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CONTRIBUTIONS
Orthopedic   Surgery
                OBSERVATIONS

ON  THE TREATMENT  OF CHRONIC INFLAMMATION OF
    THE HIP, KNEE, AND ANKLE JOINTS, BY A NEW
        AND SIMPLE METHOD  OF EXTENSION,
            THE PHYSIOLOGICAL METHOD;
LECTURES   ON   CLUB-FOOT,
      Delivered at the College of Physicians and Surgeons,
               New York (Special Course).
           By JOS. C.  HUTCHISON,  M.D.,
Visiting Surgeon to the Brooklyn (N. Y.) City Hospital; Surgeon-in-Chief to the
 Brooklyn Orthopedic Infirmary;  Consulting Surgeon to the Kings County, St.
  Peter's, and St. John's Hospitals; formerly Professor of Operative Surgery
    and Surgical Anatomy, Long Island College Hospital; Ex-President of
     the Medical Society of the State of New York,  of the New York
      Pathological Society, of the Kings County Medical Society, and
       Ex-Vice-President of the New York Academy of Medicine;
         Member of the New York Surgical Society, of the
          American  Medical Association, and Honorary
            Member of the Connecticut and the New
                 Jersey Medical Societies, etc.
      NEW YORK:
P. PUTNAM'S   SON^
     182 Fifth Avenue.
          1880.
 
\A/E

    I860
     Copyright, 1880,
By G. P. PUTNAM'S SONS.
  Stereotyped and Printed
By Rand, Avery, &■» Company,
    117 Franklin Street,
         Boston. 
DEDICATION.
                                 TO .

                EDWARD  R.  SQUIBB,  M.D.,
           late passed  assistant  surgeon, united  states navy,

                       SEfots ISooft is CnscrtbeU,

in  recognition of his distinguished professional and scientific attainments,
    and of those sterling qualities of true manliness which constitute
                 moral greatness;  but more especially

                    IN GRATEFUL APPRECIATION

of numerous acts of personal kindness, and an uninterrupted friendship of
   many years' standing, beginning when he was assistant demonstrator
      of anatomy in the jefferson medical college, philadelphia, and
        gave the writer his first lessons in practical anatomy. 
 
PREFACE.
   The  substance  of  the observations contained in this
 volume,  on the Treatment  of Chronic  Inflammation  of
 the Hip, Knee, and Ankle Joints, by what I have denomi-
 nated, the  "Physiological  Method"  of  Extension,  was
 first published in  the American Journal of the Medical
 Sciences, for January,  1879, and in the Proceedings of the
 Kings County,  New York, Medical  Society,  for April,
 1879.  The favorable  notice which these  papers received
 from  surgeons of  experience  and acknowledged  ability,
 has induced me to revise them, and to make such additions
 as have been  suggested  by a  more extended observation
 of the results  of the treatment recommended.   I present
 them in the present form, in the full confidence that the
 adoption of  the treatment by  others, will be followed by
 results equal to these which I have obtained.
  The  Lectures   on  Club-Foot, comprise the  author's
personal experience in this interesting class of deformities,
both in hospital and private  practice.  They were deliv-
ered before  the Medical  Class of the New-York College
                                             3 
4
PREFACE.
of Physicians and Surgeons, and were subsequently pub-
lished in the Medical Record, New York, 1878-79.  They
have been revised and reproduced, with additions, in  this
more permanent form, with the hope that they may supply
a simple and  practical  guide for the treatment  of club-
foot, to the medical student and to the general practi-
tioner, for whom they were especially designed.
  The author desires to acknowledge his indebtedness to
Dr. T. P. Corbally, for valuable assistance in carrying the
volume through the press, and in relieving him of  editorial
work which would have greatly taxed one otherwise much
engaged.
479 Clinton Avenue, Brooklyn, N.Y.
         May, 1880. 
CONTENTS.
THE  TREATMENT  OF  CHRONIC  INFLAMMATION  OF THE
               HIP,  KNEE AND  ANKLE  JOINTS.
Indications for the Treatment of Chronic Inflammation of the Joints of
    the Lower Extremities. — Extension, Immobility, Removal  of  the
    Superincumbent Weight of the Body. — Out-door Exercise   .    .   8
Danger from Anchylosis Over-estimated.......10
Hip-Joint Disease : History of its Treatment by Fixation and Extension.
    — Instruments which have been devised for this Purpose : their In-
    efficiency   ............12
The Physiological Treatment, recommended by the Author   .    .    .16
Cases Illustrating the Treatment........22
Chronic Inflammation of the Knee-joint: Physiological Treatment     .  32
Chronic Inflammation of the Ankle-joint: Physiological Treatment    .  37
CLUB-FOOT: ITS CAUSES, PATHOLOGY, AND  TREATMENT.
                          CHAPTER  I.
Introductory and Historical Remarks. — Rules for the Performance of
    Subcutaneous Tenotomy. — Re-union of Tendons after Subcutaneous
    Tenotomy. — Rate of Extension after Tenotomy. — Difference in the
    Normal  Anatomy of the Infant and the Adult Foot. — Varieties of
    Club-foot — Congenital and Non-Congenital  Talipes. — Causes.—
    Prognosis............45
                                                          5 
6                          CONTENTS.
                          CHAPTER  II.
Congenital Talipes Varus.—Degrees of the Deformity. — Morbid Anat-
    omy. — Mechanical and Physiological Treatment, and Age at which
    it should be commenced.........62

                         CHAPTER  III.
Congenital Talipes Varus, Continued. — Operative Treatment. — Non-
    Congenital  Talipes  Varus. — Prognosis. — Treatment. — Excission
    of Tarsal Bones in Old Cases of Congenital Varus  .    .     .    -79

                          CHAPTER IV.
Talipes Valgus,  or  Fiat-Foot. — Morbid  Anatomy. — Congenital and
    Non-Congenital. — Treatment. — Talipes Equinus. — Morbid Anat-
    omy. — Treatment. — Equino-Varus  and Equino-Valgus. — Treat-
    ment   .    .    .    .    .    .    .   .    .    .    .     .    •  93

                          CHAPTER  V.
Congenital and Non-Congenital Talipes Calcaneus. — Causes and Treat-
    ment.— Calcaneo-Varus and Calcaneo-Valgus.....112 
ORTHOPEDIC   SURGERY.
ON THE TREATMENT OF  CHRONIC INFLAMMATION
      OF  THE HIP, KNEE, AND ANKLE  JOINTS.

  It  is not  my design to consider the  symptoms, causes  and
pathology  of the various  inflammatory diseases which  affect the
joints, for this has  been done, again and  again, in surgical  text-
books, and in  numerous monographs, which are accessible to the
student of surgery.   My purpose is, to  describe a plan for the
treatment  of chronic inflammation  of the joints of  the lower
extremity, by methods which I  think are more simple, effective
and agreeable to the patient, than those hitherto employed.
  It may be stated, at the outset, that morbid conditions of the
joints are, as a rule, essentially  chronic, and whether the disease
originates  in the synovial membrane, the  cartilages, the bones or
the investing fibrous capsule, ultimately, the morbid  action in-
volves all  the  tissues, so  that, without the previous history  as a
guide, it is often impossible  to  determine  in what tissue the in-
flammation  began.   It is, to my mind, merely  a pathological
refinement, in  most cases  of joint disease, especially in childhood,
to attempt to describe the symptoms indicating distinct  pathologi-
cal  states of the individual structures composing  a joint.   The
                                                    7 
8
ORTHOPEDIC SURGERY.
treatment would be essentially the same, whether one or all of the
articular structures are contemporaneously involved.
  Surgeons of  the  present  day pretty generally  admit that the
indications for the treatment of inflammation of the joints of the
lower extremities, are :  (i),  to obtain extension of the limb; (2),
to secure immobility of the joint;  (3), to remove  the superincum-
bent weight of the  body;  (4),  to  provide  means  to enable the
patient to take exercise in the open air.  The accomplishment of
these indications, and the use  of judicious medication and proper
hygienic influences,  comprehend all the principles of treatment.
  The object  of  extension  is—(1) To correct  the malposition
of the limb.  An inflamed joint is never straight; it involuntarily
becomes flexed, nor is it possible for the patient to prevent or to
change this position.   The  flexion  takes place slowly, almost im-
perceptibly, but surely, even when the limb has been permitted to
rest quietly in bed, undisturbed either by the patient or the nurse;
the degree of flexion depends upon the intensity or the duration
of the disease.  Every joint, when it becomes inflamed, assumes a
characteristic position, which it is important to know, not merely
as a diagnostic sign, but also  as a point which may be made use-
ful in treatment.  When the  hip-joint  is inflamed, the  thigh  is
flexed on  the  pelvis,  and, as  a  rule, is slightly adducted.   The
knee joint, when inflamed, is always  more or less flexed.  In the
case of the  ankle-joint, the foot is flexed upon the leg, the heel is
raised by the gastrocnemii, and the  toes point downwards.  The
improper position  which the  joint assumes, should be corrected as
soon  as possible,  even when  the inflammation is acute;  this  is
important, in order  that  the different structures of  the joint may
not be kept in a state  of undue pressure, or  of inordinate ten- 
                   ORTHOPEDIC SURGERY.                g

 sion, either of which conditions interferes with healthy nutrition,
 and so interferes with the curative process.   As the joint becomes
 straightened, under the influence of extension, the  patient experi-
 ences an almost immediate diminution of pain.   (2) By means
 of extension, we also overcome the spasm and contraction of the
 muscles, which, by reflex contraction, press together the inflamed
 articular surfaces, and constitute the chief cause of pain in joint-
 inflammations ; but, I do not believe it possible, by  any amount of
 extension that can be  applied, to separate the inflamed  and swol-
 len interior surfaces of the joint, so  as to  relieve  them  from
 pressure and  the consequent pain.  What we do  accomplish  by
 extension is, the relief of spasm and of muscular shortening; and
 to quiet the muscles is an imperative therapeutic axiom.
   It is generally conceded that extension is an important element
 in the treatment of joint diseases, although we may differ as to the
 best method of obtaining  it and the way in which the  good re-
 sults are achieved, still  there is not so much unanimity as to the
 importance  of the fixation  of the joint.  Many American authori-
 ties maintain  that  motion  in the  joint,  at the  same  time  that
 extension is made, is a sine qua  non to success,  and they have
 devised  ingenious  instruments  for simultaneously accomplishing
 these two indications.   It is difficult to understand why motion
 should be desirable in  the treatment of  inflammation of the hip-
joint, when we consider it  important to secure immobility in in-
flammation  of all other joints.  But the "American idea," as our
English friends  term it, goes still further: we must not only have
motion with extension, but motion  without friction,  a condition
which, with  all due respect, seems  to me to be a mechanical ab-
surdity, because  the tissues covering the joint surfaces are swollen 
10
ORTHOPEDIC SURGERY.
by inflammatory deposits, and the  opposing surfaces must rub
against each other when moved.   We might with equal propriety
speak of sound without vibration of the air.
  Immobility of an  inflamed  joint,  absolute  and complete, is  a
primary,  and essential condition of its local treatment.   The more
effectually this is secured, the more rapidly and perfectly the  joint
recovers  its normal condition, and  the less danger there  is of its
being permanently damaged.  The greatest obstacle to recovery
is friction of the inflamed surfaces.   I do not mean a mere limita-
tion  of the  movements of the joint — such "rest" as  is obtained
by placing  the  limb upon a soft bed or a pillow — but  the perfect
fixation secured by a  splint or other means, which  admits of no
motion whatever.  I am aware that many excellent  surgeons be-
lieve that the danger of irreparable  structural change  and anchy-
losis of the joint, is very great, from prolonged  fixation.  This,  I
am sure, is  an error.   There may be a temporary anchylosis,  such
as arises from a diminution of the elasticity of the articular carti-
lages, and an enfeebling of the ligaments  and the muscles  from
disuse; but, such changes  are temporary or need only be so, for,
by careful  and steadily increasing use, reparation takes place in
all these structures,  and,  after a time, they show no  defect.   I
have never seen true anchylosis when the joint has been immova-
bly fixed until the inflammation has subsided, except  in cases of
extensive destruction of the joint-structures, in which case, a cure
by anchylosis is the  thing to  be  desired.  Exceptional cases, no
doubt occur, but the anchylosis takes place more  commonly when
fixation is incomplete, and more  or less motion and  friction are
permitted, before the inflammation has entirely subsided.
  In corroboration of these views I quote from a paper  by Pro- 
ORTHOPEDIC SURGERY.
n
 fessor Verneuil on this subject, lately read before the " Societe de
 Chirurgie de  Paris," Medical Times and Gazette, Oct. 18, 1879.
 " Professor Verneuil said, ' Anchylosis, in  fact,  is a ghost, which
 frightens, not  only the lay public, the patients  and their  friends,
 but also nearly all general practitioners, and  not a few surgeons.'
 .  . . ' I  affirm,' he  continues, ' that  there does  not exist a single
 fact which shows, conclusively, that fixation, however long con-
 tinued,  has ever  led to  anchylosis.  ...  I  might mention num-
 berless  examples  of well-known  cases in which the joint, for a
 long time kept immovably fixed, has, notwithstanding, retained its
 structure, and rapidly resumed its functions when permitted to do
 so.' ... He  admits that, at  the  termination of any arthritis, in
 the treatment of  which fixation, more or less prolonged, has been
 made  use of, there  is a  diminution, a suspension, even an aboli-
 tion of  movement; but  does  not see why this functional suppres-
 sion should be attributed to fixation, rather than to other causes,
 especially the  anatomical lesions  present in the joint. . . . Im-
 paired movement is, in all cases,  due to  the  disease, and not to
 the fixation. . . . The exaggerated fear, therefore, of anchylosis,
 has  caused many practitioners to commit grave errors, and  has
 frequently led  to  the too early discontinuance of passive fixation,
 and to the premature re-commencement of movement. .  . .  He
 concludes by saying that  artificial fixation, on  the one  hand, and
 natural  fixation, on  the other, are the  two principal therapeutic
 agents in diseases of the joints; the  one combats anatomical
 lesions,  the other restores physiological action.  We  may assist
 the former by various means — local, pharmaceutic, or hygienic ;
 we  favor the second  by electrization  of the peri-articular muscles,
practised during the period of fixation, with a view to the preven-
tion of degenerescence." 
12
ORTHOPEDIC SURGERY.
   The necessity for securing  the beneficial effects of outdoor air,
by means  of some portative  apparatus  which  removes  pressure
from the inflamed joint, is  now so generally appreciated that we
need not urge its importance.
   The special methods  of  meeting the  above  indications will be
described, when we consider the treatment of the diseases of par-
ticular joints.

                    HIP-JOINT  DISEASE.
   In 1835, William Harris,  of Philadelphia, first demonstrated the
value of extension and fixation of the joint, as  curative agents, in
the  treatment of morbus coxarius, and,  in  1839, ne recorded, in
one of the journals of that city, three cases treated by Hagedorn's
long splint, formerly used  in the treatment of  fractures of the
thigh.  The  suggestion of Harris was for a time  overlooked, and
we heard nothing more of extension, as  a means of treating mor-
bus coxarius, until Sir Benjamin Brodie again called attention to it,
in the fifth edition of his work on diseases of the joints, published
in 1850.  Sir Benjamin recommended extension, in the advanced
stage of  the  disease, after shortening had taken place, merely for
the  purpose  of  overcoming  deformity, and not  as a  method of
treatment adapted to all stages of the  malady.   His plan*consisted
in passing a band  around the  thigh, above the  cardyles, to which
a cord was attached; this was carried over a pulley, at the foot of
the bed,  and had a weight attached to it for the  purpose of main-
taining continuous  extension.  It was, indeed, virtually, what Dr.
Davis  subsequently called elastic  extension.  Dr. Alden March
in 1853  {Transactions of the Medical  Society of the State of
New York), also  advised  extension, as a  means of  correcting 
ORTHOPEDIC SURGERY.
13
deformity, and, in 1855, Dr. Bauer, in a paper published in "The
New-York Journal of  Medicine," speaks, for the  first time after
Harris, of the beneficial effects of extension in relieving pain and
controlling the disease, as  well as in overcoming deformity.  In
1855, Dr. H. G. Davis described a new portative  apparatus,  de-
signed to  produce extension, while allowing motion in the  joint,
and permitting the patient to enjoy the benefits  of  out-door exer-
cise, so important in the treatment of this disease.  He maintained
that motion in the joint, at  the same time that extension  is made,
is an indispensable part of the treatment, and his instrument was
devised to meet these two  indications.  It was claimed, also, by
Davis and his followers, that confinement to bed, with a long splint
applied, fixing the  joint, not only impaired the general health,  but
increased the risk of anchylosis, which would leave  the patient in
a worse condition than if left to the tender care of Nature herself.
This new method of treatment awakened the interest of surgeons,
generally; and very soon afterwards, Sayre improved or  modified
Davis's  instrument, and, with the enthusiasm of an  ardent nature,
brought the new treatment prominently into notice, and, by pub-
lished essays and lectures on  the subject, did more to secure its
general adoption  than the  originator himself  had  done.   The
instruments  of Taylor,  Vedder,  Washburn, and that devised by
myself, are also modifications of Davis's, designed  to  accomplish
the same indications, viz.:  mobility of the joint with extension.
  Barwell, Andrews, of Chicago, Bauer,  now of St.  Louis,  and
Thomas, of Liverpool, believe that the indications  for the proper
treatment of the disease are, to secure immobility of the joint with
extension, and  they have  respectively  devised very ingenious in-
struments to accomplish this purpose;  while Professor Hamilton's 
14                ORTHOPEDIC SURGERY.

wire-gauze apparatus, was  designed merely to secure immobility
of the joint, without extension.
  All these  appliances are well known in this  country, except that
of Thomas, of Liverpool, which  I  will briefly describe.  It con-
sists of a flat piece of malleable iron, from three-quarters of an
inch, to an  inch in width, by one-quarter in  thickness,  which
extends from the lower angle of the shoulder of the affected side,
in a perpendicular line, downwards, to the calf of the leg.  A strap
of hoop-iron is riveted to the top of the upright, and  nearly encir-
cles the body, a little below the axilla; another strap of iron, half
the  circumference  of the  thigh, is fastened  to  the  upright, just
below the fold of the buttock; and a third, half the circumference
of the calf, is riveted to  the lower extremity of the upright.  The
instrument is carefully moulded to the inequalities of the body, by
means of wrenches, and is well padded and covered with leather.
The apparatus having been applied, the patient is allowed to walk
on crutches, with a patten on the sound foot,  so as to elevate the
diseased limb two or three inches from the ground.
   This apparatus will not permit the patient to sit down, and ren-
ders defecation very inconvenient.
   We have, therefore, three classes  of portable appliances in use
for  the  treatment  of morbus coxarius, all of  which, with due
respect to  the ingenuity of their respective authors,  I  feel  called
upon to condemn— (i) Because they do not achieve the objects
for which  they  are  designed.   (2) If they did,  they  are  unne-
cessarily cumbrous and  uncomfortable, and  therefore  should  be
abandoned, because  the same indications can be accomplished
by a method simpler and more comfortable to the patient.
  The  notion  that extension and motion  are obtained by the 
                  ORTHOPEDIC SURGERY.                15

apparatus of Davis and his followers, is a great deception.  If you
notice a patient wearing either Taylor's or  Sayre's long splint,
which are modifications of Davis's, and most frequently used  here,
you will see, when he walks, that the whole pelvis swings, and there
is no motion at the hip-joint.  This immobilization of the joint, a
kind  Providence has secured, in spite of the efforts of the surgeon
to  prevent  it.   You  will also observe  that there  is  no extension
made by the instrument, as the inventors claim, because the strap,
which is designed to produce extension and passes from the  ends
of the adhesive plaster, beneath the extension-bar, is slackened at
every step.   This I have noticed lately in several cases, in one of
the hospitals of the city of  New York,  in which  there is a  large
orthopedic  ward, under  the  care  of an accomplished orthopedic
surgeon, who uses Taylor's  apparatus.    The instrument  merely
transfers the weight of the body, from the hip-joint, to the perineal
band, but the extension is made by the weight of the limb alone.
  The  apparatus of Andrews,  Barwell and  Bauer, are equally
inefficient in securing the objects for which  they were designed,
viz.:  to render the joint immovable, and to  produce extension of
the limb.   Thomas's instrument, by its long leverage, extending
from  the angle of the  scapula to the  calf of the leg, has some
control over the movements of the joint, but it is  unnecessary for
this purpose, and, as already indicated, is very inconvenient to the
patient;  while  the wire-gauze  apparatus of Professor Hamilton,
can have but little influence in  producing  immobility, because it
does not extend far enough above and below the joint.
  Why is it then, it may be asked, if the appliances referred to
are wholly inefficient to  accomplish what is claimed for them, and
are calculated to prove deceptive as to the results, that so much 
i6
ORTHOPEDIC SURGERY.
improvement has been reported  from them, when compared with
others not having their features ?   For my own part, I am in the
habit of explaining these favorable results by the fact that, the use
of the  instruments devised by American ingenuity, has liberated
patients from confinement within-doors, and enabled them to live
and move and exercise in the open air, instead of being treated in
bed, as was formerly done ; and also from the fact that the princi-
pal indications, immobility and extension, are obtained in spite of
the apparatus used.
   If fixation of  the joint and extension of the limb, are essential
conditions in the local treatment of morbus coxarius, and, to speak
candidly, and yet deferentially, I believe these conditions are not
secured by any of the appliances commonly used for this purpose,
the question arises : How can these indications be adequately ful-
filled with the smallest amount  of discomfort to the patient and
the least inconvenience to the surgeon?
   The method of treatment which I have adopted, and used ex-
clusively, for the last three years, and which has been used satis-
factorily, by many skilled and reliable surgeons, here and elsewhere,
is  illustrated in Figs, i and 2.  To the shoe of the  sound limb, a
steel plate, corresponding to the  sole  of the  shoe, is attached, by
upright  rods two and a half or  three inches in  length, so as to
raise the foot from the ground; — it is the shoe ordinarily used for
shortened leg.   This elevated shoe and a pair of  crutches, consti-
tute the apparatus.   As the  patient stands on his  crutches, the
diseased limb is  suspended; the  shoe should be  high enough to
prevent the toes of  the affected side from touching the ground,
and the sole covered with leather, to avoid noise when walking.
   By these simple appliances, we meet all the indications for the 
ORTHOPEDIC SURGERY.
17
local treatment of hip-joint disease;  and, I desire to emphasize the
statement that, whatever artificial appliances for fixation and exten-
sion may be added, they only tend to increase the discomfort of the
patient.
to secure immobility of the  joint, no apparatus is  necessary.
  Immobility, a condition so important in the treatment of inflam-
mation  of this, as of other joints, is secured by reflex contraction
of the peri-articular muscles, aided  by intra-capsular  effusion, and
by the voluntary effort of the patient to keep the joint at rest, on 
i8
ORTHOPEDIC SURGERY.
account  of the pain which  motion produces.   Fixation of  the
joint, is one of the earliest  symptoms and is a characteristic con-
dition  of morbus coxarius;  and  it is so  marked, that, when we
move the limb, the pelvis moves with it — there is apparent  an-
chylosis.   This rigidity continues until Nature says that immobility
is no longer necessary;  but, so long as it is necessary, she secures
it better  than we can do by any artificial appliances.  In the later
stages  of the  disease, motion is  desirable, and  gradually, as  the
inflammation subsides,  the muscles  become relaxed,  motion re-
turns, and  anchylosis is prevented, except in cases  in which there
is  extensive destruction of the  joint-surfaces, and then cure by
anchylosis is the thing to be desired.

