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COXTPvIBUTIOXS 
 
 ORTHOPAEDIC SURGERY. 
 
 BY 
 
 A. SYDNEY ROBERTS, M.D., 
 
 LATE SURGEON TO THE PHILADELPHIA HOSPITAL, ORTHOPEDIC SURGEON TO THE OUT-PATIENT 
 
 DEPARTMENT IN THE UNIVERSITY HOSPITAL ; INSTRUCTOR IN ORTHOPEDIC SURGERY 
 
 IN THE UNIVERSITY OF PENNSYLVANIA ; OUT-PATIENT SURGEON TO THE EPISCOPAL 
 
 HOSPITAL; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA 
 
 AND OF THE AMERICAN ORTHOP.EDIC ASSOCIATION | MEMBER OF THE 
 
 PENNSYLVANIA STATE MEDICAL SOCIETY, PHILADELPHIA 
 
 COUNTY MEDICAL SOCIETY, PATHOLOGICAL SOCIETY, 
 
 NEUROLOGICAL SOCIETY, ETC. 
 
 WITH A BRIEF BIOGRAPHICAL SKETCH 
 
 BY 
 
 JAMES K. YOUNG, M.D., 
 
 PROFESSOR OF ORTHOPEDIC SURGERY, PHILADELPHIA POLYCLINIC ; CLINICAL PROFESSOR OF 
 ORTHOPEDIC SURGERY, WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA | INSTRUCTOR 
 IN ORTHOPEDIC SURGERY, UNIVERSITY OF PENNSYLVANIA ; ASSISTANT ORTHO- 
 PEDIC SURGEON, HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA ; 
 SURGEON TO THE HOSPITAL FOR CRIPPLED CHILDREN. 
 
 PHILADELPHIA 
 
 1898. 
 
■n 
 
 
 DORNAN, PRINTER, 
 PHILADELPHIA. 
 
PREFACE 
 
 This work represents all the collected writings of the 
 late Dr. A. Sydney Roberts except a collection of quota- 
 tions entitled "In and Out of Book and Journal," which 
 enjoyed a large sale as a popular gift-book. 
 
 The present collection is undertaken for private distribu- 
 tion only, for the sole purpose of increasing the interest 
 in the subjects of which it treats, and is prepared by the 
 editor as a debt of gratitude for many past kindnesses. 
 
 Permission has been generously given by Messrs. Lea 
 Brothers & Co., the J. B. Lippincott Co., and Messrs. 
 Wm. Wood & Co. 
 
 J. K. Y. 
 
CONTENTS. 
 
 Biographical Sketch of Dr. A. Sydney Roberts. By James K. 
 
 Young, M.D. 1 
 
 Club-foot: Talipes. Roberts and Ketch. Reprint from the 
 Reference Hand-book of the Medical Sciences, by courtesy 
 of the publishers, Messrs. Wm, Wood & Co , who have 
 also loaned the illustrations 23 
 
 Pott's Disease. Keating's Cyclopaedia?, Vol. III. . . . 123 
 
 The Spinal Arthropathies. Medical News, February 14, 1885. 177 
 
 Clinical Lectures on Orthopaedic Surgery : Club-foot. Medical 
 
 News, March 13 and 20, 1886 . . . . . .195 
 
 Clinical Lectures on Orthopsedic Surgery : Knock-knee and 
 Bow-legs, with Remarks upon Rhachitis. Medical News, 
 February 4 and 18, 1888 237 
 
 Flat-foot : A New Plantar Spring for its Relief. Medical and 
 
 Surgical Reporter, April 6, 1889 265 
 
 Chronic Articular Osteitis of the Knee-joint, and Description 
 of a New Mechanical Splint. Medical News, July 26, 
 1884 283 
 
 Deformity of the Forearm and Hands. Annals of Surgery, 
 
 February, 1886 291 
 
M E M I R 
 
 OF 
 
 DR. ALGERNON" SYDNEY ROBERTS. 
 
INTRODUCTION. 
 
 Each profession has its own manner of honoring 
 its dead. 
 
 There is a custom among the members of the 
 Bar suggestive of brotherhood. When one dies 
 who has adorned the profession, a general meeting 
 of the Bar is called, a Judge presiding. At such 
 meeting each and every member may pay his tribute 
 to the departed — placing, as it were, a flower upon 
 the bier of a brother whose victory they had wit- 
 nessed. 
 
 In our profession, that of medicine, no such cus- 
 tom obtains. Would it not be well by this or some 
 means to inculcate such a spirit of camaraderie f 
 
 In lieu of such a custom, it seems highly fitting 
 that I, as pupil, friend, successor, upon whom in 
 some measure his mantle has fallen, should pay my 
 tribute to the sacred memory of the departed. When 
 one of the medical profession whose ability and 
 attainments mark his individuality pre-eminent 
 passes into eternity, those who linger may take 
 note of his scholarly attainments and professional 
 skill, and emulate his many virtues. 
 
 Biographies of men of eminence and merit, while 
 calculated to please a large class of readers, have a 
 
4 MEMOIR OF A. S. ROBERTS. 
 
 greater and more intrinsic value. They present to 
 those in the heyday of youth a stimulus and encour- 
 agement ; to those in the meridian of their career, 
 the satisfaction that a justifying parallel may be 
 discovered; while to those who are entering the 
 evening of well-earned rest from labor, a reconcilia- 
 tion may often be found by adopting, as Cooper 
 remarks, "the comfortable self-assurance that the 
 frowns of fortune or some unlooked-for fatality 
 have alone prevented them from enjoying a similar 
 distinction or becoming equally useful members of 
 society." 
 
 If in the present undertaking my expressions 
 occasionally savor somewhat of enthusiasm, my re- 
 spect for him when a student, my gratitude to him 
 as his pupil, and the affection borne him during my 
 later association with him, may be offered in apology 
 of its degree if not in justification of its fault. 
 
 I would take this opportunity of expressing my 
 deep sense of gratitude to those friends who have 
 furnished me with various data relating to the sub- 
 ject of this history, without which it would have 
 been incomplete. 
 
 Dr. Roberts was the son of Algernon S., Jr., and 
 Sarah (Carstairs) Roberts, grandson of Algernon 
 S. Roberts. He combined the sturdy elements of 
 the Welsh blood with the purest Scotch, his father's 
 Welsh ancestry having first settled in this country 
 in 1683, and his mother coming of a long line of 
 Scotch ancestors. 
 
 He was born December 19, 1855, in Philadelphia. 
 His early education was received at Ilallowell pri- 
 
INTB OD UCTION. 5 
 
 vate school, from private tutors, and especially from 
 Mr. Henry Galbraith Ward, now a distinguished 
 lawyer in New York city. His education and prep- 
 aration for college were completed at an early age, 
 as a private pupil of Professor Thomas Chase, of 
 Haverford College. The influence of Professor 
 Chase and Mr. Ward upon the development of his 
 mind is shown in the scope of his medical works 
 and the character of the literature produced by him. 
 
 When Mr. Ward first met him he was a slight 
 and rather shy boy, but constantly improving in 
 strength and confidence. His remembrance of Dr. 
 Roberts is as a very favorite pupil. He was very 
 regular and faithful in his studies, and gave promise 
 of a future which he afterward developed in his 
 chosen profession. He was restive under restraint, 
 and school discipline was irksome to him, as he 
 learned more rapidly than many of his companions. 
 Yet, in fact, he did not apply himself closely to 
 study until he commenced the study of medicine, 
 which he took up with great earnestness. 
 
 During his youth he was very fond of drawing, 
 and was very clever with tools, traits which in after 
 life were of the greatest service to him. 
 
 His inclination toward the study of medicine as 
 a profession was first shown while at Haverford 
 College with Mr. Chase, when he wrote to a member 
 of his family of his desire to study medicine, and 
 asked to have a skull sent to him, adding that he 
 " would like one with all the teeth." 
 
 Eminently fitted by nature, environment, and 
 education for the medical profession, the decision 
 
Q MEMOIR OF A. S. ROBERTS. 
 
 having once been made, he devoted himself to its 
 study with all the energies of his soul, as Gross has 
 said of Valentine Mott : " He loved surgery as his 
 mistress, and his constancy merited all the favors 
 which she so lavishly showered upon him." 
 
 With a decidedly artistic taste, his leaning was 
 toward the study of architecture, and particularly 
 drawing and similar studies, and he told me his 
 tendency always was in favor of the profession of 
 a railroad engineer, especially bridge-building. 
 
 There is no doubt that if he had decided to enter 
 the profession of engineering his success would 
 have been equally as great as in the one which he 
 chose. In this connection the incident of Dr. 
 Physick recurs to us as being a circumstance of 
 similar kind. Dr. Physick's father was a silver- 
 smith, and it was always the son's regret that his 
 father would not permit him to follow in his foot- 
 steps, although, as every one knows, Dr. Physick 
 was the most distinguished surgeon of his time. 
 
 Dr. Roberts was particularly fortunate in the 
 choice of a preceptor. It was in the office of Dr. 
 Keen that young Roberts first became fully inspired 
 with that love for his profession which ever after- 
 ward was a remarkable feature of his career. 
 
 Henceforth forever his ambition was not simply 
 to be the doctor, as Pope would have it, 
 
 "Sole judge of truth in endless error hurled, 
 The glory, jest, and riddle of the world," 
 
 but to be a great surgeon. 
 
 To be a great surgeon is an ambition for which 
 
INTRODUCTION. 7 
 
 any one might strive, for, with Gross, I unhesitat- 
 ingly assert, without fear of successful contradiction, 
 that it " requires as much intellect, talent, genius, 
 and knowledge to form a great surgeon as it does 
 to form a great lawyer, judge, divine, general, or 
 statesman." 
 
 Dr. William W. Keen at this time was laying for 
 himself the foundation of the enviable reputation 
 that he now enjoys. From the introductory address 
 delivered by Dr. Keen in his course of lectures on 
 anatomy at the Philadelphia School of Anatomy 
 the following year, we gain some idea of the charac- 
 ter of the instruction given by him at that time. 
 As the successor of Dr. Agnew in the old Philadel- 
 phia School of Anatomy, he demonstrated not only 
 his thorough knowledge of this important branch of 
 medicine, but also his ability to instruct students, 
 and moreover to entertain them, by his delightful de- 
 scriptions of the early history of practical anatomy. 
 
 In addition to the regular winter term in the 
 Medical Department of the University of Pennsyl- 
 vania, Dr. Roberts attended three full spring courses 
 of lectures in this school, and was graduated there- 
 from on March 12, 1877. 
 
 His fondness for the study of pathology led him 
 early to use the microscope in the pursuit of his 
 studies, a somewhat unusual procedure in those 
 days, but by virtue thereof he secured honorable 
 mention for his thesis, and subsequently became 
 Assistant Demonstrator of Histology. 
 
 Having determined to enter the profession of medi- 
 cine, Dr. Roberts began his study with all the energy 
 
8 MEMOIR OF A. S. ROBERTS. 
 
 of his young manhood. Roused by the earnestness 
 of his preceptor, Dr. "W. W. Keen, and surrounded 
 by the spirit of enthusiasm everywhere rife in the 
 University, his progress was marked. 
 
 To thoroughly understand the influence of the 
 times, one must mark the conditions of the Univer- 
 sity at the entrance of Dr. Roberts. 
 
 The Medical Department of the University con- 
 tained at the time bat seven major chairs. 
 
 The spirit of progress and development that char- 
 acterized the institution from its beginning, in 1740, 
 as a charitable school manifested itself in marked 
 epochs of change. 
 
 Dr. Roberts entered the study of his profession 
 in 1873, when every department throbbed with latent 
 life, only wanting the accepted time to manifest itself 
 in marked and brilliant change. Daily contact with 
 this spirit through the formative years of his devel- 
 opment assured the permeation of his character with 
 the same animation that prompted the actions of his 
 preceptors. 
 
 Every energy of his young manhood, every ambi- 
 tion of his life, every demand of his intellectual 
 nature found its response in the spirit of the insti- 
 tution during those years. 
 
 Prominent among those who toiled and waited 
 stood Dr. William Pepper. 
 
 Recounting the years of progress, and identified 
 with the University, he reviewed the past and fore- 
 cast the future. In his most interesting address 
 upon " Higher Medical Education — the True Inter- 
 est of the Public and Profession," he recounts the 
 
INTR OD TJCTION. 9 
 
 long heroic struggle of the friends of the University 
 to obtain an ideal standard. Weeks and months had 
 lengthened into years, hope had given place to dis- 
 appointment, effort had ended in discouragement 
 times over, before the glad day of victory had 
 dawned. 
 
 Dr. Roberts took up his life work at this auspi- 
 cious time, his year of graduation, 1877. 
 
 This year marked, according to Dr. Pepper : 
 
 1. The establishment of a preparatory examina- 
 tion. 
 
 2. The lengthening of the period of collegiate 
 studies to at least three full years. 
 
 3. The careful grading of the course. 
 
 4. The introduction of ample practical instruction 
 of each student both at the bedside and in labora- 
 tories. 
 
 5. The establishment of fixed salaries for the 
 professors, so that they would no longer have any 
 pecuniary interest in the sizes of their classes. 
 
 Such standards maintained meant new men in 
 new places. The realms of science with their hidden 
 treasures awaited the enthusiastic student explorer 
 who brought to this undiscovered country intelli- 
 gence, enthusiasm, and patient perseverance. 
 
 The few noble lives that had uplifted the standard 
 of advance were reinforced by able men in the new 
 lines that diverged from their original centre. The 
 number in the Faculty was increased, a long list of 
 clinical instructors, demonstrators, and lecturers 
 was added. Faculties of departments increased 
 with each advance. Enthusiasm spread from the 
 
10 MEMOIR OF A. S. ROBERTS. 
 
 council chambers of faculty and trustee conferences 
 to the students in the amphitheatre. The stimulus 
 to mental activity that did not scorn the drudgery 
 of toil, nor ignore the opportunities of daily doing, 
 developed from the pupils men who became in turn 
 leaders in other circles, representatives of the new 
 developments and expressions of the ideas of their 
 Alma Mater. Little by little the alpine height of 
 excellence was attained until the University stood 
 peer with other institutions of acknowledged emi- 
 nence. An expression of the higher manifestation 
 of her influence was exemplified when at her instance 
 the State Board of Examiners was suggested, and 
 again the profession felt the fortifying bulwark of 
 her power. Standards of excellence were demanded 
 that should protect alike physician and patient. 
 
 In the midst of this consuming energy Dr. Roberts 
 stepped into the arena of the profession, full of en- 
 thusiasm and culture, proud to have the lines of life 
 fall to him in an hour of accepted progress. Stimu- 
 lated to action, he would at once do credit to his 
 profession and to his Alma Mater who conferred 
 his degree. One cannot wonder that then to him 
 came the ambition that would pay tribute to the 
 power that had placed him at once upon a plane of 
 advanced thought and enrolled his name among 
 her instructors. To him it was not an ambition to 
 find place amongst institutions that " sprung up as 
 mushrooms in a night," but he toiled to be worthy 
 at once of position in his profession and University. 
 
 The class of '77, in which Dr. Roberts graduated 
 from the University of Pennsylvania, contained 
 
INTE OD UGTION. 1 1 
 
 several men who have since distinguished them- 
 selves in the different branches of their profession. 
 Among them we notice the names of James M. 
 Anders, Joseph Price, Matthew N. Oyer, Francis 
 X. Dercum, Henry F. Formad, Thomas H. Fenton, 
 Isaac C. Gable, Herman Haupt, Jr., William Hob- 
 son Heath, William C. Hollopeter, Rush S. Huide- 
 koper, Fairfax Irwin, John H. Musser, J. Wilkes 
 O'Neil, Andrew J. Parker, and George A. Piersoll. 
 
 In 1877 he served in the Emergency Corps of the 
 State militia in the coal region riot of Pennsylvania 
 as volunteer in the First Troop, Philadelphia City 
 Cavalry, being assistant to Dr. William G. Porter, 
 surgeon to the First Brigade, 1ST. G. P. In this 
 capacity he served in the West Penn Hospital, 
 Pittsburg, being later removed with the troops to 
 Scranton. 
 
 Immediately upon his graduation from the Uni- 
 versity of Pennsylvania he was elected to the posi- 
 tion of resident physician to the Blockley Hospital 
 (which position he accepted later), where he served 
 his full term and made the acquaintance of the 
 members of the staff, who were afterward of great 
 service to him and whose colleague he soon after- 
 ward became, being very earl} 7 appointed surgeon 
 to this institution. At the suggestion of Dr. S. 
 Weir Mitchell, he decided to turn his attention to 
 orthopedic surgery as a specialty. With this in 
 view, he became resident physician in the New York 
 Orthopedic Hospital, then, as at the present time, 
 under the care of Dr. Newton M. Shaffer, surgeon 
 in charge. The influence of this training is shown 
 
12 MEMOIR OF A. S. ROBERTS. 
 
 throughout his work in this special department of 
 surgery which he adorned with so much brilliancy. 
 For two years he practised in this institution. Hav- 
 ing in his mind the old couplet, 
 
 "A little knowledge is a dangerous thing; 
 Drink deep, or taste not the Pierian spring," 
 
 he returned time and again to this fountain of knowl- 
 edge, each visit seeming to add renewed energy and 
 skill to. this promising surgeon. 
 
 With a view to practising his profession in Phila- 
 delphia, he opened an office at 133 South Fifteenth 
 Street, and at once attached himself to several hos- 
 pitals in the capacity of assistant surgeon. Almost 
 immediately he was appointed Visiting Surgeon to 
 the Philadelphia Hospital, Surgeon to the Episcopal 
 Hospital Out-Patient Department, and Instructor 
 in Orthopedic Surgery in the University of Pennsyl- 
 vania. These appointments (with occasional visits 
 to other hospitals, in consultation with other sur- 
 geons) occupied his time very fully and added 
 greatly to his amount of knowledge and his success 
 in this special department. 
 
 Through his personal exertions the orthopedic 
 shop of the University Hospital was organized, a 
 building erected for the purpose and thoroughly 
 equipped at an expense of nearly $2000. The con- 
 tin nation of the usefulness of this shop, and the 
 furnishing of free apparatus to indigent persons, 
 have been secured in perpetuity by the endowment 
 by members of his family of the A. Sydney Roberts 
 Apparatus Fund. 
 
INTB OD UCTION. 13 
 
 This was the first, and is still the only shop of its 
 kind connected with a medical college hospital. Its 
 continued usefulness proves the foresight and wis- 
 dom of Dr. Roberts' good judgment in establishing it. 
 
 It was at this time that my personal knowledge 
 of Dr. Roberts began, and during those happy days 
 when I " walked the boards " of the Philadelphia 
 and Presbyterian Hospitals in company with my 
 preceptor, Dr. William G. Porter, I had an oppor- 
 tunity of seeing Dr. Roberts at work in these 
 institutions. I was at once impressed with his thor- 
 oughness, his grasp of the subject, and the success 
 he obtained in the treatment of this neglected 
 branch of surgery. The impressions then gained 
 were only intensified by more close association with 
 him in after years. 
 
 His experiences at the different hospitals led him 
 early to desire to be a teacher. The occasion soon 
 offered itself in lectures delivered at the University 
 of Pennsylvania and in the course of clinical lec- 
 tures which he delivered at Blockley upon ortho- 
 pedic surgery, the latter being the first clinical 
 lectures ever delivered upon the subject in Phila- 
 delphia. 
 
 As a teacher he was thorough, clear, and impres- 
 sive. Without any effort at rhetorical display, he 
 impressed the students at once with his thorough 
 knowledge of the subject and of his desire to impart 
 freely to them all the knowledge he had acquired. 
 
 His diagnosis was accurate, and his selection of 
 the proper treatment or apparatus was made with 
 the greatest consideration for the comfort and speedy 
 
14 MEMOIR OF A. S. ROBERTS. 
 
 recovery of the patients. If an operation was re- 
 quired the necessity for it was stated in such a 
 manner that it was never refused. 
 
 His practice was principally among the better 
 class of society, and much of it came to him from 
 consultations with other physicians and through the 
 recommendation of Dr. S. Weir Mitchell, Dr. Wil- 
 liam W. Keen, and Dr. Newton M. Shaffer, all of 
 whom indorsed him in most unqualified manner. 
 His practice was active during the short time he 
 was engaged in it, and there is no doubt that had 
 he continued he would have acquired a large clien- 
 tele and a lucrative income from this source. While 
 his practice was largely among the better and more 
 influential classes, he was as kind to the poor as to 
 the rich, and I have known a mother, who was too 
 frail to carry her child to the hospital, advised by 
 him to bring it to his office to be treated cheerfully 
 and thoroughly without a fee. Among his papers 
 were found many letters from poor patients express- 
 ing their gratitude, and many of the nurses on duty 
 at the Philadelphia Hospital during Dr. Roberts' 
 service have remarked his kind manner to the des- 
 titute. 
 
 At this time he employed assistants for certain 
 portions of his work. A large number of black and 
 white sketches and colored drawings were made, 
 casts were taken, and his hospital-books were kept 
 most accurately by Dr. S. R. Jenkins, now of Char- 
 lottetown, Prince Edward's Island, Canada; Dr. 
 William S. Johnson, now of Germantown, and my- 
 self. His manner toward his assistants was always 
 
INTR OB UCTION. \ 5 
 
 kindly and considerate, and on one occasion I was 
 myself the recipient of a trip South through his 
 interest in my physical condition. 
 
 Although his career was brief, he performed a 
 number of important and difficult operations upon 
 patients committed to his care. These were always 
 done in a most thorough and skilful manner, and 
 every detail was carefully thought out before any 
 operation was undertaken. His instruments and 
 apparatus of all kinds were of the finest, and he 
 used them as freely in the treatment of the poorest 
 individuals as in operations upon the more wealthy 
 patients. Soon after his election to Blockley he 
 several times performed osteotomy of the femur 
 (Mace wen's operation) with full antiseptic precau- 
 tion and with perfect results. Excision of the knee 
 he frequently performed, as well as tenotomies of all 
 kinds, after which latter operations he usually em- 
 ployed an apparatus of some kind specially prepared 
 for the patient. 
 
 As a surgeon, he was cool, deliberate, and thor- 
 ough, and his success was uniform and phenomenal. 
 
 His genius was dazzling, burning ever brighter 
 with a steady flame. His career, like that of Bis- 
 chat, was meteoric, brief, but brilliant; and if the 
 measure of talent and genius be success, the esti- 
 mate placed upon his career must be great. The 
 limits were boundless, but few men ever attain the 
 topmost round of the ladder of fame, and genius 
 must add time to her industry, no matter how steady 
 and persistent. 
 
