Fig. 7. 
Fig. 8. 
sole of the shoe, and passing on the outer side of the legs, 
reaching as high as the hips. At the hips, the rods are bent 
at the top, so as to pass behind the bnttock, and incorporated 
in a strap which girdles the hip. If the top portions are 
properly bent, he considers it impossible, when the pieces 
on the two sides are fastened together behind, for either of Early Childhood. 
13 
foot to turn in, as it is held out by the outward rotation of the 
opposite limb. I have never tried this instrument, but should 
think it would make an exeellent hip rotator, especially if the 
ends of the two rods be fastened together behind the buttock 
with a piece of elastic or spring. 
Adjustable force is produced by the addition of a ratchet or 
ratchets to the foregoing, so that the vertical axes of the attach- 
ment girths may be placed in different planes at the will of the 
surgeon, thus effecting rotation when the attachments are 
fastened about the limb. As a representative of this class may 
be mentioned Sayre’s rotating screw, depicted in Fig. 7 ; and 
in instances where it has been desired to rotate the limb at the 
hip, I have used this with satisfactory results. This instrument 
might be much improved by the addition of a ratchet just below 
the knee, and also below the foot, thus providing for rotation 
of the foot and leg, as well as the rotation of the entire limb 
at the hip, which it now accomplishes. 
Spring force is the most generally advantageous power used 
in the treatment of inversion, because of its lightness and 
effectiveness, and the spiral spring seems to be the most efficient 
form. 
So far as I am aware, there are but two forms of spiral 
spring to effect a rotation of an inverted limb. 
First, the coiled spiral of Dr. Gregory Doyle, and second, 
the twisted spiral of the writer. 
The action of both is that of constant coaxing, the muscles 
being assisted without being supplanted, or, more correctly, 
the bony framework of the limb is kept in proper position, so 
that the muscles may act normally. They are both light and 
comfortable, and easily managed. There is one feature of the 
writer’s apparatus which Doyle’s does not possess, and that is, 
support; for the former is an articulated, continuous, steel 
strip, which strengthens the limb as well as rotates it. 
Dr. Doyle’s rotator consists in a coiled spiral spring extend- 
ing along the outside of the leg from a pelvic band, or corset, 
to the shoe, held in position by girths about the thigh and leg 
(Fig. 8). If these girths be fixed, the constant tendency of 
the spring to uncoil itself turns the thigh on the pelvis, the leg 
on the thigh, and the foot on the leg ; and, as the instrument 
is exceedingly flexible, it is very nicely adapted to young cliff- 14 
Stillman : Orthopedic Deformities 
dren and others when support of the limb is not required. But 
in so many cases of inversion, the articulations of the limb are 
so lax that some support is also desired, and for such cases an 
instrument consisting of a flat steel strip (Fig. 9), extending along 
the outside of the limb, from the shoe to the hip, articulated at 
ankle and knee, and provided with suitable girths, may be em- 
ployed. This strip is twisted outward (thus forming a spiral) 
between the ankle and calf girths, thus (the foot being turned 
outward at the pivot beneath the shoe) turning the leg on the 
thigh. The strip is also twisted outward between the thigh 
Fig. 9. 
Fig. 10. 
girths, thus forming a spiral which rotates the thigh on the 
pelvis without the necessity of a pelvic band (see Figs. 9 and 
10). The amount of rotation can be regulated at will by 
means of small clamps connected with the two twisted spirals. 
There can be no given rule for the employment of any of these 
instruments, nor would every case be equally well treated by any 
special one. The well-balanced surgeon who has in mind the 
principles governing the cure of such deformities, adapts and 
adopts certain instruments to produce given results in certain 
cases, and it is a mistake for one to confine himself to any one of Early Childhood. 
15 
plan of treatment. Certain instruments are preferable to 
others, which, in their turn, possess special advantages in still 
other cases, and it depends entirely upon the judgment of the 
practitioner, his knowledge of surgical mechanics, and his skill 
in adaptation, whether he shall obtain a more prompt cure than 
his neighbor. 
The braces should be remove 1 often (at least twice daily) for 
the thorough rubbing, kneading, and, if possible, electrical 
treatment of the deticient muscles. THE AMERICAN JOURNAL OF OBSTETRICS 
and K 
DISEASES OF WOMEN AND CHILDREN. 
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GEORGE B. FOWLER, M.D., Editor of Department of Diseases of Children. 
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