 to obtain extension of the limb, no apparatus is  required.
  Extension is made by the weight of the suspended limb, which
is  equal  to  one-fifth of the whole body,  and is greater  than  the
weight usually employed for extension.   This is quite sufficient to
subdue the  spasm of the muscles which  crowd  the head of  the
bone into  the inflamed acetabulum, and is the chief cause of
the pain  which the patient experiences.  In a child  weighing sixty
pounds, for example, the weight of the limb would be about twelve
and a  half pounds, which is more than the  child would bear by
the ordinary method of extension  by weight and pulley.  We all
know how promptly contraction of the muscles of the extremities,
in case of cholera, or from other causes,  is overcome  by forcible
extension.  The pain in the part is relieved, not  by  separating the
inflamed  articular surfaces,  as has been  claimed, for  we cannot
separate  them to an appreciable extent, by any amount of exten-
sion that can  be applied.  The  extension not only relieves pain 
ORTHOPEDIC  SURGERY.
19
 but it  corrects  the malposition  of the limb, whatever  it may be,
 and  prevents the deformity  which would otherwise occur,  from
 contraction of the muscles or from partial dislocation of the  head
 of the  bone.  By means  of the elevated shoe and crutches, the
 weight of the body is  removed from the diseased joint, and the
 patient can   enjoy all the  benefits of open-air exercise,  condi-
 tions so  evidently necessary as  to require  no special considera-
 tion.1
   Experience has proved what Nature seems to indicate, that the
 method of extension here described, is more efficient and more
 agreeable   to  the  diseased  parts  involved, because  it is more
 gradual and  uniform, and  is  less  arbitrary and constraining, and,
 therefore,  excites  less  reflex  resistance  than  any other method
 hitherto employed.  There is a certain instinctive, unconscious
 recoil, in the mind of every patient, young or old, against  all the
 various devices  of constraint or imprisonment, which  a splint or
 apparatus implies.
   This plan  of treatment should  be  adopted  at  once,  whatever
 the  stage  of the  disease,  and be continued until the cure is com-
 pleted, except in the comparatively rare form of arthritic coxalgia,
 in which is suddenly  developed  an acute inflammation  of the
 synovial membrane and other soft structures of  the joint, attended
 with great  constitutional disturbance and excruciating pain, which
   1 I have seen, quite recently,  that Dr. Taylor, in a paper published in The New York Med-
 ical Record, September, 1867, says, that " Many have advised, as I sometimes have when
 circumstances were such that nothing better could be done, to wear a thick sole on the foot of
 the well leg, and use crutches, letting the lame leg hang."  He seems not to have pursued the
 method successfully and satisfactorily, because, as he says, "the difficulty is in carrying
the plan into practice with sufficient perseverance and uniformity."  Dr. Sayre has also called
my attention to the recommendation, in his work on Orthopedic Surgery, of similar appliances
for the treatment of sacro-iliac disease. 
20                ORTHOPEDIC SURGERY.
is increased by the slightest movement of the limb or the shaking
of the bed.   In such cases, it  would be  inappropriate, at first.
Until after the acute  symptoms  have subsided, such cases should
be treated in bed, with the long splint and the weight  and pulley,
together with other appropriate remedies.  But in all other forms
of the disease, in all its stages, whether the first, second or third,
the method of treatment is appropriate, if the patient is old enough
and  has  sufficient strength  to  use  the crutches.  Mr. William
Adams, of London, in a letter just received from him, says, "There
can be no doubt whatever of the great value of your suggestion to
put  the raised boot  on the  sound leg,  in hip-joint disease, and
allow the  patient to  move  about on  crutches, but both the case
and  the stage must  be selected."  I am quite sure that a larger
experience will  satisfy my friend  Mr. Adams,  that the physio-
logical method is  applicable to all cases, except those  I have
mentioned.
  There may be cases in which it will be necessary to make exten-
sion, at night, by the weight  and pulley, to relieve the usual noc-
turnal pain, while  the elevated shoe and crutches are used during
the day; but I have  not thus far met with any, even among those
who  had  used the night-extension  with some portative apparatus
during the day,  up to the time they came under my treatment,
and  there can be no stronger  proof of the efficiency and  the
appropriateness of my method.
  I have,  however, found night-extension useful in cases in which
the muscles are contracted,  on account of the  neglect of early
treatment.  In these cases, the weight and  pulley, at night, in
addition  to the  elevated  shoe  and  crutches,  during the day,
enables us sooner to overcome the  flexions of the limb.  In such 
ORTHOPEDIC SURGERY.
21
cases, we may also derive benefit from adding a weight to the heel
of the shoe of the diseased side, when the increased extension can
be  borne; but, my belief is,  at present,  that night-extension  is
unnecessary for the purpose of relieving pain.
  The patient  soon learns that relief from  pain  is obtained  by
suspending the diseased limb, and then he  is glad to walk or to
stand on the crutches, three or four hours daily.  This appears to
be sufficient to relax the muscles to such a  degree  that  spasmodic
contraction, with the accompanying pain,  does not  take place at
night.
  For children who  are too young, and for older persons who are
too  feeble to  use common crutches, Darrach's  wheeled crutch
(Fig. 3), or the ordinary go-cart,
are admirable  aids  to  locomo-
tion.   Darrach's  crutch  is the
best, as it is so constructed that
the patient may be  partially sus-
pended in the crutch,  if  neces-
sary, by a perineal band, which
prevents  fatigue, and it is  also
lighter and more elegant in its
construction.  The elevated shoe
should be  used with either in-
strument.  If a case comes un-
der treatment at so advanced a
stage that resection is necessary,
the elevated  shoe  and  crutches
should be used, after the active
symptoms following the  operation have subsided, instead of adopt-
 
22
ORTHOPEDIC SURGERY.
ing the  usual practice  of confining the patient to bed and  using
the weight and pulley.1
  Since I first  called attention  to the physiological treatment of
hip-joint disease,  in  the American Journal of the Medical Sci-
ences,  January,  1879, the  method has been extensively  used  in
several large hospitals, and evidences of its efficiency have been
furnished  me, from many  private sources.   To illustrate the ad-
vantages of this plan  of treatment,  I will  narrate a few of the
cases in which it has been used by myself and by other surgeons.
  The following was the first case to which it was applied, and,
for this reason, I reproduce it from the paper already referred to.
  Case  I.  Morbus Coxarius {second stage), treated by the Ele-
vated  Shoe and  Crutches, Eight Months; Perfect Recovery. —
Ed. W., aged six years, a well-formed boy with good antecedents,
was referred to  me by Dr. George W. Baker, of this city.   I saw
him first,  July 3,  1877, and  obtained  the  following history: He
fell from a sleigh  seven months  ago, and struck on  his  left hip.
Soon afterwards, he had pain  in the hip and knee, growing  more
severe at night.  He had been in bed two weeks, with  his  thigh
and leg flexed, and his mother  noticed that whenever the limb
was abducted  during sleep, he was instantly awakened by pain.
After spending two weeks in bed, the pain  having  diminished, he
went about the house limping.
  1 Dr. Schenck, Medical Superintendent of the Kings County Hospital at Flatbush, uses a
wooden substitute for the steel or iron patten, in the large institution under his charge.  It con-
sists of two pieces of wood, of the length and width of the shoe, separated from each other to a
proper distance and connected by two upright  pieces which project an inch or two above the
upper horizontal piece before and behind, so that the foot cannot slip backwards or forwards.
It is fastened to the shoe by straps and buckles like a skate, and answers every purpose of the
steel instrument for hospital patients who do not walk upon pavements, and it costs nothing
as it is manufactured by convalescent patients.  Dr. Schenck informs me that he treats all his
cases of hip-disease by the method I have described, with the most gratifying results. 
ORTHOPEDIC SURGERY.                23
   When he came under my observation, he had pain in the knee,
shooting upward toward the hip, growing much worse at night and
when the  weather was  damp.   The  limb  was  abducted  and
apparently lengthened, the foot  everted,  the leg slightly flexed
upon the thigh, and the thigh upon the trunk, partial obliteration
of the  gluteo-femoral fold; the  peri-articular muscles were rigid,
so that an attempt to move the joint moved the pelvis with it, as
if anchylosis existed at  the joint; striking the  heel and  the tro-
chanter major, increased  the  pain in the joint, and, when laid
upon the floor, the effort to bring the popliteal  space in  contact
with it, produced a marked curve in the lumbar vertebras.  In
short, he presented the symptoms of the second stage of  morbus
coxarius, in a marked degree.   The  elevated shoe and crutches
were ordered,  with open-air exercise and a proper regimen.
  At the end  of a fortnight, the pain had diminished, his aspect
had  improved, and he  bore pressure  over the  trochanter much
better.   I saw him from time  to time, and noticed  a steady im-
provement.
  March 6, 1878. — He has had no pain for a long time : all the
motions  of  the  joint are as perfect  in one  leg as in the other,
except that the diseased leg cannot be so  completely flexed  upon
the trunk, as the well one. As a precautionary measure he was
directed  to  continue  the  use  of the  elevated shoe and crutches,
for the present.
   July 4. —Two or three weeks since, he dispensed with shoe
and  crutches, by  my  direction.  All  the motions  of the  joint
are perfect  and painless;  he  walks  as  well as he ever did;  no
pain developed  on pressure about the  hip, slight atrophy of the
limb, no deformity; is well nourished,  bright and cheerful, and, 
24                ORTHOPEDIC SURGERY.

as a pugilist, holds his own with  any boy of his age, in the neigh-
hood.   I  present  this case  as an  example of  the  best  cure of
hip-joint disease I  have ever seen.
  Case II. Morbus  Coxarius {thirdstage), treated  with the Ele-
vated Shoe and Crutches, for Eight Months ; Complete Recovery.
Notes  by  A.  R. Paine, M.D. — Richard V., aged six years,  was
brought to the Brooklyn  Orthopedic Infirmary for treatment, Feb.
12, 1878.  His mother  stated that, about one year ago, he fell
down stairs, striking on  his left hip.  Disease  in the joint  soon
followed,  for which  he was treated with electricity, and wore  a
modification of  Davis's splint.  The limb is now adducted, slightly
flexed  at  the hip-joint, and  the foot is  inverted, resting with the
ball upon the opposite instep;  the gluteo-femoral fold  is oblite-
rated ; there is considerable pain in the hip, increased by pressure
over the trochanter, great  pain  in  the  knee and swelling behind
the joint.   He is also very anaemic.
  Davis's  apparatus was discontinued;  he was directed to use
an  elevated shoe, two  and  three-fourths inches in height,  and
crutches, and to be in the open air at  least  three  or four hours
daily.  He was also ordered cod-liver oil and iron.
  March  12. — He has been much more comfortable  since the
elevated shoe and crutches were  substituted  for the  apparatus
previously used.   His  appearance  has improved, and he  has no
pain.   His mother  has  continued  to  use  Davis's  apparatus at
night, lest the nocturnal pains might return.  She was told that  it
was unnecessary, and directed to discontinue it.
  April 5. — His  general health  is very good; no pain even
when  considerable flexion and  rotation are made.   His mother
left off the night  apparatus  as directed; says that he has no 
ORTHOPEDIC SURGERY.
25
nocturnal pain,  and  sleeps as well without the apparatus as he
did with it.
   Oct. 29. — The position of the limb and foot is perfectly nor-
mal, no shortening; the joint  moves freely in  all directions with-
out  pain; the most  careful examination shows no evidence of
disease, and he looks and feels well.  He is directed to continue
the use of the elevated shoe and crutches for some time  longer,
as a precautionary measure, although I now consider the case one
of perfect recovery.
  This little patient was shown to the  members of the Medical
Society of the County of Kings, at the April meeting, 1879.  He
had not used the crutches and shoe for some  months previously,
and his recovery was pronounced complete.
  Case II. Morbus Coxarius {third stage), treated with the Ele-
vated Shoe and Crutches;  Recovery after less than five months'
treatment. — Fred. R., three years old, was brought to the  Ortho-
pedic Infirmary  Feb. 14, 1879, ana^ me  record of his case was
made by Dr.  H. W. Rand.
  The parents think  the present  trouble  commenced  when the
child was six  months old.   He is tolerably well nourished, and
gives no  history of injury.   When  he  began  to  creep,  it was
noticed that he favored the right leg.  Two months later, swelling
appeared  around the  hip-joint,  most prominent  in  the  groin,
where  it was  opened by the family physician, and discharged a
thin yellowish  fluid.
  Since the child began to walk, he has  always borne the most
weight on the ball of the foot, rarely allowing  the  heel to touch
the floor, owing to flexion of the thigh  on the trunk.   He com-
plained of very little pain, until Dec. 11 of last year, since which
time pain has been almost constant and referred to the hip-joint. 
26
ORTHOPEDIC SURGERY.
  When presented at the Infirmary, the  thigh was flexed on the
abdomen, the foot inverted, the pelvis drawn up, on the affected
side, the nates  flattened, and the gluteo-femoral crease  lowered.
Movement of  the thigh excited spasmodic action in  all the
muscles around the  joint,  presenting apparent anchylosis  of the
hip-joint,  the  pelvis  moving  with  the femur.  Pressure of the
head  of the femur against the acetabulum and  pressure behind
the trochanter,  caused pain.
  Ordered elevated shoe (2^ inches) for left foot, and crutches.
  Patient returned  March  4.  Has learned to  walk with the
crutches,  and has had  no pain for  the  past week.  When seen,
March 11, he was still  entirely free from pain, movement excited
less spasmodic  action in the muscles around the joint, and the
flexion of the thigh on the abdomen had somewhat diminished.
   July 8. — All tenderness and pain about the joint have disap-^
peared, the limb is  straight, there  is still some rigidity of the
 joint.  The shoe and crutches were  dispensed with.  This patient
was found six months after treatment was discontinued, and care-
fully examined  by Dr. W. M. Thallon, who furnished the following
note.  r' The boy has continued quite well and  has very good use
of  the  leg.  Except on very  close  examination,  the  previous
existence of morbus coxarius, would not be suspected."
  A point of interest in the case is, the early age (three years),
at which children may be taught to use the elevated shoe and
crutches.  This patient was  also presented at  a meeting  of  the
Medical Society of the  County of Kings.
  The notes of the following three cases,  were  kindly furnished
me by Dr. C. E. Fritts,  of Hudson, N.Y.
  Case  IV. Morbus Coxarius, treated with the Elevated Shoe 
ORTHOPEDIC SURGERY.
27
and Crutches, for five months and a half; Recovery complete. —
" I. D. H., aged ten years, first consulted me, May 22, 1879.   He
complained of severe  pain in  the right hip-joint  and lameness,
which  began one month before;  these symptoms were  growing
steadily worse, the  foot  was inverted, there was  fulness of the
gluteal region, the gluteal fold was partially obliterated, the thigh
was flexed somewhat upon the pelvis, reflex contraction of the
muscles  around the  joint  produced  apparent anchylosis,  any
attempt to move the joint  caused him  great pain, pain was  also
produced when the  trochanter was pressed inward, and when the
heel was struck.
  " He was put to bed and kept quiet for one week, during which
time I had the elevated shoe, advised by Dr.  Hutchison, made
for him, and he was put upon it, with the  crutches, May 30.  On
the same  day, he was seen by  Dr.  Vanderveer, Professor of
Surgery in the Albany Medical College,  who  concurred in the
diagnosis and treatment.
  " After using the shoe and  crutches for two  weeks, all pain in
the joint passed away.  The patient wore  the  shoe and  crutches
for  five months, when the  shoe was  laid aside, and  he  used the
crutches alone for a couple of weeks  longer, touching  the  right
foot, lightly at first, but afterwards bearing equal weight  on both
feet.  The crutches were now thrown  aside, and he was allowed
to walk without any artificial support.
  " An examination, five  and one-half months after treatment was
begun, shows  that the position of the limb  and foot is  normal,
there is  no shortening, the joint moves freely  in  all directions,
without pain, there  is no evidence of  any joint trouble whatever,
and  I  consider him perfectly and entirely recovered."  Dr. Fritts 
28
ORTHOPEDIC SURGERY.
writes, April 8, " This boy has  not  used a crutch or worn his ele-
vated shoe since Jan. i, 1880."
  Case  V. Morbus Coxarius {third stage) ; Abscesses from Dis-
eased Bone; Recovers. — " This patient  was a boy seven  years
old,  who  began to complain of pain in  his right  hip, one year
before I  saw him, ascribed to jumping some time previously.
There is no evidence of a constitutional taint of any kind.
  " On examining the limb,  I found the thigh flexed on the pelvis
and  adducted, and  the  foot  inverted;  there  was considerable
swelling behind the joint, with fluctuation and an  abscess subse-
quently opened  behind from under the  gluteal muscles, and an-
other, on  the  outer aspect of the thigh, below the  tensor vaginae
femoris.   There was but  little motion in the joint, and pressure
upon the joint, or motion, caused great pain. The pain was worse
at night.  He was put upon the elevated shoe  and  crutches, June
1, 1879.   He was very soon relieved of all pain, and his general
condition  began at once to improve."
  Dr. Fritts writes, April 8, 1880, "The present condition of this
boy  is excellent, the sinus have all closed, the eschars adherent
to the bone;  there is quite free movement of the joint, without
the  slightest pain; he bears his weight upon the limb without in-
convenience, has gained flesh and  is hearty and robust.  Before
using the  high shoe  and crutches, he  was carried about in  his
nurse's arms, was  very much emaciated, and  his  relatives were
expecting  him to die soon."
  Case  VI. Morbus Coxarius {third stage) ; Abscesses from Dis-
eased Bone ; treated with Elevated Shoe and Crutches ;  Recovery.
— "A girl,  aged nine  years,  came under my observation, June
1, 1879, with disease of the right hip-joint of three years standing. 
ORTHOPEDIC SURGERY.                29
 There was no history of injury and no constitutional taint.  There
 were three fistulous openings  discharging pus, — one in front of
 the  joint, one on the outer part of the thigh and one behind the
 joint; the thigh was flexed upon the pelvis, adducted, and the
 foot was inverted; there was little or no motion in the  joint, and
 any  effort to move it, and  pressure  over  the trochanter, caused
 great pain ; the  pain was  not worse  at night.  She had used, for
 a  long time,  a  modification  of Davis's splint.   She was put at
 once upon the elevated shoe and crutches advised by Dr. Hutchi-
 son, and the  local  symptoms and general  condition  began to
 improve in a very short time."
   In a letter dated April 8,  1880, the  reporter says, "The present
 condition of this patient is remarkably good;  all the abscesses and
 sinuses have healed; eschars  adherent to bone; there is but little
 shortening; good motion in the joint and only a slight limp in
 walking."
   The notes of the following case were kindly furnished by  Dr.
 C L. Squire, of Elmira, N.Y.
   Case VII.  Morbus Coxarius {third stage) ; Abscesses; Pro-
 gressive  Improvement. — " The  patient, a  boy ten years old, fell
 upon the ice  Dec. 30,  1878,  striking upon his left hip, and was
 taken home on a sled by his companions.  Within ten  days, symp-
 toms of  trouble  with his hip  showed themselves.  The boy was
 healthy and his family history excellent.
   "I saw him first, March 2, 1879, iw0 months after the injury; he
 then exhibited marked symptoms of morbus coxarius.  The thigh
was  flexed upon  the  pelvis and adducted;  the foot was  inverted;
there was marked swelling about the joint;  the gluteo-femoral fold
was  lowered and partially obliterated;  motion of the  joint  and 
30                ORTHOPEDIC SURGERY.

crowding  the head of the femur into the acetabulum increased
the pain;  the pain was much worse at night.   He also had necro-
sis of the left tibia.  He was put upon sodium salicylate (Squibbs'),
which was  followed by complete  relief of pain except when mo-
tion or pressure were made.
  "On March 31, he began the use of the high shoe and crutches
with great relief to his local symptoms.   During  the  month  of
September an abscess formed and opened  just below the tro-
chanter."
  April j, 1880. — "My patient  has been doing remarkably well
since the  last report.  He still wears the elevated shoe, and is in
the streets, with the crutches, a good share of the time.  There is
a fistulous opening just below  the trochanter which is discharging
moderately. . . . The necrosis and  exfoliation  of  the opposite
tibia,  has  been a serious  complication, but even with  this addi-
tional difficulty, the elevated shoe has been of the greatest advan-
tage to him, allowing him to take healthful  exercise in the open
air.  His  appetite is  excellent, he is  free from  pain, sleeps well,
and is decidedly improving in every sense."
  The above cases are taken, without selection, from among those
which have terminated or are  approaching recovery; incomplete
cases  are  unsatisfactory.   I  have preferred also  to give cases
which were  treated by other  surgeons, and were reported  by
them:  this is true of all the  above cases except  the  first,  the
second  and the third which were treated at the infirmary which is
under my supervision; the remainder, I have never seen, but the
reliability of the  reports and the reporters cannot be questioned.
I think it  is not too much  to say that they show better, more
rapid  and  more  useful results, obtained by  the "physiological 
ORTHOPEDIC SURGERY.
31
 method," than by the  older methods of treatment, and I am sure
 with  less annoyance and discomfort both to the patient  and to
 the surgeon.
   The  simplicity of the method, enables the general practitioner
 to conduct the treatment of such cases without the aid of a " spe-
 cialist," or the professional instrument-maker.
   I do not wish to underrate the service which has been rendered
 to orthopedic surgery by specialists, but, I simply protest against
 the prevalent idea, that  diseases and deformities of the limbs and
 other parts of the  body, can be properly treated only by an ortho-
 pedist, or in an orthopedic hospital.
   As  an evidence  that general  practitioners of medicine and sur-
 gery,  are, since I called attention to the physiological treatment of
 hip-disease, treating  such cases  themselves,  I may state that,
 whereas  I formerly had a  good  many private patients  of this
 class sent to me for treatment, the number has diminished.   Meta-
 phorically speaking, " Othello's occupation's gone."
   Every surgeon of experience, has met with  cases in which it
was impossible to apply  any  kind of portative apparatus  to the
 diseased limb, on account of abscesses and fistulous  openings
about the joint.   The  only alternative  in those  cases has been,
confinement to bed, with the weight and pulley, in order to prevent
deformity and pain, thereby depriving the patient  of the benefits
of open-air exercise, so important in the treatment of this class of
cases.   I recall several cases  that  have  terminated fatally, and
others that  have  required  resection, whose lives, in the former
class,  I  now believe, might have  been saved,  and in the other,
cures  might  have been effected without  operation, if  they had
enjoyed the advantages  of fresh air, on the high shoe and crutches. 
32                ORTHOPEDIC SURGERY.