 Some of his lectures before the students at the 
 
16 MEMOIR OF A. S. ROBERTS. 
 
 Philadelphia Hospital were afterward published in 
 book form, and comprised two upon club-foot, two 
 upon knock-knee, and one upon flat-foot, with a 
 description of a new plantar-spring for its relief. 
 His writings include a complete article on Pott's 
 disease of the spine, in Keating's " Encyclopaedia," 
 vol. iv, a most comprehensive article. In conjunc- 
 tion with Dr. Samuel Ketch, of New York, he 
 wrote an article upon club-foot in Buck's "Reference 
 Handbook of the Medical Sciences." This article 
 contains the best bibliography upon this subject ex- 
 tant, and I doubt if anything will ever be written to 
 compare with it. In 1 884 he read a paper before the 
 Pennsylvania State Medical Society upon " Chronic 
 Articular Ostitis of the Knee-joint," with a descrip- 
 tion of a new mechanical splint, which was published 
 in the " Medical News," on July 26, 1884. Among 
 other articles written at this time was one upon the 
 spinal arthropathies, published in the " Medical 
 News," February 18, 1885, which attracted con- 
 siderable attention. The photographs collected, 
 illustrative of this subject, but not published till 
 subsequently, comprise the best group of photo- 
 graphs upon this subject that has ever been col- 
 lected. About this time he reported a case of 
 deformity of the forearm and hands, which was 
 published in the "Annals of Surgery," in Feb- 
 ruary, 1886. This contains the pictures of the 
 splint, modified from that of Dr. Shaffer, of New 
 York, and employed by Dr. Roberts in the treat- 
 ment of knee-joint diseases. After his retirement 
 from practice he published a volume of selections 
 
INTR OD UGTION. 1 7 
 
 from literature, which he called "In and Out of 
 Book and Journal," which was published by Lipp- 
 incott & Company, and had an extensive sale. 
 
 His writings are not as large as one would expect 
 considering the amount of work which he did. This 
 is probably due to his dislike to writing and his 
 attention to more practical matters. His writings 
 are of the highest order, and reflect great credit upon 
 him for the amount of research and the quality of the 
 matter contained. 
 
 He reported many operations before the Patho- 
 logical Society, and exhibited specimens, several of 
 which I now have in my possession. 
 
 He was a Fellow of the College of Physicians of 
 Philadelphia, a Fellow and Yice-President of the 
 American Orthopedic Association, a member of the 
 Philadelphia County Medical Society, the Patho- 
 logical Society, the Neurological Society, the State 
 Medical Society, the American Medical Society, and 
 a delegate to the International Medical Congress in 
 London. 
 
 In personal appearance Dr. Roberts was of me- 
 dium height, strongly and compactly built, of a 
 florid temperament, high forehead, good features, 
 and carrying with him the impression of great re- 
 serve force. His manner was that of a cultured 
 gentleman, and his associations such as would de- 
 velop a manner which was at once kind and firm. 
 His characteristic was a particular sensitiveness. 
 His disposition was quick and impulsive, but kind 
 and forgiving ; a warm and faithful friend. With 
 truth it could be said that his friendship was eternal. 
 
 2 
 
18 ME MO IE OF A. S. ROBERTS. 
 
 The estimate of Dr. John H. Musser, his most 
 intimate friend, is so thoroughly descriptive of Dr. 
 Roberts' best qualities, that I take the liberty to 
 quote it in full. Speaking of his friend Roberts, he 
 writes : 
 
 " Fortunately for me, our friendship was not alone 
 professional. On two occasions I travelled in Europe 
 with him, and on several occasions in this country. 
 Here it could be seen he was a man of affairs. This 
 was the least, however. I constantly marvelled at 
 his wide acquaintanceship with the fine arts — paint- 
 ing and painters, sculpture and sculptors, architec- 
 ture, etc. He was familiar with the development of 
 art in all its phases and of all its schools. His 
 early training in painting taught him to be an excel- 
 lent critic. He could criticise accurately the color- 
 ing or appreciate the value of the thought in the 
 work of art and its development. Furniture, tapes- 
 tries, decorations, metal work, glass, and china had 
 been the subject of study, and their relations to 
 industrial development. After a visit with profit 
 and pleasure to an art gallery, a museum, a palace 
 with its art treasures, it was interesting and marvel- 
 lous to go with him to some great mechanical works 
 or some piece of engineering and see with what 
 rapturous delight he appreciated it, and with what 
 knowledge of technical detail he could explain the 
 mysteries of the mechanism. When I tell you he 
 was a critic of no mean order, and a man of exqui- 
 site taste, with an extraordinary appreciation of the 
 beautiful in art, } T ou can readily see how enjoyable 
 a companion he was. 
 
INTB OB TJCTION. 1 9 
 
 " Roberts also loved nature, and, whether on the 
 boundless ocean, in the mountains of Switzerland, 
 in the pastoral scenes of England, or the rougher 
 charms of Scotland, he was always full of enthu- 
 siasm and appreciation of the beauties of nature. 
 Roberts's fondness for animals led him to study 
 them, and he was an excellent judge of horse, of cow, 
 of dog. He was fond of out-door sports, and was 
 an expert in shooting, rowing, and the like. How 
 almost unlimited were his sympathies, and how 
 boundless was his knowledge ! He had a most ex- 
 cellent memory, and the history of the countries we 
 travelled through was at his fingers' ends. This 
 added to the charm of our travels. 
 
 " Curiously, although of broad culture Dr. 
 Roberts was not a linguist. Language was not 
 mastered easily by him, although his writings show 
 he was a master of English ; his conversational 
 powers, that he could command it at will. 
 
 "Roberts appreciated music. I recall the delights 
 he showed at the music of the evening service at 
 Cologne Cathedral. He was not as familiar with the 
 literature and development of this art as others." 
 
 Dr. Samuel Ketch, another personal friend of Dr. 
 Roberts, has paid tribute to his memory in his 
 Presidential Address, published in the last volume 
 (1897) of the " Transactions of the American Ortho- 
 pedic Association." 
 
 His office was neat, plain, and well arranged, and 
 one could see at a glance that it was the office of a 
 practical and progressive surgeon. In office details 
 his early education and business qualities were 
 
20 MEMOIR OF A. S. ROBERTS. 
 
 everywhere conspicuous. His horses and carriages 
 were neat and elegant to a degree. His office hours 
 were from 8 to 11, and were always promptly kept. 
 His stationery was always the same Imperial Bond, 
 of a beautiful marine-blue tint, and his penmanship 
 had a style and character that were unmistakable. 
 
 While in the enjoyment of everything that would 
 tend to make him happy, and with the prospect of 
 a great and growing future before him, his health 
 began to fail, and he was compelled to retire from 
 practice in 1888 and seek change in the country. 
 In resigning his positions at the different hospitals 
 (two of which it was my privilege to receive), a sin- 
 cere regret was expressed in his resignation that he 
 was compelled to give up practice at this time. 
 
 In his letter of November 23, 1888, to me, in 
 speaking of resigning his position as instructor in 
 orthopedic surgery, he evinced his keen interest in 
 the future progress of conservative orthopedic sur- 
 gery. " I have to-day," he writes, " sent to the 
 University and to the University Hospital my resig- 
 nations, and hope you may be an applicant for the 
 positions I vacate, and I trust that if you secure the 
 appointments you will push the work in the interest 
 of conservative orthopedy." 
 
 Having decided to retire from active practice, he 
 gave away many of his instruments, the most expen- 
 sive ones to his personal friend, Dr. William G. 
 Porter, to his preceptor, Dr. William W. Keen, and 
 myself. All of his orthopedic apparatus and all of 
 his special books upon orthopedic surgery were 
 received by me in this way, and my indebtedness 
 
INTB OD UCTION. 21 
 
 to him has already been expressed by the partial 
 dedication to him of my work upon orthopedic 
 surgery. 1 
 
 Although in feeble health for some time, his death 
 occurred suddenly and unexpectedly, at Newport, 
 on August 17, 1896. The funeral took place from 
 his late residence, at Bala, on Thursday morning, 
 at 11 o'clock, the interment being private. His 
 earthly remains were interred in the family vault 
 at Laurel Hill Cemetery. 
 
 At the University Club, just before the dinner, 
 March 11, 1898, when a guest of Dr. De Forest 
 Willard and myself, Dr. Newton M. Shaffer said of 
 his friend Dr. Roberts, " Had he practised until 
 to-day, his reputation would have been national." 
 
 Accidental expressions of character in a man's 
 life many times live after him in enduring form. 
 Near the home of his ancestors, at the side of the 
 public highway, it pleased Dr. Roberts to erect a 
 fountain at which the hurrying traveller might pause 
 and drink. 
 
 The shadows may fall and shut from sight familiar 
 scenes, the passing throng, the granite fountain 
 with its cooling stream, but through the darkness 
 unheeded the limpid stream flows on and in the 
 morning blesses the new day. 
 
 The years glide on, the shadows fall ; 
 
 But works his hands have wrought live on ! 
 
 1 Treatise on Orthopedic Surgery. 
 
CLUB-FOOT: TALIPES. 
 
CLUB-FOOT: TALIPES. 
 
 Definition. Under the generic term Club-foot, 
 or Talipes, are included all cases of deformity of the 
 foot, whether on an antero-posterior or transverse 
 plane, and which are presented in a departure from 
 the normal relation of the foot to the leg or of the 
 foot to itself. This abnormal relation may consist 
 of a flexion, extension, inversion, or eversion. 
 
 Synonyms. Ger., Klumpfuss; Lat., Pes con- 
 tortus; Fr., Pied hoi; It., Piede torto; Sp., Pie 
 truncado. 
 
 Varieties. Club-foot is most conveniently di- 
 vided into two classes, namely, the simple and com- 
 pound, and of the former we have four typical 
 forms. These are talipes varus, talipes valgus, 
 talipes equinus, and talipes calcaneus. The first 
 form, talipes varus, is characterized by an elevation 
 of the inner side of the foot, the sole being turned 
 inward and the anterior portion of the foot adducted. 
 In talipes valgus, its opposite, the outer side of the 
 foot is raised and the sole everted. Talipes equinus 
 presents itself as an elevation of the heel, the foot 
 being in a position of extension, the patient walking 
 on the ball of the foot. In talipes calcaneus the toes 
 are raised, the foot being in a position of flexion, 
 and the patient walking on the heel. The two first- 
 
26 
 
 MEMOIR OF A. S. ROBERTS. 
 
 mentioned deformities occur on a lateral, the two 
 latter on an antero-posterior plane. To these four 
 simple forms some authors add other forms : Talipes 
 cavus, where the arch of the foot is increased, and 
 talipes planus, its opposite, where the sole rests 
 upon the ground, the arch being diminished. Re- 
 cently Shaffer, of New York, has described another 
 class, that of non-deforming club-foot. Any com- 
 bination of the simple varieties gives us the com- 
 pound form : talipes equino-varus and equino-valgus, 
 and calcaneo- varus and calcaneo- valgus. Schemat- 
 ically these different forms may be pictured as 
 follows : 
 
 ' Simple 
 
 Varieties . -j Compound 
 
 I 
 
 Other forms , 
 
 f Lateral 
 
 ( Antero-posterior 
 
 f Equino- 
 
 ( Calcaneo- . 
 
 i Cavus. 
 Planus. 
 Non-deforming. 
 
 f Varus. 
 { Valgus. 
 | Equinus. 
 | Calcaneus. 
 ] Varus. 
 { Valgus, 
 f Varus. 
 { Valgus. 
 
 Relative Frequency. In obtaining informa- 
 tion concerning the relative frequency of the differ- 
 ent forms, much difficulty is experienced, owing to 
 the different nomenclature, notably for varus and 
 equino-varus, used by those making statistics on 
 the subject. From Tamplin's table, published in the 
 "London Medical Gazette" for October, 1851, and 
 covering 1780 cases of club-foot, both congenital 
 and acquired, 764 of the former were recorded to 
 101(5 of the acquired form. By these tables it is 
 shown that by far the larger number were of the 
 acquired variety, the proportion, as stated by 
 
CLUB-FOOT: TALIPES. 27 
 
 Adams, being- as 3 : 2. Of the congenital variety, 
 the tables show a preponderance of cases of talipes 
 varus, but no distinction is evidently made between 
 the simple varus and the compound form, talipes 
 equino-varus. The tables are appended : 
 
 Congenital. 
 
 Cases. 
 
 Talipes varus 688 
 
 Talipes valgus 42 
 
 Talipes calcaneus .19 
 
 Talipes varus of one foot and valgus of the other. 15 
 
 Total 764 
 
 Of the 688 cases of talipes varus, 182 affected 
 the right foot only ; 138 affected the left foot only ; 
 363 affected both feet, and 5 cases were complicated 
 with other deformities. 
 
 Of the 1780 cases, 1016 were non-congenital ; 
 999 were distributed as follows : 
 
 Acquired. 
 
 Cases. 
 
 Talipes equinus 401 
 
 Talipes valgus 181 
 
 Talipes equino-varus 162 
 
 Talipes calcaneus and calcaneo- valgus . . ,110 
 
 Talipes equino-valgus 80 
 
 Talipes varus 60 
 
 Talipes varus of one foot and valgus of the other. 5 
 
 Total 999 
 
 Reeves, in an experience of ten years at the Royal 
 Orthopedic Hospital, London, gives equino-varus 
 as the most frequent congenital form, and also states 
 that the primitive forms of club-foot are rare as 
 congenital deformities. Sayre, in his work on " Club- 
 
28 MEMOIR OF A. S. ROBERTS. 
 
 foot,*' and also in the article in his work on " Ortho- 
 paedic Surgery and Diseases of the Joints," gives no 
 statistics as to the relative frequency, but states 
 that the simple forms of club-foot are very rare, the 
 deformity being nearly always a combination of 
 two forms. F. Busch gives equino-varus as the 
 most frequent form. Duval has recorded 1000 
 cases of club-foot, and of these 574 were congenital ; 
 364 of these were in males and 210 in females. His 
 statistics as to relative frequency are very valuable, 
 and are as follows : 
 
 
 Cases. 
 
 Boys. 
 
 Girls. 
 
 Equinus and equino-varus 
 
 417 
 
 215 
 
 202 
 
 Varus .... 
 
 532 
 
 302 
 
 230 
 
 
 22 
 
 14 
 
 8 
 
 Calcaneus 
 
 9 
 
 6 
 
 3 
 
 Extreme calcaneus . 
 
 20 
 
 13 
 
 7 
 
 Adams, in his work on " Club-foot," gives talipes 
 equinus as by far the most frequent non-congenital 
 deformity. Little states that he has seen two cases 
 of congenital equinus, as does also Brodhurst. 
 Tamplin discredits entirely the congenital origin of 
 pure equinus, and states that he had not seen a case. 
 Detmold has reported 167 cases of club-foot, and 
 states that of these 93 occurred in both feet. Gross 
 remarks that the congenital variety rarely affects 
 both feet in an equal degree ; that in his own expe- 
 rience the single forms were considerably greater in 
 number. Lannelongue has collected statistics at 
 the Maternity Hospital (Paris) covering a period 
 of ten years, from 1858 to 1867 inclusive. He has 
 shown that in 15,229 births, 8 children were born 
 with club-foot, which gives a proportion of about 1 
 
CLUB-FOOT: TALIPES. 29 
 
 case in 1903 births. As yet the influences of climate 
 and social position have not been determined. It 
 probably occurs more frequently among the poorer 
 classes. 
 
 From the foregoing statistics, which have been 
 considered sufficient, the following facts may be 
 deduced : 
 
 1. The greater relative frequency in males. 
 
 2. That the varus types are the most frequent. 
 
 3. That the right foot is affected more frequently 
 than the left. 
 
 4. That both feet are more frequently affected 
 than a single one. 
 
 5. That the purely primitive forms are rare. 
 Etiology. There are two classes of club-foot, 
 
 namely, the congenital and acquired, and in study- 
 ing their etiology we shall consider the former class 
 first. In no department of medicine is there so 
 much that is mysterious and unexplained as is 
 involved in the causation of deformities of congeni- 
 tal origin. From earliest times they have been the 
 subject of a vast amount of labor and inquiry, and 
 while these investigations have resulted in many 
 speculations and a few facts, the theories established 
 by them still leave much to learn concerning the 
 real origin of this class of cases. The question is 
 beset with difficulties from the onset, from the fact 
 that the life of the foetus in utero is not subject 
 to any direct scientific means of investigation, and 
 we are compelled to study the subject from such 
 aids as comparative physiology, embryological data, 
 and post-partum existence and diseases furnish us. 
 
30 MEMOIR OF A. S. ROBERTS. 
 
 Could we positively admit the question of diseases 
 of the fetus, such as pertain to post-partum exist- 
 ence, the problem would be relatively simple. Many 
 authors, notably Little, have, from the similarity in 
 the deformities of the congenital and acquired para- 
 lytic forms, assumed this ground. Outside of the 
 similarity in the appearance of the deformities, this 
 view is not tenable, for it has not been proven that 
 a foetal myelitis or meningitis has existed. The 
 microscope has not, as yet, demonstrated changes 
 taking place in the foetal brain or cord, such as 
 occur in infantile, cerebral, or spinal paralysis. An 
 electrical examination shows very markedly differing 
 reactions in the muscles of the two forms, and pa- 
 tients suffering with congenital club-foot can, by 
 the exercise of volition, use the muscles of the leg 
 and foot, while such is not the case in the acquired 
 form. These differences, together with the external 
 appearances of the parts affected — the one cold, 
 flaccid, and atrophied; the other of normal surface 
 temperature, plump, and of rounded contour — indi- 
 cate an entirely different causation of the deformity. 
 
 Heredity, with its mysterious influences, physical 
 and psychical, also enters into this complex ques- 
 tion, and is undoubtedly a factor in the etiology of 
 many cases. Did space permit, many instances 
 might be quoted as illustrative of this. From these 
 we can as yet deduce no better explanation of its 
 influence than the transmission of personal config- 
 uration. 
 
 Arrest of development has also been assigned as 
 a cause for the production of congenital club-foot. 
 
CLUB-FOOT: TALIPES. 31 
 
 Although many cases occur in which there is a 
 coexistence of such deformities as spina bifida, 
 hare-lip, and cleft palate with club-foot, yet the feet 
 themselves show no arrest of development, but only 
 the same change of plane as is shown in the cases 
 born without these coexisting deformities. Changes 
 in the tarsal bones, principally the astragalus and 
 os calcis, have been described by many authors, 
 but by none more thoroughly than by Adams and 
 Hueter. These changes consist in alterations in 
 the form and plane of these bones, but they are by 
 no means constant, and differences of opinion are 
 held as to their being primary or causative, or secon- 
 dary, as results of the deformity itself. The most 
 recent investigations tend to maintain the latter 
 theory. It has also been found that use of the 
 deformed foot largely increases the malposition and 
 form of the tarsal bones. A. Luecke also considers 
 the osseous structure as the seat of primary lesion 
 in club-foot. He and others have shown that at a 
 a certain period all foetuses are club-footed, and 
 Luecke claims that by the constant movement of 
 the child in utero the articular surfaces are so 
 modified by the attrition produced as to enable the 
 child's feet to assume a normal position before birth; 
 any interference with these movements would, how- 
 ever, prevent this attrition, and the child would be 
 born club-footed. Against this ingenious theory it 
 may be argued that use increases the deformity 
 after birth. Why it should act differently before is 
 not easy to understand. We also know that in 
 acquired cases, such as are due to spastic paralysis, 
 
32 MEMOIR OF A. S. ROBERTS. 
 
 for instance, want of use does not so change the 
 articular surfaces as to cause permanent club-foot, 
 tenotomy in many cases restoring the foot to its 
 form and function. Perhaps of all the theories 
 advanced, that which ascribes congenital club-foot 
 to abnormal intra-uterine pressure, due to lack of 
 amniotic fluid, has received the largest number of 
 adherents. Most of the older writers, and many 
 modern ones, prominently Volkmann, Kocher, Vogt, 
 Banga, and Parker, are among its most noted advo- 
 cates. Here it is maintained that the foetal foot 
 is permanently fixed in one position by the intra- 
 uterine pressure, and consequently, at birth, the child 
 is club-footed. It has, very reasonably, been argued 
 against this view, that if a decreased amount of 
 amniotic fluid and consequent abnormal pressure 
 were productive of club-foot, other organs which 
 had been subjected to the same pressure would also 
 be deformed. Yet such is not the fact, clubbed 
 hands, legs, and thighs being among the rarest of 
 deformities, very seldom complicating the pedal 
 malformation. It has also been shown that many 
 children have been born club-footed where no appre- 
 ciable difference in the quantity of liquor amnii, 
 judging from previous labors, could be ascertained ; 
 and we have recently seen a case of double equino- 
 varus in a twin, the other child showing no deform- 
 ity whatsoever. Billroth states as follows : " The 
 typical form of this congenital deformity appears to 
 indicate that it depends on a disturbance of a typical 
 (symmetrical?) development of the lower extremi- 
 ties ; for if festal disease, disturbance of an irritative 
 
CLUB-FOOT: TALIPES. 33 
 
 nature, or abnormal pressure in the uterus were at 
 fault, cases would probably differ." He also quotes 
 Eschricht as showing that at the commencement of 
 their development the lower extremities lie with 
 their backs against the abdomen, the hollows of 
 their knees being against the belly ; so during the 
 earlier months the legs must rotate on their axes, 
 and the toes which pointed backward must point in 
 the opposite direction. If the embryonic extremities 
 lie so close as to appear united under a common 
 skin, or be really united, the above-mentioned rota- 
 tion of the limbs cannot take place, and in this 
 deformity (siren) the feet are turned directly back- 
 ward. This rotation on the axis, which was arrested 
 in the above case, does not take place fully in club- 
 foot, the rotation in the foot is not fully accomplished. 
 Billroth states further, that according to this, con- 
 genital club-foot would come among the cases of 
 obstructed development; about its cause he con- 
 cludes we know as little as we do of other deformi- 
 ties of the same class. 
 