  What a  boon it is to get rid of the paraphernalia with which
the diseased limb was  formerly encumbered, — the  harness  and
the trappings, the weight and pulleys and the adhesive plaster, the
perineal bands and the iron splints, and all  the  discomforts which
their use implies !

                     THE KNEE-JOINT.
  From the diseases of the hip-joint, we will descend to  those of
the knee; but, we must take the metaphor, as Mr. Solly says, in an
anatomical, not in a surgical  sense ;  for the frequency with which
inflammation occurs in the knee-joint,  owing to  its  complicated
mechanical machinery and its  exposed  position, both in relation
to atmospheric changes and its liability to receive  injury from vio-
lence, invests the subject with an interest to the surgeon quite  as
great, if  not greater, than that which pertains to the hip-joint.
   In morbid conditions  of the  knee-joint, the  indications for
treatment are, in all respects, the same as in inflammation of the
hip-joint, with the addition of compression over the joint.
  The knee is not, like  the hip, surrounded  with powerful muscles,
which, by their  rigidity, immobilize  the diseased  hip-joint.   It is
necessary,  therefore, in  the case of the knee, to bring to our aid
some mechanical restraint, in order to secure complete rest.   To
cause fixation of the knee-joint, I use splints made of hatter's
felt, such as  is shown in  Fig.  4.   It consists of seven layers  of
thin muslin each saturated with shellac, and well  rolled  together,
while hot.   It is manufactured, of this  thickness, specially for me,
by  Mr. Holley,  of South  Fifth Avenue, New York, and may  be
obtained from Tiemann, and, I suppose, from other surgical-instru-
ment makers.  That ordinarily sold consists of  but five layers  of 
ORTHOPEDIC SURGERY.
33
cloth, which, for most cases, is not firm  enough.  To give com-
plete rest  to the joint, the splint should extend half-way up  the
thigh, and to a corresponding point below the knee, and  should
be wide  enough to nearly surround the limb (Fig. 4).   A splint
shorter than this, and merely wide enough to cover
the posterior part of the limb, does not secure the
complete immobility which I have insisted upon in
the treatment of diseases of the joints, when abso-
lute rest is demanded.  The splint having been
cut of the proper length and width, which may be
easily done with a sharp knife, the limb is covered
with a stocking, and the  felt,  made pliable, pre-
ferably by dry heat in an oven  or before an open
fire, or by immersion in very hot water, is applied
to the limb, and covered  quickly and firmly with
a bandage from below upwards, so as to mould it
to all the inequalities of the surface.  While the
splint is  being applied, an assistant should make
extension from  the  foot,  so as to straighten the
limb as much as possible, in cases where the joint
is flexed; but no violent effort  should be made to     FlG-  ■*■
reduce the malposition; this can  usually be  accomplished  by the
gradual,  painless (physiological) extension made  by the weight of
the limb, to which  we shall presently refer.  The  surfaces  of the
joints are  morbidly sensitive to pain, which would be greatly in-
creased,  if  they were suddenly and forcibly pressed together, in the
effort to  reduce the deformity at once.  If the  surgeon's hands
are very  sensitive to heat, he may handle the  splint better by wear-
ing a pair of cotton gloves, wet in tepid or moderately cold water.
 
34
ORTHOPEDIC SURGERY.
So soon as the splint regains its inflexibility, and this  it does very
quickly, it may be removed, trimmed up and holes punched in it, an
inch, or an inch and a half, from the front edges, for lacings.  The
object in punching the holes a little way back from the edges, is
to permit the splint to be made smaller, by cutting off the edges,
so that pressure  may be kept up, as  the knee  diminishes in size.
The splint should nearly meet in front, and be laced  as tightly as
the patient can bear it, with comfort; all the benefits of elastic press-
ure may be secured, by surrounding the  knee with a layer of wool
wadding, which  never becomes matted, never loses its elasticity,
and is  an  extremely comfortable method  of making pressure, if
the patient should complain of  discomfort from the splint.  If, in
any case, it  is considered desirable to leave  the  top  of the  knee
uncovered, a semicircular piece may be removed  from either side
of the splint, and windows may be cut, at any point,  where there
are fistulous openings which require dressing.   The splint may be
made more comfortable  in warm weather, by perforating it, here
and there, with a punch.   If the leg is rotated on its  longitudinal
axis, with a  tendency to  inversion or eversion  of the foot, this
should be prevented by extending the splint down to the foot.
  If the leg is flexed, when the splint is first applied, and cannot
easily be forced into a  straight position, the angle of the splint
should be changed, from time to time, as the leg becomes straighter,
under the influence of extension by its own weight. This may be
done by softening the posterior part of  the splint, by  the  applica-
tion of  a sponge dipped in hot water; a bandage  should  then  be
firmly applied, while extension is made upon the leg, by the hands
of an assistant.   So soon  as the  splint hardens, the bandage is
removed and  the lacings tightened.  The splint, although firmly 
                  ORTHOPEDIC SURGERY.                35

applied, does not interfere with the straightening  of the joint, by
the extension made by the weight of the leg.
   I prefer the felt  splint to one made  of plaster of Paris, leather
or liquid glass, because, while it is equally firm, it is also  lighter,
may be equally well  adapted to the inequalities of  surface about
the knee, is more easily applied, its angle may be changed with-
out removing it from the knee, and it may be unlaced and opened,
to examine the  parts, or  it may be removed,  without  disturbing
the joint.
   By means of the knee splint, we not only fix the  joint and
contribute to  correct its malposition, but we also  make compres-
sion upon the part, which  is a valuable therapeutic auxiliary in
the management of these  cases, and its importance must  not  be
overlooked.   Compression   causes  absorption of  non-purulent
effusions into  the joint, removes the boggy, infiltrated condition
of the  connective  tissue which surrounds it, protects the part,
and  gives support to  the  relaxed ligaments and the synovial
membrane.
   Extension is  best  accomplished by the use  of the elevated
shoe and crutches, which have already been described,  in con-
sidering the treatment of  hip-joint disease  (Figs. 1 and 2).  The
weight of the suspended leg, which may  be  estimated  as one-
twelfth  to one-tenth  of  the weight of the  body, eight  to  ten
pounds, in a body weighing one hundred pounds,  is  quite suffi-
cient to tire out the muscles, which, by reflex contraction, compress
the already suffering tissues within the joint, increasing the pain
and  leading to interstitial absorption — in  short, the muscles are
restored to their normal length.  By means of extension, we also
correct  the  malposition of  the  limb, which is usually contracted 
36                ORTHOPEDIC SURGERY.

to an angle of a hundred and twenty degrees; but extension has
not the slightest influence  in separating  the diseased  articular
surfaces, which,  however,   I  do  not consider necessary.  This
method of extension is so gradual and uniform, and therefore so
soothing to the  diseased parts, that the muscles  are  enticed to
relax, if such  an expression is permissible in  this connection,
instead of being irritated and stimulated to contraction.
  The  apparatus of Professor Sayre, for producing extension of
the diseased knee-joint, as well as  the appliances of H. G. Davis,
and Sherman, of Chicago, for the  same purpose, are creditable to
the inventive  genius  of their  respective authors; but,  those who
have  used either of them, must be aware of the skill and experi-
ence necessary to apply them properly, the constant attention they
require to keep them suitably adjusted, and the discomfort to the
patient, produced by the irritating effects of the adhesive plaster
with which they are all attached to the limb.  Moreover, the effort
to  produce forcible  extension  by these various devices,  excites
reflex  resistance, and the patient, young or old, instinctively re-
coils  from the attempt to overcome muscular contraction by an
exertion of strength, applied by means of an apparatus.
   The weight  of the body being removed from the diseased joint,
by  the use of  the elevated shoe and crutches, the  patient should
be  kept out of doors as much as practicable, and if old enough
to  understand the rationale of the treatment, the importance of
using the crutches three or four hours daily, should be explained
to  him, and,  if necessary,  their employment enforced.   Patients
should also understand the importance of  keeping the  joint  at
rest.   They not infrequently complain of the  restraint  of the
splint, and secretly  remove it themselves; and this is especially 
ORTHOPEDIC SURGERY.
37
true of dispensary patients,  not because  they  really suffer pain
from the  position or the confinement of the limb,  but  because
they are afraid of  losing the use  of the joint.  I mention this,
not to induce  you to shut your ears  or disregard the complaints
of patients — on the contrary, I think they always  deserve  atten-
tion — but to warn you against being deceived by such persons.
  There are  many  mild cases of chronic inflammation  of the
knee-joint, characterized  by slight effusion into  the joint, and
tenderness on pressure over the lower part of the inner condyle
of the  femur,  or at the inside  of the head of the  tibia, in which
there is no pain on pressing the articular surfaces together.   In
such cases, the application of the knee splint is sufficient to effect
a cure, without the use of the elevated shoe and crutches.
  When the  disease has resulted in destruction of the  joint
and caries,  either  from  the violence of the attack,  or  from
the advanced  stage  of the disease when  it came under observa-
tion, we may  still hope  to  save the  limb  and effect a  cure  by
anchylosis.  In fact, by rigidly carrying out  the  indications  above
referred to, of which the first in importance, in all joint inflamma-
tions, is perfect  immobility  of the  part, the most  unpromising
cases, not infrequently recover; but, if the patient  is becoming
exhausted by suppuration, and there is not  sufficient  recuperative
power left to  throw off the  disease, resection or amputation may
become necessary.

                     THE  ANKLE-JOINT.
   In the treatment of inflammation of the ankle-joint and its con-
sequences, perfect rest of the parts by mechanical means, and the
removal of pressure from the diseased articular surfaces, is quite 
38
ORTHOPEDIC SURGERY.
 as important, and, I may add, quite as satisfactory, as  in  diseases
 of the hip and knee, and the indications may be met in the same
 way.  Instead of the felt, I prefer to use, for fixing the ankle, two
 splints made of plaster  of  Paris,  because  they are  more easily
 adapted to the inequalities of the surface about this joint; one is
 to be applied in front, and the other behind, extending from the
 middle of the leg  to the ends of the metatarsal bones, and wide
 enough to leave an interval of half an inch between the edges, on
 the inner and the outer side.   The splint should be made of  two
 layers of Canton  flannel, of coarse  texture, or of  three layers of
 coarse towelling, cut  of the  proper length and width.  One layer
 of cloth is laid upon a  table and covered with  liquid plaster, of
 the consistence of  cream and spread smoothly, with a table-knife.
, The other layers  are  then immersed in the plaster and  applied
 evenly and  smoothly over the first;  and when both splints have
 been prepared, one is applied in front and  the other behind, with
 the under surface  of the first  layer, which is not covered with
 plaster, next to the skin, and a roller bandage is firmly applied
 over the  splints, from below upwards.  The surgeon should now
 grasp the foot, and, holding it at a right angle with the leg, make
 extension until the  plaster hardens, which requires about five min-
 utes.   The  bandage  should then be removed,  and the  splints,
 surrounded  by three  or four strips of adhesive  plaster, and  the
 bandage re-applied more  loosely.   Windows may be  cut in  the
 plaster, so as to allow any openings that may exist in the parts, to
 be uncovered (Fig. 5).
   In all cases of diseased ankle-joint, the heel is raised more or
 less, by the  contraction of the gastrocnemii, if it is permitted to
 pursue its own course, and the toes point downwards, and in such 
                   ORTHOPEDIC SURGERY.                39
 cases it is important to overcome the contraction  of the muscles,
 and  place the joint  at rest, with the foot in its  normal relation
 to the leg, in order to secure its prop-
 er position,  should  anchylosis   take
 place;  and  to relieve  the pain  pro-
 duced  both  day and  night,  by the
 unremitting muscular contraction.
   To remove pressure  from  an  in-
 flamed  ankle-joint  and  to  provide
 means  for letting the  patient  get the
 benefits of the  open air, is not less
 important  than in  the case  of a  dis-
 eased hip  or knee  joint.   To accom-
 plish  these  essential   indications,  a
 variety  of  instruments have been  de-
 vised.  But they are liable to the same
 objections which  have  been  found to
 the appliances used for producing ex-
 tension  of the knee-joint.  After an experience, somewhat extended,
 in the treatment of these affections, I have no hesitation in recom-
 mending the elevated shoe and crutches, as the best and simplest
 method of making extension and removing pressure; it is just as
 effectual for the ankle as for the knee and hip joints.  The weight
required is not great, and the weight of the foot  is sufficient to
overcome the muscular contraction.
  If the foot, from long neglect, cannot at once  be brought to a
right angle with the leg, the  splints should be renewed every five
or six days, and the extension increased a little  at each applica-
tion, until the foot is brought into proper relations with the leg.
 
40
ORTHOPEDIC SURGERY.
  The advantages which the treatment here described possesses
over that commonly employed, in  the  management  of  chronic
inflammation of the  joints of the lower extremities, are : —
  i. It saves the surgeon the trouble and annoyance of applying
and carefully watching the instruments in ordinary use,  to see that
proper extension is kept up, and undue pressure  prevented :  while
the patient's comfort is greatly promoted by dispensing with  ad-
hesive plasters, which irritate the skin and require removal from
time to time, and by discarding the perineal band, in hip-disease,
which is a constant source of discomfort.
  2. The spasmodic  contraction of the peri-articular  muscles is
overcome by the gentle, persuasive and painless  (physiological)
extension, made by the weight of the limb, for several  hours each
day, whilst  forcible  extension, either  by the ordinary portative
instruments or by the weight and pulley, irritates  the muscles and
stimulates them to resistance and contraction, both of which must
be overcome by main force.
  3. I am quite confident, judging from the experience thus far
obtained,  that the plan of managing diseases of the  joints here
described, will shorten their duration more decidedly than can be
done by the older methods of treatment.
  4. The apparatus — if so simple a thing deserves the name of
apparatus — is  inexpensive, and  can  be made by any ordinary
mechanic.
  It is with a just deference to established usages that  I ventured
to condemn as  useless or  hurtful, the appliances hitherto in use,
in the  treatment of diseases of the hip, knee  and ankle joints,
and to commend to professional notice new and  simpler methods.
I should not have had the temerity to do so, had not  my convic- 
ORTHOPEDIC SURGERY.
41
tions, based upon practical  experience,  seemed  so plainly  to
warrant  the  positions I  have endeavored to maintain.  These
convictions  have  been strengthened, also, by the favorable  opin-
ions expressed of the treatment  of  hip-joint  disease, by this
method, since the publication of my paper upon the subject, by
many surgeons in this country and abroad, for whose  judgment I
have long been accustomed to entertain the highest respect. 
 
    ON  CLUB-FOOT:





ITS CAUSES, PATHOLOGY, AND TREATMENT. 
 
CLUB-FOOT.
                       CHAPTER  I.

INTRODUCTORY AND  HISTORICAL REMARKS. — RE-UNION OF TENDONS
   AFTER SUBCUTANEOUS  TENOTOMY,  AND  RULES FOR THE  OPERA-
   TION. --RATE OF  EXTENSION AFTER TENOTOMY.--DIFFERENCE IN
   THE  NORMAL ANATOMY OF  THE  INFANT AND THE ADULT FOOT.
   — VARIETIES OF CLUB-FOOT. — CONGENITAL AND NON-CONGENITAL
   TALIPES. — CAUSES. — PROGNOSIS.

   Gentlemen, — In a special course of  lectures, which  I  have
been appointed to  deliver in this institution,11 desire to call your
attention to the  surgical treatment of that class of deformities or
malformations, which  is commonly expressed by  the term, club-
foot.   In doing so, I shall open to you  a much-neglected, but,
humanely speaking,  one  of the most attractive chapters of mod-
ern surgery.  I say " modern  surgery," purposely, for it is impor-
tant  for you, on  many accounts, to  know that this department of
orthopedic surgery,  as well as some others which will  be men-
tioned  by other  instructors, is much younger than the present
century.   Our older surgeons  readily recollect the modest begin-
             1 The College of Physicians and Surgeons, New York.
                                                  45 
46                ORTHOPEDIC SURGERY.
nings of their practice in the  division of tendons, and even those
who do not consider themselves old, well remember to have seen
deformed  persons, who, through a long life, have borne  without
hope, the miseries attendant on  unrelieved club-foot which,  in
earlier years, might easily have been cured.   It was not until 1816,
that the  eminent  surgeon, Delpech, began  this procedure with
hesitation  and with indifferent success.   In this connection I will
ask you to fix in your memory, as one of the pioneers of your art,
the name of this surgeon of Montpellier, who, if he had lived out
the ordinary span  of life, would have left a name, not easily for-
gotten, for originality of thought and  ingenuity of execution.  As
it was, he left  a book, "De l'Orthomorphie,"  printed in  1828,
which  contains  statements of  principles, and rules  for practice
that are quoted by every systematic writer on this subject, down
to the  present  day.   His four rules for subcutaneous tenotomy,
somewhat modified by the progress since  made, are followed by
the orthopedic surgeons of to-day.   It is true that, before Del-
pech's  time, tendons had occasionally been divided  by veterinary
surgeons, as well as  for the relief of club-foot, but not subcutane-
ously, so  that  it was  reserved for that surgeon  to give to the
operation, a recognized and legitimate place in surgery.   In 1831,
Stromeyer, of Hanover, improved upon  Delpech's method by the
use of a small bistoury, thus avoiding the danger of a large exter-
nal wound.   Stromeyer's cases, too,  were  almost uniformly suc-
cessful ; so that, with the publication of his experience  in 1834,
tenotomy may be said  to have gained a footing on  solid ground.
Tenotomy therefore, you will  observe, has not quite completed  its
first half-century.   After Stromeyer, the operation was  rapidly
adopted by the  best surgeons of Europe and America; by some, 
                   ORTHOPEDIC SURGERY.                47

 improved  and simplified, principally (1)  by the adoption of the
 rule;  that the section should be subcutaneous, that is to say, the
 surgeon avoids a counter-opening on the further side of the sub-
 sected tendon, while making as small an incision as possible at
 the point of  entry of the narrovv-bladed knife, and (2) by making
 the incision  in a valvular,  form, i.e., the integument is slid some-
 what to one side, as the knife is entered, so that, when it is with-
 drawn, the wound through the  skin does not exactly correspond
 with that in the deeper parts.  This step, it is believed, tends to
 prevent the  admission of air into the inner wound, thereby avoid-
 ing some of the chances of inflammation and suppuration which
 may follow the presence of air in the deeper tissues, and  interfere
 with the proper  union of  the  tendon.  I will not, now, demon-
 strate the manner in which the operation of tenotomy is ordina-
 rily performed, because I shall have occasion to do so at a future
 time.
   In this country, the tendo Achillis was first divided, according
 to  the Stromeyerian method, by the late  Dr. James H. Dickson,
 in  1835.  Thus you may learn  how slowly came the recognition
 of this  valuable operation, which already has been performed many
 thousands of times.  It  is  a simple  operation, easy pi perform-
 ance, comparatively free from  danger, from loss  of  blood  and
 from any disagreeable  after-effects.  It causes but little pain, and
 generally brings about a cure after a short  period of confinement.