 H. "W. Berg, of New York, in a very original 
 article, gives failure of rotation as the cause of con- 
 genital equino-varus. He has studied the subject 
 from specimens seen at the New York Hospital and 
 Wood's Museum of Bellevue Hospital, and describes 
 the changes in the position of the lower extremities 
 at different periods of foetal life. He shows that in 
 early life the whole leg is rotated outward, and this 
 outward rotation is accompanied by an exaggerated 
 varus, and still later, an equino-varus. This dimin- 
 ishes as the rotation to the normal position pro- 
 
 3 
 
34 MEMOIR OF A. S. ROBERTS. 
 
 gresses, but he states that even when the rotation 
 of the leg has been entirely completed some of the 
 varus still remains, and calls attention to the very 
 slight varus of the new-born. In addition he states 
 that equinus is often seen in foetuses of two, three, 
 and four months. This he does not always find, 
 and it disappears in the course of the normal growth 
 of the foot. He concludes that in the early stage 
 of foetal life varus or equino-varus is physiological. 
 He does not think pressure necessary to the produc- 
 tion of the deformity, its cause consisting, in his 
 opinion, of a non- or retarded rotation inward of the 
 lower extremity. We consider this theory of non- 
 or retarded rotation as of such importance from an 
 etiological stand-point that we quote his account of 
 its mechanism in full. He says : "As soon as the 
 joints are formed we find the thigh rotated outward 
 as far as possible, and flexed upon the body. The 
 leg is flexed upon the thigh, but not completely, for 
 this is prevented by the extreme outward rotation 
 of the thigh, which brings the inner border of the 
 leg in apposition with the abdomen of the child. 
 We have, then, the inner border of the thigh and 
 the tibial border of the leg pressed against the abdo- 
 men of the foetus, the legs crossing each other a 
 little below their middle. All of the intra-uterine 
 pressure, therefore, is thus brought to bear directly 
 upon the outer border of the thigh and leg, corre- 
 sponding to the fibular border of the leg, and also 
 upon the dorsum of the foot. The result of this is 
 that the foot is rotated in and extended (equino- 
 varus) until the sole is almost on a line with the 
 
CLUB-FOOT : TALIPES. 35 
 
 inner border of the leg, and lies against the body of 
 the foetus, while the dorsal surface of the foot is on 
 a convex-curved line with the outer border of the 
 leg, to adapt itself to the concave wall of the uterus. 
 This, I believe, is a stage in the normal develop- 
 ment of every healthy foetus ; and were the extremi- 
 ties to remain in this position, all children would be 
 born club-footed. But nature provides against this 
 by the inward rotation of the extremity, which 
 gradually takes place, carrying the leg away from 
 its position against the abdomen of the foetus ; and 
 when this rotation is completed we find the extensor 
 surface of the thigh flexed and in relation with the 
 body of the child, while the legs are flexed upon 
 the thighs, the inner or tibial borders facing each 
 other. Now the soles of the feet lie against the 
 uterine walls, and the intra-uterine pressure is 
 exerted directly upon them. This produces extreme 
 flexion of the foot upon the leg, together with an 
 outward rotation of the foot ; this movement, from 
 the constitution of the ankle-joint, accompanying 
 extreme flexion. Thus is antagonized the varus or 
 equino- varus existing hitherto. It is evident, then, 
 that upon the completeness of the internal rotation 
 or torsion which takes place in the lower extremity 
 depends the rectification of the early varus of the 
 foot. Should this rotation not take place at all, or 
 be incomplete, the foot will continue to maintain its 
 early relation to the body of the foetus and uterine 
 walls, and the child will be born more or less club- 
 footed. If this be so, we should expect to find in 
 club-footed children that the extremities are rotated 
 
36 MEMOIR OF A. S. ROBERTS. 
 
 outward. And this we do find upon examination. 
 In all of the cases of congenital club-foot (equino- 
 varus) which I have seen since my attention has 
 been directed to this subject, I have found that the 
 thigh and leg, as a whole, were rotated out, and the 
 tibia bent at its lower part, so that the feet were 
 approximated to each other in addition to being in 
 the clubbed position. All this is seen to be the 
 result of non-rotation of the leg." In 1884, two 
 years after Dr. Berg's article appeared, Drs. Parker 
 and Shattuck published a pamphlet on " The Pathol- 
 ogy and Etiology of Congenital Club-foot." Their 
 theory, as shown in their argument, is as follows : 
 " Our argument is that the feet of the foetus occupy 
 various positions during the period of intra-uterine 
 life, and that this occurs in order that the joint- 
 surfaces, the muscles, and especially the ligaments, 
 be developed so as to allow of that variety of posi- 
 tions and movements which are afterward to be 
 natural to the foot ; and we hold that when any- 
 thing (mechanically) prevents the feet from assum- 
 ing these positions at the proper time, or maintains 
 them in any given position beyond the limit of time 
 during which they should nominally occupy such 
 position, a talipes results. The variety of talipes 
 will depend upon the date of its production; its 
 severity will be in direct ratio to the mechanical 
 violence at work. If the inversion of the foot, 
 which is normal during the earlier months of foetal 
 life, be maintained beyond the normal period of time, 
 the muscles and ligaments will, as a consequence, 
 be adaptively short on one aspect of the limb, and 
 
CLUB-FOOT: TALIPES. 37 
 
 too long on the other ; a normal position of inver- 
 sion will finally become a deformity. Talipes cal- 
 caneus is, we believe, produced in a similar manner; 
 it occurs, however, later during intra-uterine life, 
 when a flexed position of the foot is normal. Being 
 thus less fundamental in character, it is also less 
 severe as a deformity than varus." 
 
 To any one who has read Berg's monograph, it 
 will appear surprising that no mention of it is made 
 by Parker and Shattuck. This is all the more 
 remarkable in that Berg had fully anticipated not 
 only all that they have advanced, but had followed 
 these data and observations to their legitimate logi- 
 cal conclusions, which for some occult reason Parker 
 and Shattuck have avoided. Had they cited Berg's 
 paper, we would have been forced to the conclusion 
 that the} 7 had attempted to prop up the old fanciful 
 mechanical theory with the support of real embryo- 
 logical data. 
 
 We have endeavored to give as succinctly as 
 possible the different theories in vogue concerning 
 the etiology of congenital club-foot. They may be 
 briefly summarized as follows : 
 
 1. The theory of pathological changes affecting 
 the child in utero. 
 
 2. The theory of mechanical forces acting upon 
 the foetus in utero. 
 
 3. The theory of heredity. 
 
 4. The theory of arrest of development. 
 
 5. The theory of non- or retarded rotation. 
 
 In conclusion we would state that it certainly 
 would seem most reasonable, with our present 
 
38 MEMOIR OF A. S. ROBERTS. 
 
 knowledge of the subject, to ascribe the causation 
 of congenital club-foot to the last-mentioned theory, 
 which has at least for its credit the fact of its being 
 demonstrable, rather than to those which for their 
 foundation either have only the similarity to condi- 
 tions produced by disease after birth, or are entirely 
 fanciful. 
 
 Etiology of Acquired Forms. By far the larger 
 number of cases of club-foot occur as acquired 
 forms, and of these infantile paralysis (poliomyelitis 
 anterior) produces the greatest number. 
 
 Without entering into a lengthy description of 
 this disease, which can be found in any of the text- 
 books on nervous diseases, and also in another 
 portion of this work, it will be sufficient to state 
 that it usually occurs during the period of dentition, 
 beginning with fever and gastro-intestinal disturb- 
 ance, with or without convulsions, and is followed 
 by paralysis more or less severe. This paralysis is 
 followed by a rapid improvement in many of the 
 muscles involved, those of the upper extremity and 
 trunk usually recovering first, while those of the 
 lower extremity remain unilaterally affected. The 
 paralysis is followed by atrophic changes, loss of 
 electro-muscular contractility, especially to the fara- 
 dic current, and deformities, of which club-foot is 
 the most frequent. For a long time it was taught 
 that the deformities produced by infantile paralysis 
 were due solely to the loss of power in one set of 
 muscles and the preponderating action of their 
 antagonists. Thus, in consequence of this loss of 
 balance in the muscles supporting the leg and foot, 
 
CLUB-FOOT: TALIPES. 39 
 
 were produced the altered relations which give rise 
 to the various forms of acquired club-foot. Delpech 
 taught that a muscle could be in a condition of per- 
 manent or tonic spasm, and the opponents being 
 paralyzed, the deformities were produced. That 
 this view is faulty has been proven by more recent 
 researches. Hueter first called attention to the fact 
 that, owing to the position assumed by the paralyzed 
 limb, its weight caused contractions, and that the 
 so-called antagonistic contractions were not at all 
 muscular actions, but were due to atrophy and lack 
 of growth. Volkmann, in his now classical lecture, 
 has gone very thoroughly into the mechanism of the 
 production of club-foot due to infantile paralysis. 
 He has shown that, owing to the superincumbent 
 weight of the body, the limbs assume positions 
 which gradually become permanent; that the so- 
 called tonic retraction does not occur, and that the 
 shortening of the muscles is due not to contraction, 
 but to growth of the limb, the foot remaining in its 
 deformed position. 
 
 A form of paralysis usually designated as spastic 
 or active — spastic paralysis (Erb), paralysis with 
 rigid muscles (Adams), and tetanoid paraplegia 
 (Seguin) — is also productive, of club-foot. In this 
 class of cases a more general dispensation of the 
 consequences of the lesion seems to be inflicted. 
 The patients have a silly or semi-idiotic look, 
 although their intelligence seems rather to be re- 
 tarded than obliterated. They frequently squint, 
 and their progression is peculiar and quite charac- 
 teristic. They walk on their toes with their knees 
 
40 MEMOIR OF A. S. ROBERTS. 
 
 pressed together, and, in order to maintain their 
 equilibrium, throw one limb over the other, walking 
 as it were cross-legged. There is general rigidity 
 and spasm of the muscles, all the reflexes being 
 greatly exaggerated. The form of club-foot in these 
 cases is usually an equinus, and the contractions 
 can, for the time being, be rectified by continuous 
 pressure, but upon its cessation the feet instantly 
 assume their old positions. Its pathology would 
 seem to indicate, in some cases, a lack of develop- 
 ment, in others a lesion of some portion of the 
 motor tract of the brain, followed by secondary 
 changes in the lateral columns of the cord. Rup- 
 precht, of Dresden, has studied the nature and 
 treatment of this condition very thoroughly, and 
 has shown not only that tenotomy in this class of 
 cases is often followed by improvement in the posi- 
 tion of the feet, but that in some cases there was 
 an accompanying improvement in the mental status 
 of the patient. For further information on this 
 very important class of cases the reader is referred 
 to his very valuable remarks in "Volkmann's series 
 of clinical lectures. Many authors believe that this, 
 or a similar condition, is an accompaniment of 
 various spinal diseases, acute compression, syphilis, 
 tumors, and caries. 
 
 Among other conditions due to disturbance of 
 the nervous system, pseudo-hypertrophic paralysis, 
 post-hemiplegic contractions, and neuromimesis are 
 productive of club-foot. While the two former 
 classes are rare as causes of acquired talipes, the 
 latter or neuromimetic are more frequent, and have 
 
CLUB-FOOT: TALIPES. 41 
 
 of late years attracted considerable attention. Ex- 
 amples of these very interesting cases have been 
 cited by Paget, Little, Skey, Shaffer, Weir Mitchell, 
 Haward, and others. They undoubtedly depend 
 upon the neurotic diathesis, and may, by their 
 similarity to the real condition, be very deceptive. 
 Shaffer has devoted considerable space to this class 
 of cases in his work on " The Hysterical Element in 
 Orthopaedic Surgery," a perusal of which will greatly 
 aid the student in the diagnosis and treatment. 
 
 Cases due to reflex paralysis have been reported 
 by Sayre and others, who claim that a functional 
 disturbance of the nervous system can cause spasm 
 of certain muscles, which, continuing for a time, 
 while healthy growth is going on in their opponents, 
 so disturbs the balance of power as to produce a 
 permanent deformity. This mode of the production 
 of club-foot has recently been the subject of much 
 discussion, many authorities altogether disbelieving 
 the origin of the deformity by this means. 
 
 The paraplegia accompanying Pott's disease of 
 the spine is also a cause of acquired club-foot. It 
 generally occurs as an equinus, and is very similar 
 to the spastic cases previously mentioned. It dis- 
 appears as the paraplegia improves. 
 
 One of the most frequent causes of acquired 
 talipes is joint-disease of the lower extremity. Here 
 it may either occur symptomatically or follow the 
 disease of the articulation. Especially is this true 
 of the ankle-joint, where, at different periods of the 
 inflammatory trouble, the foot assumes an equinus, 
 varus, or valgus position. 
 
42 MEMOIR OF A. S. ROBERTS. 
 
 A very interesting class of cases are those due to 
 occupation. In these cases, occurring principally 
 in bakers, blacksmiths, printers, and other trades, 
 the principal factors are the weight of the body 
 and long-continued position, and it is in this class 
 that we often see the inflammatory forms of club- 
 foot. A similar class of cases are those observed 
 in growing boys and girls, and usually occurring at 
 about the time of puberty. Here the deformity, 
 which is a valgus, is probably due to increased 
 weight and rapid growth of the body, without a 
 corresponding growth of the muscles and ligaments 
 of the feet. 
 
 Long-continued decubitus, as in the continued 
 fevers, has been productive of club-foot, generally 
 an equinus. Volkmann mentions one case in which, 
 after severe typhoid fever, an equinus resulted, and 
 in which a year was occupied in restoring the feet 
 to their normal position by active orthopedic treat- 
 ment. 
 
 Traumatisms, resulting in deep cicatrices and 
 burns in the neighborhood of the ankle-joint, are 
 also causes of acquired club-foot. 
 
 History aistd Literature. In studying the 
 history of club-foot it has been thought best to 
 divide the subject into three periods : a Pre-conti- 
 nental period, including the years from 460 to 370 
 B.C. ; a second, the Continental and Early English, 
 including the seventeenth and eighteenth centuries; 
 and a third, or Continental and English, which em- 
 braces the nineteenth century and brings us down 
 1 < i 1 he present day. To render the study more com- 
 
CLUB-FOOT: TALIPES. 43 
 
 plete, separate notice is given of American contri- 
 butions, especially valuable for their originality in 
 the mechanical improvements devised for the relief 
 of this deformity. 
 
 I. P re-Continental Period— B.C. 460-370. The 
 earliest author on the subject of club-foot whose 
 writings are preserved or accessible is Hippocrates. 
 He mentions very clearly deformities of the articu- 
 lations, and in all his works on ancient surgery, 
 says his translator, there is not a more wonderful 
 chapter than that relating to club-foot, on which he 
 gives most valuable information. He says: "There 
 is more than one variety of club-foot, the most of 
 them not being complete dislocations, but impair- 
 ments connected with the habitual maintenance of 
 the limb in a certain position." He says further: 
 "Most cases of congenital club-foot are remedial, 
 unless the declination be very great, or when the 
 affection occurs at an advanced period of youth." 
 For early treatment he relied on bandages, for the 
 application of which he gave very particular instruc- 
 tions. He says: " After the application of the ban- 
 dages, a small shoe made of lead is to be bound on 
 externally, having the same shape as the Chian 
 slippers. This is the mode of cure, and it neither 
 requires cutting, burning, nor any other complex 
 means." This might imply that he had seen or 
 heard of other means of curing club-foot, but of 
 them, if they existed, we have no record. 
 
 For a period of two thousand years or more the 
 subject of club-foot was apparently completely 
 ignored, and nothing was added to the knowledge 
 
44 MEMOIR OF A. S. ROBERTS. 
 
 collected by Hippocrates and handed down to us 
 by Poly bius. It was regarded by all as a subject 
 of ill omen, and those unfortunately afflicted by the 
 deformity as being especially the objects of divine 
 wrath. Superstition forbade men from even men- 
 tioning it, much less of devising means for its cure. 
 Celsus, whose writings cover so large a field, does 
 not even mention it — a fit criterion of the condition 
 of the times. 
 
 II. Continental and Early English Period — Seven- 
 teenth and Eighteenth Centuries. It was not until 
 the middle of the seventeenth century that the ques- 
 tion of club-foot again came into notice. 
 
 In 1641 Ambroise Pare, " Les GEuvres" (Lyons), 
 ascribed club-foot to the circumstance that the 
 mother, during her pregnancy, had been sitting too 
 much with her legs crossed. He also gives a model 
 of a boot for the treatment of the deformity. He 
 was followed in 1643 by Severinus, who wrote of 
 the subject. (" De Recondita Abscessum Natura," 
 Francof., 1643.) 
 
 In 1658 Arcseus, " De recta curandorum valuerum 
 rational" (Amstel.), describes a process for the 
 removal of the distortion, and figures an apparatus 
 and a boot by which he treated deformities. Fab- 
 ricius, in 1723, " Opera Chirurgica " (Batavia), pro- 
 poses an iron boot for treating deformities of the feet. 
 
 In 1741 Andry first used the term orthopedy, 
 and published a work on the subject in two volumes, 
 entitled " L'Orthopedie " (Paris). It is evident from 
 his remarks that he does not limit the use of the 
 term to club-foot, as some authors erroneously sup- 
 
CLUB-FOOT: TALIPES. 45 
 
 pose, but, under the derivation dpdbz, straight, and 
 naedbz, genitive of 7tou<:, child, the whole subject of 
 the retification of deformities is included. 
 
 Du Verney, in his " Traite des Maladies des Os " 
 (Paris, 1751), contributed a very important chapter 
 to the subject of club-foot. He recognized the 
 muscular contraction as a cause, and described the 
 distortion as due to the influence of the muscles 
 and ligaments. He writes of varus and valgus, and 
 ascribes these distortions entirely to the unequal 
 tension of the muscles and ligaments. He con- 
 cluded that those muscles which are extremely tense 
 draw the parts toward them, while their antagonists 
 yield, being relaxed. 
 
 The year 1784 brings us to the most important 
 era in the history of club-foot which we have yet to 
 record, and from this date a marked impetus was 
 given to the proper study and treatment of the sub- 
 ject. Thilenius, a physician of Frankfort, proposed 
 in this year a section of the tendo Achillis for a case 
 of talipes equinus, and the operation, an open one, 
 was performed by the surgeon Lorenz. It was com- 
 pletely successful, and the same operation was sub- 
 sequently performed by Sartorius. Thilenius has 
 written under the title, " Medicinische und Chirur- 
 gische Bemerkungen " (Frankfort). At about the 
 same time "Venel, called by some the " Father of 
 Orthopedics," settled in Orbe, Switzerland, and 
 founded an orthopedic institution. His success was 
 such that Wanzel, then eleven years of age, was 
 placed under his treatment with double club-foot. 
 By means of his shoe he succeeded in curing him 
 
46 MEMOIR OF A. S. ROBERTS. 
 
 in twenty-two months. This induced Bruckner, of 
 Gotha, " Ueber ^Tatur, Verfahren und Behandlung 
 der einwarts gekriimmten Fiisse" (Gotha, 1796), 
 and Naumburg, of Erfurt, " Abhandlung ueber die 
 Beeinkrummung " ( Leipsic, 1796), to use and perfect 
 Venel's method. Wanzel studiedmedicine later, and 
 in his inaugural thesis, " Dissertatio Inauguralis 
 medica de Talipedibus Yaris" (Tubingen, 1798), 
 described the procedure used by Venel. Besides 
 the authors already quoted, Ehrmann, of Germany, 
 Tiphaisue and Yerdier, of France, and Jackson, 
 Sheldrake, and Mark Anthony Petit, of England, 
 contributed to the literature and treatment of club- 
 foot. 
 
 Of these the most important are the writings of 
 Thomas Sheldrake, of London (1798), who consid- 
 ered the contraction of the ligaments as the essential 
 cause of club-foot. He aimed his treatment essen- 
 tially at these tissues. His own words are as follows : 
 " The essential operation to be performed in curing 
 a club-foot is to produce such an extension of some 
 of the ligaments as, if it happened by accident, 
 would constitute a sprain. It certainly is the duty 
 of the operator so to conduct this operation that 
 none of the consequences which would have taken 
 place from an accidental operation shall ensue." 
 Mark Anthony Petit, of England (1799), is claimed 
 to have had the first example of tenotomy on record, 
 and to have been the first surgeon to perform it. 
 
 This closes the second period in the history of 
 club-foot, and while we can see the gradual progres- 
 sion from a purely empirical idea, both of the nature 
 
CLUB-FOOT: TALIPES. 47 
 
 and treatment of the deformity, to a broader and 
 more comprehensive conception of the subject, it 
 will be admitted that as yet no decided scientific 
 departures had been made. The nearest approach 
 was the operation of Thilenius, which foreshadowed, 
 as it were, the researches which were to follow, and 
 which have proved of such invaluable worth to the 
 sufferers from club-foot. 
 
 III. Continental and English Period — Nineteenth 
 Century. More general attention seems to have 
 been directed toward the study and treatment of 
 deformities at the beginning of this century, and 
 many master-minds in different countries labored to 
 bring the subject from out of the half mystical, half 
 empirical atmosphere in which it was enshrouded at 
 the close of the last century. 
 
 This period was opened auspiciously by the 
 writings of Ortlepp in Germany, whose work, " De 
 Talipedibus," etc. (Jena, 1800), contains many ex- 
 cellent suggestions ; and of Bailly, in France, who 
 wrote under the title "Du traitement et de la cura- 
 bilite du pied-bot invetere " (Lyons, 1802). 
 
 They were followed in 1803 by Scarpa, of Pavia, 
 who in his work on club-foot, " Memoria chirurgica 
 sui piedi torti congeniti dei fanciulli, e sulla maniera 
 di corregere questa deformita " (Pavia, 1803), main- 
 tained the opinion entertained by Hippocrates, that 
 the tarsal bones are not dislocated, but twisted on 
 their axes, and only partially separated from their 
 mutual contact. He contended that the primary 
 disturbance is in the osseous system, and that, con- 
 sequent on this displacement, the muscles are elon- 
 
48 MEMOIR OF A. S. ROBERTS. 
 
 gated or retracted, according to their position. He 
 proved by dissection the inaccuracy of the supposed 
 cause of club-foot residing in arrest of development 
 or malformation. He designed an apparatus, uni- 
 versally known as "Scarpa's shoe," for the mechan- 
 ical treatment of club-foot, the essential principles 
 of which are retained to the present day, and on 
 which most of the apparatus used at present are 
 constructed. Jorg, of Leipsic, wrote on club-foot 
 under the title, " Ueber Klumpfusse und eine leichte 
 und zweckmassige Heilart " (1803). 
 
 On the 10th of May, 1806, Sartorius repeated the 
 operation of Thilenius. The operation, by open 
 wound and " brisement force " combined, ended in 
 anchylosis. In 1809 Michaelis, of Marburg, wrote 
 a treatise " Ueber die Schwachung der Sehnen," etc. 
 He contended that in almost every case of club-foot 
 the tendo Achillis is too short. He operated upon 
 several cases of talipes equinus by partial division 
 and rupture of the tendo Achillis. He reports that 
 after the operation he at once brought the feet in 
 their natural position. He seems to have operated 
 very frequently. In less than one year he had per- 
 formed eight operations of tenotomy: three for 
 equinus, one for varus, three for contracted knees, 
 and one for contracted fingers. 
 