   RULES FOR THE PERFORMANCE OF SUBCUTANEOUS TENOTOMY.
   Let  us now see what takes place when a  tendon is thus cut,
and how tendons re-unite.   But, first, I will describe  the manner
in which the operation  of tenotomy is ordinarily performed.   The 
48
ORTHOPEDIC SURGERY.
limb should be so held that the tendon to be divided is made to
stand out  prominently; the skin  is  slid to one side, and  the
tenotome  is carried beneath the  tendon, flatwise;  the cutting
edge is  now turned towards the tendon, which is to be divided
transversely towards the skin, by alternately raising  and depressing
the handle, without puncturing the skin on the  opposite side.
After a  tendon has been divided, pressure should be made along
the track of the instrument, as it is withdrawn, in order to exclude
the air and prevent  extravasation of blood into the subcutaneous
tissues.  The wound should be immediately closed by a compress
of lint, retained in  position by a strip of adhesive plaster, and a
" figure-of-eight"  bandage, around the foot and ankle.   The  foot
should then be put into  a  plaster-of-Paris or a felt splint, which
has been  accurately moulded to it before the operation, in  the
manner  I shall hereafter show you.  It is thus kept at rest, in the
deformed  position,  until the  puncture has healed, which usually
requires about four  days.   To straighten the  foot immediately
after the operation, would tear  open the wound, and  most likely
bring on suppuration.   On  the other  hand, if we wait too long,
we lose all the advantages to be expected from tenotomy.   When,
however, tenotomy is limited to the tendo Achillis, which has no
synovial sheath, and therefore suppuration and non-union are not
so likely to occur, the  deformity of the foot may be rectified to a
considerable extent at once and retained in the improved  position
by appropriate appliances.
  The tenotomy  knife should  have the  shape of the ordinary
blunt tenotome,  the  extremity being  sharp,  instead  of blunt.
With this  instrument,  there  is less danger of making a second
puncture than with the more pointed instrument 
ORTHOPEDIC SURGERY.
49
      RE-UNION OF TENDONS AFTER SUBCUTANEOUS TENOTOMY.
  When the tenotomy is properly performed, the sheath of the
tendon  commonly remains  intact, except at the  point  at  which
the knife  enters.  The  tendon itself is, however, completely cut
across, and the  divided structure retracts :  the one end separates
from  the  other.   The amount of retraction will, of course, vary
considerably according to the size  and power of the muscle, the
degree  of deformity to be  overcome, or the amount of forcible
motion  that may then or later, be made at  the joint.   Taking the
tendo Achillis for an  example,  the retraction is  ordinarily from
one-half an inch to  one inch, in children, and one to two inches,
in adults.   The tendon is a very slightly vascular  tissue,  hence
there is but little, if  any, effusion of blood within the sheath, after
tenotomy.  It is the exception  rather than the rule, for even the
largest  tendons  to bleed, appreciably.   Mr. Broadhurst, who has
made numerous experiments for the  purpose  of  studying the
progress of re-union, says that on the second day  " a small and
unimportant film of blood was found in the sheath, and a small
quantity of lymph was attached to  the  divided end."  Billroth is
nearly the only writer who  makes mention of hemorrhage, and he
merely  says that it  may be sufficiently abundant to hinder, and
even  prevent,  the process of re-union.    The space  between the
ends is  filled by the effusion of a grayish lymph.  This exudes from
both  ends, but more abundantly from the upper end.   On the
fourth day, the two  ends are joined by means of this soft lymph.
On the  sixth day, it becomes a well-defined, firm, and ruddy cord,
and has assumed a distinctly fibrous character.   This  is the  begin-
ning of a process of repair, which, in  the  end, forms a structure 
50                ORTHOPEDIC SURGERY.

that  is histologically identical  with  that  of the original tendon.
{Paget.)   As  the  repair advances, the tissue  increases in quan-
tity ; it hardens and matures, loses its plastic and cellular quality,
and  takes on a new and more fibrous character, and, after a few
months, it assumes almost exactly the appearance of the old ten-
don.   The  microscope is then  unable to discriminate  between
the old  and the new.   The gross appearances are very nearly the
same as  to  outline, surface, size, and strength; only in color is a
difference recognizable.  The new tendon is more grayish in hue,
and has a less pearly lustre, than the original.

              RATE OF EXTENSION AFTER TENOTOMY.
  Although  this new material is soft at first, it rapidly strengthens,
so that  in from thirteen  to  twenty  days it becomes  sufficiently
strong to sustain the weight of many pounds.   It is susceptible of
extension to any degree required for the  relief of deformity, even
for weeks.   On this account it is well not to undertake, too rapidly,
the removal of extreme deformities;  but  it  is  wiser, in certain
cases, to  continue a gradual extension during a period of from
two to three weeks, or even longer, in paralytic cases, and in per-
sons of feeble health.  It should be  remembered, and I desire  to
emphasize this point,  that force may be prematurely  applied  in
such a way as to ruin the result, by causing the  ends of the  ten-
dons to  be  drawn so  far apart as to  render re-union impossible.
This was done when the operation was  less understood.  In such
a case, a deformity, the opposite to that already existing, is pro-
duced.    It is not  sufficient simply to remove  the  malposition
caused  by a  shortened tendon  or  muscle.  The restoration of
function  must be  held in view,  and,  of course, all  power to do 
                  ORTHOPEDIC SURGERY.                51

this is lost, if an important muscle is permanently severed from its
point of insertion.   Rest, after tenotomy, should be allowed the
limb for a period of from four to  six days, rather longer in adults
than in infants.   Extension of the newly-forming band or bands
of connecting tissue,  should  then  begin gradually.   Immediate
extension has been recommended, but, for reasons  already given,
gradual extension, covering a period of two or three weeks, appears
to offer the best prospects of success.   The deposit of new mate-
rial will thus be  held under control, and  the  new tendon will not
be put unduly on the stretch.  Mr. William  Adams advises that,
in the atrophied limbs of paralytic patients, the efforts  at  restora-
tion to a normal position be continued, little  by little, for not less
than five or six weeks.

  DIFFERENCE IN THE NORMAL  ANATOMY OF THE  INFANT  AND THE
                          ADULT  FOOT.
   In order that we may  understand the physiology and  the patho-
logical anatomy of the child's foot, it is important for us  to study
its  normal anatomy,  which differs materially  from that of the
adult.  It is all the more important to direct your attention to this
matter, because  the text-books, as well as the lectures on ortho-
pedic surgery hitherto published, are silent upon this  subject.   The
plates and  the descriptions  of the foot which they  contain, relate
only to the adult foot.   With the exception of the pelvis and the
pelvic organs at  puberty, there is no part  of the body that under-
goes greater anatomical and physiological changes than  the human
foot, from birth until the eighth year.   A comparison of the  foot
of the child with that of the adult is therefore important.
  The foot comprises all that part of the lower extremity situated 
52
ORTHOPEDIC SURGERY.
below  the tibio-tarsal articulation.    The  orthopedic  surgeon  is
principally interested in the superior and inferior surfaces, as a
deviation from their normal outline, marks the  degree  and the
direction of the deformity.   The  adult  foot is in the form of an
arch, convex above and concave below.   The superior surface  at
its highest point, formed by the  astragalus, receives  the whole
weight of the body, transmitted  to it through the tibia  and ankle-
joint.   The  inferior surface  transmits the weight  to  the ground.
The convex form of the  superior surface,  gives great  freedom  to
the movements of the leg,  and, in connection with  the  marked
Fig. i.  Foot of adult: A, oscalcis;  B, astragalus; C, transverse tarsal joint; D, scaphoid;
   E, external cuneiform; F, middle cuneiform; G, internal cuneiform; H, cuboid; I, meta-
   tarsal bones.

flexibility of the  organ, admits of great changes in  the direction
of its long axis, and in the  position and direction of the centre  of
gravity;  while the concave form  of the  inferior surface and  the
number  of  bones that enter into  its formation,  give it flexibility
and  strength, allowing it to  accommodate itself to all the irregular-
ities of surface with which it is brought in contact.   The  inferior
surface is also marked by a double arch;  the first and most impor-
tant, extends from the heel to the ball of  the great and  little  toes;
the second, extending laterally, is formed  by the scaphoid,  cuboid,
and  cuneiform bones, and reaches to the  tarsal extremities of  the 
ORTHOPEDIC SURGERY.
53
metatarsal bones (Fig. i).  The points of pressure, when the foot
is applied to the  ground, are the posterior inferior extremities of
the os calcis and the anterior inferior extremities of the metatarsal
bones of the great and little toes.
   In the  infant, the  conditions  are very different.   The  inferior
surface of the foot is flat, or nearly so, the arch hardly perceptible
(Fig.  2).    The convexity  of the  superior  surface is  scarcely
marked, for the tissues are soft and abundant and adapted to bring
to it the greatest amount  of  nutrition.
At birth,  and  for some  time  subse-
quently,  the  feet  are adducted  and
turned inward,  so that  their  inferior
surfaces look towards each other, and
the inner ankle  is  scarcely observable.
This  condition  continues  during the
movements  of  flexion  and  extension,
and  if we attempt to place the  child
on its  feet,  the outer border first touches  the  ground.  This
is not a deformity;  it is  a normal  condition that  changes with
development.  The feet are now unfit to support the weight of the
body, as they are not yet  sufficiently developed for that purpose.
The  bones that  are destined to become solid  and firm, are rudi-
mentary, cartilaginous ;  few of them have more than a single point
of ossification, and they are connected merely by soft bands which
will ultimately become powerful and  elastic ligaments.  This is not
the foot that is described in the  text-books, the foot  that is ordi-
narily capable of supporting a body weighing one or two hundred
pounds, and  under extraordinary circumstances, as in  leaping and
jumping from heights, sustaining without inconvenience a pressure
equal to many hundreds of pounds.
Fig. 2. Feet of the infant. 
54
ORTHOPEDIC SURGERY.
  Gu£niot has  pointed out the following  method of determining
whether the inversion of the foot, which exists at birth, is a normal
or a pathological condition :  Hold  the child under the  arms, and
turn its back to an open fire, it immediately flexes  the thigh on the
trunk and the legs upon  the thighs, and  turns the feet outward,
the  sole towards the heat.  This last movement cannot be accom-
plished if the feet are deformed.
  The size of the  foot, its length and  breadth, is greater  in  the
Fig. 3. Adult astragalus.
infant, in proportion to its height, than in the adult, and the whole
foot is larger in proportion to the size of the body.   The  part of
the foot anterior to the tibio-tarsal articulation, attains its  normal
shape  and  development  much earlier  than the  posterior part.
The foot increases  in length more rapidly on the inner, than on
the outer side, and  it is owing to this fact that the sole is gradually
turned outwards.   These  changes  are the result  of alterations
that take place in the different bones  of the  foot, during growth, 
ORTHOPEDIC SURGERY.
55
and the progress of ossification;  they are much more marked at
four, and about the eighth year, all the  bones  have  assumed their
normal proportion.
   The astragalus may be considered the most  important of all  the
bones of the foot, and it is the first to assume  definite form.   The
os calcis, on the contrary, undergoes a much more marked change ;
in the infant, the anterior part is long, and the tuberosity unusually
small.   (Figs.  3 and 4.)   The tuberosity extends but little beyond
the  posterior border of the astragalus,
and the groove in which  the astraga-
lus  moves,  has  little  depth.    The
apophysis  is hardly perceptible, the
under surface  is almost flat,  and the
height, particularly on  the inner bor- fig. 4. Astragalus of infant.  (After
der,  is  extremely  low, as compared
with the other  dimensions of the bone.   This condition is hardly
changed at two years.
   The movements of the foot are not  the same in  the infant as
in the adult.    In the infant, flexion and extension are much  more
restricted,  while adduction  and  rotation inward,  of the sole, is
much greater than in the adult.   This is due,  in a measure, to  the
laxity of the  ligaments, but the difference  in  the conformation of
the  articulating  surfaces,  exercises  by far the greatest  influence.

  1 The extent of motion possible in the tibio-tarsal articulation and its direction as observed
in the adult differ very much from that found in the infant.  The  dimensions of the bones are
also relatively different: compare for instance the os calcis of the adult with that of the infant.
On the inner side the suspensory ligament (S) is much lower in the infant. The inner surface
of the bone from the  top of the posterior articulating surface sinks gradually;  in the  adult it
descends longitudinally with the articulating surface, rises again over the sustentaculum almost
to the level of the body of the bone, and then descends anteriorly.
 
56
ORTHOPEDIC  SURGERY.
As  the individual  becomes  older, and  the  articulating surfaces
assume a more vertical direction, the movements of adduction and
version of the foot inward, are greatly diminished,  and at eight
years, the movements are precisely those of the adult.

                    VARIETIES OF CLUB-FOOT.
  From the earliest periods, four varieties of  club-foot have been
recognized.  They are  designated  respectively:  Talipes  varus,
when the foot is adducted and  the sole turned inward;  Talipes
valgus, when the foot is abducted and the sole turned outward;
Talipes equinus, when the foot is forcibly  extended, the heel being
elevated and the sole turned backward ; and lastly, Talipes calca-
neus, comprising those cases in which the foot is  strongly flexed,
the sole being directed forward.  But  beside  these simple forms,
four compound varieties  are  met  with, namely: Talipes  equino-
varus; Talipes equino-valgus; Talipes calcaneo-varus, and Ta-
lipes calcaneo-valgus.  All these forms of club-foot are beautifully
illustrated in the casts, most of which were taken from cases occur-
ring in the practice of Dr. Detmold, Emeritus Professor of Clinical
and Military Surgery in this institution.  Although he was  not  the
first to perform tenotomy in this country, we are certainly indebted
to him for the earliest impulse to orthopedic surgery in the United
States.  His  monograph on  club-foot, long  since out of  print,
attests his professional ability, and his enthusiasm  in  this  depart-
ment of surgery.
  It is to be observed, that all the varieties  of talipes  present one
common characteristic, viz.:  the  deviation  of the  plantar surface
from the normal position, and by no  amount  of force  can  the
whole  plantar surface be brought in contact with  a horizontal 
ORTHOPEDIC SURGERY.
57
 plane.  This  condition  depends chiefly on a change of relation
 between the astragalus and the bones with which it is connected.

             CONGENITAL AND NON-CONGENITAL TALIPES.
   Each of the varieties of club-foot may be either of congenital
 or of non-congenital origin, the latter  being by far the  more  fre-
 quent.   From statistics taken from  the Maternity  Hospital, at
 Paris, during  a period  of  ten years, from 1858  to 1867 inclusive,
 it is shown that there were 15,229 births, 8 being born with club-
 foot : one case of club-foot for every 1,903 births.   {Lannelongue
 on Congenital Club-Foot,  Paris, 1869.)   Mr. Tamplin gives  the
 following statistics, to  show the relative frequency of club-foot to
 other  deformities,  and  the  comparative frequency of congenital
 and non-congenital cases: Of 10,217  cases of  deformities of all
 kinds, treated at the Royal Orthopedic  Hospital, London, 1,780
 were cases of club-foot;  764 were congenital, and 1,016 were
 non-congenital.  The proportion of congenital, to  non-congenital,
 being  as  three to two  {Adams on Club-Foot).  The  question,
 whether the  deformity is  congenital or  has been acquired after
 birth, is of great importance; for although the  treatment  is simi-
 lar, the prognosis, both as  regards the  duration of the treatment,
 and the ultimate usefulness  of the  foot, after the  removal of  the
 deformity, is much  more favorable in the congenital, than in  the
 non-congenital variety.  It is necessary, therefore, to distinguish
 between the two forms, and in young subjects this is  easily done.
 The difference in the  external appearances  of the two classes  of
 cases, is strongly marked;  but in adults there is often great diffi-
 culty in deciding the question, for the reason that the characteristic
features of the two varieties  become effaced, when the  child  has
walked upon the foot for a  long time. 
58
ORTHOPEDIC SURGERY.
  I  will now mention a  few salient points  which will  aid  us in
making a  differential diagnosis.   In congenital club-foot, before
the child is old enough to have walked  much, the muscles  retain
their normal size and characteristics; the toes can be flexed, there
is  some mobility of the  ankle-joint,  but the  foot is quite  rigid,
owing  to the  adapted shortening of the ligaments.  On the sole
of the foot there is, in cases of varus, a transverse depression cor-
responding with the medio-tarsal joint.   There are also  marked
irregularities on the dorsum of the foot, due to the distortion of
some of the tarsal bones, and the temperature and  color of the
skin is unchanged.
  In non-congenital club-foot there is, from the first, a tendency
to atrophy  and fatty degeneration of the muscles of the  leg.   The
toes are permanently flexed; the great toe is, however, sometimes
in a state of forced extension, so severe that  it cannot be  flexed;
the temperature is diminished and the skin is of a bluish color.  In
cold weather, patients frequently  suffer  from chilblains; there is
an absence of marked  rigidity of the foot, which  obtains  in  con-
genital cases, and instead of the permanent irregularities  noticed
on  the  dorsal surface, in congenital cases, the foot, in the  non-
congenital variety, presents a generally rounded and smooth exter-
nal surface.
  In old cases, when the  child has walked  on the foot for some
time, the  distinctive features of  congenital and  non-congenital
club-foot, are  less marked.   The  muscles of the  leg, in the  con-
genital form, from want  of use, become gradually atrophied, but
there is no considerable  structural degeneration, as in the  non-
congenital, and the movements  of the foot,  in  both  varieties, are
greatly restricted.  Owing  to  the  diminished vitality of  the  parts, 
ORTHOPEDIC SURGERY.
S9
non -congenital  cases  suffer considerably from irritation  of the
cushions which bear the pressure, and great inconvenience and
pain are experienced in walking, on account of the relaxed condi-
tion of the ligaments.   Still, the extremely wasted and paralytic
condition  of the limb, the diminished temperature  and  bluish
color of the skin observed in the non-congenital variety, will mate-
rially aid in the diagnosis.

                            CAUSES.
   The  causes  of club-foot  have been a subject of considerable
controversy, but the scope of these lectures and the strictly practi-
cal character which I propose to give them, will not permit  an
extended  notice  of the  various theories  that have  been pro-
pounded, to explain the etiology of this deformity.  The question
is one  of  scientific  interest, rather than of practical  importance.
If I may be permitted to advance an opinion, I should  say that
both the congenital and  the acquired form of talipes, depend upon
some irritation of the cerebro-spinal centres causing convulsions in
the foetus, as well as in a newly born child, which result  either
in muscular contraction  or in motor paralysis.  There is, however,
this  marked difference,  that in the  congenital form there is, in
a majority of cases, spasmodic muscular contraction,  and in the
non-congenital  cases there is, nearly always, paralysis of certain
muscles or groups of muscles; in the former also  fewer  muscles
are involved than in the latter.
  Many orthopedists favor the  theory that  congenital  deformities
of the feet, depend upon malposition and pressure of the foetus in
utero, while  mothers delight  to  refer physical imperfections  in
their offspring,  to the influence of material  impressions, and mid- 
6o
ORTHOPEDIC SURGERY.
wives narrate such cases, with circumstantial evidence of astound-
ing conclusiveness.
   Congenital  talipes  is often  hereditary,  and  numerous cases
might be cited  in which mothers have given birth to several club-
footed children, and in many cases the hereditary  tendency has
existed even through several generations.  The following illustra-
tion,  which probably gave rise  to a serious domestic trouble,  is
one of  a number, furnished  by Lannelongue.  (On  Congenital
Club-foot: Paris, 1869.)  "$th Observation. — The case  related
by Bruckner was  attended with unpleasant  circumstances: Van-
nier is club-footed, his wife is not; their first three  children were
club-footed, the  fourth was not; Vannier accuses his wife."
   It is an interesting fact, yet one which cannot be satisfactorily
explained, that the number of cases of club-foot is much greater
among males  than among females, and that the two  feet are liable
to be attacked with nearly equal frequency.
   In  some cases  of  talipes, certain complications are found to
exist which also  demand attention.  The inversion of the toes, in
talipes varus, does not always depend upon the malposition of the
foot in the transverse tarsal articulation.  In  the  knee-joint we
sometimes  find  a  great laxity of all the ligaments, and  the knee
can be bent  in  any direction with great  facility.  In consequence
of this, the leg turns inward as well as  the foot, in the act of walk-
ing, and  this continues, even after the foot  has been  returned to
its normal shape.  This complication should be noticed and atten-
tion called to it at  the  commencement of  the  treatment, for  it
renders the after-treatment tedious and troublesome.   Some cases
are also complicated by an extreme rigidity of the ligaments of the
knee, a rigidity so great that the leg is  fixed in one posture,  and 
ORTHOPEDIC SURGERY.
6l
can neither be flexed nor extended.  These conditions should not
escape the surgeon's attention, for they materially modify the prog-
nosis and the duration of the treatment.
  In regard to the prognosis, in talipes, you must  also remember
that  the severity of the  case depends,  not  so much  upon the
degree of the deformity, as on the resistance offered to the resto-
ration  of the foot, by manipulation, to its  proper form and normal
position.  In some apparently severe cases, the distortion is easily
overcome by manipulation, whilst others, presenting  the same
grade of deformity, are much more rigid and unyielding. 
62                ORTHOPEDIC SURGERY.
                       CHAPTER  II.

CONGENITAL  TALIPES VARUS.--DEGREES OF THE DEFORMITY. — MOR-
  BID  ANATOMY.--MECHANICAL  AND  PHYSIOLOGICAL  TREATMENT,
  AND AGE  AT WHICH IT  SHOULD BE COMMENCED.