 Artopoeus, in 1810, " Sur la torsion congenitale 
 des pieds des enfans," and Goepel, in 1811, " De 
 Talipedibus varis ac valgis, corumque cura," were 
 also important contributors. 
 
 In 1816 Delpech, of Montpellier, executed the 
 fourth operation of tenotomy on record. He vir- 
 
CLUB-FOOT: TALIPES. 49 
 
 tually did a subcutaneous operation, inasmuch as 
 he made a small opening through the skin and 
 remote from the tendon. He laid down the fol- 
 lowing important rules for the performance of the 
 operation : 
 
 1. The tendon was not to be exposed. The knife 
 was to be entered at a distance from the tendon, 
 and not through an incision in the skin parallel to it. 
 
 2. After section the divided ends of the tendon 
 were to be brought together, until reunion. 
 
 3. Gradual and careful extension was to be made 
 before complete union. 
 
 4. Complete extension being made, the limb was 
 to be fixed in this position, and kept there until 
 union was perfect. 
 
 From Delpech's work, " Chirurgie Clinique de 
 Montpellier " (Paris, 1816), and " De l'Orthomor- 
 phie " (1828), it does not appear that he again per- 
 formed tenotomy. 
 
 In 1817 D'lvernois wrote an essay on club-foot 
 entitled " Essai sur la torsion des pieds et sur le 
 meilleur moyen de les guerir." 
 
 He was followed in 1820 by Palletta, who at- 
 tempted to prove that the primary cause of the 
 deformity consisted in a deficiency, complete or 
 partial, of the internal malleolus (" Exercitationes 
 pathological.," Paris, 1820). 
 
 In 1823 Rudolphi, in his " Grundriss der Phy- 
 siologie," added much valuable information to the 
 pathological anatomy of club-foot. He believed that 
 club-hand and club-foot did not depend on extrinsic 
 causes, but frequently occurred in young children 
 
 4 
 
50 MEMOIR OF A. S. ROBERTS. 
 
 from irritation and spasmodic action. He also first 
 called attention to the fact that distortions occur in 
 the embryo as early as the third and fourth months 
 of foetal life. 
 
 From 1823 to 1831 many important contributions 
 to the study of club-foot were made. Of these the 
 most noticeable were those of Mellet, "Considera- 
 tions generales sur les deviations des pieds ; " James 
 Kennedy, of Glasgow, "On the Management of Chil- 
 dren in Health and Disease" (1825); Stolz, in 1826, 
 " Memoire sur une variete particuliere du pied-bot ;" 
 Brims, " Dissertat. inaug. de Talipede varo" (1827) ; 
 Pech, " De Talipedis vari et valgi causa " (1828) ; 
 Cruveilhier, " Anatomie Pathologique " (Paris, 
 1829), who entertained erroneous ideas of club-foot 
 and hand, thinking that a cramped position in utero 
 was the sole cause of these congenital distortions ; 
 Tortuae, in 1829, " Praktische Beitriige zur Therapie 
 der Kinder-Krankheiten" (Minister) ; Buchetmann, 
 1830, " Diss, inaug. Abhandlung ueber die Platt- 
 fuss" (Erlangen); and Loeb Davides (1830). 
 
 From the time of Delpech until 1831 it does not 
 seem, judging from the writers just quoted, that the 
 operation of tenotomy had been placed on such a 
 basis that its performance had been often repeated, 
 or its merits further investigated. In 1821 Stro- 
 meyer not only resuscitated, but established the 
 operation on a permanent and scientific basis. By 
 his discoveries he not only made the operation pop- 
 ular, but, showing the impunity with which muscles 
 and tendons might be divided, opened the field for 
 the relief of deformities which before had baffled the 
 
CLUB-FOOT: TALIPES. 51 
 
 surgeon, and which had condemned the sufferer to 
 a lifelong incapacity. Like all new departures, 
 however, his disciples undoubtedly overdid the 
 operation, and its applicability was oftentimes lost 
 in the desire to perform it. Thus its proper appli- 
 cation and the counter-indications for its perform- 
 ance have only been the result of experience ; but 
 to Stromeyer and his influence is undoubtedly due 
 the success attained by surgeons at the present day 
 in the operative treatment of club-foot. He wrote 
 under the title " Beitrage zur operativen Ortho- 
 padik" (Hanover, 1838). In 1833 Stork wrote 
 very learnedly on " De Talipedibus varis." He was 
 followed in 1835 by Vincent Duval, whose writings, 
 " Traite pratique du Pied," and u Des Vices Con- 
 genitaux de Conformation des Articulations," con- 
 tain many useful observations. He made many 
 important statistical deductions, and also proposed 
 a classification and nomenclature, which, however, 
 have not come into general use. He is also said to 
 have been the first operator upon the tendo Achillis 
 in France. In the same year Blance wrote his 
 " Diss, inaug. de novo ad Talipedem varem." Ryan, 
 of London, in his " Practical Treatment of Club- 
 foot" (1835), criticises the three divisions of club- 
 foot into equinus, varus, and valgus, as having 
 the merit of being short, but the want of being- 
 exact. Thus, he says, it is necessary that the form 
 of club-foot called equinus should be carried to the 
 greatest degree of development to give to the pa- 
 tient's foot the appearance of a horse-foot, and an 
 examination of thirty cases seemed to justify this 
 
52 MEMOIR OF A. S. ROBERTS. 
 
 criticism. In regard to the etiology, he considered 
 general or partial paralysis dne to cerebro-spinal 
 disease, and the bad position of the child in utero 
 as the two great causes ; other less important ones 
 he found in direct injuries, contusions, inflammation 
 of the knee or tibio-tarsal joint, and nerve lesions. 
 He did not think tenotomy a justifiable operation, 
 unless all other means failed. 
 
 In 1836 W. J. Little, of London, who was a 
 sufferer from acquired club-foot, and who vainly 
 attempted to have an operation performed in Eng- 
 land, proceeded to Hanover, where he was operated 
 on by Stromeyer for an equino-varus. In July of 
 the same year he himself nerformed the operation 
 in Hanover. He then went to Berlin, and with 
 Dieffenbach treated numerous cases of distortion. 
 On February 20, 1837, Little is soid to have divided 
 the tendo Achillis for the first time in England, 
 although the honor was claimed by two men before 
 him, by M. A. Petit, in 1799, and by Whipple, of 
 Plymouth, in May, 1836, who states that when he 
 performed the operation he was not aware that it 
 had been performed on the Continent, and that 
 Brodie, to whom he wrote on the subject, discoun- 
 tenanced i ;, but that Liston sanctioned the opera- 
 tion. To Little, however, is undoubtedly due the 
 credit of popularizing the operation in England, 
 and to his influence the advancement of orthopedic 
 surgery is largely owing. He is said to have been 
 the first to use the term "Talipes" (Talus, an ankle, 
 and pes, a foot) in its generic signification, although 
 the term had previously been used by writers in a 
 
CLUB-FOOT: TALIPES. 53 
 
 more limited sense. He saw and described talipes 
 calcaneus, and made extensive researches into the 
 pathological anatomy of club-foot, considering the 
 muscles as the parts primarily attacked. In regard 
 to tenotomy, Little says : " The most favorable time 
 for division of tendons is a few months before the 
 child may be expected to walk — about the age of 
 six or eight months, until which time mechanical 
 apparatus should be used." Little wrote his "Trea- 
 tise on the Nature of Club-foot " in 1839, and " On 
 the Nature and Treatment of the Deformities of the 
 Human Frame " in 1853, both being standard works 
 on the subject to this day. Kennedy, of Dublin, 
 " Obcervations on Cerebral and Spinal Apoplexy, 
 Paralysis, and Convulsions of New-born Children," 
 and Martin, " Premier Memoire sur le Pied-bot," 
 were also among the most prominent publications 
 of this year ; the latter ascribing congenital club- 
 foot to deficiency of the liquor amnii. In 1837 
 Sewald (Berlin) wrote his celebrated thesis, " Diss. 
 inaug. de Talipedibus," as also Lode, " Diss, inaug. 
 de Talipedibus varis et curvatura Manus," etc. In 
 the same year Pivain wrote his essay entitled, " Sur 
 la Section du Tendon d'Achille," etc. Attention 
 was also called to the subject of flat-foot, by Never- 
 mann, in an article entitled " Ueber den Platfuss 
 und seine Heilung." In 1838 Kness studied the 
 subject carefully, and embodied his researches in an 
 article, " De Talipede Varis," and Wigel in the 
 same year gave a resume of the operative treatment 
 under the title " De Operatione Vari." 
 
 In 1839 Velpeau, of Paris, gave much attention 
 
54 MEMOIR OF A. S. ROBERTS. 
 
 to the subject of club-foot, and wrote on the sub- 
 ject in his " Nouveaux Elements de Medecine Ope- 
 ratoire." He advised, after division of the tendons, 
 the reduction of the foot, by a powerful instrument, 
 to its normal position, and also its immediate fixa- 
 tion. He called attention to the importance of the 
 posterior tibial tendon, and describes the operation 
 for its division, its dangers, and advantages. 
 
 In the same year Krauss wrote on " The Cure of 
 Club-foot, Bent-knee, Long JSTeck, Spinal and other 
 Deformities, with Cases." He was an ardent advo- 
 cate of tenotomy, although he says " in congenital 
 club-foot, if advice be early sought, a cure may be 
 attempted by mechanical means alone, but never- 
 theless, in children one and two years old tenotomy 
 is better." Hauser " on Talipes Varus " (Tunice), 
 and De Russdorff, " De Talipedibus," were also im- 
 portant contributors in this year. Between the years 
 1834 and 1840 we find tenotomy practised, and its 
 effects upon the tendons very carefully studied, by 
 such men as Bouvier, of Paris, Pauli, Von Amnion, 
 Phillips, Held, Scoutetten, of Strasbourg, Bonnet, 
 of Lyons, Jules Guerin, of Paris, Dieffenbach, of 
 Berlin, and Pirogoff. The researches of Bonnet are 
 described in his "Memoire sur la section du tendon 
 d' Achillo dans le traitement des Pieds-bots;" Pauli 
 in his essay " Ueber de Klumpfuss und dessen 
 Ileilung." The other contributors are : Von Am- 
 nion, who studied the effect of tenotomy very care- 
 fully in his " De Plrysiologia Tenotome ;" Phillips, 
 k% Mibcutaneous Tenotomy in Club-foot;" Held, 
 ; ' Sur le Pied-bot;" Scoutetten (Strasbourg), "Mem- 
 
CLUB-FOOT: TALIPES. 55 
 
 oir on the Radical Cure of Club-foot;" Bonnet 
 (Lyons), " Trait e* des Sections Tendineuses," etc.; 
 Jules Guerin (Paris), " Memoir upon the Etiology 
 of Congenital Club-foot;" Dieffenbach (Berlin), 
 "Ueber die Durchschneidnng," and Pirogoff, 
 " Ueber die Durchschneidung der Achilles." 
 
 From the experiments of Bonnet, he was led to 
 regard the cause of congenital club-foot as residing 
 in the tibial nerve. Pirogoff described two modes 
 of performing tenotomy : 
 
 1. Introducing the knife between the skin and 
 tendon and cutting inwardly. 2. Introducing the 
 knife between the bone and tendon and cutting out- 
 wardly. The latter operation was always followed 
 by effusion of blood into the sheath of the tendon. 
 
 Jules Guerin believed tenotomy was not necessary 
 for very young children, and that bandages were 
 alone sufficient for the reduction of varus. He is 
 among the first to have used plaster of Paris in the 
 treatment of club-foot. 
 
 Scoutetten's mode of treatment was by tenotomy 
 and an apparatus combining fixation with flexion 
 and extension. 
 
 In 1840 Coates published his "Practical Observa- 
 tions on the Nature and Treatment of Talipes or 
 Club-foot," etc. (London), and Heine, of Stuttgart, 
 his " Beobachtungen ueber Lahmungszustande der 
 Extremitaten und deren Behandlung," a very scien- 
 tific work on the production of the deformities. 
 
 In 1841 Vallin, in his "Abridged Treatise on 
 Club-foot" (Nantes), gave it as his opinion that 
 muscular contraction played the most important 
 
56 MEMOIR OF A. S. ROBERTS. 
 
 part in the production of club-foot. He say s : " The 
 circumstance which has the most influence upon the 
 efficacy of the treatment of club-foot by apparatus 
 is the possibility of acting directing upon the dis- 
 placed bones, and upon the causes which produced 
 their displacements." 
 
 In the same year Kennedy, of Dublin, wrote his 
 " Observations on Paralytic Affections met with in 
 Children," which contains many important notes on 
 club-foot. In 1842 Dunbar writes of the subject in 
 his "Notes on the Surgery of Deformities, Club- 
 foot." In this year Lizars (Edinburgh), " Opera- 
 tion for Cure of Club-foot," says that " the child 
 must be old enough to walk before the operation of 
 tenotomy is performed. Two or three years of age 
 is the earliest time at which tenotomy should be 
 practised." After tenotomy, he advised a bandage 
 from the instep to the toes, and over this a paste- 
 board splint. In 1843 Rilliet and Barthez write 
 learnedly on the subject in their "Traite clinique et 
 pratique des Maladies des Enfants," and Petitjean 
 wrote his work " Du Pied-bot." In 1845 Chelius, 
 in his "System of Surgery" (London), devotes 
 some space to the subject. In 1846 the most 
 important work was that of Tamplin, whose " Lec- 
 tures on the Nature and Treatment of Deformities " 
 (London) was long one of the standard works on 
 the subject, and may be advantageously consulted 
 by the student at the present day. He devised 
 many new modes of treatment, and his statistics as 
 to relative frequency are very valuable. Meyer, 
 " De Talipede varis," etc., and Muller, " De Valgi 
 
CLUB-FOOT: TALIPES. 57 
 
 pedis aetiologia quaedam," also wrote in the same 
 year. Morrison, in 1847, " Snr les Pieds-bots," and 
 Berstedt, " De Pedum Deformitatibus" (1848), are 
 valuable contributions. In 1849 Lonsdale wrote 
 his celebrated work " On Some of the More Practical 
 Points Connected with the Treatment of Deformi- 
 ties " (London). 
 
 In 1850 Degaille wrote on the etiology and treat- 
 ment under the title " De l'Etiologie et du Traite- 
 ment du Pied-bot." He was followed, in 1852, by 
 Bishop, of London, whose work, " Researches into 
 the Pathology and Treatment of Deformities in the 
 Human Body," is a careful summary of the subject. 
 At about this time much attention was given to 
 the repair of tendons after tenotomy, and, although 
 investigations concerning this process had been 
 made by Von Amnion, Guerin, Pirogotf, Koerner and 
 others, it was left for Gerstaecker (1851), " Diss. 
 Histol. de Regeneratione Tendinum;" Thierfelder 
 (1852), "Trans. Path. Society" (London, vol. vi., 
 1855) ; J. H. Boner (1854), " Die Regeneration der 
 Sehnen," etc., who performed many experiments on 
 rabbits, but especially Paget, " Lectures on Surgical 
 Pathology " (London, 1853), who has detailed 
 minutely the microscopic changes through all the 
 stages of the reparative process, and to whom we 
 are largely indebted for our knowledge of the sub- 
 ject, to show the exact mode in which the required 
 elongation of muscles is obtained in order to cure 
 the deformities for which the operation is performed. 
 Adams, in 1855, also performed experiments upon 
 rabbits in which the tendo Achillis had been divided 
 
58 MEMOIR OF A. S. ROBERTS. 
 
 subcutaneously, and has written " On the Nature 
 and Treatment of Club-foot" (London, 1856), and 
 a " Treatise on the Reparative Process in Human 
 Tendons " (London, I860), in which he gives a 
 resume of the published descriptions of experiments 
 on animals, as well as post-mortem examinations in 
 the human subject. His work " On Club-foot : its 
 Causes, Pathology, and Treatment," is the most 
 exhaustive on the subject, and received the Jack- 
 sonian prize for 1864. It has passed through 
 several editions. 
 
 Brodhurst, of London, has contributed largely to 
 the subject of club-foot, the most important of his 
 writings being " On the Nature and Treatment of 
 Club-foot" (London, 1856) and his work " Ortho- 
 pedic Surgery." He was a decided advocate of 
 tenotomy, and employed it to the exclusion of all 
 other means of treatment, considering it better, even 
 in the most simple cases, to divide the tendons. He 
 made numerous experiments upon the reparative 
 process following the section of tendons, the results 
 of which were embodied in a communication to the 
 Royal Society (November, 1859), entitled " On the 
 Repair of Tendons after their Subcutaneous Divi- 
 sion." From 1853 to 1863 many valuable papers 
 upon the subject of club-foot appeared. Among 
 the most noteworthy were those of Todd, " Clinical 
 Lecture on Paralysis " (London, 1854) ; Bouchut, 
 " A Practical Treatise on the Diseases of Children " 
 (1855); Beckel, " De Pede Yaro" (1856); Vetter, 
 "De cyllopodia cum descript. casus pedi vari;" 
 Ksau, "Beitrage zur Lehre von Plattfuss ; " 
 
CLUB-FOOT: TALIPES. 59 
 
 Quicken, " De Talipedibus" (1859); Ebner, "Die 
 Contracture!! der Fusswurzel und ihre Behandlung" 
 (1860) . In 1863 Barwell, " Cure of Club-foot with- 
 out Cutting Tendons," rendered himself famous by 
 offering objections to, and strongly opposing, the 
 practice of tenotomy, which after nearly a century 
 of use had, of course, become very popular, and 
 was supported by all the great surgeons. His 
 treatment was directed to the restoration of the lost 
 equilibrium in the opposing sets of muscles ; to sub- 
 stituting a force for the paralyzed muscles, to be 
 applied as nearly as possible in the direction and 
 position of the paralyzed muscles ; to treating the 
 foot, not as a whole, but as a compound of many 
 bones ; and to allowing the weakened muscles to 
 regain their power by what might be called passive 
 motion. This he endeavored to accomplish by the 
 use of india-rubber bands, also called " artificial 
 muscles." In his objections to tenotomy he argues 
 that the contraction is the result of paralysis in the 
 opposing muscles. When the tendon is cut, all 
 opposition to such contraction is annihilated, and 
 the muscle itself contracts and the calf shortens. 
 Tonic contraction of the muscle, however, still con- 
 tinues, and the cicatricial contraction will reproduce 
 the same deformity when the apparatus is removed. 
 Non-union occasionally takes place. Weber, " Ueber 
 die Anwendung permanenter Extension durch elas- 
 tische Strange bei pes valgus" (1863), also advo- 
 cated elastic force. Adams, in 1866, writes that 
 Heather Bigg had used the same plan several years 
 prior to Barwell. Many works appeared during the 
 
60 MEMOIR OF A. S. ROBERTS. 
 
 latter end of this period, and the literature of club- 
 foot is now very voluminous. Stoess, in 1866, wrote 
 on "Du Traitement du Varus;" Richter, in 1867, 
 on " De Talipedibus Varis ;" Mezger, in 1868, " De 
 Behandlung van di Stortistic Pedis mit Fricties ; " 
 Hirschfield, in 1869, " Ueber die Behandlung der 
 Klumpfusse ; " Francellon, in the same year, "De 
 TEtiologie du Pied-bot Congenital." In 1870 Nie- 
 den, " Ueber die Entstehungsweise und Ursache des 
 angeborenen Klumpfusses ;" Volkmann, "Ueber 
 Kinderliihmung und paralytische Contracturen " 
 (Klinisehe Vortrage, ~No. 1), and Marx, " Ueber 
 Pes Varus." In 1871 James Hardie, " On the Pa- 
 thology of Club-foot and other Allied Affections" 
 (London); A. Luecke, " Ueber den angeborenen 
 Klumpfuss" (Volkmann's Klinisehe Vortrage), and 
 Brodhurst, " Deformities of the Human Body " 
 (London). In 1872 Keverchon, " Sur le Pied-bot," 
 and " Du Traitement des Pieds-bots par le Massage 
 force." In .1877 Chalot, " Du Pied Plat et du Pied 
 Creu Valgus Accidentels." In 1878 Kocher, " Zur 
 Etiologie und Therapie des Pes Varus Congenitus" 
 (" Deuts. Zeit. f. Chrr.," Bd. ix.), and Bornemann, 
 "Zur Therapie des Pes Varus Congenitus." In 
 ,1880 Van Hees, " Ueber Pes Equino-varus." In 
 1881 Kuprecht, " Angeborene spastische Glieder- 
 starre und spaslische Contracturen" ("Klinisehe 
 Vortrage") ; Dieffenbach, " Ueber Pes Varus und 
 seine Behandlung;" Koutier, "Du Pied-bot Acci- 
 dentel," and Ulcoq, " Du Pied-bot Consecutif a, la 
 Paralysie infantile et de son Traitement." In 1882 
 Pascaud, "Of Certain Orthopedic .Vpparatus em- 
 
CLUB-FOOT: TALIPES. 61 
 
 ployed in the Treatment of Club-foot" ; Noble Smith, 
 " Surgery of Deformities." In 1883 Schwartz, 
 " Des Differentes Especes de Pied-bot, et de leur 
 Traitement." In 1884 Parker and Shattuck, " The 
 Pathology and Etiology of Congenital Club-foot." 
 In 1385 Reeves, "Practical Orthopaedics" (section, 
 Talipes or Club-foot). 
 
 This brings us to the close of the third period, 
 and down to the present day. We have endeavored 
 to give the more important works which mark the 
 history of the subject, and to note those particularly 
 whose views characterized the development of new 
 theories as to etiology and treatment. 
 
 American Contributors — Nineteenth Century. In 
 1835, four years after Stromeyer performed his first 
 operation, Dr. James H. Dickson, of North Caro- 
 lina, is reported to have performed the operation of 
 subcutaneous tenotomy for the first time in America. 
 
 In 1839 Mutter, of Philadelphia, delivered " A 
 Lecture on Club-foot," in which he advocated well- 
 regulated and continued extension, which he believed 
 was the only thing necessary, especially for the 
 young and feeble. In other cases he advised ten- 
 otomy and the proper fixation and retention of the 
 foot, followed by apparatus. He believed the imme- 
 diate or proximate cause of congenital club-foot was 
 a contraction of the tendo Achillis. Accidental 
 causes of acquired club-foot he ascribed to contu- 
 sions, sprains and luxations, fractures, preternatural 
 laxity of the ligaments, and partial paralysis of the 
 lower extremities. 
 
 In 1840 Detmold, of New York, in his "Essay 
 
62 MEMOIR OF A. S. ROBERTS. 
 
 on Club-foot," states that the only remedy to be 
 relied upon in the cure of club-foot consisted in the 
 extension of the contracted muscles, gradually in- 
 creased and continued until one set of muscles lose 
 the inclination to spasmodic contraction, and their 
 antagonists regain their activity. In regard to the 
 causes of club-foot, he believed the first and most 
 frequent cause to be " irregular muscular action," 
 the stronger muscles contracting, and the weaker 
 ones yielding ; second cause, paralysis ; third cause, 
 a local stimulus or irritation, setting up contraction. 
 He thought that in cases due to the first cause, the 
 prognosis was gravest, and most favorable when the 
 condition was due to prolonged contraction from a 
 local stimulus. A pupil of Stromeyer, and having 
 had the opportunity of seeing him operate, he was 
 an ardent advocate of tenotomy, and to him and 
 Mutter is due the credit of making the operation of 
 subcutaneous tenotomy popular in this country. 
 Although many articles in different journals ap- 
 peared upon the subject of club-foot, and many 
 plans of treatment showing much originality were 
 devised, it was not until 1866 that a methodical 
 account of the subject was given by Prince, in his 
 " OrthopaBdics " (Philadelphia). He also gives a 
 \«iy ingenious plan for holding the foot, for the 
 purpose of affixing apparatus for the removal of the 
 deformity. He was followed in 1867 by Davis, who 
 was the originator and promulgator of the " exten- 
 sion " theory, and to whom much credit is due for 
 his original work in the treatment of deformities. 
 In his work, "Conservative Surgery," he claims 
 
CLUB-FOOT: TALIPES. 63 
 
 that he had practised Barwell's plan many years 
 before Barwell adopted it. In 1868 Bauer's " Or- 
 thopaedic Surgery " was published. It is undoubt- 
 edly the most complete and scientific work upon the 
 subject up to this date, and its chapter on Talipes 
 is a very comprehensive and exhaustive one. In 
 1875 Say re, in "A Practical Manual of the Treat- 
 ment of Club-foot," shows himself a decided advo- 
 cate of " Barwell's artificial muscles," although he 
 does not believe in this method to the exclusion of 
 other means of mechanical treatment and tenotomy. 
 
 In this work he gives many excellent practical 
 suggestions for the treatment of the deformity, and 
 in this, as well as other departments of orthopedic 
 surgery, he has done much for the advancement of 
 the subject. 
 
 Shaffer, of N"ew York, has devised many impor- 
 tant improvements in mechanical appliances for 
 the cure of club-foot, and has contributed valuable 
 articles to the literature of the subject. The most 
 important of these are : " Traction in the Treatment 
 of Club-foot" (1878) ; "Hysterical Joint-Affections" 
 (1880), in which he reports very interesting cases 
 of "hysterical club-foot;" and "Non-deforming 
 Club-foot " (1885), originating in this last contribu- 
 tion a new class of cases, previously little observed 
 or studied. 
 
 Phelps, of Chateauguay, advocated and practised 
 division of the tendo Achillis, and then of all struc- 
 tures down to the bones opposite Chopart's joint. 
 He read a paper on the subject before the Interna- 
 tional Medical Congress at Copenhagen, entitled 
 
(54 MEMOIR OF A. S. ROBERTS. 
 
 " The Treatment of Equino-varus by Open In- 
 cision." 
 
 Hingston, of Montreal, " On Certain Forms of 
 Club-foot" (1881), reports four eases of severe 
 equino-varus treated by open incision. 
 
 Berg, of New York, has written a very original 
 and valuable article on " The Etiology of Congenital 
 Talipes Equino-varus " (1882), the studies of the 
 author throwing much light upon this very vexed 
 question and antedating the researches of Parker 
 and Shattuck, of London, by several years. Many 
 other names might be added to the foregoing ones, 
 most conspicuously those of Paneoast, of Phila- 
 delphia; Hutchison, of Brooklyn; Yale, of New 
 York ; Bradford, of Boston ; all of whom have 
 added either to the treatment or the literature of 
 club-foot. 
 
 Varieties Especially Considered. Under 
 this heading will be included a short account of the 
 different forms of club-foot and their treatment, as 
 well as some considerations concerning their morbid 
 anatomy, pathology, diagnosis, and prognosis. 
 
 The purely primitive types of club-foot are so 
 rare, either as congenital or acquired deformities, 
 that authors have, under the titles Varus, Valgus, 
 Equinus, and Calcaneus, usuall} 7 included the com- 
 pound forms, and nearly all works upon the subject 
 have described the changes found in them when 
 referring to the bones, ligaments, muscles, etc., in- 
 volved in the malformation. This has led to much 
 confusion in both nomenclature and statistics. It 
 was thought necessary to call attention to this fact 
 
CLUB-FOOT: TALIPES. 65 
 
 before proceeding to a description of the primitive 
 types. 
 
 Talipes Yarns. Synonyms : Ger., Klumpfuss; Fr., 
 Pied-hot varus. The simple form is undoubtedly 
 one of the rarest of either congenital or acquired de- 
 formities, it being generally associated with equinus, 
 and almost all authors when writing of varus de- 
 scribe the compound form, Talipes Equino-varus. 
 In the mildest form there is a slight inversion of 
 the anterior part of the foot, the heel not being 
 elevated. In a true case of varus, therefore, the 
 deformity would take place at the transverse tarsal 
 joint, the deformity being on a lateral plane. The 
 changes, bony, muscular, and ligamentous, as well 
 as the treatment of the simple form, will be best 
 described under the head of Talipes Equino-varus. 
 
 Talipes Valgus. Splay-foot, Flat-foot. Syno- 
 nyms : Ger., Plattfass ; Fr., Pied-hot valgus. This 
 deformity may be congenital or acquired, the latter 
 form being very frequent, the congenital rare. In 
 the congenital form there are e version and elevation 
 of the outer border of the foot, the weight of the 
 body being sustained upon its inner side. With 
 this we find a sinking of the normal convexity of 
 the arch. Here, as in varus, in the primitive type, 
 the deformity takes place on a lateral plane, and 
 occurs at the transverse tarsal joint. 
 
 The bones are, as a rule, not very much displaced,, 
 the principal changes taking place in the astragalus 
 and scaphoid bones, the os calcis only being impli- 
 cated when there is a co-existing equinus. The 
 astragalus is generally pushed downward and for- 
 
 5 
 
6Q 
 
 MEMOIR OF A. S. ROBERTS. 
 
 ward, and is seen as a prominence upon the inner 
 side of the foot, with the rotated scaphoid bone, 
 
 Fig. i. 
 
 Acquired talipes valgus. 
 
CLUB-FOOT: TALIPES. 67 
 
 which is also prominent. The enboid bone is in- 
 volved, being slightly rotated outward, and the 
 malleoli have a lower plane than normal. The liga- 
 ments implicated are those upon the plantar surface 
 and inner side, the calcaneo-scaphoid ligament 
 being relaxed. 
 
 The muscles principally involved are the peronei 
 and the extensor longus digitorum, the tendo Achillis 
 only participating when there is an equino-valgus. 
 
 Pes Valgus Acquisitus (see Fig. 1). The ac- 
 quired form, generally known as splay-foot or flat- 
 foot, occurs very frequently, and if all the cases 
 were grouped under the common title of Talipes 
 Valgus, would undoubtedly constitute the most 
 frequent form of club-foot. A reference to the 
 section on the Etiology of the Acquired Forms 
 shows the different causes of this deformity. The 
 principal ones are paralysis, rhachitis, ankle-joint 
 disease, rheumatism, and it is common in growing- 
 boys and girls, as well as in certain occupations 
 requiring long standing in one position. 
 
 It also occurs secondarily in knock-knee and 
 traumatism. In talipes valgus pain is a very 
 prominent symptom, and many cases have been 
 justly described as " inflammatory flat-foot." The 
 general changes found in the acquired forms con- 
 sist essentially of a flattening of the arch of the 
 foot, the weight of the body falling mostly upon 
 its inner side. This brings the scaphoid and inter- 
 nal cuneiform bones closer to the ground, and it is 
 at these points that the patients complain greatly 
 of pain. The astragalus may also be displaced in 
 
68 
 
 MEMOIR OF A. S. ROBERTS. 
 
 the same direction. In some cases there are mus- 
 cular contractions, the contraction taking place in 
 the abductors, the adductors being in a condition 
 of paresis. Where the cases occur as a result of 
 infantile paralysis, the tibialis anticus is usually 
 affected, more rarely the tibialis posticus, and in 
 these cases in which the paralysis is of long stand- 
 ing or extensive, the prognosis is unfavorable. The 
 cases are always tedious, necessitating a long time 
 for their cure, but otherwise, as a class, talipes val- 
 gus of the acquired form is usually relieved by 
 treatment. 
 
 Fig. 2. 
 
 Talipes equinus. 
 
 Talipes Equinus (see Fig. 2). Synonyms : Ger., 
 Pferdefuss, Sjritzfuss; Fr., Pied-bot equin. This 
 may be a congenital or acquired deformity, but 
 
CLUB-FOOT: TALIPES. 
 
 69 
 
 congenitally it occurs very rarely, Little and Broad- 
 hurst stating that they had seen but two cases, and 
 Tamplin, according to Adams, discredits it entirely 
 as a congenital deformity. In a typical case the 
 foot should be extended, the patient walking on the 
 ball of the toes. The acquired form of talipes 
 equinus is, on the contrary, a very frequent deform- 
 ity ; especially is this true of the paralytic form. 
 
 Fig. 3. 
 
 Severe talipes equinus. 
 
 The most frequent cause of the deformity is 
 found in infantile spinal paralysis. Its influence in 
 the production of the different forms of talipes, and 
 the explanations have been mentioned under the 
 section on Etiology. Other causes are found in 
 spastic paralysis, neuro-mimesis, post-hemiplegic 
 contractions, wounds, cicatrices, and long-continued 
 decubitus. 
 
 In this form of talipes the os calcis is raised, and 
 may even be in direct contact with the tibia. The 
 
70 MEMOIR OF A. S. ROBERTS. 
 
 astragalus is displaced downward, showing as a 
 prominence on the dorsum of the foot. Where the 
 deformity has advanced there occurs a decided 
 bend at the transverse tarsal articulation, and the 
 scaphoid is brought in contact with the os calcis. 
 
 Fig. 4. 
 
 Severe talipes equinus. 
 
 In the severer forms there is also a marked contrac- 
 tion of the plantar arch, these cases constituting 
 the pes cavus of some authors. Where the patient 
 has extended the toes in walking, the proximal 
 phalanges form articulations with the superior sur- 
 faces, of the metatarsal bones. In some old cases 
 where the deformity was allowed to exist without 
 interference, the bones after death have been found 
 very light and cancellous. 
 
 The ligaments are contracted upon the plantar 
 
CLUB-FOOT i TALIPES. 
 
 71 
 
 surface, and elongated upon the dorsum of the foot. 
 Adams found the astragalo-scaphoid ligament much 
 lengthened, as also the interosseous and calcaneo- 
 
 astragaloid ligaments. 
 
 Fig. 5. 
 
 Talipes calcaneus. 
 
 The muscles involved are the posterior ones, the 
 gastrocnemius, plantaris, and soleus acting through 
 the tendo Achillis. Pancoast asserts that the soleus 
 is chiefly at fault, and has operated upon this mus- 
 cle ; but extension and flexion at the knee-joint so 
 affect this deformity, increasing or lessening it, as 
 
72 MEMOIR OF A. S. ROBERTS. 
 
 to show the marked influence of those muscles 
 attached to the condyles of the femur. 
 
 The prognosis in talipes equinus is very favor- 
 able, patients having been relieved of the deformity 
 at all ages. 
 
 The diagnosis is easily made, the only difficulty 
 being at times the discovery of the cause. The 
 history of the case will generally decide this. Its 
 appearance is diagnostic, and by simply raising the 
 leg with the patient in a sitting position, the knee 
 being depressed, the amount and character of the 
 deformity will be easily ascertained. Care should 
 be taken not to allow flexion at the knee-joint, for 
 if this be permitted, the posterior muscles will allow 
 more flexion at the ankle-joint, so that if the de- 
 formity be slight it will disappear, thus showing 
 that false conclusions as to the amount of the 
 deformity have been reached. 
 
 Talipes Calcaneus. Synonyms : Ger., Hacken- 
 fass ; Fr., Pied-bot talus. As a primitive deformity 
 it is the rarest of all varieties. In this condition 
 we have the direct opposite of the equinus form. 
 The foot is flexed upon the leg, its dorsum ap- 
 proaching the tibia ; while the heel is lowered, and 
 the sole of the foot elevated (Fig. 5). Here the 
 displacement occurs at the tibio-astragaloid articu- 
 lation, and, as in equinus, upon an antero-posterior 
 plane. 
 
 in the congenital form the bones are not much 
 altered. The astragalus seems to be drawn back- 
 ward and its neck more in contact with the tibio- 
 fibular surfaces, while the anterior part, superiorly, 
 
CLUB-FOOT: TALIPES. 
 
 73 
 
 is posterior to the tibia. The os calcis follows the 
 oblique direction of the astragalus, and becomes 
 vertical in its position. 
 
 The acquired form is also very rare, and is usually 
 the result of infantile spinal paralysis, affecting the 
 posterior calf muscles (Fig. 6). Other causes are 
 
 Fig. 6. 
 
 Paralytic talipes calcaneus. 
 
 injuries, too rapid stretching of the tendo Achillis 
 after tenotomy, and disease in the neighborhood of 
 the ankle-joint. 
 
 In addition to the bony changes described under 
 the congenital forms, there is an exaggeration of all 
 the displacements there mentioned. The ligaments 
 posterior to the ankle are lengthened, and contracted 
 upon the front and upon the plantar surface, the 
 plantar fascia being contracted. The muscles in- 
 
74 MEMOIR OF A. S. ROBERTS. 
 
 volved are the extensor proprius pollicis and longus 
 digitornm, as also the tibialis anticus. The pero- 
 nens tertius may also be involved. The deformity is 
 easily diagnosticated, and the prognosis is favorable 
 in congenital cases, and while this is not so true of 
 the acquired variety, great relief may be obtained 
 by suitable orthopedic appliances. 
 
 It will be unnecessary to give in this article 
 elaborate accounts of pes cavus or pes planus. 
 
 In the former, pes cavus, there is simply an 
 increased concavity of the plantar arch, while the 
 dorsal convexity is abnormally prominent. It may 
 be a congenital or acquired variety, the latter being 
 much more frequent. 
 
 Pain is a very prominent symptom in this class 
 of cases, and, the pressure coming upon the heads 
 of the metatarsal bones and the heel, callosities and 
 corns form which are very painful. Walking in 
 many cases is accomplished with the greatest diffi- 
 culty, owing to the pain, and the gait is charac- 
 teristic. 
 
 Pes planus is considered by many authors as 
 simply a spurious valgus. Here the depression is 
 localized on the inner side of the plantar arch, but 
 without the eversion of the sole. It is very common 
 in certain races, and the negro is peculiarly liable 
 to this deformity. Infants, as a rule, have flat feet, 
 but the arch is developed when they begin to walk. 
 None of the anatomical changes noted in typical 
 valgus occur in this condition, excepting, perhaps, 
 those cases in which the deformity has existed for a 
 long lime, when a true valgus may ensue. 
 
CLUB-FOOT: TALIPES. 
 
 75 
 
 The symptoms are very similar to those of valgus, 
 and pain is in many cases present. 
 
 In this condition we do not have the eversion of 
 the sole, nor is there the abnormal condition of the 
 astragalo-scaphoid articulation, such as we see in 
 
 the true valgus. 
 
 Fig. 7. 
 
 Paralytic talipes equino-varus. 
 
 Compound Forms of Club-foot. In these forms 
 of club-foot we may have an association of all the 
 primitive types of the deformity. When, therefore, 
 we speak of a compound club-foot, we refer to a 
 deformity having the characteristic qualities of two 
 
76 MEMOIR OF A. S. ROBERTS. 
 
 or more of the primitive types. Thus, most fre- 
 quently we meet 
 
 Talipes equino-varus (Fig. 7), in which we find 
 extension and adduction combined, the deformity 
 taking place both on an antero-posterior and on a 
 lateral plane. As a congenital deformity this com- 
 pound form is the most frequent of all the varieties 
 of club-foot, and is met with in every degree of 
 severity. Authors have attempted to divide these 
 degrees, but, like the stages of morbus coxarius, 
 they are more arbitrary than real, and have no prac- 
 tical importance. The morbid anatomy shows the 
 os calcis drawn upward, from the horizontal to a 
 more vertical position. It is also rotated on its 
 vertical axis, and its aniterior extremity directed 
 inward, its posterior extremity pointing outward 
 and toward the fibula. The cuboid, maintaining its 
 relation to the os calcis, follows the inward direction 
 of its anterior part. The astragalus follows the os 
 calcis forward, so that the posterior portion of its 
 superior articular surface is in contact with the 
 inferior articular surface of the tibia, the anterior 
 part of its articular facet projecting at the dorsum 
 of the foot. The shape of the astragalus may be so 
 much altered by these changes that the anterior 
 articular surface looks inward instead of forward. 
 The scaphoid bone is drawn inward, upward, and 
 backward, carrying with it the cuneiform bones, tho 
 metatarsal bones retaining their relation to the tarsi, 
 being displaced inward. Many authors have written 
 upon the deficiency of the inner malleolus, consid- 
 ering it to be one of the causes of the deformity. 
 
CLUB-FOOT: TALIPES. 
 
 77 
 
 Neither Little nor Adams has found this in his 
 dissections. The question of these changes being 
 primary or secondary has already been discussed in 
 speaking of the etiology. 
 
 Fig. 8. 
 
 Double congenital equino-varus. 
 
 The ligaments at birth show very little alteration 
 in structure, but in more advanced cases the plantar 
 ligaments are contracted, as also the internal lateral 
 and posterior ligaments. These may offer great 
 resistance to eversion of the foot, and Adams has 
 shown that the anterior portion of the internal lat- 
 eral ligament, passing from the malleolus to the 
 scaphoid bone, may render this particularly difficult. 
 
 The muscles at birth show no particular changes, 
 and although the limb on the affected side is gener- 
 
78 MEMOIR OF A. S. ROBERTS. 
 
 ally smaller than its fellow, the muscles themselves 
 are normal, but undeveloped. It is important to 
 remember that in consequence of the altered rela- 
 tions of the bones, the tendons may be much dis- 
 placed. Thus the tendo Achillis is more external, 
 being nearer the fibula, the tibialis posticus more 
 forward and inward, and further separated from the 
 tendo Achillis. 
 
 Fig. 9. 
 
 Severe congenital equine- varus . 
 
 Little has given the position of the tibialis posti- 
 cus as being " exactly midway between the anterior 
 and posterior borders of the leg on its inner aspect." 
 The tendons running in front of the ankle-joint pass 
 near to the inner side, that of the tibialis anticus 
 pissing over the inner malleolus. The vessels and 
 nerves follow the deformity, but retain their relations 
 to the tendons. 
 
CLUB FOOT: TALIPES. 79 
 
 In this class of cases the prognosis is generally 
 favorable, although the varus is much more amen- 
 able to treatment than the equinus. 
 
 The acquired form of the compound deformity is 
 also very frequent, being most commonly due to 
 infantile spinal paratysis. Other causes may be 
 found in those already given in the description of 
 talipes equinus. The morbid changes follow closely 
 the description given above of the congenital form. 
 The prognosis, especially when the cause is a cen- 
 tral one, is much more unfavorable, this being readily 
 appreciated when we consider the destruction of the 
 cells in the cord. We have written of this com- 
 pound deformity at some length, because it is 
 undoubtedly the most frequent of all forms of club- 
 foot, and also is the most difficult of treatment. 
 
 HJquino-valgus simply consists of the combination 
 of the two primitive forms, equinus and valgus, and 
 for the morbid changes the reader is referred to the 
 description of these two varieties. 
 
 Calcaneo-varus and valgus are such rare forms of 
 talipes that little is necessary for their description. 
 A study of the component simple forms entering 
 into their formation is all that is necessary for their 
 diagnosis, morbid changes, and treatment. 
 
 Non-deforming Club-foot. For a full description 
 of the very interesting form of cases designated by 
 Dr. Shaffer, of New York, as " Non-deforming 
 Club-foot," the reader is referred to the New York 
 "Medical Record" for May 23, 1885, where an 
 account of their characteristics and pathology, with 
 some remarks on treatment, is given. Dr. Shaffer 
 
80 
 
 MEMOIR OF A. S. ROBERTS. 
 
 has undoubtedly described a new class of cases, 
 practically unknown or unrecognized by other ob- 
 servers (Fig. 10). Here we shall only allude to the 
 condition briefly. Dr. Shaffer says, " In non-deform- 
 ino- club-foot all the conditions found in certain 
 
 Fjg. 10. 
 
 Non-deforming club-foot. 
 
 forms of talipes exist with the exception of the 
 exaggerated deformity. That is, there is a loss of 
 normal relation between the articulation at the ankle 
 and the muscles which act upon it, involving also 
 in many instances the tarsus, producing a condition 
 
CLUB-FOOT: TALIPES. 81 
 
 which prevents normal flexion at the ankle-joint, 
 and modified mobility, with slight deformity at 
 the tarsal, metatarsal, and phalangeal articulations. 
 "With this state of affairs we find, as a result, vary- 
 ing with the conditions present, actual disability, 
 pain, sometimes very severe, in various parts of the 
 foot, ankle, leg, and even reflected to the lumbar 
 region, and tender and inflamed articular surfaces, 
 especially at the junction of the first metatarsal 
 bone with its phalanx. If these effects be wanting, 
 we have only an awkward or peculiar gait associated 
 with painful callosities and corns at various points 
 upon the foot." Furthermore, he says, " Non- 
 deforming club-foot may occur at any age. I have 
 seen it in infancy, when doubtless its etiology is 
 the same as that of congenital club-foot. It occurs 
 rarely as an acquired condition in children, though 
 often the ' good result ' of many surgeons after ten- 
 otomy and treatment leaves behind it a condition 
 like that I have attempted to describe. It is seen 
 very frequently during the period of second growth 
 — the adolescent period — in both sexes, when at 
 that particular age there are not apt to be many 
 important sequelae. It usually does not reach its 
 full development until adult life and full growth is 
 attained. It occurs more frequently in the female 
 sex, and ivhen looked for, is found sometimes in 
 rapidly growing girls, and especially in those whose 
 growth has been apparently arrested before the 
 average height is reached. And what is very im- 
 portant and to a certain extent remarkable is this : 
 it is found very often associated ivith true rotary 
 
82 MEMOIR OF A. S. ROBERTS. 
 
 lateral curvature of the spine. We may have a con- 
 dition of non-deforming: club-foot from five different 
 causes: 1, Non-deforming club-foot seen after polio- 
 myelitis anterior ; 2, non-deforming club-foot which 
 follows simple and uncomplicated malposition, habit, 
 etc.; 3, non-deforming club-foot produced by trau- 
 matism, sprains, etc.; 4, non-deforming club-foot 
 found after the infectious diseases of childhood, 
 especially diphtheria and scarlet fever ; 5, the non- 
 deforming club-foot due, as I believe, to some remote 
 trophic disturbance, and seen quite frequently co- 
 existing with true lateral curvature." 
 