  I will now consider the different forms  of club-foot, beginning
with congenital talipes varus,  the  variety  of club-foot most  fre-
quently met with at birth, and  that which has received the largest
share of attention from orthopedic  surgeons.   Talipes varus con-
sists in the adduction of the foot by the tibialis  anticus, the raising
of its inner border, the semi-rotation of its inner half by the action
of the  tibialis  posticus,  and  the  elevation  of the  heel by the
muscles of the calf.  This is the ordinary type of the deformity,
                                  but there are several grades of
                                  distortion, which are charac-
                                  terized  by the  extent of the
                                  deviation  of the foot  from the
                                  normal position.
                                    In  the  mildest  grade  of
                                  varus, which  is  comparatively
                                  rare, there is  only a  slight  in-
                                  version  of the anterior part of
                                  the foot,  and the  heel  is not
                                  materially elevated.   This va-
riety is well illustrated by Figs. 5 and  6.  But the  grade which is
 
                  ORTHOPEDIC SURGERY.               63

ordinarily seen is shown in this cast (Fig. 7).  The elevation of
the heel, you observe, is  more decided; the anterior part of the
foot  is  turned  inward,  so
that it forms  a  right angle
with its normal axis, the sole
is  turned  backward  and the
dorsum   directly   forward,
placing the inner border of
the  foot  upward  and  the
outer  border  downward.
The inner  malleolus  is  al-
most obliterated;  the  exter-
nal, on the  contrary, is more prominent  than natural, and seems
to  be  placed behind, and below, its usual position.   A still more
exaggerated degree of distortion is illustrated by this cast (Fig. 8) ;
                Fig. 7.                           Fig. 8.

but,  fortunately,  this  degree  of deformity is  not often met with.
The inner edge of the foot  is drawn upward, so that the navicular
 
64
ORTHOPEDIC SURGERY.
and  the  internal cuneiform bones, lie in contact with the inner
ankle, and the toes are turned directly upward;  the dorsum of
the foot  is directed forward, the heel is drawn up; there is often
rigid contraction of the plantar fascia,  which produces  shortening
of the  foot, and a deep transverse depression in the sole.
  Where a club-foot has been used for some time in walking, the
pressure  of the weight of the body produces  important consecu-
tive  changes.   The  weight  of the body, instead  of  being trans-
mitted through the  arch  of the  foot, which is so  beautifully
designed  by nature  to receive it, is  thrown  upon  the  external
border, and in severe cases the child  walks even  on the dorsum
of the foot, owing to the doubling into the sole, of the fourth  and
fifth  metatarsal bones.  A soft  cushion  of fat and cellular tissue,
is  formed on  the  back of the foot, which enables the weight of
the body to be  borne with  comparative ease  and comfort.   The
ankle-joint and the joint between the  bones of the foot, become
stiff  from disuse, on account of the  rigidity  of the  tendons  and
ligaments which connect them  together.  The narrowing of the
transverse arch  of the foot, produces  a well-marked longitudinal
furrow in the sole, which terminates at  the  junction of the middle
with the  posterior  part of the foot (" the transverse  tarsal articu-
lation"), in  an obliquely transverse  depression.   These  depres-
sions are absent  or are  but slightly marked, in non-congenital
cases.  The  casts before you  illustrate  the  appearance of the
deformity (Figs. 9 and 10).

            ANATOMY OF CONGENITAL  TALIPES VARUS.
   The appearances  presented, on  the dissection of a case of
varus, depend on the degree of  the deformity and the age of the 
ORTHOPEDIC SURGERY.
65
 subject.  In  all cases, however,  the structures which  enter  into
 the composition of the limb, undergo  degeneration for want of
 proper  use.  The  bones  be-
 come lighter, and  the  limb
 is often shortened to the ex-
 tent  of half  an inch  or  an
 inch.  The ligaments become
 adapted to the altered position
 of the  bones.   The  muscles
 become atrophied little by lit-
 tle,  and remain  small,  even ^—— ^
 after the limb  has been re-               FlG- 9-
 stored to its natural form, and the functions of the muscle restored.
   In  the  severe  forms of varus, important deviations from  the
 natural  form  and  position, are  observed  in some  of the tarsal
                                     bones.   This  is  especially
                                     noticeable  in  the astraga-
                                     lus, the os calcis, and  the
                                     os  naviculare.   The astra-
                                     galus  assumes an  oblique
                                     direction  downward and for-
                                     ward ;  its  superior  articu-
                                     lating surface  becomes  al-
                                 —  most  vertical,  so that only
                                 ~~   the posterior two-thirds  are
                                     in contact with the articulat-
ing surface of the tibia.   The  anterior third can  be felt  on  the
dorsum of the foot, covered only by the elongated capsular ligament
of the ankle-joint  and the  skin.   Owing  to the displacement of
Fig. 10. 
66
ORTHOPEDIC SURGERY.
the scaphoid bone inward, the outer portion of the anterior articu-
lar head of the astragalus can be felt on the dorsum of the foot; the
external articular facet is in close contact with the fibula, the inter-
nal is imperfectly developed, and its contact with the inner malleo-
lus is slight and imperfect; the neck is turned inward, and it is this
obliquity, chiefly, which gives the characteristic inversion of the foot
that distinguishes the deformity.  The astragalus has no muscle in-
serted into it, nor any taking its origin from it.  The changes in form
and position, which it undergoes, take place as a  consequence of
the mechanical forces operating on the other two principal bones
of the foot, to which it  is accurately fitted,  and whose movements
it must follow.   The os calcis, likewise, occupies an oblique, and,
in aggravated cases, nearly a vertical position, from the elevation
of its tuberosity by contraction of the  triceps muscle;  the tube-
rosity is inclined towards the fibula, and, in  severe cases, is found
in actual contact with  it.  The anterior  extremity  is  directed
obliquely forward and  inward.  The bone sometimes becomes
arched  in  its  long axis, the convexity being  directed outward.
The scaphoid bone is drawn forcibly  inward, and  upward, so that
its  tuberosity lies immediately under,  and in  contact with the
inner malleolus, "and its  long axis is parallel  with the long  axis of
the  astragalus, and  also  of the leg.  The position of  this bone
has  the greatest influence in determining  the  grade of the de-
formity.  The other tarsal bones, viz., the  cuboid and the  cunei-
form,  remain very  nearly  in  their normal positions — they are
directed inward,  to  correspond with the  inclinations of  the os
calcis and navicular bones.   In  adult cases  of club-foot, however,
the cuboid  bone becomes prominent on the dorsum of the  foot,
which is turned  downward, and supports the weight of the body 
ORTHOPEDIC SURGERY.                67
 in walking.  The  muscles  chiefly concerned in producing con-
 genital talipes varus,  are  those of the  calf of  the  leg and  the
 tibials.  These  are rigidly  contracted, while  the peronei and  the
 extensor longus digitorum, are lengthened and kept on the stretch.
 By far the most powerful of these muscles, and  the  most impor-
 tant in the production  of the deformity, is the triceps  sura?, con-
 sisting of the gastrocnemius, soleus  and plantaris, which, through
 the  tendo Achillis, has a  common insertion into the tuberosity
 of  the os calcis.   It has been  shown by the experiments  of
 Duchenne (de Boulogne1), that the action of the gastrocnemius
 and soleus muscles is, first, to extend with great force, not merely
 the  posterior part of the foot, but also the external half of  the
 anterior part; and, second, the moment the astragalus reaches its
 extreme  point of  extension, the  muscle causes the os calcis to
 glide on  the articulating facets on  the  under surface  of the  as-
 tragalus, in an oblique direction  from behind, forward, and from
 within, outward.   This slipping of the os calcis on  the  astragalus,
 produces a double movement of rotation of the os  calcis on its
 greater axis,  and on the axis of the leg, causing adduction  of  the
 foot and  the turning  outward  of its dorsal surface.  The triceps
 sura  is,  therefore, "an extensor  adductor," and any one  can
 demonstrate this double  function  of the muscle, by applying  the
 poles of a Faradic battery  over its  course.   It  will  be observed
 that the  contraction of the muscle, under the influence  of  the
 electric current produces,  first, extreme  extension  of the  foot in
its tibio-tarsal articulation; it then rotates it, so that its point is
directed  inward and the heels outward; at the same  time it is
turned on its  antero-posterior axis,  its external border  is  still
       1 De l'Electrization Localised, par Duchenne (de Boulogne), Paris, 1861. 
68
ORTHOPEDIC SURGERY.
further lowered, while the inner border is elevated.  The result
is, the sole of  the  foot  faces  inward.  It can now be  under-
stood that  the  permanent contraction of  the  triceps surae,  is
sufficient, of itself to produce slight cases of talipes varus.  The
tibialis posticus muscle, which is inserted into the scaphoid bone,
and  the   tibialis anticus,  which has  its  insertion into the in-
ternal cuneiform and first metatarsal bones, by their contractions,
lift  the  inner  border of the  foot and rotate it inward, and thus
become powerful agents in the production of the  deformity.  The
tibialis posticus is,  sometimes, so much contracted that its  tendon
is forced  out of the groove behind the internal malleolus, and  is
situated on the outer side, or even in front of this process; and,
instead of running obliquely  downward and forward towards its
insertion  into the navicular bone, as in  the normal foot, it passes
directly downward from the inner malleolus, to its  insertion into
the displaced navicular bone.  {Adams.)   It is important to bear
in mind  these altered relations  of the tendon,  when it is to be
divided.   The tendon of  the tibialis anticus muscle, at the point
where it   is usually divided, as  it crosses  the ankle-joint,  is very
much displaced  inward.   The ligaments which bind together the
different  bones of the foot, and in some cases the plantar fascia,
especially its inner portion, contribute materially to keep  up the
deformity, and to resist the reduction of the foot  to its  normal
position.   When the foot  has been for  a long time in a deformed
position,  and  its motions  have  been greatly restricted, the liga-
ments and  aponeurosis adapt themselves to the altered position
of the bones.  The ligaments  become  shortened on  the con-
tracted side, and lengthened on the convex side  of the deformity.
In some severe cases, the  ligamentous adaptation  and contraction, 
ORTHOPEDIC SURGERY.
69
is so firm on the concave  side, as to resist the efforts to restore
the foot to its normal  position, even after all  the  contracted ten-
dons  have  been  divided.   Langenbeck says that it is not the
muscles that offer the greatest resistance, but the ligaments, and
the contraction of the connective tissue.  In  some cases — those
that originate  at  an  early period of  uterine life — there "is not
merely  a mechanical resistance to the reduction of the deformity,
but there is also an elastic  power in the different tissues, which  is
more marked in  the  contracted  ligaments  than in those which
have  been  over-stretched.  This is one of  the  most  frequent
causes of relapses in conducting the  treatment of this deformity.
The mechanical forces to be overcome  are, it will be remembered,
the contracted muscles of the  leg, the  contracted ligaments  on
the concavity of the foot, and in some cases the shortened plantar
fascia.

                          TREATMENT.
  In  considering the  therapeutics  of  talipes, a  question which
presents itself  at  the  very threshold is,  "At  what age shall the
treatment be commenced?"  I have no hesitation in saying that,
if the child is  in  a  fair condition of health, the treatment should
be  commenced when  it is six  or eight weeks old.   Nothing  is
gained  by delay, but, on the contrary,  we know very well that the
longer the foot is permitted to remain  in an abnormal position,
the greater is the resistance to be overcome, owing to the shorten-
ing of the ligaments which  is constantly going on, thereby fixing
the bones more firmly in  their abnormal position.  It  has been
objected to very early treatment: first, that the child's skin will
not bear the pressure of the mechanical force necessary to keep 
70
ORTHOPEDIC SURGERY.
the foot in  position,  that ulceration  and gangrene  are  likely to
supervene; and second, that there is great difficulty in adapting
mechanical appliances to an undeveloped and misshapen foot.  A
considerable  experience in  the  use of plaster-of-Paris splints, in
the treatment of club-foot, has convinced me that such objections
are unfounded, and club-foot  can be treated, in the  youngest and
most delicate children, without the slightest discomfort.   Is there,
on  the  other hand, any age beyond which we  cannot hope  for a
cure?  According to  Bouvier, it is  rare to obtain  a satisfactory
result, in congenital club-foot, after the age  of fifteen or  twenty
years, even with the aid of tenotomy.  He says that talipes and
equinus, are curable at a later period than varus and  valgus.  Mal-
gaigne thinks that we cannot hope for any improvement  in con-
genital varus  after the eighteenth  year, and this opinion, which is
concurred in by most writers, will  hold true  in  the  generality of
cases.
  I do not propose to consider the various plans of  treating varus
which have been practised, from time to time, by English, French,
German, and American surgeons, for, however interesting  and
instructive  such a discussion might be, it would be impossible to
engage  in  it with  the limited time  I can give to it.  The plan
which  I  propose is, to describe merely the treatment adopted by
myself, after an experience  somewhat extended, in  the  Brooklyn
Orthopedic  Infirmary, and the Brooklyn City Hospital,  as  well as
in private practice.   This  experience  comprehends the  trial of
various plans of  treatment  which  have had the indorsement of
high authorities.  " The scientific treatment of talipes varus, when
severe, as of several  other deformities of the limbs," Mr. William
Adams  very properly remarks, " can  only be accomplished  by a 
ORTHOPEDIC SURGERY.
71
 judicious combination  of the  operative, mechanical, and physio-
 logical  means, while many of the failures still witnessed in the
 practice of those who  have  not devoted  much  attention to the
 subject, are due to the want of this combination of principles, too
 frequently considered as  antagonistic  to  one another, but  which
 modern  science  teaches us are only reliable, in so  far as their
 mutual  dependence is  recognized and applied by  the scientific
 insight  of the  surgeon."1   Mr. Adams has, more  strongly than
 any  other  writer, inculcated the importance of the physiological
 treatment,  in addition  to the  operative  and mechanical, in the
 management of varus.    The physiological treatment consists in
 passive  motions of  the tibio-tarsal, transverse  tarsal,  and  other
 joints of the foot,  shampooing the muscles with dry, hot flannels
 — dry heat having a marked influence in restoring nervous energy
 — and localized electrization (galvanization and Faradization)  of
 the muscles,  especially of the weakened peronei muscles.   Every
 experienced  orthopedist must  recognize  the value  of  the  judi-
 cious combinations of those  methods  of treatment, in severe
 cases.    You must  not suppose that when you have removed the
 deformity, by the division of the contracted muscle, and the use
 of mechanical appliances, that you  have effected a  cure.  You
 have only palliated the case, and you may have the mortification
of witnessing a relapse, or of seeing  that the usefulness of the
limb  has not been materially increased  by the treatment:  you
have  not used all  the  means  at your command.   In order to
effect a  cure, you must give tone to the muscles of the limb, pro-
mote its nutrition, re-establish  its innervation, and  loosen up the
 joints by the use  of  electricity, local gymnastics,  and friction.
                   1 On Club-Foot, p. 32, London, 1876. 
72                ORTHOPEDIC SURGERY.

The physiological after-treatment, is equally, and  often more im-
portant than the operative  or mechanical.   The function of the
limb must be restored, as well as its form.   In a certain number
of cases, tenotomy is indispensable  in the treatment of club-foot,
whilst  in other cases,  a  cure  can be  effected  by the use  of
mechanical and physiological means alone.  Now let us consider
the management of cases of club-foot in which operative treatment
is unnecessary, or in which a reasonable doubt of its necessity,
exists.    I have already stated  that the severity of the case, and
the  consequent  prognosis,  does  not depend so  much on the
degree of distortion, as on the resistance offered to  the reduction
of the deformity, by manipulation.   In  cases apparently severe,
we can sometimes easily overcome the distortion by manipulation,
while other cases, presenting  even a less degree of deformity, are
rigid and unyielding. In deciding, therefore, whether an operation
be necessary in any given case, we  must be guided by the degree
of the rigidity, rather than by  the  grade of the  deformity.   If
we can,  by taking hold of the foot with the hands, bring it quite,
or nearly into its  normal relations with the leg, it is not, as a rule,
necessary to practise tenotomy.  The  operation  should, in such
cases, supplement the mechanical  treatment, if it should  be  found
necessary.  I am aware that many orthopedic surgeons are  preju-
diced  against the use of mechanical appliances without tenotomy,
claiming that it subjects the child to great torture,  causes it to cry
and wail during  the whole course  of  the treatment, not   infre-
quently produces  fever and convulsions, and renders a suspension
of treatment necessary.  I  have myself witnessed these dire con-
sequences, from the use of Scarpa's  shoe and its various  modifica-
tions, which exert pressure upon prominent parts of the foot; but, 
                   ORTHOPEDIC SURGERY.                73

 by the use  of plaster of Paris, applied as I shall now describe,
 which presses not upon the bony prominences  merely,  but uni-
 formly upon every square inch  of surface to which it is applied, a
 great  deal of  mechanical force can  be used, and for a long time,
 without the  slightest  pain to the child.1   For the reasons, there-
 fore, that the  application of plaster of Paris  is painless, whatever
 amount of pressure  may be applied,  and that  the  duration of
 treatment  is greatly abbreviated,  I cannot too strongly urge this
 method of treatment, at first, and  until the distortion has been
 overcome, whether tenotomy has been practised or not.
   The mode  of application,  I  will  now  show you.    This little
 patient is  the subject of talipes  varus, of a mild form,  which I
 expect to  be  able  to cure without  tenotomy.   I take two pieces
 of coarse canton-flannel, long enough to extend from the head of
 the tibia  around  the heel, to the ball  of the great toe, and wide
 enough to embrace two-thirds  or three-fourths  of the circumfer-
 ence of the leg.   Flannel, with coarse meshes such as I show you,
 or coarse  towelling, should be selected, because they hold a large
 quantity of the soft  plaster.   Fine, fresh plaster, such as dentists
 use, should always  be preferred.   Unless it  is fresh, it does not
 set quickly, and the  hands of the surgeon, while holding the foot
 in position, will tire  before the plaster has hardened, and the foot
 returns somewhat towards its abnormal position.   The plaster is
 put into a bowl,  and warm water is  added, stirring constantly,
until the  mixture is of the consistency of cream.   Warm water is
used because  it hastens  the hardening of the plaster.    One layer

  1 Plaster was first used in the treatment of club-foot by Dieffenbach. See also papers on
Treatment of Deformities of Foot with Plaster, by Professor J. L. Little, Medical Record,
vol. i., p. 537; and the late Dr. Enos, Trans. Med. Soc. Slate N.Y., 1863. 
74
ORTHOPEDIC SURGERY.
 of the  cloth  is now laid  upon  the  table, and its upper surface is
 covered with  a layer of the liquid plaster, spread smoothly with a
 spatula or a table-knife.   The second layer of cloth is then  im-
 mersed in the liquid plaster and applied evenly and  smoothly over
 the first.   The under surface  of the first layer, you will observe,
 is not covered with the plaster, and it is this surface  which is to be
 applied  next  to the skin.  I  now, with the aid of an assistant,
 place it around the limb, from the head of the tibia to the ball, of
 the great  toe, carefully folding in the redundant cloth  around the
 transverse tarsal and  tibio-tarsal joints, where greater strength of
 bandage  is  required, and then cover  the  whole  with a roller-
 bandage.  I now grasp, with one hand, the in-turned foot,  in front
 of the transverse tarsal  joint,  and  force  it outward, elevating, at
 the same time, the external border, while with the other hand, the
 heel is  forced downward.   By these manipulations, I abduct and
 rotate outward, the bones in  front  of the transverse tarsal joint,
 and flex the foot at the tibio-tarsal articulation.  The foot is firmly
 held  in  this position  until the  plaster hardens, which  usually re-
 quires about five minutes, if the plaster is fresh.   When the rigid-
 ity of the tissues is  considerable, which is not  the case  in this
 patient, the foot may be fixed more firmly in the  new position, by
 the application of some  of the  liquid plaster over that portion of
 the bandage  which surrounds  the   back part of the foot,  and
 ankle.  The dressing  should be removed every four or five days
 and a new dressing applied, the foot having been first  thoroughly
washed, rubbed, and manipulated, so as to loosen  the transverse
tarsal, tibio-tarsal, and calcaneo-astragaloid articulations,  and  to
stimulate  the  innervation  of the muscles.  Friction and  passive
movements, which cause but little pain, materially aid in restoring 
                   ORTHOPEDIC SURGERY.                 75

 the freedom of the joints, and in expediting the reduction of the
 deformity, and should never be  omitted.   At each re-application
 of the dressing, the  foot  may be  brought nearer to  its normal
 position — from five  to eight dressings, usually, being sufficient to
 reduce the  deformity, completely.  When  this has been accom-
 plished, the foot may be put into one of Ahl's adaptable club-foot
 splints, as shown in Fig. 11.   This splint I have found extremely
 useful, at this stage of the  treatment.   It is made  of felt, stiffened
 with shellac, and  is  very  pliable, when  heated.   To  adapt this
 splint, it  is  immersed in  boiling water until  it be-
 comes pliable, and is then applied to the foot and
 leg, which have been previously covered with a thick
 stocking; the foot is now forced into position with
 the hands, in the manner already described after the
 application  of the  plaster-of-Paris splint, and held
 until it hardens;  it is now  covered with  a roller-
 bandage.  The splints remain pliable for a few sec-
 onds only,  and  it is well to protect the hands
 from the heat, with cotton  gloves which  have been wet with cold
 water.   One advantage of this  splint is,  that it can  be readily
 removed  and re-adjusted by the mother, who should be instructed
 to  shampoo the muscles,  and manipulate  the foot in the manner
 already described, in order to restore motion to the joints.
   It is of the greatest importance that undue pressure shall not
 be  made  upon  any particular part  of  the foot, for fear of produ-
 cing abrasion of  the  skin  or superficial gangrene,  which would
 necessitate a suspension of  the treatment.   If,  therefore, the child,
 by restlessness  or otherwise, shows signs of pain, the splint should
be  at once removed,  and  a layer of wool-batting placed over the
points of greatest pressure,  and the splint re-adjusted.
 
76
ORTHOPEDIC SURGERY.
  The electric current, Faradic or constant, will materially  assist
in restoring the  functions of the  muscles, which have  lost their
power, not  from absolute paralysis, in  the  congenital  cases, but
from  disuse.  The felt splint may be  used until the child is able
to walk.   It is better, however, as the deformity has been reduced
by the above  method, to  apply Scarpa's shoe, as  modified by Tie-
mann, which  is  shown in Fig.  12.   This not  only retains the
foot in position, but applies the principle of continued elastic ex-
                tension, first enunciated by Dr. Henry G. Davisl
                or by Mr. Heather Bigg,2 and subsequently adopted
                by Mr. Barwell and Dr. Sayre.   This apparatus,
                with its arrangement of spiral  springs, does not in
                any way interfere with  the action of the muscles;
                indeed, the elastic  springs act  as substitutes or
                as assistants to the elongated muscles, which are
                weakened by disuse, and by aiding in developing
                this  contractile  power, often  prevent, and some-
                times help to  overcome  fatty degeneration.  At
                             the  same time the contracted  mus-
                             cles, ligaments,  and  fascia,  while
                             they are  kept on  the  stretch, also
                             have the opportunity of contracting
                             and thus acquiring tone,  the  func-
                             tion of the muscle being  in no way
interfered with.   Sayre's modification of Scarpa's shoe,  is also an
excellent instrument.  It differs from Tiemann's  (Fig. 13), in having
a ball and socket joint,  instead of a lateral hinge,  under the hollow
of the foot,  and  rubber  tubing is substituted for the coiled wire
    1 American Med. Monthly, March, 1857.   2  Orthopraxy, p. 289, 2d edition.
G.TIEMANN&CO.N.Y.
Fig. 12. 
ORTHOPEDIC SURGERY.
77
springs :  the latter, however, are more durable.   It  is extremely
important that the apparatus be accurately fitted to the limb, in
all its parts, and that  the joints correspond exactly  with the axis
of rotation  of the articulations on
which they  are to  act.  When the
child is  old  enough  to  walk, the
shoe should be used during the day
and  the  felt  shoe at night.   The
mother should manipulate the foot,
in the  manner  already  described,
regularly  twice  a  day,  when the
shoes are changed.
  When  the  foot  has acquired its
natural position,  if the child is old
enough, it should be encouraged to
stand and to walk.  The weight of
the body becomes  a very valuable gymnastic  agent, and con-
tributes  very materially to  the  removal of the last traces  of  the
deformity.   We should make use of this aid, as  early as possible.
If the tendons are perceptibly contracted after the mechanical and
physiological treatment has been used a month, then tenotomy
should be practised, at once.    It  may still be possible to make a
cure by apparatus alone in such cases, but tenotomy will shorten
the treatment and expedite the cure.  The treatment of the case,
after tenotomy, will be considered hereafter.
  Such is the plan of treatment which I would advise in cases of
club-foot,  in  which operative  treatment  is  unnecessary,  or, in
which a reasonable doubt of its necessity exists.   The  plaster-of-
Paris shoe is incomparably superior to any other,  in the beginning
 
78
ORTHOPEDIC SURGERY.
of the treatment, and until the  deformity is reduced.  It is the
most comfortable for the patient, it retains the foot  in the  exact
position in which the surgeon's hands put it,  and indeed becomes
a  substitute  for the hands and keeps up  a constant and  long-
continued pressure which  would be  impossible  with the hands
alone.  "The hand," says Bouvier, "is the ideal of mechanical
means for reducing the deformity," and this  opinion is indorsed
by all practical orthopedists. 
ORTHOPEDIC SURGERY.
79
                      CHAPTER  III.

CONGENITAL TALIPES VARUS, CONTINUED. — OPERATIVE TREATMENT.
   — NON-CONGENITAL  TALIPES  VARUS.--PROGNOSIS.--TREATMENT.
   — EXCISSION OF  TARSAL  BONES IN  OLD CASES  OF CONGENITAL
   VARUS.

   Tenotomy. — When  the  foot cannot be restored,  by manipula-
tion, to its normal relation with the  leg, or when the os calcis is
elevated in a marked degree, so  that the foot cannot be flexed
nearly to a right  angle with the leg, tenotomy is absolutely neces-
sary.   It is not impossible, even in such a case as  this, to accom-
plish  a cure,  sometimes,  by mechanical appliances alone, but
the length  of  time requisite to obtain a cure will often exhaust the
patience and perseverance of both surgeon and patient, and the
child is frequently abandoned  to its  fate.   Experience has also
satisfied me  that relapses  are much  more  common, in severe
cases,  when they are  treated  without tenotomy.  It is a mere
waste of time, to attempt  the  cure of  such cases  by the employ-
ment of apparatus alone.   For the  reasons already given, tenotomy
should be practised as early as the third month, if the child  is in
good health.
  The treatment of talipes varus by  operation, consists  in the
subcutaneous division of the tendons of the contracted  flexor and
extensor muscles of the foot,  which,  by their  contraction, resist
the restoration of the  foot  to its  normal position, by mechanical 
8o
ORTHOPEDIC  SURGERY.
and other means.  The most  powerful  of these muscles — those
which exert the greatest  influence in opposing the reduction  of
the deformity — are the triceps  surse, which, as we have shown,
not only extend the foot at the ankle-joint, but also adduct it, and
move  it in the astragalo-calcanean joint, and, in addition to this,
powerfully resist the abduction of the foot, and are  sufficient to
produce slight  cases of club-foot.
   The operative treatment, as  practised  by the English surgeons,
Adams,  Broadhurst, Little, and  Tamplin, consists, in a majority
of cases, in the division of the tendo Achillis and the tendons  of
the tibialis anticus, tibialis posticus, flexor longus digitorum, and,
in some cases,  the extensor longus hallucis and the  plantar fascia.
They divide the operative treatment into two stages:  First, the
varus  is converted into  equinus, by cutting the tibial and  long
flexor  tendons, and gradually everting  the foot by mechanical
means;  secondly, after the deformity is transformed  into a  sim-
ple equinus, the tendo Achillis is divided,  and the extension at
the  ankle-joint is reduced.  During a  number  of  years I  faith-
fully followed the  rules established by the English  surgeons, and
the results were quite satisfactory to myself and to  my patients;
but, it  occasionally happened  that I omitted to divide the  pos-
terior  tibial tendon, in very fleshy children, on account of  the
danger of dividing the  long  flexor of  the  great  toe,  and  of
wounding the posterior tibial artery, which lies in close  proximity
to the  tendon, the danger being much increased in fleshy chil-
dren, and still I obtained the same satisfactory results.  This expe-
rience induced  me to abandon, gradually, the English method  of
treatment, and  for  some years past I have  limited  the operative
treatment,  in a majority  of cases, to the  division  of the tendo 
ORTHOPEDIC SURGERY.
81
Achillis,  and in exceptional cases, the plantar fascia, for the fol-
lowing reasons:  i. The section of six or eight tendons, which  is
often done by  the  English  orthopedists,  where  both feet are
deformed, is of itself a matter of  no small  consequence.  More-
over, it has been abundantly shown, though not sufficiently appre-
ciated, that tendons  invested  by  synovial sheaths, including the
tibialis posticus, the flexor longus  digitorum, &c, never, or hardly
ever, re-unite after they have  been divided, yet the foot may not
be rendered useless by the operation.   2. When  the deformity is
severe, and the resistance offered to the reduction of the foot
considerable, it requires a long time to abduct the foot and rotate
it outward, whether the tendons of the tibial muscles have  been
divided or not, which  is evidence that the deformity depends  on
another cause  than the contraction  of these muscles.  3. Actual
experience has shown that no  operative treatment is  necessary in
ordinary  infantile cases, except the section of the Achillis and now
and  then of the plantar fascia.
  The division of the tendo Achillis, as performed  at the present
day, is a  perfectly safe  and simple operation.   The  surgeon, hav-
ing every thing in readiness for the operation, places the  patient
on  his abdomen,  with the foot hanging over the edge  of the
table, an assistant steadies the limb, while the surgeon  grasps the
foot  with one hand, and forcibly flexes it, so as to put the  tendon
on  the stretch.   He then, with a tenotome, punctures the skin
close to the inner border of the tendon, from half an inch, to an
inch and a quarter, according to the age of the patient, above its
insertion, and carries  it  obliquely downward  {Adams),  beneath
the tendon, to its opposite side.  He then turns  the edge of the
knife toward the  tendon, depresses the  handle and divides the 
82
ORTHOPEDIC SURGERY.
tendon with a clean, transverse cut; the knife is  now  withdrawn
flatwise, so as not to enlarge the external wound.   I  must caution
you against putting the  tendon too violently on  the stretch, lest
the knife be  carried entirely through  the  integument, and thus
convert a subcutaneous wound into an open  one, with  its  atten-
dant consequences of  suppuration, &c.   I have said that the
operation is a perfectly simple  and safe one, but it  should be
remembered that the posterior tibial artery is placed at  the inner
edge of the tendon, superiorly:  it becomes  detached about the
middle  of the  tendon,  and is entirely separated  from  it, at the
inferior portion (Fig. 14).  The artery is  accompanied in all its
course  by two  large veins, and by  the  posterior tibial nerve.
Now, we are warned by these  facts, that, if the tendon  is divided
too high  up,  the artery, the veins, or even the nerve may be
wounded,  and if, on the contrary, the section is made too low
down, there will be danger of opening the synovial bursa, which
is  interposed  between  the tendon and the  upper part of the
tuberosity of the os calcis.  You  can understand  now the impor-
tance of the  direction  to divide  the  tendon,  in adults, fifteen
lines above the os calcis, while  the point  of division, in infants,
must be varied according to the child's age; but it ought never
to be less  than five or six lines from the heel.  In infantile, con-
genital, cases the division of the tendon is indicated  by a  snap,
and the divided ends separate so  as to  leave a gap at the seat of
division.   In  adult cases, and in those of paralytic origin, there
is no audible snap, and the divided ends of the tendon are  sepa-
rated to a very slight degree, owing to the rigidity of the ligaments
of the  joints  and the  paralyzed  condition  of the  muscles.   It
sometimes happens that a few of  the fibres of the tendon escape 
ORTHOPEDIC SURGERY.                  83
division, in which case the knife should be re-introduced  and  the
section completed.
        Fig.  14.  Relation of tendons divided in varus and equinus.  (Erichsen.)
   A.  Tibialis posticus.  Point at which cut.     H.  Extensor longus pollicis.
   B.  Flexor longus digitorum.               I.  Posterior tibial artery.
   C.  Tendo  Achillis.  Point at which cut.      J.  Dorsalis pedis artery.
   D.  Flexor longus pollicis.                 K.  Posterior tibial nerve.
   E.  Tibialis anticus.  Point at which cut.     L.  Part of annular ligament.
   F.  Plantar fascia.                       M.  Saphena vein.
   G.  Abductor pollicis.

   Although I  do not  advise  the  division of the  tendons  of the

tibial muscles,  in the treatment of talipes varus in the infant, as you

may be influenced  by the examples of the  eminent English  sur- 
84
ORTHOPEDIC SURGERY.
geons whose names I have mentioned,  to follow their practice, I
will describe the operations, which may  in any event be done as a
useful anatomical exercise on the cadaver.
  The tendon of the tibialis anticus muscle, is usually so prominent
under the skin as to make its  division  remarkably easy and free
from danger, as it  is not enclosed in a synovial sheath, and  the
arteria dorsalis pedis, besides being deeply seated, is placed on the
external side of the extensor proprius pollicis pedis.  It should be
divided, as  it passes over the  ankle-joint, by entering the knife
close to the tendon, upon its outer side,  so as to  avoid the artery,
carrying it beneath the tendon and dividing it from below, upward
towards the skin.
  The  tendon  of the tibialis posticus muscle, is,  in many cases,
divided with difficulty, and  the operation is  by  no means  free
from danger, on account  of  its proximity to  the posterior tibial
artery.   Fortunately, its division is  rarely necessary.    I  have
adopted the following method: The child is  laid upon its back
and the leg and  foot firmly  held by an assistant;  the  latter is
everted, so that the inner side looks directly upward.   Now place
the thumb of the left hand on the posterior edge of the tibia, as a
guide,  and puncture  the skin with a sharp-pointed tenotome, half
an  inch above  the  inner  malleolus, and open the sheath of the
tendon, freely.   The blunt-pointed tenotome, which should always
be  used in this operation, is then passed into the wound, and
keeping its  flat surface close to  the bone, it is slipped between the
bone and the tendon, the edge turned against the tendon which is
divided, whilst the assistant forcibly abducts the foot.   In  the leg
of a fat infant, the inner edge  of the malleolus and the posterior
edge of the tibia, cannot be  distinctly defined; and  for cases of 
ORTHOPEDIC  SURGERY.
85
this sort, which are by no means  infrequent, we should adopt the
plan of Dr. Little, viz.:  taking the antero-posterior diameter of
the leg, make the puncture exactly in the middle of this line.  I
must beg you to bear  in  mind that this tendon should never be
divided,  unless the necessity for the operation is  clearly demon-
strated, because, in addition to the reasons already  given, this and
all other tendons  that  run through tubular sheaths, often fail to
unite after they have been divided.
  The plantar fascia is sometimes so contracted  as to offer a
serious impediment to the restoration of the  foot,  and requires to
be divided, in order to  overcome  the shortening of  the foot, and
to expand its longitudinal arch.   The operation is rarely necessary
in infantile cases and in childhood, but is more frequently required
in adults.  It is usually sufficient to sever the  inner division of the
fascia,  but we may also find it necessary to divide the central divis-
ion.  The  operation  consists in puncturing the skin close to the
inner edge of the inner division, and then introducing a tenotome
behind the fascia as close to it as possible, and dividing it towards
the skin.
  At what time  is it  desirable  to begin to  straighten the foot?
Stromeyer has shown that re-union of  the tendons may be com-
plete at the end of the fifth day, and that the tendinous exudation
solidifies so rapidly that, in  ten  days, it  may be impossible  to
reduce the  deformity.   The  plan which  I  have  adopted  is  to
remove the  plaster  splint which  was  applied immediately after
tenotomy, on the fourth day, wash the foot well, apply another
plaster splint, force the foot  towards  its normal  position,  in the
manner already described, and hold it until the plaster sets.   This
splint  should  be re-applied  every third or fourth day, and each 
86
ORTHOPEDIC SURGERY.
time, when it is removed, the foot should be washed and rubbed
and  the articulations loosened  as much as possible,  by passive
movements, in  order to restore  the freedom of the joints.   The
foot should be  brought gradually to its normal position, and even
into the position of varus, by increasing the extension, somewhat,
each time the plaster dressing is  applied.   The deformity can usu-
ally be reduced in the course of two or three weeks, without undue
pressure upon any part of  the foot, and without the slightest pain.
It should now be put into  the club-foot shoe (Fig. 12), which will
hold the  foot  in the normal position, without pain and  incon-
venience.  The shoe  must be removed night and morning, and
the ankle  and  transverse tarsal joints,  manipulated  for  fifteen
minutes by the mother, and the muscles, especially the peronei,
should  be well shampooed.  This shoe should  be replaced  at
night  by  the felt shoe.  The object  of  gradual  extension is  to
regulate the length of the new  material which is  formed, and  to
unite the divided extremities of the tendon.  When the extension
is excessive, the new material may be elongated so as to make the
re-union imperfect, or even prevent it from taking place altogether,
and a  previously healthy muscle may have its strength materially
impaired, or  it may even be rendered  useless.   Standing and
walking on the foot will contribute essentially to remove the last
traces of the  deformity.
  How long shall this treatment be continued ?  We answer,  until
the deformity is  overcome,  and the  natural  movements  of the
joints  are  entirely restored.   The  time  required to  accomplish
this will depend on the age of the  patient,  and the  kind and
degree of rigidity which the case  presents.   After the division  of
the tendo Achillis, the chief  resistance to  reduction  is offered  by 
ORTHOPEDIC SURGERY.
87
 the ligaments;  occasionally, however, the tibial  muscles refuse to
 yield to mechanical  treatment, and the division of one  or  both
 becomes  necessary.  In severe cases, in which the deformity has
 been considerable, and the  resistance  to  reduction obstinate, it
 may be necessary to continue the  treatment  for eight or twelve
 months.   For a longer period than this,  even, the foot may exhibit
 a tendency to return to its abnormal position, and, so long as this
 tendency  exists, the  treatment should  be  continued.  Relapses
 frequently occur from a neglect of this
 important rule.   When the deformity
 has been entirely removed, and  free
 motion obtained  in the  joints,  the
 child should wear, during the daytime,
 the boot  which is represented in Fig.
 15.  It differs from an ordinary leath-
 er shoe  in being open farther down
 in front, so that the  foot  can be in-
 troduced  with greater ease ;  to this  is
 added a  steel plate, fastened to  the
 outer side of the heel, with a mova-
 ble joint to correspond with the ankle, and connected  above  with
 a  strap encircling the calf of the leg.   This  boot  maintains the
 joints in  their normal  position  during  growth,  and   assists  the
 muscles in acquiring symmetrical  action.
  The physiological treatment, consisting of frictions with dry, hot
 flannels,  passive motion,  electricity, &c,  as  I  have  previously
 described, should be  rigorously pursued.   It has  an  important
influence in overcoming the  deformity and  in  restoring the  func-
tions  of  the  muscles and joints.  The re-establishment of  the
 
88
ORTHOPEDIC SURGERY.
functions of the foot is scarcely less  important  than  the removal
of the deformity.  If the treatment is limited  merely  to overcom-
ing the distortion of  the foot by operative and  mechanical means,
very little benefit will have been conferred upon the patient.   The
gait will be awkward  and inelastic, from the want of normal move-
ments in the articulations, and there will  be  great danger of  a
recurrence  of the deformity.
  Congenital varus  is frequently  accompanied with  a bad con-
               dition of the ligaments  of the knee-joint, which
               allows the leg and foot to turn inward,  in the act of
               walking, even after the deformity has  been cured,
               and free motion at  the  ankle-joint has been  re-
               stored.  In order to control this tendency to inver-
               sion  of the foot,  a retentive  apparatus  must be
               used  which  extends above the  hip-joint, and is
               connected with a  pelvic belt.   Such an appliance
               is  shown in Fig. 16.  The pelvic belt is made
               oval,  so as to prevent its turning upon the body,
               and the perpendicular stem is  thus kept in a line
               with  the body, while the foot  may be  set to any
               degree of obliquity, by  the position  of the shoe
               in  the plate to which it is  attached.  The instru-
               ment should  be worn as  long  as any tendency
to inversion exists.
  The treatment  of talipes varus, which  I  have recommended
differs, in  some important  respects,  from  that  pursued by  the
English orthopedists; and I should not have  presumed to  differ
with such high authorities, if I had not subjected the various plans
of  treatment to the  test of actual  experience, in a  considerable
 
ORTHOPEDIC SURGERY.
89
number of cases, both  in public and  in private practice.  I will
briefly recapitulate the mode of treatment which I employ.
   1. A large number of cases of varus can be cured, by mechani-
cal means  alone, if the foot can be brought, by  manipulation,
completely or nearly into its normal relations with the  leg.  Plas-
ter-of-Paris splints,  either without or  with  tenotomy,  should  be
used, until the deformity is reduced,  and then a club-foot shoe
should be substituted for it, employed in the manner which I have
advised.   You need have no  apprehensions of having  a stiff  and
unwieldy foot after the cure of the  deformity, a result  much
dreaded by orthopedists who have not used the gypsum splint or
have not employed  it in the manner I have recommended.
   2. In a large  majority of cases, I limit tenotomy to the  tendo
Achillis.   It  is only in  exceptional cases of varus, that section of
any other tendon is required.
   3. The  physiological  treatment should  be practised from the
beginning, and continued until the distortion has been overcome,
the motions of the joints restored, and the functions of  the muscles
re-established.  Remember that you have not cured  the patient
by reducing the deformity; the limb will be of little  use unless the
functions,  as well as its form are  restored.
   Non-congenital   talipes varus generally  arises  from  infantile
paralysis, caused by the irritation of teething, or from a disturb-
ance  of the  cerebro-spinal system of nerves, arising from  some of
the  disorders of childhood; it is  also,  sometimes,  caused by
inflammation or injury of the joint.  These cases  are not usually
seen  until  after the period of childhood, for although the cause
which leads to the deformity, generally begins in infancy, the dis-
tortion is  developed very gradually, and the surgeon  is not  con- 
9°
ORTHOPEDIC SURGERY.
suited  until  the  inconvenience  in  walking  has  become very
decided.  When all the muscles  of  the leg  are  paralyzed, the
tendency  of the weight of the body  is to twist  the foot inward,
during progression, and this tendency is more marked and  rapid,
when the paralysis is limited to the abductor muscles, the peronei,
extensor longus and sometimes the extensor pollicis.   The adduct-
ors, having no active opposing force, invert  the  foot during loco-
motion.  It is important to diagnosticate the  non-congenital from
the congenital form of varus, because  the prognosis is much more
favorable,  as regards the usefulness of the limb,  in the latter than
in the  former variety.   In young subjects there  is no difficulty in
making a diagnosis, but when non-congenital cases are seen  in the
adult there is  often great difficulty in  deciding  the question,
because the  characteristic features   of  the  two forms  become
effaced when the foot  has  been used in walking for a long time.
But the wasted and paralytic condition of the  limb, the rounded
and  smooth external surface  of  the  foot, observed in the non-
congenital  variety,  is in such  marked  contrast with the  definite
irregularities and rigidity of the foot  in  the  congenital variety, as
to materially assist in the diagnosis, even in adult  cases.
  The  prognosis, in non-congenital talipes, is  favorable, so  far as
it relates to the  simple  removal of the deformity, but as regards
the power and usefulness of the  limb,  it is  much less favorable
than in the congenital form, except in those  cases not caused by
paralysis.
  The  treatment of non-congenital talipes,  is  conducted on the
same general principles  that guide us in the management  of the
congenital  form of  the distortion.  Tenotomy,  however, is only
necessary in exceptional cases.  The  mechanical and physiologi- 
ORTHOPEDIC SURGERY.
91
cal treatment, is generally sufficient  to  restore  the  foot  to its
normal position, and this is ordinarily accomplished in about one-
third the time that  is required for the  congenital cases, owing to
the weakened condition of the muscles and the want of rigidity in
the ligamentous structures.  It is necessary to conduct  the  me-
chanical treatment  more cautiously than in the congenital deform-
ity, in  order to avoid sloughs from pressure, which are more likely
to take place,  owing to the paralytic condition, and the consequent
diminished vitality of the limb.  The same appliances may be used
that we have  advised  for congenital  talipes, viz., the plaster-of-
Paris splint, or the felt splint, until the deformity is reduced;  and
then, an appropriate club-foot shoe, which you  must be  sure fits
the foot  accurately and  comfortably, may be worn (Fig. 12).
The physiological treatment is  even  more important in this form
of the disease than in the congenital, and should be thoroughly
and persistently applied.  When the deformity cannot be reduced
by mechanical and  physiological treatment, we must, in addition,
divide the resisting  structures, in the manner already described.
  After the  deformity has been cured, it will be necessary, in con-
sequence  of the paralytic  condition of the limb, for the patient
to wear  a  retentive  apparatus for many years.  The apparatus
which  I have shown you before, will answer for most cases.   (See
Fig. 15.)   If, however, the paralysis extends to the muscles  above
the knee, the support should  be carried up to  the  hip-joint, and
connected with  a  steel belt  around  the  waist.   (See Fig. 16.)
The foot  should also be supported, at night, by a felt  splint or
some  simple form  of shoe  (Fig.  15),  in  order  to  prevent a  re-
contraction  of the ligaments and muscles, and a consequent return
of the deformity. 
92
ORTHOPEDIC SURGERY.
  Before leaving this subject, I must not neglect to call attention
to the operation of excision  of one or more  of the tarsal bones,
which is sometimes practised in old and  bad cases of congenital
varus, in the adult.
  The late Mr. Solly, of St. Thomas' Hospital, removed the cuboid
in one case, and the operation has  been repeated four times, suc-
cessfully, by Mr. Davy, of the Westminster Hospital.   The  latter
surgeon has also, in  three cases, removed a wedge-shaped  block
of the tarsal arch, embracing the cuboid, the head of  the astraga-
lus, part of the scaphoid, the base of the little  metatarsal  and a
chip of the external cuneiform bone  {British Medical Journal,
Dec.  15,  1877) ; and  Mr. Davis-Colley, of  Guy's Hospital, has
performed a similar operation.  The astragalus has been removed
by Mr. Lund, of Manchester, and by Professor Erskine Mason, of
New York, for the same deformity,  the latter gentleman not having
been aware that the operation had been previously practised.
  I have  had  no personal experience with these  operations, but
in confirmed  and very  aggravated cases the patient  is, I think,
entitled to the benefits they may confer. 
ORTHOPEDIC SURGERY.
93
                      CHAPTER  IV.