 All the forms which have been described may be 
 simulated by the so-called " neuromimeiic" or hysteri- 
 cal club-foot. Their diagnosis is always surrounded 
 with difficulty, and the differentiation of the symp- 
 toms demands great caution. The treatment, once 
 the diagnosis is clear, should be addressed mainly 
 to the neural symptoms and the general " morale " 
 of the patient. It may become necessary, all other 
 means having failed, to divide contracted tendons, 
 as instanced in a case in which we divided the tendo 
 Achillis. This case is related by S. Weir Mitchell 
 in his " Lectures on Diseases of the Nervous Sys- 
 tem" (Philadelphia, 1885, p. 129). 
 
 Treatment. In beginning the treatment of a 
 case of club-foot the surgeon should have in view 
 two principal objects : first, the removal of the de- 
 formity ; second, the restoration of the functions of 
 the foot. To accomplish this, many and various 
 devices have been resorted to, and a history of these 
 would furnish an interesting chapter to the subject. 
 
CLUB-FOOT: TALIPES. 83 
 
 It will be impossible in a limited space to describe 
 all the methods which have been used by surgeons 
 in the treatment of club-foot, and it will be neces- 
 sary to discuss only such as are in common use at 
 present, and embody the most scientific principles 
 for the removal of the deformity. The remarks of 
 Adams are here very appropriate. " The scientific 
 treatment of talipes varus, when severe, as of several 
 other deformities of the limbs, can only be accom- 
 plished by a judicious combination of the operative, 
 mechanical, and physiological 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." 
 
 The general treatment of club-foot is best divided 
 into : 
 
 I. The Mechanical. 
 
 II. The Operative. 
 
 Under the head of mechanical means are in- 
 cluded : 
 
 1. Manipulations; their object being to stretch 
 the foot to its normal position. These may consist 
 of passive motions, shampooing, and the "kneading" 
 of the part. The importance of the hand as an in- 
 strument for the correction of the deformity cannot 
 be too strongly insisted upon, and the best appa- 
 ratus is that which closely follows its action. "The 
 
84 MEMOIR OF A. S. ROBERTS. 
 
 hand," says Bouvier, "is the ideal of mechanical 
 means for reducing the deformity." 
 
 2. Massage and Electricity. These are, strictly 
 speaking, physiological means, but as their applica- 
 tion is mechanical, we have placed them under that 
 heading. These agents, as applied especially to the 
 paralytic forms, will be found referred to in another 
 portion of this work (see article Infantile Paralysis). 
 
 3. Splints. The use of splints embodies the ap- 
 plication of such mechanical principles as will serve 
 to correct the disturbed form of the foot. They 
 may be used as permanent unyielding dressings, 
 i. e., plaster of Paris or silicate of soda ; or they 
 may utilize elastic force, as in the apparatus of 
 Barwell and Sayre ; or, finally, they may combine 
 extension with fixation, as seen in the various modi- 
 fications and improvements on Scaipa's shoe. 
 
 The operative treatment of club-foot consists of: 
 1. Tenotomy, or division of contracted tendons. 
 The proper time for the performance of tenotomy 
 has been the cause of much difference of opinion, 
 some advocating its immediate performance, and 
 others deferring it until such time as the patient is 
 able to walk. In the majority of cases the early 
 operation, if the case be of such a nature as to pre- 
 clude the possibility of cure by simple mechanical 
 means, is to be preferred. Experience alone can 
 give the best indications for the operation, the 
 presence of rigidity, reflex spasm (Sayre), or an 
 excessive amount of deformity not being in them- 
 selves sufficient reasons. The patient application 
 of mild means should always be attempted before 
 
CLUB-FOOT: TALIPES. 85 
 
 the performance of an operation, however slight it 
 may seem to the surgeon. 
 
 Modes of Operating. Tendons and fasciae are 
 most conveniently divided from below toward the 
 skin, but some surgeons prefer to insert the knife 
 between the tendon and the skin and cut inward. 
 The latter method, where the relation of the vessels 
 and nerves is much disturbed, is attended with con- 
 siderable danger. The form of tenotome used is 
 largely a matter of choice ; as a rule, only two are 
 
 Fig. 11. 
 
 Position for performance of tenotomy. (From Sayre.) 
 
 necessary. The best tenotomes for ordinary use 
 should be one with a straight blade and sharp point 
 for making the skin puncture, and another with a 
 probe- point for completing the section of the tendon. 
 The handles should be round, flattened upon the 
 surface corresponding to the dorsum of the blade. 
 The patient, having been anesthetized, is placed 
 upon the table in a convenient position and in a 
 
86 MEMOIR OF A. S. ROBERTS. 
 
 good light, and one assistant grasping the part to 
 be operated firmly, the other places the limb not to 
 be operated upon out of the Avay (see Fig. 11). 
 The preparatory puncture having been made with 
 the sharp-pointed knife, the operator introduces the 
 probe-pointed tenotome flatwise, as close to the 
 tendon as possible, and beneath it, and, its cutting 
 edge being then turned toward the tendon, a saw- 
 ing motion is imparted to the tenotome, and the 
 tendon carefully divided. An assistant should 
 firmly tighten the tendon during the operation, and 
 as the section approaches completion relax his hold 
 on the part gradually. As tendons differ very much 
 in their resistance, this precaution is very necessary, 
 as otherwise, if not observed, the tenotome would 
 be very likely to cut through the skin. 
 
 After the division of the tendon the knife is with- 
 drawn and slight pressure made over the wound. A 
 pad of lint fixed with adhesive plaster is placed over 
 it, and the foot and leg bandaged. The immediate 
 care of the foot after tenotomy is a source of much 
 difference of opinion. Many surgeons believe in 
 immediate restoration of the foot to its normal posi- 
 tion. Others bandage it to a splint in the deformed 
 or slightly less deformed position, and gradually 
 restore the limb during the process of cicatrization. 
 In our opinion the application of such apparatus as 
 will give the surgeon complete control of the parts, 
 and at the same time allow extension, according 
 to the activity in the reparative process, is most 
 desirable. 
 
 Several accidents may happen in the performance 
 
CLUB-FOOT: TALIPES. 87 
 
 of tenotomy. Among these are, division of the 
 skin, making* an open wound ; wounding of the 
 posterior tibial or internal plantar artery; false 
 aneurism and inflammation in the sheath of the 
 tendon, or imperfect union of the tendon. These 
 are to be treated according to ordinary surgical 
 principles. 
 
 Adams has given a resume of the different ac- 
 counts of the reparative process in the tendons, 
 such as were found by Hunter, Mayo, Von Am- 
 nion, Guerin, Pirogoff, Koerner, Paget, and others. 
 These observations show that the space between 
 the divided ends of the tendon soon becomes filled 
 up by plastic matter and serum ; that in this new 
 matter bloodvessels multiply rapidly, the new tissue 
 surrounding the divided ends as callus unites the 
 ends of fractures. This becomes changed into 
 connective tissue and firm, and combining with the 
 intermediate substance contracts gradually, assum- 
 ing as it does the character of new tendon. 
 
 2. Myotomy. Little need be said of this pro- 
 cedure. It is scarcely ever done. Professor Joseph 
 Pancoast, of Philadelphia, believed in the sole action 
 of the soleus muscle in the production of equinus, 
 and divided the muscle for the relief of this de- 
 formity, but the operation has never come into 
 general use. 
 
 3. Tarsotomy and Tarsectomy. The first men- 
 tioned procedure is the division of such bony struc- 
 tures as are involved in the deformity by means of 
 the osteotome, the second consisting of the removal 
 of a wedge-shaped piece of the bones. When we 
 
88 MEMOIR OF A. S. ROBERTS. 
 
 consider how seldom these operations seem to be 
 necessary, it is somewhat surprising that, as was 
 recently shown by Lorenz, fourteen operations have 
 been devised, exclusive of tenotomy, for the cor- 
 rection of talipes. They are : 1, Linear osteotomy 
 of the scaphoid practised on the plantar surface 
 (Hahn) ; 2, linear osteotomy of the tibia above the 
 malleolus (Hahn) ; 3, enucleation of the cuboid 
 (Solly); 4, enucleation of the astragalus alone 
 (Lund, Maron); 5, the same with the resection of 
 the tip of the external malleolus (Maron, Keid) ; 
 6, excavation of the spongy portion of the astrag- 
 alus, leaving the articular surfaces ( Verebely) ; 7, 
 enucleation of the astragalus, and excision of a 
 wedge-shaped piece from the anterior portion of the 
 os calcis (Hahn); 8, enucleation of the astragalus 
 and cuboid (Albert and Hahn), or of the astragalus 
 and scaphoid (West); 9, enucleation of the astrag- 
 alus, cuboid, and scaphoid (West); 10, enuclea- 
 tion of the scaphoid and cuboid (Bernet); 11, 
 resection of the head of the astragalus (Liicke, 
 Albert) ; 12, excision of a wedge from the outer 
 half of the neck of the astragalus (Hueter) ; 13, 
 excision of two wedges, perpendicular to each other, 
 with bases at Chopart's articulation, and the astrag- 
 alo-calcanean joint (Rydygier) ; 14, excision of a 
 wedge without regard to any individual bones (O. 
 Weber, Davies-Colley, R. Davy). In the experi- 
 ence of the authors these operations are rarely 
 necessary, and, perhaps, only applicable in adult 
 eases which have resisted all other forms of treat- 
 ment, or in relapsed cases in which the inflammatory 
 
CLUB-FOOT: TALIPES. 89 
 
 products have so agglutinated the different struc- 
 tures as to render other measures impossible. For 
 a full description of these different surgical proced- 
 ures the reader can consult the special treatises, 
 and also the article of Davies-Colley ("Transac- 
 tions of the Medico-Chirurgical Society," vol. lx. 
 
 p. ii). 
 
 4. Brisement Force. Under this procedure are 
 classed all operations which have for their object 
 the immediate restoration of the form of the foot, 
 either by the hand or by powerful instruments. 
 
 5. Multiple Tenotomy and Open Incision. The 
 division of all the contracted tendons at one sitting- 
 has been performed, but has not met with general 
 approbation, owing to the fact that no appropriate 
 point of resistance is left afterward that can be 
 utilized for mechanical treatment. Indeed, although 
 it is the practice of English surgeons to divide 
 many tendons, the tenotomy in this country is 
 usually limited to the tendo Achillis", plantar fascia, 
 and tibialis anticus and posticus. 
 
 Open incision has recently been commended by 
 Drs. Phelps and Hingston. A more extensive 
 experience in this procedure will best decide its 
 relative merits. 
 
 6. Amputation. As a dernier ressort in severe 
 paralytic cases, in which the patient prefers an arti- 
 ficial foot, and where all ordinary means have been 
 exhausted, amputation has occasionally been per- 
 formed. 
 
 Treatment of Special Varieties. Having 
 finished the general remarks on the treatment of 
 
90 MEMOIR OF A. S. ROBERTS. 
 
 club-foot, we will now proceed to give an account 
 of the special varieties. 
 
 Talipes Varus. Pure varus, either as a congeni- 
 tal or acquired deformity, occurs so infrequently 
 that a consideration of the principles involved in its 
 treatment, and the means employed, had best be 
 deferred until we arrive at the treatment of talipes 
 equino-varus. 
 
 Talipes Valgus. Congenital cases, treated soon 
 after birth, may be cured by manipulations alone, 
 these having for their object the carrying of the 
 foot to a more inverted position. To retain the foot 
 in a good position after these movements, adhesive 
 plaster (Maw's) with a roller bandage may be em- 
 ployed. Where the deformity is rather more severe, 
 external splints of a simple character, composed of 
 tin, gutta-percha, or hatter's felt, may be used. 
 These are moulded to the part, and a gradual inver- 
 sion of the foot accomplished. The application of 
 massage and electricity to the weakened anterior 
 tibial muscle may be resorted to with advantage, 
 and rest should also be enjoined. In the more 
 severe forms of congenital valgus tenotomy of the 
 peronei and extensor longus digitorum occasionally 
 becomes necessary. 
 
 In acquired valgus the treatment also varies with 
 the amount of the deformity and cause. In mild 
 forms unattended by contraction of tendons, the 
 application of a simple ankle support, composed of 
 two lateral uprights connected with a band to en- 
 circle the calf, and with an inner pad corresponding 
 to the axis of the astragalo-scaphoid articulation, 
 
CLUB-FOOT: TALIPES. 91 
 
 and attached to the bottom of a shoe, may be used. 
 In the majority of cases additional support may be 
 obtained by the insertion of a tempered steel sole 
 into the shoe, so moulded that its convexity has a 
 direct bearing upon the weakened plantar arch (see 
 
 Fig. 12. 
 
 Ankle support for valgus. 
 
 Fig. 12). In this condition Drs. Barwell and Sayre 
 advocate the use of elastic bands to supply the 
 action of the weakened tibialis anticus muscle. In 
 addition, where the means above referred to cannot 
 be procured, good results may be obtained by the 
 
92 MEMOIR OF A. S. ROBERTS. 
 
 use of plaster-of-Paris or silicate of soda splints, 
 moulded to the foot in a position of varus and 
 allowed to set, care being taken to remove them 
 from time to time, when the parts should be care- 
 fully inspected, and the splint readjusted to the 
 corrected deformity. In this connection, as the 
 treatment for the two conditions is the same, talipes 
 planus or spurious valgus may be considered. Here 
 there being a simple giving way of the arch, due 
 to relaxation of the ligaments and plantar fascia, 
 it is only necessary to supply this deficiency by 
 a tempered steel sole inserted in the shoe. In 
 more pronounced forms, approaching in char- 
 acter true valgus, the same treatment as was ad- 
 vocated in speaking of talipes valgus will be neces- 
 sary. 
 
 Talipes JSquinus. This form of club-foot occur- 
 ring so infrequently as a congenital deformity, it 
 will not be necessary to describe any special treat- 
 ment for its relief. We will, therefore, proceed at 
 once to a consideration of the acquired form. The 
 most frequent cause of acquired equinus being 
 infantile spinal paralysis, we should endeavor to 
 improve the condition of the affected muscles by 
 electricity, massage, etc. The paralysis occurring 
 in the flexor muscles, we must be prepared to 
 counterbalance the antagonism of the extensor 
 muscles by suitable apparatus. The best method 
 of doing this is accomplished by those instruments 
 which combine the principles of extension with 
 fixation. Of these there are many, most of them 
 being improvements on the original Scarpa's shoe, 
 
CL UB-FOOT: TA LIPES. 
 
 93 
 
 and we will revert to these more fully when describ- 
 the treatment of talipes equino- varus. 
 
 Talipes Calcaneus, Here, as in most of the 
 typical simple forms, little need be said of the con- 
 genital variety. When there are no contractions of 
 the anterior tibial muscles, simple manipulation and 
 passive motion will easily overcome the deformity. 
 
 Fig. 13. 
 
 Apparatus for talipes calcaneus, with artificial posterior 
 muscle. 
 
 When the deformity is more severe, an ankle sup- 
 port, having a stop-joint, preventing motion of 
 extreme flexion, may be used, or a similar support, 
 to which an artificial posterior muscle is attached, 
 similar in character to that shown in Fig. 13. In 
 the large majority of instances the treatment just 
 
94 MEMOIR OF A. S. ROBERTS. 
 
 described will be all that is necessary ; but in some 
 cases it is expedient at times to resort to tenotomy 
 of the tibialis anticus, extensor proprius pollicis, 
 longns digitorum, together with the peroneus ter- 
 tius. All of these tendons may be reached through 
 a single puncture made in front of the ankle-joint, 
 close to the inner border of the tendon of the ex- 
 tensor longus digitorum, care beiug taken to avoid 
 the anterior tibial artery. Mechanical support, such 
 as has been already described, may be used after 
 the operation. 
 
 In those cases which are due to infantile spinal 
 paralysis, and in which a marked contraction of the 
 plantar fascia produces a " cavus," it may be neces- 
 sary to divide the contracted fascia, but this must 
 be carefully considered, as many cases obtain a cer- 
 tain amount of support from this very contraction. 
 Where the deformity arises from excessive length 
 of the tendo Achillis, the muscles themselves being 
 unimpaired, a radical procedure consists in excision 
 of the elongated tendon and suture of the divided 
 ends. The operation is performed as follows : An 
 incision being made down to the tendon, the sheath 
 is opened and raised by a blunt hook or spatula, 
 and folded or pinched between the fingers, so that 
 the amount necessary for excision may be accurately 
 ascertained. A silver-wire, silk, or gut suture is 
 then passed through the tendon, about a fourth of 
 an inch above and below the place of the incision of 
 the tendon. This will prevent the slipping of the 
 ends into the sheath. The ends are then approxi- 
 mated, the sutures twisted and buried into the 
 
CLUB-FOOT: TALIPES. 95 
 
 tendon. In the opinion of the authors this will 
 seldom be found necessary, although several suc- 
 cessful instances are upon record. 
 
 Treatment of the Compound Forms. In the 
 treatment of the compound forms of the deformity, 
 the various elements entering into their formation 
 will have to be dealt with. Thus, taking for exam- 
 ple equino-varus, we have to deal with a deformity 
 taking place on two distinct planes, the equinus 
 being on an antero-posterior one, and corresponding 
 only with the tibio-astragaloid articulation, and the 
 varus on a transverse plane, corresponding to the 
 transverse tarsal joint. It is plain, therefore, that 
 all appliances intended for the relief of the com- 
 pound forms of club-foot, and which have for their 
 object the rectification of both elements simul- 
 taneously, are essentially false. That the elements 
 entering into the formation of the compound forms 
 should receive separate treatment has been especially 
 emphasized by Dr. Little and Mr. Adams, of Lon- 
 don. Little has stated that the varus or valgus 
 should be thoroughly corrected before entering 
 upon the treatment of the antero-posterior deformity, 
 and Adams has pointed out the advantage and ad- 
 visability of using the os calcis and contracted 
 tendo A chillis as a fixed point upon which the 
 tarsus may be extended, thus obtaining by these 
 means a gradual unfolding of the deformed foot. 
 
 Talipes Equino-varus. By far the largest number 
 of cases, both congenital and acquired, coming under 
 the care of the orthopedic surgeon, are cases of 
 talipes equino-varus, and we shall endeavor to give 
 
96 MEMOIR OF A. S. ROBERTS. 
 
 somewhat in detail the various methods in use for 
 the treatment of this deformity. We have already 
 pointed out the advisability of dividing the treat- 
 ment of compound forms into two distinct periods. 
 Thus in equino-varus our attention will be first 
 directed to the inversion, or to the deformity occur- 
 ring on a lateral plane. Of the various methods in 
 vogue, the following will be considered : 
 
 1. Manipulation, massage, and electricity. 
 
 2. Retentive dressings. 
 
 3. Extension and fixation. 
 
 4. Elastic extension. 
 
 5. Tenotomy, combined with extension and fixa- 
 tion. 
 
 6. Brisement force. 
 
 7. Tarsotomy or tarsectomy. 
 Manipulations and massage may with advantage 
 
 be used in the slighter cases of varus, but these 
 agents are useful in all cases of whatever severity, 
 and the nurse is to be especially informed of the 
 value of these agents. It is undoubtedly a fact 
 that much can be done with the hand alone, and 
 many cases of varus have been cured by these 
 simple processes. The attendant should be in- 
 structed as follows : The foot being firmly grasped 
 and the os calcis being fixed, the anterior part of 
 the foot is to be gradually brought into a valgoid 
 position. This motion should be repeated several 
 times at short intervals ; the foot is then shampooed 
 and may be placed in a light retention dressing. 
 The manipulations should be used morning and 
 night, and the splint modified as the amount of 
 
CLUB-FOOT: TALIPES. 97 
 
 varus is corrected. It may be well in this connec- 
 tion to say a few words concerning massage. This 
 is not, as is popularly supposed, a simple rubbing 
 of the parts, but consists in a systematic " knead- 
 ing" of the skin and deeper structures. These 
 movements should consist of alternate friction and 
 manipulation, the circulation of the skin being 
 increased by pinching, while the subcutaneous cellu- 
 lar tissue and muscles may be more deeply grasped. 
 Light percussion of the parts will also be beneficial. 
 The use of electricity in the weakened condition of 
 the muscles, but more especially in the paralytic 
 forms of club-foot, is a most important adjuvant to 
 the treatment. 
 
 Retention dressings may consist of simple adhe- 
 sive plaster attached around the foot and secured on 
 the external aspect of the leg ; it should be grad- 
 ually tightened as the foot is everted, the dressing 
 being kept in place by a roller bandage. This is 
 the simplest form of retentive dressing. Moulded 
 splints of gutta-percha, hatter's felt, sole-leather, or 
 rawhide may also be used in simple cases of varus. 
 These articles, being cut to fit the parts, are placed 
 in hot water and softened, the foot being held in the 
 position the operator wishes to secure. The sub- 
 stance used is then moulded to the parts, and 
 secured by a roller bandage. The dressings may 
 be changed from time to time according to the 
 improved position. Splints of plaster of Paris or 
 silicate of soda may be applied in the same manner. 
 As dressings they have the disadvantage, when ap- 
 plied as fixed splints, of not allowing a careful daily 
 
 7 
 
98 
 
 MEMOIR OF A. S. ROBERTS. 
 
 inspection of the parts, excoriations and sloughs 
 being especially liable to ensue. When they are 
 employed it would seem advantageous to cut them, 
 as they would then still retain their retentive prop- 
 erties, and allow manipulation, massage, etc. 
 
 Fig. 14. 
 
 Varus brace applied ; A, before, B, after the deformity has been 
 corrected. 
 
 Extension and fixation may be most effectually 
 used in overcoming the lateral deviation by the use 
 of Shaffer's modification of Taylor's ankle support 
 (see Fig. 14, a and b; Figs. 15 and 16). This 
 consists of a steel trough fitted to the internal aspect 
 
CLUB-FOOT: TALIPES. 
 
 99 
 
 of the leg, extending from the internal malleolus to 
 the upper third of the tibia. Hinged to this is the 
 continuation of the trough, terminating in a joint 
 which articulates with the foot-plate, allowing antero- 
 posterior motion at this point. This joint has been 
 added to Shaffer's original " lateral shoe," and by 
 it we can adjust it to a coexisting equinus. A 
 
 Fig. 15. 
 