TALIPES VALGUS,  OR FLAT-FOOT. — MORBID ANATOMY. — CONGENITAL
  AND  NON-CONGENITAL. --  TREATMENT. -- TALIPES  EQUINUS. --
  MORBID ANATOMY. -- TREATMENT. -- EQULNO-VARUS AND EQUTNO-
  VALGUS. --TREATMENT.

  I  will now consider another  deformity  of the foot, known  as
talipes valgus.  This distortion is the direct opposite of varus, and
is much less common, especially as a congenital  affection.  We
shall study first the congenital form.
  An attempt has been made to distinguish between  flat-foot and
talipes valgus, but the distinction is  purely arbitrary,  and  they
should be regarded merely as degrees of the same distortion.   The
term  " flat-foot" is applied  to that condition in which there  is
simple sinking of the arch
of the foot;  and " valgus "
to that state, in which, in
addition to the obliteration
of the arches, there is  ever-
sion and  elevation of the
outer border  of the  foot,
and the weight of  the  body
rests  on its  inner  margin.
The cast represents this de-
formity a little  more  marked than we usually see  it.   (Fig. 17.)
A more severe distortion is shown by this cast.  (Fig.  18.)
 
94
ORTHOPEDIC SURGERY.
  The arches of the foot, which you will remember are scarcely
perceptible in early infancy, are held in position  chiefly by  the
calcaneo-scaphoid  ligament, and  the ligaments  connecting  the
scaphoid with the cuboid and the  cuneiform bones.   A weakness
or congenital elongation of these ligaments, permits the  arches to
sink.  The foot,  consequently,  presents  a  flattened  appearance,
and its  various movements are seriously interfered with.   Some-
times  the longitudinal arch is reversed, so that  the  plantar surface
of the foot is convex instead of being concave.  This flattening of
                          the  arches, together with a greater or
                          less degree of eversion  of  the anterior
                          part  of the foot, which takes place at
                          the  transverse tarsal joint, constitutes
                          the essential features of valgus.
                            When, in addition to the deviation
                          just  described, we  have  elevation or
                          depression of the os calcis,  the com-
                          pound varieties of talipes, equino-valgus
                          and  calcaneo-valgus  are  produced.
          Fig. j8.
                          But these  do not merit  special consid-
eration ; they may be considerd as cases  of talipes valgus, with or
without  contraction  of the  gastrocnemius muscle.   When  the
patient  begins to walk, all  the external characteristics of con-
genital valgus become more marked, and  the pain  and inconven-
ience  which  he suffers  in  walking, are  much  greater  from  this
deformity than from congenital varus.
  Morbid Anatomy. — Dissection shows that the deviation of the
foot, in  valgus, is due to the rotation of the bones of the poste-
rior part of the foot, particularly the scaphoid and the os calcis, on
 
ORTHOPEDIC SURGERY.
95
the cuboid; the deviation  of the bones, however, is not so great
as in varus; the os calcis is rotated to such a degree that its inner,
concave, surface is turned downward, and its long axis has become
oblique from  behind, forward, and from without, inward, and its
tuberosity is elevated to a variable extent.
   The astragalus may occupy  its normal  position, or it may be
tilted forward  and obliquely downward, at  birth, by the elevation
of the tuberosity of the os  calcis.   The  scaphoid and cuboid
undergo a certain amount of rotation, and are  completely luxated
upon the  astragalus and os calcis.    On  the  inner  side  of the
foot, three bony prominences are noticed : the internal malleolus,
the head of  the  astragalus, and  the tubercle  of the  scaphoid,
which is much depressed.
   The ligaments on  the inner side of the foot are  elongated, while
those on the dorsum and external side are shortened; exactly the
reverse of what is observed  in congenital varus.   It is unnecessary
to go into details.
   The muscles in  this  deformity, as in cases of congenital varus,
are merely shortened, without alteration of structure; and, after
the cure of the  deformity, the muscular power  of the limb is un-
impaired.   The  deviation in the  direction  of the tendons  is less
marked in valgus than in varus, and they are less easily recognized.
In ordinary cases the contracted muscles are the peronei and the
long extensors of the toes, and, in severe cases, the triceps surae.
The peroneus  tertius and  the  long extensors of the toes, in their
action, raise the  outer edge  of the foot; the peroneus brevis, and
the longus, abduct the  anterior part.
  The prognosis, in  congenital valgus, is usually favorable.  When
the treatment  is begun at an early age, the distortion is easily over- 
96
ORTHOPEDIC SURGERY.
come, and the usefulness of the limb can, as a rule, be perfectly
established.   When, however, the limb has been walked upon  for
some time, or when the deformity is  associated with some  malfor-
mation of the leg, there is greater difficulty in  effecting a  perfect
cure.

                NON-CONGENITAL TALIPES  VALGUS.
  The external character, and the changes in the relative positions
of the bones which are observed in congenital valgus, are so simi-
lar to that of the  non-congenital  form of the affection, that  the
description of the former may properly be applied to the latter.
The longitudinal and transverse arches of  the foot  are obliterated,
so that the inner margin of the sole rests flat upon the ground, in
standing.   At first, the arches are partially restored when the super-
incumbent weight is removed; but, after a time, the gradual yield-
ing of the tarsal ligaments in the sole of the foot,  causes the foot
to remain flat.   In persons who stand  much,  these ligaments
sometimes become so much elongated that the  plantar  surface
becomes convex, reversing the normal arches of the foot, as in the
congenital form.   The outer margin  of the foot is not raised, as
in the congenital variety, because there is no active muscular con-
traction ;  in fact, there is a feeble and over-stretched condition of
the muscles, which gives rise to more or less eversion  of the foot.
Obliteration of the arches of the foot, producing flat-foot, is there-
fore  the  essential  characteristic of  non-congenital valgus.   In
cases of very long standing, however, the foot, from long-contin-
ued  use, becomes bent upon itself,  at the  transverse tarsal joint,
and is held in this position by the  muscles, which  become  perma-
nently shortened. 
                  ORTHOPEDIC SURGERY.               97

   This form of valgus may be caused by infantile paralysis, affect-
ing one or both tibial muscles; sometimes, it follows convulsions
which have been  excited  by dental irritation, or by febrile disor-
ders ;  it may result from injuries or from disease  of the ankle-joint
or foot;  or from debility of the ligaments and muscles, accompa-
panied with general debility.   It often arises from the patient's
habit of carrying heavy weights, or from his being for many hours
in succession on his feet, especially if he has  not a vigorous  phy-
sique.

               TREATMENT OF CONGENITAL VALGUS.
   The pain and lameness  produced by talipes valgus, are greater
than exist in any other deformity of a similar degree, and, hence,
this  branch of the subject should  receive most careful attention.
The rules laid down for the treatment  of congenital varus, apply
equally to the deformity now under consideration.  A judicious
combination  of  the  physiological, mechanical,  and  operative
means, varying with the amount of deformity and the rigidity of
the foot, is as important in one distortion as in the  other.  If the
foot can be completely adducted, or brought nearly into its normal
relations with the leg, by the hand, tenotomy is not usually required.
In such cases we can effect a cure  by  the application  of gypsum
or felt splints, in the  manner already shown for  the  treatment of
varus.  The foot, however, must be forced into a position  directly
the reverse of that  practised in varus—by  grasping it with the
hand, in front of the medio-tarsal joint, and forcing  it inward, ele-
vating at  the same  time  its inner border; while, with the other
hand, the heel,  if it  is elevated, is forced downward.  The  foot
is  held in  this position until the plaster " sets."   The  same  rules 
98
ORTHOPEDIC SURGERY.
given for  the  removal and re-application of the  plaster, and for
the physiological treatment of varus, are applicable to this  deform-
ity.  When the distortion has  been overcome by the treatment here
described, an apparatus essentially similar to that used in varus, but
acting in  an opposite  direction, should be applied (Figs. 12 and
13).  A convex pad should also be placed inside the  shoe, in the
normal  situation of  the  arch of the foot.  This  presses  inward
and upward, and elevates and supports the arch of the foot.  As
soon  as the child is able to  walk, it should  be encouraged to do
so,  for the weight of the body on the foot assists materially in the
removal of the last traces of the deformity.
  If the tendons continue rigid, and the distortion is not overcome
by the diligent use of plaster-of-Paris splints for three or four weeks,
it is then necessary to resort  to  tenotomy.  The  peronei  tendons
only require division, in the slighter cases.  In more  severe cases,
it may be  necessary also  to divide the extensor longus digitorum
and peroneus  tertius.  When the gastrocnemius is tense  and un-
yielding, producing  equino-varus, the tendo  Achillis should  be
divided.   The rule is to  divide the tendons when retraction can-
not be overcome.  The muscles offer a real  and  invincible resist-
ance  to the means  employed for that  purpose.  The  peroneus
longus and  brevis tendons may be  divided, one  inch above the
external malleolus, in the following manner: The  leg, lying upon
the inner side, is firmly held by an assistant, with one  hand, while
the foot is forcibly adducted, by the other.   You then, with the
forefinger  of the  left hand,  feel for the tendons, which  you will
generally find  raised  above the level of the  fibula; introduce the
tenotome  flatwise, between  the bone  and the tendons,  turn the
sharp edge of the knife to  the tendons, and divide them trans- 
                  ORTHOPEDIC SURGERY.                99

versely.  The  extensor  longus  and  peroneus  tertius  should be
divided, when necessary, just where they pass over the ankle-joint,
in the following manner : —
   The foot is adducted,  by an assistant, a puncture is made close
to the inner side of  the extensor longus, a tenotome is passed  be-
neath the  tendons,  and  they  are divided  from below upward
towards the skin.  The tendons are prominent  and tense, so that
you will have no difficulty  in ascertaining that they are completely
divided.  If it is also necessary to divide the tendons of the ante-
rior tibial and extensor pollicis — and this is sometimes  the case
in old subjects — the knife can be re-entered at  the same puncture,
and carried in the opposite direction, beneath the tendons, flatwise,
and cutting towards  the  skin.  You can then apply a pledget of
lint over the puncture, and secure it in position  by a strip of adhe-
sive plaster and a bandage, around the foot and ankle.  The part
should at once be put into a plaster-of-Paris or a felt  splint, which
has been carefully moulded to the deformed foot before the opera-
tion, and kept in this position for three  or four days, when all  the
dressings are removed, the  parts well  washed, a  plaster splint
applied in the manner already shown, and  the foot forced toward
its normal position ;  this splint should  be removed every third or
fourth day, at each application bringing the foot nearer to its natu-
ral position.  When  the deformity has been reduced, the foot can
be retained in an appropriate club-foot shoe, without pain or  in-
convenience.  In some  severe  cases, it  may be necessary to use
an  apparatus which extends up  the thigh,  with  a  free hinge-joint
at the knee.  It is merely an elongation of the ordinary apparatus,
but is more powerful in its action.
  The club-foot shoe should be worn during the day, for six or 
IOO
ORTHOPEDIC SURGERY.
twelve months, in order to allow the bones, muscles, and ligaments
to adapt themselves to the changed position of the foot.  After
the removal  of the deformity, and to guard  against  relapse, a
retentive apparatus  should also be worn at night.   This may con-
sist of a lighter metal shoe or of a felt splint.
  The physiological treatment is as important here as  in  varus,
and should be practised during the whole course of the treatment,
until  the functions, as  well  as the form  of the  foot,  are fully
restored.
  The tendency to relapse is  not so  great in valgus as in varus,
                                   because it is  a less compli-
                                   cated deformity, and  it may
                                   be prevented by  the  use of
                                   an ordinary valgus shoe, after
                                   the  club-foot  apparatus has
                                   been laid aside.  The heel
                                    should be raised on the inner
                                    side,  so  as  to throw the
weight  on the outer side of  the foot, and an elliptical steel plate
inserted into the sole of the  shoe, for the purpose of sustaining
the arch of the foot;  this support must  be gradually discontin-
ued.   (Fig. 19.)

             TREATMENT  OF NON-CONGENITAL  VALGUS.
   The treatment of non-congenital valgus is  essentially similar, in
principles and in detail, to the treatment appropriate to the con-
genital form.   Operative treatment, however, is  rarely necessary,
the mechanical and physiological  means alone  being sufficient, in
a large majority of cases, to effect a cure.
 
ORTHOPEDIC SURGERY.
IOI
  The next frequent cause  of non-congenital valgus  is,  general
and local debility,  producing what  is  commonly  called " flat-
foot ;" and in these cases, the  general health should receive care-
ful  attention.   Fresh air, good food,  iron, quinia, &c, should be
judiciously used; while, in  many cases, the only local treatment
required  is a  properly-constructed valgus shoe, such as I have
before described (Fig. 19).
  In more severe cases, it may be  necessary to carry a steel  sup-
port from the shoe up the leg,  on the outer side, to  be  connected
with a plate which surrounds the calf, having a joint at  the ankle.
This apparatus is sometimes required for many years.
  When there  is marked eversion of the foot and  deviation of
the heel, we endeavor to reduce the deformity with the plaster-of-
Paris splint in the manner already described, and, when the dis-
tortion  is  overcome, the  club-foot shoe already recommended,
should be applied.   When, as  in severe and long-standing cases,
the deformity cannot be overcome by mechanical means, it  may
be  necessary  to divide the  tendo Achillis, or the extensor and
peronei tendons; but tenotomy will seldom be  required in non-
congenital cases.
  Special exercises, frictions,  galvanism, &c,  are extremely im-
portant in this form of club-foot, especially when it has  a paralytic
origin;  indeed, the physiological  treatment, properly  and  thor-
oughly carried  out, not  only  contributes  to  the cure, but  also
materially aids in preventing a  relapse of the deformity.

                        TALIPES EQUINUS.
  I will  now call  attention to the simplest and most frequent
form of club-foot, talipes equinus,  or horse-foot, so called from its
supposed resemblance to the  foot of the horse. 
102
ORTHOPEDIC SURGERY.
  In  the  opinion of all  authors, simple equinus  is rarely con-
genital, but we  find, at birth, combinations of this  distortion with
other varieties, such  as  equinus varus and  equinus valgus.  " I
have  met,"  says  Mr. Tamplin,  "with pure  talipes  equinus con-
genitus."  It usually  occurs in  infants, under  five years of age,
but it may commence much later in life.
  In well-marked cases of talipes equinus, there is complete  ele-
vation of  the heel, unaccompanied with  lateral distortion,  either
inward or outward, increase  in  the concavity of the longitudinal
arch,  producing  shortening  of  the  foot, and a  corresponding
prominence  of  the  head of the astragalus on  the  dorsum.  The
patient, in walking,  rests  entirely on the  heads of  the  metatarsal
bones, which become  separated from one  another in consequence
of the pressure of the weight of the body, so that the anterior
                        part of the foot is increased in width.
                          These appearances  are  well shown in
                        the cut  (Fig. 20), which represents  a
                        typical case  of  talipes equinus, in  the
                        adult.  There are, however, various de-
                        grees  of the  deformity,  depending on
                        the amount of flexion in  the tibio-tarsal
                        articulation.   We may have simply rect-
                        angular contraction of the tendo Achillis,
                        a condition  in which the heel touches
                        the ground,  and the  movements  of the
                        ankle-joint are  free,  except  when  the
                        patient attempts to raise the foot beyond
the right  angle, when the  leg  is extended, giving rise to great
inconvenience in walking ; or the deformity may involve the utmost
possible elevation of the os calcis.
 
ORTHOPEDIC SURGERY.
103
Fig. 22.
  The toes  are  usually in a condition of forced extension —
drawn up at right angles to the metatarsal  bones, as is seen in
                  the  cut (Fig.  21).   This indicates that the
                  anterior muscles of the foot  and  leg  retain
                  their power; and when they
                  are  affected with spasm, the
                  toes are flexed  upon them-
                  selves,  as  seen  in  the cut
                   (Fig. 22).
                     In exceptional cases,  all
                  the   anterior  muscles  are
                  completely  paralyzed,  and
                  the  ligaments  are  greatly
      FlG- "•       relaxed.  The  foot  then be-
comes bent  upon itself,  so that  the  dorsal surface  rests  upon
the ground.  This condition is well represented  by the cut (Fig.
23)-
  When  we   study  the
pathological  anatomy  of
this  deformity, we find  that
the  bones have undergone
very little change in form.
This is true  even in cases
which, beginning in  child-
hood,   have   existed  for
many  years.  The position
of  the bones,  however, is
materially altered.   The
tuberosity of the os calcis is  raised,  by the contraction of the
Fig. 23. 
104               ORTHOPEDIC SURGERY.
gastrocnemius and soleus  muscles, sometimes, to  such a degree
that the  upper surface of this bone is brought in contact with
the posterior surface of the tibia.  The degree of  elevation of
the heel  depends,  not merely  on  the  amount  of contraction
of the muscles  of the calf, but also on the  amount of flexion of
the anterior  or  the posterior part of the foot, at the transverse
tarsal joint.
  The degree  of elevation of the  heel is  often  more apparent
than  real.  The  elevated  position  of the  os calcis causes the
astragalus to project downward  and forward, and  its head pre-
sents prominently, on the dorsum of the foot (Fig. 20).
  The metatarsal bones approximate to  a vertical position,  and,
in old and severe cases, their anterior extremities are separated
laterally, thus increasing the breadth of that part of the  foot.  In
the cases  already mentioned, when the  paralysis is complete and
the foot is retroverted, the metatarsal bones are situated at right
angles to the leg, as seen in Fig. 23.
  The ligaments are either elongated or contracted, according to
their situations on the  anterior  or the posterior surfaces of the
foot, and in proportion to the degree and duration  of the deform-
ity.  The  muscles chiefly concerned  in the  production of talipes
equinus, are the triceps surae, which elevate the os  calcis, and the
flexor brevis digitorum, which contracts the  longitudinal arch of
the foot.   The plantar fascia is  also contracted.  The structure
of the muscles will be found in varying stages of fatty and fibrous
degenerations, the changes depending upon  the cause and  dura-
tion of the deformity.   In  cases of paralytic origin, especially,
fatty and fibrous degeneration usurp the place of normal muscular
fibre, while, in cases of spasmodic origin  and those arising  from 
ORTHOPEDIC SURGERY.
I05
injuries, the healthy muscular  tissue has  degenerated very much
less.
   Causes. — By  far the most  frequent causes of  non-congenital
talipes equinus are,  muscular  spasm  of the triceps  surae, and
paralysis of the  anterior muscles  of the foot and  leg.  It also
arises from wounds of the gastrocnemius,  or of the nerves  supply-
ing that muscle, and abscesses occurring in the course of the
muscle,  and  about the  ankle-joint,  long-continued, unchanged
position, and from scrofulous and rheumatic  inflammations of the
ankle-joint.
  Prognosis. — With  regard to the prognosis of talipes equinus,
we  must consider, in  the first  place, the nature of the cause —
whether the ankle-joint is directly or indirectly affected.
  In  the former class of cases, the deformity depends,  usually,
upon  paralysis of the  flexors of the  foot, and contraction of the
triceps  surae,  and  the prognosis  is based  upon the  degree of
paralysis, and  the condition of  the  muscular structure.
  When it  is  produced  by a  puncture  or other wound of the
muscles of the calf, or their nerve-trunks, or by abscesses in the
course of the muscle  or in the neighborhood of the ankle-joint,
the prognosis  is  gen-erally favorable, both as regards the removal
of the deformity, and the restoration of the functions of the  foot.
  When the  distortion arises  from causes directly affecting the
joint,  such as rheumatic  or  scrofulous   inflammation, in which
there  is a strong disposition to bony anchylosis, the prognosis is
less favorable.
  The age of  the patient, as well as  the  duration  and degree of
the deformity, have an important influence  on the length of the
treatment, and also on the ultimate result, and should cause  us  to
be guarded in our prognosis. 
io6
ORTHOPEDIC SURGERY.
   In a large majority of cases, the deformity can be removed by
 appropriate treatment, and the foot can be kept in proper posi-
 tion, by suitable appliances; but, to  re-establish free motion, and
 complete voluntary power over the  foot, and to give tone to the
 muscles, is not so easily accomplished, especially  when  the dis-
 tortion is due, either to complete paralysis  of the  flexor muscles,
 or to causes directly affecting the interior of the joint.  In  cases
 of long standing, the bones  themselves participate  in  the de-
 formity, and  of  course  this malformation exercises  a  material
 influence on the prognosis.