 Lateral view of varus brace, applied to deformity. 
 
 worm or endless screw operated by a key, and seen 
 at a, Fig. 14, acting upon the sole-plate at right 
 angles to the direction of the hinge, enables the 
 surgeon to apply the apparatus accurately to the 
 extremes of varus (or valgus), and by means of a 
 key to bring the foot in the desired position. The 
 splint should always be applied to the foot in its 
 
100 
 
 MEMOIR OF A. S. ROBERTS. 
 
 deformed position, and maintained there by a roller 
 bandage, as seen in Fig. 14, a. Then, by the use 
 of the endless screw operated by the key, the foot 
 can be brought into the corrected position as seen 
 in Figs. 14, b, and 16. This simple apparatus, 
 which, with a little instruction, can easily be applied 
 and adjusted by the nurse or parent, allows of daily 
 inspection, manipulation, and massage. In the 
 severer forms of equino-varus, in which the lateral 
 
 Fig. 16. 
 
 Lateral view of varus brace, showing deformity corrected. 
 
 element is in excess, owing to the marked tarsal 
 deviation and plantar contraction, the simple lateral 
 brace above described has been found insufficient, 
 and Shaffer has for these cases devised a more pow- 
 erful apparatus, which can best be described in the 
 following personal communication. 
 
 " The success which has attended the use of the 
 
CLUB-FOOT: TALIPES. 101 
 
 extension or traction shoe 1 in the treatment of the 
 antero-posterior deformities of club-foot, led me to 
 seek some method by which traction could be 
 applied to the lateral deformities of the tarsus — 
 and especially those found in confirmed cases of 
 equino-varus. The conventional club-foot shoe 
 with the ball and socket or hinged joint in the foot- 
 plate, at a point corresponding with the medio-tarsal 
 joint, has proved very unsatisfactory, especially in 
 cases where there was much tarsal deformity or any 
 considerable plantar contraction. The limited suc- 
 cess attending the use of the lateral shoe 2 led me to 
 use this splint as a starting-point for further experi- 
 ment. After various efforts I have perfected an 
 apparatus which may be described as follows : To 
 this simple lateral shoe, with its hinged lever and 
 screw, which imparted a lateral force principally 
 to the os calcis, I added the antero-posterior worm 
 and screw of the extension shoe, which latter gave 
 an antero-posterior pressure. I then divided the 
 foot-plate (with its retaining side curve) at a point 
 opposite the medio-tarsal joint, and instead of the 
 ball and socket or hinge, I added an extension or 
 traction bar to the concave or (in varus) the inner 
 side of the tarsal deformity, with the centre of 
 motion at the convex or (in varus) the outer side of 
 the foot. The apparatus is placed upon the inner 
 side of the foot (in varus), and the heel being 
 retained in the heel-cup by the conventional strap 
 or pad, the hinged bar and screw are first used to 
 
 1 Vide New York Medical Record, November 23, 1878. 
 3 Op. cit. 
 
102 
 
 MEMOIR OF A. S. ROBERTS. 
 
 make pressure laterally against the os calcis. The 
 key controlling the worm and screw is then used to 
 
 Fig. 17. 
 
 flex the foot sufficiently to exert a slight degree of 
 force upon the gastrocnemius muscle, and when this 
 
 Fig. 18. 
 
 Fig. 19. 
 
 position is gained the tarsal traction is applied by 
 using the extension or traction rod, which, acting 
 upon the hinged centre of motion at the outer bor- 
 
CLUB-FOOT: TALIPES. 
 
 103 
 
 der of the foot, carries the anterior part of the foot 
 forward, and direct traction is exerted upon the 
 resisting tarsal tissue. In many severe cases of 
 talipes equino-varus, the tarsal traction shoe has 
 overcome the deformity without the aid of ten- 
 otomy." 
 
 Fig. 20. 
 
 Elastic Extension. To Mr. Richard Barwell, of 
 London, is due the credit of first employing elastic 
 traction in the treatment of club-foot, and Dr. 
 Sayre has popularized it in this country. For the 
 principles embodied in Barwell's method the reader 
 is referred to the section on History and Literature. 
 
 The application of Barwell's dressing has been 
 so lucidly explained by Professor Sayre that we 
 
104 MEMOIR OF A. S. ROBERTS. 
 
 quote his remarks in full : " This consists in cutting 
 from stout adhesive plaster, spread on canton-flannel, 
 or the ' mole-skin plaster,' a fan-shaped piece. In 
 this are cut several slips converging toward the 
 apex of the piece, for its better adaptation to the 
 part (see Fig. 17). The apex of the triangle is 
 passed through a wire loop with a ring in the top 
 (Fig. 17), brought back upon itself, and secured by 
 sewing. The plaster is firmly secured to the foot 
 in such a manner that the wire eye shall be at a 
 point where we wish to imitate the insertion of the 
 muscle, and that it shall draw evenly on all parts of 
 the foot when the traction is applied. Secure this 
 by other adhesive straps and a smoothly adjusted 
 roller. 
 
 " The artificial origin of the muscle is made as 
 follows : Cut a strip of tin or zinc plate, in length 
 about two-thirds that of the tibia, and in width 
 one-fourth the circumference of the limb (see Fig. 
 19). This is shaped to fit the limb as well as can 
 be done conveniently. About an inch from the 
 upper end fasten an eye of wire. Care should be 
 taken not to have this too large, as it would not 
 confine the rubber to a fixed point. The tin is 
 secured upon the limb in the following manner: 
 From the stout plaster above mentioned cut two 
 strips long enough to encircle the limb, and in the 
 middle of each make two slits just large enough to 
 admit the tin, which will prevent any lateral motion ; 
 then cut a strip of plaster, rather more than twice 
 as long as the tin, and a little wider ; apply this 
 smoothly to the side of the leg on which traction is 
 
CLUB-FOOT: TALIPES. 105 
 
 to be made, beginning as high up as the tuberosity 
 of the tibia. Lay upon it the tin, placing the upper 
 end level with that of the plaster (see Fig. 20). 
 Secure this by passing the two strips above men- 
 tioned around the limb (Fig. 21), then turn the 
 vertical strip of plaster upward upon the tin. A 
 
 Fig 21. 
 
 slit should be made in the plaster where it passes 
 over the eye, in order that the latter may protrude. 
 The roller should then be continued smoothly up 
 the limb to the top of the tin. The plaster is again 
 reversed, and brought down over the bandage, 
 another slip being made for the eye, and the whole 
 secured by a few turns of the roller. A small chain, 
 a few inches in length, containing a dozen or twenty 
 
106 MEMOIR OF A. S. ROBERTS. 
 
 links for graduating the adjustment, is then secured 
 to the eye in the tin. 
 
 " Into either end of a piece of ordinary india- 
 rubber tubing, about one-fourth of an inch in diam- 
 eter, and two to six inches in length,, hooks of the 
 pattern here exhibited (see Fig. 18) are fastened by 
 a wire or other strong ligature. One hook is fast- 
 ened to the wire loop on the plaster on the foot, and 
 the other to the chain above mentioned, the various 
 links making the necessary changes in the adjust- 
 ment." The dressing when complete is shown in 
 Figs. 20 and 21. 
 
 The arrangement of Barwell's dressing may be 
 changed to suit the special deformity which it is 
 designed to treat. Sayre states that the only 
 objection which may be urged against this plan of 
 treatment is that the adhesive plaster sometimes 
 slides and changes its position, soon becomes worn 
 out, and requires frequent readjustment, and will 
 often excoriate. To overcome this defect he has 
 devised a club-foot shoe, upon the general plan of 
 Scarpa's shoe, in which the motive power consists 
 of elastic bands, and which can be resorted to when 
 the child is old enough to walk. It is applicable to 
 varus and valgus, and is thus described : In the 
 sole, opposite the medio-tarsal articulation, is placed 
 a ball and socket, or universal joint. " This sole 
 and part embracing the heel consists of strong 
 sheet steel, covered with leather on both sides. Two 
 lateral upright bars, B (Fig. 22), jointed at the 
 ankle, are fastened near the heel and to the collar- 
 band ; G, H, and J arc points for the attachments 
 
CLUB-FOOT: TALIPES. 
 
 107 
 
 tubing, with 
 
 of artificial muscles made of rubber 
 hooks and chains at their ends. To the inside walls 
 of the shoe, near A^ two flaps of chamois leather are 
 attached to lace together, which, passing over the 
 front of the ankle-joint, keep the heel firmly in the 
 back part of the shoe " (Say re). 
 
 Fig. 22. 
 
 Tenotomy Combined with Extension and Fixation. 
 In some cases it may be necessary, where they have 
 resisted the means described above, to resort to 
 tenotomy. This is best divided into two distinct 
 stages, as follows : 
 
 1. Tenotomy of the tendon of the anterior tibial 
 muscle and the anterior portion of the internal 
 lateral ligament (Adams), combined with the appli- 
 cation of a lateral varus splint. 
 
 2. Division of the plantar fascia, and subsequent 
 mechanical extension of the deep plantar ligaments 
 (Noble Smith), the extension being well accom- 
 
108 
 
 MEMOIR OF A. S. ROBERTS. 
 
 plished by the above-described modification of 
 Shaffer's varus splint. 
 
 Here it may be urged, it is of the utmost impor- 
 tance that the strictest care be exercised after the 
 performance of tenotomy. It is to the want of 
 careful after-treatment that the majority of the bad 
 results and relapses may be traced, and tenotomy 
 should never be performed where this necessary 
 after-care cannot be given. 
 
 Fig. 23. 
 
 Brisemeat forcr, a procedure which has been at- 
 tended with considerable success, and where the 
 time at the disposal of the surgeon has been limited, 
 has been performed in several ways. Of these the 
 
CLUB-FOOT: TALIPES. 109 
 
 two most frequent are that in which manual force is 
 employed, the patient being under an anaesthetic, 
 and that in which the force is applied by means of 
 a powerful instrument. Bradford, of Boston, has 
 devised such an instrument, which is described in 
 the " Boston Medical and Surgical Journal " for 
 March 20, 1884, and is shown in Fig. 23. 
 
 Tarsotomy and tarsectomy, and their application, 
 have already been alluded to in the remarks on the 
 general treatment of club-foot. 
 
 Having considered in detail the various methods 
 for overcoming the varus element in talipes equino- 
 varus, and before proceeding to a discussion of the 
 means employed in the correction of antero-pos- 
 terior deformities, we may very properly give some 
 consideration to the normal amount of flexion and 
 extension at the ankle-joint. This has been sum- 
 marized by Shaffer as follows: "Its function, except 
 in extreme extension, is that of a plain hinge-joint. 
 In the condition we have to deal with, flexion and 
 extension are the only movements to be considered. 
 Extension of the foot, in the adult, is limited at 
 about 135°, or 45° more than a right angle, using 
 the long axis of the tibia as the plane of measure- 
 ment. Flexion stops at about 70°, or 20° less than 
 a right angle (see Fig. 24). The position of the 
 foot in standing upon an even surface, with the 
 knee in full extension, is about 90°. The amount of 
 flexion and extension varies in different individuals, 
 but these figures, based upon actual experiment 
 and measurement, represent, I think, the average of 
 normal movement in the living adult subject." 
 
110 
 
 MEMOIR OF A. S. ROBERTS. 
 
 Upon this must be based our efforts in the reduc- 
 tion of these deformities, and we should endeavor 
 to obtain a resultant position of the foot as near 
 normal as possible : thus, in talipes equinus the 
 aim should be to make it possible for the foot to 
 describe an arc which will end in the position shown 
 in the figure as 70°, and in calcaneus extension 
 should be possible until the normal position marked 
 135° is attained. 
 
 Fig. 24. 
 
 Various degrees of normal flexion and extension at the ankle-joint. 
 (Shaffer's modification of Noble Smith's scheme.) 
 
 The means at our disposal for the accomplishment 
 of this, are : 
 
CLUB-FOOT: TALIPES. HI 
 
 1. Manipulation, Massage, and Electricity. These 
 have the same function in the anteroposterior de- 
 formity as was described in speaking of the varus 
 element. It is only in the application of these forces 
 that the difference exists. Here manipulations, etc., 
 should be directed to those muscles and tendons 
 producing the equinus, the application of the forces 
 mentioned having for their object the conversion of 
 the equinus into a calcaneus position. 
 
 2. Hetentive dressings have been so thoroughly 
 described when speaking of varus, that it is not 
 necessary to repeat the description here. All the 
 articles there mentioned for the construction of sim- 
 ple splint may be used with advantage in equinus, 
 both before and after tenotomy. 
 
 3. Extension and Eixation. The ordinary forms 
 of apparatus used to accomplish extension and fixa- 
 tion consist essentially of two uprights running 
 parallel, and placed on either side of the leg, con- 
 nected by a band to surround the calf; a joint cor- 
 responding to the ankle ; a heel-cup with a strap 
 and pad to secure the os calcis ; and a sole-plate, 
 with or without a hinge, to correspond with the 
 medio-tarsal joint. This, which is the usual modi- 
 fication of Scarpa's shoe, is made the means for the 
 application of force intended to act in place of the 
 anterior and lateral muscles. The objection to the 
 ordinary forms of apparatus used for the correction 
 of antero-posterior deformities has led Newton M. 
 Shaffer, of New York, to criticise them as follows : 
 " It seems very easy to construct an apparatus with 
 a joint to correspond with the tibio-astragaloid 
 
112 MEMOIR OF A. S. ROBERTS. 
 
 articulation, and to make this joint the centre of an 
 artificial movement imparted to the anterior part of 
 the foot through the medium of the foot-plate. But 
 let us see what happens when we attempt to do this 
 with the ordinary forms of apparatus. The centre 
 of motion, so far as the equinus position is con- 
 cerned, is at the tibio-astragaloid articulation. The 
 resistance lies in the post-tibial muscles, and the 
 power is applied in front to the tarsus and metatar- 
 sus — the object being simply to flex the foot and 
 bring down the heel. As the anterior part of the 
 foot rotates upon its artificial ankle-joint centre, or, 
 to put it in other words, as we crowd the os calcis 
 into the heel-cup, and attempt to flex the foot in 
 very much the same manner we would shut the half- 
 opened blade of a knife — the heel, unless restrained, 
 slips forward. The attempt is made to control this 
 movement by tying the heel down to the foot-plate 
 and in the heel-cup, with the heel-strap. If, after 
 this heel-strap (the analogue of the anterior annular 
 ligament) is tied, a considerable pressure be applied 
 in the direction of flexion (even in many cases after 
 tenotomy), the further tendency of the heel (being 
 restrained in front by the heel-strap) is to slip up- 
 ward and backward away from this artificial annular 
 ligament, ultimately, in many cases, resting on the 
 top of the heel-plate, which forms the cup. When 
 this occurs, all control over the foot is lost, as it 
 turns toward that side upon which the contractions 
 exist. One of the direct effects of mechanical 
 flexion, as applied in the customary forms of ap- 
 paratus, to overcome either a post-tibial or a 
 
CLUB-FOOT: TALIPES. 113 
 
 plantar contraction, is to crowd the tarsal bones 
 together. 
 
 " The foot-plate rotates around an axis, the centre 
 of which is the ' ankle-joint ' of the apparatus. The 
 point at which the retaining force and counter- 
 pressure (under the heel-strap), which holds the foot 
 in the apparatus, is made, must also rotate around 
 the pivotal point. Upon this heel-strap we must 
 rely principally for the means of retaining the foot 
 in the apparatus, and it supplies the only important 
 means for regulating the relation of the anatomical 
 to the artificial centre. If the foot, as a whole, could 
 be secured perfectly in the apparatus, and be made, 
 as we apply a gradually increasing force, to mechan- 
 ically follow the direction imparted to it by the arti- 
 ficial mechanism, the trouble would be reduced to 
 the minimum. Our artificial would then correspond 
 to the human mechanism. But, principally through 
 the causes referred to, the centre of rotation in the 
 foot and in the apparatus become changed in their 
 relations to each other, and all the pressure exerted 
 under these circumstances is productive of injury. 
 As pointed out, the tarsal bones become crowded 
 together, the heel slips beyond the control of the 
 apparatus, exposed points are apt to become ex- 
 coriated, and the result, while sufficient force has 
 been employed, though misapplied, is very discour- 
 aging in very many instances." 
 
 In view of the justice of these criticisms, and to 
 overcome these faults, Shaffer has devised an im- 
 proved extension club-foot shoe, a modification of 
 Scarpa's shoe, which presents nothing novel with 
 
 8 
 
114 
 
 MEMOIR OF A. S. ROBERTS. 
 
 the exception of an extension-bar acting upon the 
 sole of the brace. 
 
 The club-foot extension apparatus (Fig. 25) con- 
 sists of the ordinary uprights fastened to the heel- 
 
 Fig. 25. 
 
 Extension equinus brace, adjusted to deformity. 
 
 piece by a plain joint on one side, and an endless 
 screw, A, on the other. This screw allows us, by 
 using a key, to place the foot-piece of the apparatus, 
 as a whole, in any antero-posterior position we 
 choose, and to alter it at will, either before or after 
 application to the foot. That part of the foot-piece 
 
CLUB-FOOT: TALIPES. 
 
 115 
 
 which corresponds with the tarsus and metatarsus 
 is joined by a common extension-rod, c, to the por- 
 tion which lies under the os calcis. With a key we 
 are enabled to extend the anterior part of the foot- 
 piece at pleasure. 
 
 To apply this instrument, we first, by means of 
 the key, place the foot-piece in a position that will 
 
 Fig. 26. 
 
 Extension equinus brace ; first stage of correction. 
 
 exactly correspond with the antero-posterior position 
 of the foot (whether tenotomy has been performed 
 or not). We then secure the heel by tying the heel- 
 strap, d, and by means of another Avebbing-strap, e, 
 passing over the tendo Achillis, immediately above 
 
116 MEMOIR OF A. S. ROBERTS. 
 
 its insertion into the os calcis, secure it to the ante- 
 rior or extension portion of the foot-piece by buckles 
 on either side, as shown in the figure. The key, at 
 
 b, is now used to flex the foot, in overcoming to the 
 desired extent the tendo Achillis resistance. " When 
 this shall have been accomplished it will be found, 
 as in all similar apparatus where the artificial flexion 
 alone is depended on to overcome the post-tibial 
 resistance, that the posterior aspect of the heel is 
 pressing against the heel-plate " (see Fig. 26). In 
 varus the cuboid, in valgus the scaphoid bone, be- 
 comes uselessly crowded, and in a direction which 
 does little or no good. All the tarsal bones are 
 also crowded together by the force which is acting 
 in the arc of a circle, the centre of which is the 
 ankle-joint. But now, a turn or two of the key, at 
 
 c, brings the foot under control, and the centre of 
 motion being thus transferred, the heel must neces- 
 sarily describe an arc whose centre is at the point 
 of resistance, d, and is thus brought firmly into the 
 heel-cup, and if the extension force be further ap- 
 plied, will rest squarely upon the extension-bar, 
 thereby securing flexion at the ankle corresponding 
 to the degree of flexion of the foot-piece of the 
 brace, as shown in Fig. 27. If the tarsal de- 
 formity be only slight, the pressure at the cuboid 
 or scaphoid is modified ; the compression of the 
 tarsus is relieved; the plantar fascia, the plantar 
 muscles, and the tarsal ligaments are actually 
 stretched; besides which, the os calcis is placed 
 tinder restraint; in this way the traction force 
 passes through the tarsus directty to the tendo 
 
CLUB-FOOT: TALIPES. 
 
 117 
 
 Achillis. The mechanical counter-extension, of 
 course, is at the heel-strap, d. It simply retains 
 the foot in a position that allows a certain amount 
 of force to be expended on the contracted tissues. 
 The greater pressure under the heel-strap, however, 
 is exerted by flexing the foot with key b, rather 
 
 Fig. 27. 
 
 Extension equinus brace ; complete correction. 
 
 than by using the extension at c. Particular pains, 
 however, should be taken not to make these com- 
 bined forces too great. " As a matter of precaution 
 I always place several thicknesses of sheet-lint or 
 a thick layer of absorbent cotton (this latter makes 
 an excellent elastic pad) under the heel-strap and 
 
118 MEMOIR OF A. S. ROBERTS. 
 
 at the sides of the heel-cup. If a very considerable 
 extension is necessary, I pass an additional padded 
 strap over the lower end of the tibia, passing the 
 tapes attached back of the two uprights, securing 
 them in front over the pad. It is a matter of sur- 
 prise to me how well, with a little care, pressure is 
 tolerated at this exposed point under the heel-strap, 
 and, also, how little traction, applied in the manner 
 indicated, through the tarsus, is necessary to accom- 
 plish the object." In order to inspect the part 
 exposed to pressure without removing the appa- 
 ratus, it is only necessary to loosen the heel-strap 
 and turn key c until the extension-rod drops from 
 the cylinder, when the entire posterior part of the 
 apparatus may be easily removed. " The part under 
 the heel-pad should be inspected once a day. An 
 important point may be mentioned here : it is always 
 well to overcome almost wholly the lateral malposi- 
 tion of the tarsus before applying direct traction. 
 Time will be saved, and some annoyance also, if 
 this rule be uniformly followed." 
 
 The force which may be exerted by the above 
 apparatus should not be applied continuously, as 
 is popularly supposed. On the contrary, it should 
 be used as an intermittent force, and at stated 
 intervals. 
 
 In order to maintain the position gained by the 
 extension as used above, it is well to place the foot 
 in ;i retention shoe whilst the patient sleeps. The 
 same apparatus may be used when the foot has been 
 brought to a right angle, where it can be secured by 
 means of a stop-joint (see Fig. 28). 
 
CLUB-FOOT: TALIPES. 
 
 119 
 
 Should the above extension and fixation apparatus 
 be unobtainable, good results are often secured by 
 the use of the means described under the head of 
 
 Retentive Dressings. 
 
 Fig. 28. 
 
 Retention equinus shoe. 
 
 4. Elastic extension has already been spoken of in 
 detail when discussing the treatment of the lateral 
 deformity. The methods of Barwell and Sayre, so 
 adapted as to meet the antero-posterior deformity, 
 as shown in Figs. 20, 21, and 22, describe the appa- 
 ratus used by them. 
 
120 MEMOIR OF A. S. ROBERTS. 
 
 5. Tenotomy, combined with extension and fixation, 
 will comprise the division of the tendo Achillis, with 
 the necessary after-treatment, this completing the 
 third stage in the treatment of the compound form, 
 talipes equino-varus. No especial description is 
 required for the division of the tendo Achillis, and 
 the after-treatment has been discussed under the 
 general consideration of tenotomy. 
 
 Two conditions may be alluded to before closing 
 this section. 
 