                           TREATMENT.
   The treatment of talipes equinus  involves the use of mechani-
 cal,  physiological, and operative  means,  depending upon the
 cause and degree of the deformity.
   For cases caused by paralysis of the flexor muscles,  the physio-
 logical and mechanical treatment, is usually sufficient.  We should
 endeavor to  overcome the paralysis, according to  the rules pre-
 viously suggested  for the physiological treatment,  viz., by passive
 exercises, frictions, dry heat, massage, electricity, &c.
   We should at the same time endeavor to counterbalance the
 action of the extensors, by the  use of the apparatus here repre-
 sented (Fig.  24).   It consists of two lateral, upright bars, fastened
 to the iron sole  of a strong shoe, jointed  at the ankle, and  con-
 nected to a band below the knee.  A stout, elastic  strap,  extends
 from  a  stirrup over the toes, to the  calf-band, and supplies the
place of the paralyzed flexors.   This  strap may be regulated to
any  degree of tension.  The heel  is  retained in its place by  a
strap across the instep. 
                   ORTHOPEDIC SURGERY.               107

   In mild cases — those in which the foot can be flexed with the
 hand — the apparatus, conjoined with the physiological treatment,
 will be sufficient to accomplish  a cure.   If these means fail, shall
 we, in  paralytic  cases, resort  to tenotomy?  This  will depend
 upon the  degree  of paralysis of the flexors,  and the  degree of
 contraction of  the extensors.  If there  is complete  paralysis of
 all the  anterior muscles  of  the leg, with but slight contraction
 of the posterior muscles,  I have no hesitation in saying that no
 benefit will result from the operation.
 The  paralysis  is, however,  usually
 limited to a few muscles, while others
 retain a  considerable  amount  of
 power.   The  muscles  involved,  and
 the degree of paralysis,  can be quite
 accurately  determined  by galvaniza-
 tion, or by faradization.
   When the paralysis is not complete,
 I  should recommend section of the
 tendo Achillis,  for it is  a matter of
 experience, that the  removal of the         e tiemann & co-
 contraction materially  aids   in  the            IG'24'
 restoration of power  to the paralyzed muscles.
   The tendo Achillis must be  divided, in the manner previously
 described  (page 79), and the subsequent treatment consists in
keeping the foot at rest,  in its abnormal position for three or four
days, by  the use of a plaster splint, and  afterwards  applying  the
apparatus just described (Fig. 24).
   The tension  of the  elastic strap  should be so regulated  as to
bring the foot very gradually to its normal position,  not making
 
io8
ORTHOPEDIC SURGERY.
the extension too  rapidly, lest the  connecting medium be too
much elongated, and thus destroy the function  of the gastrocne-
mius, or produce the opposite condition, calcaneus; nor so slowly
that  the  tendon will be re-united before  the  distortion has  been
entirely removed.  The extension  should  be completed in about
six weeks.
   What shall  we do  for cases of rectangular contraction of the
tendo Achillis ?  In these cases, you will remember that  the  heel
touches the ground, in standing, and there is sufficient contraction
of the tendo  Achillis to prevent flexion of  the  foot, beyond  a
right angle with the leg, but there is no obvious deformity.   This
slight contraction,  however, gives rise  to  serious inconvenience
and lameness,  as you can readily understand, when you remember
that we raise  the  foot beyond the right angle, in every act of
walking or running.
   This class of cases may arise  from any of the causes  of talipes
equinus already  enumerated, and we  may say, generally, that the
same rules of treatment apply to them, as to other cases, with the
exception that, in no  case  should tenotomy be  performed, unless
the muscles are in  a healthy condition.  In other conditions, the
operation  may often  be  performed  with great  benefit to the
patient.
   In cases of talipes equinus, the result of active  contractions or
spasm of the extensor muscles, or arising from  causes affecting the
joint, the  treatment should be initiated by tenotomy.
   Passive exercises, electricity, &c,  even when  combined  with
mechanical treatment, will not overcome the distortion, except in
very recent and slight cases;  but they are useful adjuvants to the
operative  treatment.   If any of the joints that are essential to the 
ORTHOPEDIC SURGERY.
109
proper movements  of the foot are anchylosed, it will be useless to
attempt a cure even by a section of the different tendons.
  The  tendo  Achillis  is,  usually, the  only tendon  requiring
division;  but, occasionally, you will find  the  posterior tibial, and
the peronei, so tense that the foot cannot  be flexed, even by con-
siderable  force, after  the  tendo Achillis  has  been  divided, thus
making their division  also necessary.
  You are not often required to divide either the plantar fascia or
the flexors of the toes, although they may appear quite tense and
contracted before any tendons are divided.  You will  find  that
the contraction of the longitudinal arch  of the  foot disappears, and
that the toes assume their natural position, at least as a general
rule, when the foot has been brought to  a  rectangular position with
the leg.   Should they not do so, the division  either of the flexor
tendons or the  plantar  fascia,  or both, in severe  cases  of long
standing,  may become necessary.

                  TREATMENT AFTER OPERATION.
  After the  cutaneous punctures have healed, Scarpa's shoe must
be applied, and gradual mechanical extension  made, until the  foot
is restored to its normal position.  The  extension, should  be so
conducted as to regulate properly the length  of the new material,
uniting the divided extremities of the tendon.
  The physiological treatment must be  employed, as soon as  the
position of the foot has been  restored by mechanical means, for
the purpose of establishing the functions of the joints and muscles;
for you would commit a very grave error,  if you limited your treat-
ment merely  to the removal of the malposition of the  foot.  "To
restore the foot to its  normal  position," says Malgaigne, " is not to 
no
ORTHOPEDIC SURGERY.
cure  it,  any more than we cure a fracture when we try to re-
duce it."  Unless  the  power to use the limb has been  restored,
but little benefit has been conferred upon the patient.  Electricity,
shampooing, dry heat,  and flexion and extension of the foot, for a
quarter of an  hour, two or three times a day, are the means to be
used,  in these  and similar cases, until the parts are brought into as
healthy a condition as  can be obtained.
  It is often necessary, after the distortion has been removed, and
                      the functions  of  the joints restored,  to
                      support the  ankles by two side steel sup-
                      ports,  attached to  the boot, having joints
                      corresponding to the ankle-joints and con-
         Fig. 25.                              Fig. 26.
nected at the calf by a metal plate,  to which a strap is attached,
fastening  in  front.  A stop-joint at the ankle may be used, if
necessary.  With this apparatus, and proper attention to exercise,
there need be no  apprehension of re-contraction taking place.
               EQUINO-VARUS AND EQUINO-VALGUS.
  Equino-varus and equino-valgus are compound varieties of club-
foot, characterized by a certain amount of inversion or eversion of 
                  ORTHOPEDIC SURGERY.               in

the anterior portion of the foot, in addition to the elevation of the
heel, which is the marked feature.
  The  special form  of distortion is  determined  by the relative
power of the adductors, and abductors of the foot.  The deform-
ity is well shown in Figs. 25 and 26.   The prognosis, pathology,
and treatment  of both the compound varieties, are essentially the
same  as that of simple talipes  equinus, except that,  in  order to
control  the lateral inclination of the foot, it may be necessary to
have the sole  of the shoe divided  transversely, at a point corre-
sponding to the transverse  tarsal joint (Figs. 12 and 13). 
112
ORTHOPEDIC SURGERY.
                       CHAPTER  V.

CONGENITAL AND NON-CONGENITAL TALIPES  CALCANEUS.--CAUSES.--
      TREATMENT. — CALCANEO-VARUS  AND CALCANEO-VALGUS.

  I now invite  attention to another deformity of  the  foot, viz.,
talipes calcaneus, which,  like  the  varieties  hitherto  described,
occurs both as a congenital and a non-congenital  affection — the
two varieties differing so greatly, both in  pathology and  in  treat-
                            ment, as to  demand a separate, con-
                            sideration.   The  congenital form is
                            almost as rare  as equinus.  The es-
                            sential  characteristic  of talipes cal-
                            caneus,  is depression of  the   heel.
                            In the  congenital variety,  which we
                            will first describe, there is, in  addi-
                            tion to  the depression  of the  os
                            calcis, marked flexion of the dorsum
                            of the  foot  against the front of the
                            leg (Fig. 27), and the condition is
exactly the reverse of talipes equinus, in which there is an extreme
degree of extension of the foot.  The foot is retained in a  flexed
position, by the  contraction of  all the muscles whose tendons pass
over the  front of the ankle-joint, and stand out very prominently.
  The bones undergo very little change in their relative  positions;
indeed, the deformity is only an exaggerated degree of one of the
 
ORTHOPEDIC SURGERY.
"3
natural motions or positions of the foot, and the deformity, in the
infant, can  be  easily overcome by gentle manipulation;  but on
removing the hand, the foot  is immediately drawn up again, by
the contraction of  the  muscles.   The  facility with which the foot
can be brought to a normal position, indicates  that  structural
shortening has not taken place, either in the flexor muscles, or in
the ligaments on the anterior part of the  foot.   In rare cases,
however, the foot is held firmly  in its flexed position,  in conse-
quence of the structural shortening of the anterior muscles of the
leg and the anterior ligaments, and operative proceedings may be
necessary to overcome the distortion.

                          TREATMENT.
   Congenital talipes calcaneus, which is only seen in infants and
young children, may  be regarded  merely  as a malposition from
intra-uterine pressure.  It  is the least important, as well as the
rarest  deformity of the feet,  and  yields readily to the simplest
treatment.   Surgical interference is not usually required.   It  is
only necessary in ordinary cases   to  extend the  foot, to make
frequent passive  motions of the ankle-joint,  and  to  use frictions
with the hand,  over the anterior  muscles  of the  leg.   The cure
may be hastened by the application to the  front of the leg and
foot, of a well-padded metal splint, which  should be straightened
from time to time, as the foot improves.
   In the rare cases  in which there is permanent  contraction of the
flexor  muscles,  namely, the extensor longus  digitorum, peroneus
tertius, extensor proprius  pollicis, and  the  tibialis anticus, they
should be  divided  as they pass over  the  ankle-joint, where they
are tense and prominent.   A  sharp-pointed tenotome is inserted, 
ii4
ORTHOPEDIC SURGERY.
close to the inner side of the extensor longus, and carried outward,
beneath  the tendon  of that  muscle, and  also of the  peroneus
tertius, which are then divided towards the skin; the knife is with-
drawn, and re-introduced and  passed inward, beneath the anterior
tibial  and extensor pollicis tendons, which are divided in the same
way.  You will  avoid the risk of  puncturing the anterior tibial
artery, by keeping  the point of the knife close to the tendons to
be  divided.  The wound should be immediately closed with a
pledget of lint, retained with adhesive plaster and a  bandage.
  After three or four days, you should begin the mechanical  treat-
ment, which consists in  the application of the padded metal splint,
in the manner just described.  The foot should be extended daily,
and you will, in  the course  of three weeks, without much pain or
inconvenience, be enabled to bring  it to a state of complete  exten-
sion.  When this has been accomplished, the splint may be  left
off  for an hour or two each day, and passive motions  and manipu-
lations practised, until  the tendency to  contraction has ceased.
This is of the greatest importance, also, to the development of the
infantile muscles.  There is but little tendency to  relapse, and in
the after-treatment no retentive apparatus is required.

              NON-CONGENITAL TALIPES CALCANEUS.
  This deformity of the foot  has been designated by  Barwell as
talipes cavus, by Bauer as talipes  simplex  sive plantaris, and by
others it is described as talipes  calcaneus valgus.   I prefer to
describe it  under  the name of,  non-congenital talipes calcaneus,
because  of its resemblance, in the  early stage, to  congenital  cal-
caneus, for, in  addition to depression of  the tuberosity  of the
calcis, there is, in  the early stage, slight elevation  of the anterior 
ORTHOPEDIC SURGERY.
IT5
part of the foot  (Fig. 28).  At a later period, however, the  foot
becomes flexed upon itself, at the transverse  joint, the anterior
portion is bent downward,
the  transverse  arch is
lost, while  antero-poste-
riorly,  the sole is deeply
arched.   This affection
is  usually  of  paralytic
origin,  the paralysis be-
ing generally confined to
the  triceps  surae,   but,
sometimes  it   extends to
all the extensor muscles.
Fig. 28.
I cannot better describe this deformity
Fig. 29.
than by directing your attention to the appearances  presented by
this cast (Fig. 29), which was taken from the right foot and leg of 
n6
ORTHOPEDIC SURGERY.
a girl eleven years old, who was the subject of infantile paralysis,
affecting the triceps extensor muscles of the leg, at two and a half
years of age.  It will  be noticed that the foot, in front  of  the
transverse  tarsal  joint  is  bent downward.  The flexion  of  the
anterior part of the foot is secondary, and  is due to the action of
the peroneus longus, chiefly, assisted by the posterior tibial, these
muscles supplementing the sural muscles, as extensors of the foot.
These muscles acting, while the triceps  surae are paralyzed, in their
efforts to keep the foot normal by their extending force, must neces-
sarily drag  down the anterior tarsus, so that the ball and the heel
approximate each other, and the  sole  is so deeply arched that a
mouse could run under it without touching it, as was the case in
Lady Hester Stanhope's  foot, which was  remarkable for  a high
plantar arch.   The transverse arch has  disappeared.   The  foot is
also a little rotated outward, by the action of the peroneus  longus,
its farther rotation being prevented, by the action of the  posterior
tibial.   It will be perceived that the head  of the metatarsal bone
of the great  toe, is forcibly depressed.   This is due to the  normal
contraction of the  peroneus  longus, which is  unopposed  in  this
part of its function.  It  will  be  seen also that the os calcis is
depressed,  so that the  patient walks on the tuberosity, instead of
walking upon the normal under-surface  of  the  bone, and that the
only parts of the  foot which touch the ground,  are the ball of the
great toe and the tuberosity of the heel.  The  muscles of the calf
are wasted, owing to the long-standing paralysis, and the back of
the leg, from  the knee downward, is very nearly straight,  instead
of  presenting the curved outlines  observed  in the  normal  leg.
Even the os calcis has lost its prominence,  and the  tendo Achillis
feels like a thin and narrow ribbon.  The limb  is cold, the circula- 
ORTHOPEDIC SURGERY.
117
tion languid, and the patient suffers easily from chilblains; in fact,
we  have here the usual concomitants of a paralytic limb.
  You can imagine that the inconvenience  caused by  such an
affliction is very great, and the lameness considerable;  the relaxa-
tion of the ligaments deprives  the foot of all  useful motion and
firmness, and walking is accomplished with great difficulty without
the aid of artificial support.
  The usual cause of non-congenital calcaneus is infantile paraly-
sis, principally  confined  to the  sural muscles; but  sometimes
all  the muscles below the knee are paralyzed, except those whose
contraction produces the deformity.   It may also be caused by
improper union of the  tendo Achillis after section or accidental
rupture, by separating the ends too far before they had united, or
it may be produced by the contraction of a cicatrix resulting from
a wound or burn on the dorsum of the foot.   A condition of the
foot resembling non-congenital calcaneus is  artificially produced
among the Chinese women, of the higher order, by confining the
feet by short  shoes  and improper
bandages  during infancy  (Fig. 30).
  It has  been found, upon dissec-
tion, that the  relative  position  of
the bones is considerably changed.
We have  already alluded to  the
depression of the tuberosity of the
os  calcis, while its anterior part is
                                        Fig. 30. (After Adams.)
elevated;  and,  as  a consequence
of this, there is a great obliquity of the astragalus, its  trochlea
projecting  posteriorly, while the  articular surface of the tibia is
thrown forward  upon the neck of the astragalus, and the anterior
 
n8
ORTHOPEDIC SURGERY.
portion of its trochlea.  The  bones,  in front  of the transverse
tarsal joint, are pulled downward, by the action  of the  peronei
muscles, diminishing the length  of the  foot, and increasing  the
longitudinal arch.
  Owing to the changed  position of  the bones, the ligaments on
the dorsum of the foot, and behind the ankle-joint, are elongated;
those in front of  the  ankle-joint  and those in the sole, together
with the muscles with which they are connected, are contracted.
  When the distortion arises from paralysis, and is of long stand-
ing, the muscles are in a state of atrophy and fatty degeneration,
more or less complete.
  The prognosis, in cases  of this deformity arising from paralysis,
is  usually unfavorable, and our treatment can only be  palliative.
We can remove the deformity in  a measure, but we  cannot give
power to the muscles.

                          TREATMENT.
  In  paralytic cases, if the patient is seen soon after the distortion
has begun, we  can not only prevent any considerable deformity,
by the  use of suitable appliances, but muscular power  can,  in  a
measure, be restored by means of electricity or galvanism, heat,
stimulating  applications, rubbing, &c.  The apparatus  which  I
would advise, is the one I here  show you (Fig. 31, Tiemann's).
It consists of two lateral steels, carried up the leg and secured by
a band around the calf, with a joint  at  the ankle.  The  anterior
part of the  foot is depressed,  and the heel is elevated by a  steel
spiral  spring, placed on  a  pivot, and  playing between brackets of
the leg and ankle-stem.   This apparatus, I consider preferable to
the india-rubber cords fastened posteriorly to the heel below,  and 
ORTHOPEDIC SURGERY.               119
to the calf-band above, so as to imitate the tendo Achillis.   If,
however, the latter apparatus should be employed, the  spur pro-
jecting from  the  posterior part of the heel should be dispensed
with  because  it is in the way, and liable to catch surrounding
objects, especially when descending the stairs, and the cord should
be fastened directly to the heel by means of  a leather strap.
  You may be surprised to learn that this affliction is usually over-
looked in  the  early stage, and, when it is recognized and brought
to, the attention of the surgeon, considerable
deformity  has  taken place.   The earlier it
is treated, the more  readily is the  distortion
overcome.   When, unfortunately, much time
has  elapsed before  the  deformity  is  dis-
covered, there is marked depression  of the
os calcis and  great  increase of the longi-
tudinal arch of the foot, and  the  ligaments
and muscles have adapted themselves to the
altered condition of the foot, so as to give it
a considerable degree of firmness, which ena-        c.^""
bles the patient to walk quite well.  In such
a case, while physiological treatment  and mechanical  appliances
may increase  the usefulness of  the  foot, and  may be used  in
appropriate cases, it is extremely probable  that tenotomy would,
on  account of the  paralysis of  the muscles, allow the foot  to
dangle about  and become almost useless, and render some  me-
chanical  apparatus  indispensable.   Operative  treatment  is less
appropriate in this, than  in other forms of club-foot.   In excep-
tional cases, it may be necessary to divide the contracted extensor
and  other  tendons,  and  the  plantar fascia,  and then proceed  to
 
120
ORTHOPEDIC SURGERY.
extend and elongate  the foot by the use of a Scarpa's shoe, and
by pressure  on the dorsum of the foot.  When the distortion has
been reduced, the patient  may wear the shoe  which I have just
described, for  the  purpose  of supporting the limb.   I desire to
warn you against  exciting  the  expectations  of your patient  too
much.    He should be informed that the treatment can only be
palliative, — that there is no reasonable probability that the para-
lyzed muscles will regain their normal power.
  In cases  of  talipes  calcaneus, the result of non-union of the
divided tendo Achillis or of too great an elongation of the re-
uniting  medium,  Dr.  Little advises  incising  the  edges  of  the
un-united tendon, or dividing the uniting medium with a tenotomy
knife, and then approximating  the  ends by placing the foot in an
extended position.   In such a case, he has  known an abundant
effusion  of plastic material  to take place, and firm union of the
tendon, at the  end of two weeks.
  When  the distortion is caused by cicatricial contraction, on the
front of the leg or dorsum of the foot, such a treatment should be
adopted  as seems to be indicated in each particular case.
  Calcaneo-varus and calcaneo-valgus are  slight and  unimpor-
tant  modifications of talipes calcaneus.  Their characteristics are
sufficiently indicated by their designations, and the pathology and
treatment are  essentially the same as in the simple varieties, and
do not therefore deserve separate consideration.
  I have now, gentlemen,  completed what  I  have  to say to you
upon the subject of club-foot, in accordance with the plan which
I proposed  for myself at the outset.   No attempt has been made
to treat  the subject exhaustively, or to  amuse  you  with novelties,
and  I have endeavored to  avoid ad captandum  or random state- 
ORTHOPEDIC SURGERY.
121
ments.   It has been my purpose to give you, in as concise and
simple a manner as  possible, the results of my personal observa-
tions and reflections upon  the subjects we have  considered,  to
unfold to you, as  I stated  at  the outset, a much-neglected, but a
most attractive chapter  of  modern  surgery, and to impress upon
you  general principles  which  I  trust will enable  you to treat
club-foot, wherever you  meet  it, without the assistance of the
specialist or the hospital surgeon.
  To those of you who may desire to study more fully and more
in detail the  subject of talipes,  I  would  recommend  the  great
work of Mr. William Adams, of London, by far the ablest mono-
graph upon  this subject in any language.
  In conclusion, gentlemen, I desire to express my sincere thanks
for the  interest you have manifested and for your uniform courte-
sy, and to  wish  you every  success  in  the profession of your
choice.
Stereotyped and Printed by Rand, Avery, &■» Co., Boston. 
 
 
 
 
 
 
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