 First : Symptomatic or compensatory equinus, a 
 condition found after shortening of the leg from 
 whatever cause, the patient attempting to equalize 
 length of the extremity affected by standing upon 
 the ball of the foot. This is easily corrected by the 
 addition of a high sole or patten. 
 
 Second : A condition of "residual " varus. Often, 
 even after the foot has been brought into excellent 
 position, a slight inversion of the anterior part of 
 the foot remains. This is often due to a relaxed 
 condition of the hip- and knee-joints, allowing of 
 abnormal inward rotation of the foot. To correct 
 this, many forms of apparatus have been devised. 
 Those of Gregory Doyle, or Stillman's modification 
 (see Fig. 29), as also those of Dr. Sayre and Dr. 
 Stedman, afford the best means at our disposal for 
 overcoming this condition. 
 
 Talipes Equino-valgus. The principles of the 
 treatment of club-foot having been fully discussed 
 under the caption Talipes Equino-varus, it is only 
 necessary here to speak of the modification of 
 methods caused by the difference in the direction of 
 
CLUB-FOOT: TALIPES. 
 
 121 
 
 the deformity, and the tissues involved. Owing to 
 its extreme rarity the surgeon is seldom called upon 
 to treat cases of this kind ; but here, as in talipes 
 equino-varus, it is necessary to overcome the ele- 
 
 FlG. 29. 
 
 Stillman's modification of Gregory Doyle's spiral spring 
 apparatus for residual varus. 
 
 ment of valgus first, which may be accomplished 
 by means similar to those mentioned when speaking 
 of equino-varus, the extension force, however, being 
 applied to the contracted peronei group ; after the 
 reduction of the lateral deformity, the equinus is 
 
122 MEMOIR OF A. S. ROBERTS. 
 
 overcome by the same means as serve to correct 
 the same deformity coexisting with varus. Mas- 
 sage, electricity, and the other adjuvants heretofore 
 mentioned should all be used in the manner already 
 described. 
 
 Similar methods will apply to Talipes Calcaneo- 
 varus and valgus. When speaking of Talipes Cal- 
 caneus, the means for the correction of the deformity 
 were fully discussed, and attention was called to the 
 application of rubber muscles posteriorly, and to 
 excision and suture of a portion of the tendo Achil- 
 lis. Reference to this portion of the article will fur- 
 nish details of these methods ; the lateral deformity 
 will, of course, require the same methods of treat- 
 ment as are called for by similar lateral deviations 
 occurring in the compound forms already described. 
 
 For the works which have been consulted in the 
 preparation of this article the reader is referred to 
 the section on History and Literature. 
 
POTT'S DISEASE 
 
POTT'S DISEASE. 
 
 DefhstitiojST. Pott's disease of the spine, so 
 called from the accurate, although not the first, 
 description of caries of the vertebrae, by Percival 
 Pott in 1779, is a lesion of the vertebral bodies or 
 intervertebral disks, characterized by inflammatory 
 changes, progressive in character, and ending in 
 total or partial destruction of the parts involved, 
 usually terminating in anchylosis more or less com- 
 plete, with the characteristic posterior deformity. 
 
 Synonyms . Posterior curvature, angular curva- 
 ture, spinal arthritis or osteitis ; Greek, Kyphosis ; 
 French, Mal-de-Pott, Cyphose; German, Spitz- 
 huckel. The objection to most of these terms is 
 that they express either a pathological condition or 
 a result of the disease, in no wise making clear or 
 improving the conception of the trouble. It would 
 thus seem well to retain the commonly-accepted 
 name of Pott's disease. If any scientific term were 
 to be adopted, Spondylitis avouM be the least open 
 to objection. 
 
 ETIOLOGY. 
 
 Pott's disease is essentially a disease of child- 
 hood, although not entirely limited to this period of 
 life, it having been found in the fetus, in extreme 
 
12G MEMOIR OF A. S. ROBERTS. 
 
 infancy, in middle age, and in very old people. As 
 a rule, however, it is most often found between the 
 ages of three and fourteen years. Sex exerts no 
 special influence in its production, although those 
 who believe only in the traumatic origin of the dis- 
 ease speak of its more frequent occurrence in males, 
 from their presumed greater liability to injuries. 
 
 In a general consideration of the etiology of Pott's 
 disease it will be well to divide the subject into — 
 
 1. Exciting causes — traumatisms and fevers. 
 
 2. Diathetic causes — tubercle, scrofula, rheuma- 
 tism, syphilis, etc. 
 
 Excitixg- Causes. In the question of causation 
 of Pott's disease, injury occupies so important a 
 place in the minds of both the profession and the 
 laity that a brief discussion of its significance as a 
 causative factor may not be amiss in this connection. 
 
 In almost all cases presented for examination, the 
 information is usually volunteered that the patient 
 has received a blow or a fall. A more careful ques- 
 tioning elicits, as a rule, a very vague etiological 
 description of the traumatism. Thus it often hap- 
 pens that in a child presenting a marked deformity 
 the traumatism assigned as its cause is referred to 
 a very recent period and is in character entirely out 
 of proportion to the supposed result. There can be 
 no doubt that, in the majority of cases presenting 
 clinically, the relations of cause and effect, consid- 
 ered from the stand-point of injury, are such as in 
 no wise to account for the symptoms presented. If 
 it should be accepted that the most frequent causes 
 of Pott's disease are concussions and blows, as 
 
POTTS DISEASE. 127 
 
 urged by the traumatists, it would follow that many 
 thousands of children in daily receipt of such in- 
 juries would be the victims of this disease or of 
 some analogous joint-trouble. That this is not the 
 fact is proved by the comparative infrequency of 
 the disease in question. Again, the amount and 
 character of injury are important considerations. 
 Thus, in many children a very slight traumatism 
 has been given as the cause of the subsequent 
 trouble, and in many cases, if no other conditions 
 were present, might be accepted as a definite cause. 
 Against these may be placed the severe injuries 
 and falls received in childhood, terminating in a 
 short time in perfect recovery or in death. From 
 this it follows that in the one case there must be 
 some special or underlying condition predisposing 
 to the production of a chronic insidious disease, 
 while in the other case the healthy organism so 
 modifies the process that a different result is brought 
 about. 
 
 The fact of the matter, as it appears to me, is that 
 injury, considered purely as a primary determining- 
 cause, has no claims to special consideration in the 
 large majority of cases ; that Pott's disease often 
 develops without any history of such injury as 
 would show a conclusive connection between the 
 injury and the disease ; and that at best it is but the 
 exciting cause bringing into activity an underlying- 
 general condition, and manifested by its local ex- 
 pression at the site of the supposed traumatism. 
 
 Among the causes of caries of the spine which 
 stand in the relation of direct exciting agents, the 
 
128 MEMOIR OF A. S. ROBERTS. 
 
 continued fevers of childhood, measles, scarlatina, 
 etc., and in fact all depressing conditions lowering 
 the vitality, are prominent and direct etiological 
 factors. The same underlying condition described 
 as giving potency to injury is undoubtedly often 
 present, the difference in the traumatism being 
 simply one of character and degree. The influence 
 of a depressing poison on a tender developing bone 
 is none the less on account of this difference in 
 causation, although manifest often in a different 
 manner. 
 
 Diathetic Causes. Our knowledge of scrofula 
 and tubercle in their causal relations to Pott's dis- 
 ease is as yet not of that definite character which is 
 desirable, and therefore cannot receive more than a 
 passing notice. When we speak of scrofula refer- 
 ence is had rather to a state or vulnerable condition 
 of the tissues than to a complete pathological entity. 
 Scrofula, therefore, we would refer to as a condition 
 of the system rendering it peculiarly prone to chronic 
 inflammations of a low type, retrogressive in char- 
 acter, and often occurring] without adequate cause, 
 accompanied by certain marked tendencies to skin- 
 affections, glandular enlargements, and bone-disease. 
 
 Tubercle at the present day plays so important a 
 role in its etiological relation to bone-inflammations 
 of the chronic type, and is of such consequence, 
 that a detailed discussion would hardly be in place 
 here. For a complete description the reader is re- 
 ferred to the article on tuberculosis, in another 
 section of this work. 
 
 Syphilis and rheumatism may at times be diathetic 
 
POTT'S DISEASE. 129 
 
 conditions productive of Pott's disease, but as yet 
 no direct evidences have been collected concerning 
 these conditions and their manifestations in the 
 malady under discussion. 
 
 PATHOLOGY. 
 
 Pathologically it may be well here to regard the 
 lesions found in Pott's disease as identical with the 
 changes found in other bone structures in which 
 there is tubercular caries. This is destructive in 
 character, and may be confined to a single vertebra 
 or may involve several. (Pig. 30.) 
 
 Fig. 30. 
 
 Showing extensive erosion of clorso-lumbar vertebrae. 
 
 It is in many cases attended or limited by the 
 occurrence of a rarefying osteitis. In the strumous 
 form of rarefying osteitis the first step in the pro- 
 
 9 
 
130 MEMOIR OF A. S. ROBERTS. 
 
 cess of inflammation is that of congestion, the bone 
 appearing as if blood were extravasated throughout 
 its structure; secondly, there is the formation of 
 granulation-tissue ; and lastly there occurs a degen- 
 eration and softening of the new formations, with 
 purulent exudations and absorption of bone-tra- 
 becula?. JSTow the bone-corpuscles undergo fatty 
 degeneration, and are presently destroyed, and, 
 
 i 
 
 Erosion of lumbar spine, popliteal abscess, without deformity. 
 
 owing to strangulation of the vessels, caseation of 
 the inflammatory products results. When the dis- 
 ease is rapid the cancellous spaces and Haversian 
 canals are filled with pus. The process, being a 
 strumous or tubercular one, differs from simple 
 traumatic rarefying osteitis, arising, as it does, from 
 
POTT'S DISEASE. 
 
 131 
 
 an internal or constitutional cause, or from such 
 local irritation that a slight injury would bring it 
 into activity. Even such injury is not necessary to 
 provoke this strumous or tubercular caries, it often 
 arising from no appreciable cause. A peculiar 
 feature of this caries is its limitation to spongy 
 bone-tissue, it rarely affecting the transverse, artic- 
 ular, or spinous processes primarily. (Fig. 31.) 
 
 Fig. 32. 
 
 Characteristic " hunchback " deformity. 
 
 Again, this degenerative process assumes different 
 degrees of intensity, being in some cases superficial, 
 involving only a portion of the anterior surfaces of 
 the vertebrae, while in other cases it not only exca- 
 vates the body of the vertebra?, but also attacks the 
 
132 MEMOIR OF A. S. ROBERTS. 
 
 intervertebral fibro-cartilages and the adjacent soft 
 parts, giving rise to abscess. (Fig. 32.) Not 
 infrequently the abscess is confined within the bone, 
 the exudation becoming purulent, the granulation- 
 tissue breaking down, the pus and debris collecting 
 into an abscess-cavity, and the walls of the abscess 
 being composed of the inflamed disintegrating bone 
 and lined by caseous pus. 
 
 It oftener happens that in rarefying osteitis the 
 bone is absorbed in such a manner that an island of 
 
 Fig. 33. 
 
 &t 
 
 (■■■; 
 
 l&. 
 
 
 Marked angular curvature, resulting in compression, myelitis, 
 and paraplegia. 
 
 osseous substance is separated from the rest by a 
 belt of granulation-tissue and dies, giving rise to 
 the caries necrotica, but if it retains its vascular 
 connection it forms a living sequestrum. While 
 
POTT'S DISEASE. 133 
 
 the bodies of the vertebrae are being absorbed, osteo- 
 plastic or protective osteitis takes place about the 
 neural arches, being a conservative action, prevent- 
 ing by sudden dislocation a crushing of the spinal 
 cord. (Fig. 33.) 
 
 A class of cases were first described by Brodie 
 in which no suppuration took place, and these have 
 at a more recent period been designated as dry 
 caries, or caries sicca. They are identical with the 
 so-called " osteitis fungosa " (Billroth), and are 
 characterized by the presence of interstitial granu- 
 lation-tissue growing throughout the bone. Here 
 the granulation-tissue fills the Haversian canals and 
 medullary spaces, and insidiously eats its way into 
 the bony meshes. In this class of cases the granu- 
 lation-tissue may undergo fatty degeneration and 
 caseation without suppuration. 
 
 It will be readily seen that the foregoing condi- 
 tion differs widely from the simple rarefying osteitis, 
 or caries, the result of injury, there being in the 
 latter no underlying vice of the system. In this 
 class of cases we have first a simple dilatation of 
 the bloodvessels, followed by a pouring out of liquor 
 sanguinis and leucocytes. In many cases the pro- 
 cess stops at this point, and, the inflammation sub- 
 siding, resolution takes place, the parts returning to 
 their normal contour. This limited caries undoubt- 
 edly explains the rapid recovery of many cases of 
 so-called spondylitis following traumatism, and may 
 also happen when Pott's disease follows one of the 
 exanthemata, the patient being of sound constitu- 
 tion at the time. 
 
134 MEMOIR OF A. S. ROBERTS. 
 
 SYMPTOMATOLOGY. 
 
 Before attempting to enter into a complete de- 
 scription of the symptoms as met with in the 
 different regions of the spine in a case of Pott's 
 disease, some general consideration of the different 
 stages is of importance, and of these we will begin 
 with the stage of invasion. 
 
 In the vast majority of cases the general health 
 of the patient has been for a greater or less time 
 below the normal standard. Even without any 
 tubercular or strumous history or appearance that 
 is marked, there is a condition present best expressed 
 by the comprehensive term malaise. A child shows 
 indifference to its surroundings, its usual occupa- 
 tions or enjoyments, and presents a listless, dejected 
 appearance. It is easily tired and irritable, and 
 appears sick. The appetite, previously good, be- 
 comes affected ; the child loses flesh, and the skin 
 assumes an appearance very different from the clear 
 look of perfect health. The muscular tissues often 
 become flabby, and the total appearance of the 
 patient indicates that it is affected by some insidious 
 potent malady. 
 
 Here we have the condition met with in many 
 bone-diseases, especially where the epiphyses are 
 principally affected, the so-called " incipient stage," 
 or, as it has been otherwise designated, the " pre- 
 t nbercular " or " vulnerable " condition. This stage 
 often escapes detection, the symptoms rarely being 
 connected with the disease, and their importance 
 being frequently overlooked. These symptoms in- 
 
POTT'S DISEASE. 135 
 
 dicate the existence of a period, and their correct 
 interpretation at this time is of the utmost impor- 
 tance as regards the ultimate result of the case, this 
 being the most favorable time to avert an increase 
 of inflammation and prevent deformity. 
 
 Stage of Paiist. Succeeding the rather general 
 disturbance just described, we come to a period the 
 most important symptom of which is pain. The 
 pain of Pott's disease varies greatly in character 
 and extent, and its location is always dependent on 
 the site of the inflammation. 
 
 It will be well in this connection to say a few 
 words regarding the commonly-accepted idea that 
 the pain of caries of the spine is always to be found 
 posteriorly localized at the seat of the disease as 
 manifested by the deformity. Much importance 
 in making an examination of the spine has been 
 attached to the recognition of this local pain, by 
 means of hot sponges and other substances passed 
 along the spinal column. Nothing could be more 
 fallacious, experience showing that the pain of Pott's 
 disease is referred to the posterior portion of the spine 
 only in very rare instances. 
 
 The pain of Pott's disease is, as a rule, subacute, 
 varying greatly in character and in degree, in many 
 cases being intermittent, at other times being de- 
 scribed as lancinating and intense. There is a 
 marked relation between the rapidity and extent of 
 the inflammation and the amount of pain. Its loca- 
 tion may be tersely stated as following the general 
 law that pain which is the result of nerve-irritation 
 is reflected to its periphery. Thus, it ic often found 
 
136 MEMOIR OF A. S. ROBERTS. 
 
 below the seat of the disease and anteriorly (gas- 
 tralgia), but rarely above it, the exception occurring 
 in some cases of cervical caries. As a rule, the pain 
 is worse in the earlier stages and at night, and is 
 aggravated by motion and position. Cases have 
 been recorded, however, where pain has been entirely 
 absent through the whole course of the disease. 
 
 Stage of Muscular Rigidity. We next meet 
 with a condition of the muscles which is of impor- 
 tance in both diagnosis and prognosis. This is a 
 state of spasm or rigidity, and is supposed to be 
 due to reflex irritation of the nerves supplying the 
 diseased bone. Its presence is regarded as pathog- 
 nomonic of osteitis. Here, as in all the large artic- 
 ulations, where the condition of the muscles is 
 constantly found associated with joint disease, its 
 function would seem to be an attempt to mobilize 
 the part, and is nature's effort to bring about this 
 end. It is an early sign, sometimes appearing even 
 before pain is complained of, and continues to a very 
 late stage of the disease. This constitutes at times 
 the only available symptom, and is at all times of 
 the greatest practical importance in diagnosis when 
 properly interpreted. It is not to be confounded 
 with the bony rigidity found at a late period of the 
 malady, the result of partial or complete anchylosis. 
 This reflex muscular spasm is unique in character, 
 and its study in connection with chronic bone dis- 
 ease shows peculiarities not found in other condi- 
 tions. It is an unyielding tetanoid spasm, present 
 day and night, being, so to speak, forever on guard 
 to prevent any injury to the diseased part. It yields 
 
POTT'S DISEASE. 137 
 
 only to complete anaesthesia, ordinary doses of opium 
 or chloral not affecting it. Accompanying this 
 spastic condition of the muscles, the result of nerve 
 irritation, we also have a specific atrophy, reflex in 
 character, and noticeable at times in Pott's disease 
 where the mnscles are well developed, especially in 
 the erector spinae group, and progressing in direct 
 ratio as the disease advances. This symptom is 
 not always so easy to determine in Pott's disease 
 as in other articulations, located more specifically, 
 but is undoubtedly always present. 
 
 Stag-e of Deformity. Although, rationally 
 considered, the deformity of spondylitis takes place 
 at a later period than the stages already mentioned, 
 it is by no means unusual, especially in public prac- 
 tice, for it to be the first symptom of sufficient 
 importance to attract the attention of the parents 
 or friends to the patient, or deemed worthy of the 
 care of the surgeon. This projection backward of 
 one or more spinous processes is identical with that 
 period already mentioned when speaking of pathol- 
 ogy, where there is a breaking down of the vertebral 
 bodies forming the anterior support of the spine. 
 The superincumbent weight falling on the weakened 
 support increases the projection, causes abnormal 
 pressure on the carious and weakened vertebrae in 
 their changed direction, and alters the normal curves 
 of the spinal column. Where the carious process 
 is rapid and extensive, the amount of deformity 
 will be proportionately large, and sharp or gradual, 
 according to the amount of disease present. Where 
 the long gradual curve is present, it shows a large 
 
138 MEMOIR OF A. S. ROBERTS. 
 
 area of inflammation, but not necessarily a rapid 
 one. On the contrary, where only one or two 
 vertebrae are involved in the carious process, the 
 deformity is sharper and well defined. In the 
 cervical and lumbar regions determination of the 
 amount of disease by the appearance of the deform- 
 ity is entirely unreliable, the deformity in these 
 situations, owing to the anatomical position and 
 construction of the vertebrae, rarely attaining the 
 proportions found especially in the mid-dorsal spine. 
 By some authors it is held that the shape of the 
 curvature establishes the suppurative or non-sup- 
 purative character of the lesion. Thus, it has been 
 maintained that caries sicca frequently involves a 
 number of the vertebrae primarily, the resulting pro- 
 jection partaking more of the character of a true 
 curvature, while but few vertebrae or only a single 
 one are involved in the acute suppurative variety, 
 giving rise to the sharp, angular deformity. 
 
 Stage oe Abscess. Among the most common 
 of the consequences of caries of the spine is the 
 formation of abscesses, which during their formation 
 and course give rise to important symptoms. While 
 these, as a rule, are more frequently met with in the 
 later periods of the disease, the patient is at no time 
 exempt from them, and they may occur at the earliest 
 time, even before deformity is visible. Again, some 
 cases run their entire course without the appearance 
 of an abscess, while in other cases abscesses have 
 been detected, which have disappeared without 
 opening or giving rise to any marked disturbance. 
 These collections of pus, coming from the carious 
 
POTT'S DISEASE. 139 
 
 foci, follow the general rule of the least resistance, 
 and in their passage important parts and organs are 
 protected by the fasciae. It may be stated that they 
 open at some distance from the point of origin and 
 according to the site of the lesion. The most com- 
 mon situation for the formation of these abscesses 
 may be broadly stated to be found in connection 
 with caries of the dorso-lumbar region. The dorsal 
 abscesses find their way beneath the ligamentum 
 arcuatum into the sheath of the psoas muscle, and 
 are guided by the attachment of the sheath of this 
 muscle under Poupart's ligament and into Scarpa's 
 triangle, where they most commonly open and dis- 
 charge their contents. Caries of the lower lumbar 
 spine gives rise to the so-called lumbar or gluteal 
 abscess. This has its normal outlet through the 
 great sacro-sciatic notch, and most often points at 
 the lower border of the gluteus maximus. Some- 
 times these lumbar abscesses appear posteriorly, 
 having perforated the quadriceps lumborum, and 
 make their appearance at or about the seat of the 
 disease. In caries of the upper or cervico-dorsal 
 vertebras abscesses pass in front of or behind the 
 sterno-mastoid, or into the posterior wall of the 
 pharynx, where they are known as retro-pharyngeal 
 abscesses. Again, they may be found in the thorax, 
 forming a mediastinal abscess, and discharge into 
 the trachea, bronchi, or oesophagus, or at some 
 external point. 
 
 While we have, for the convenience of the reader, 
 given the usual course pursued by these spinal 
 abscesses, it is not to be understood that they all 
 
140 MEMOIR OF A. S. ROBERTS. 
 
 follow these methodical directions. Indeed, their 
 course is subject to the greatest vagaries. Thus, 
 we have records of cases where the abscesses opened 
 at various abnormal positions — in the mouth, lungs, 
 bronchi, stomach, intestines, bladder, and rectum, 
 or in external parts remote from the site of forma- 
 tion. A remarkable circumstance in connection 
 with the course of abscesses connected with spinal 
 caries is the very rare occurrence of a fatal termina- 
 tion directly traceable to them. We have, however, 
 already spoken of the protection afforded to impor- 
 tant adjacent parts and organs by the fascia? along 
 which the abscess passes. 
 
 As a rule, not much disturbance of a general 
 nature is experienced during the development and 
 course of an abscess. The patient may have an 
 exacerbation of evening temperature, with slight 
 chilliness and perspiration. Pain is slightly in- 
 creased, the latter ceasing, however, as the pus 
 reaches an external situation, or where inflammation 
 does not occur in the sac itself. The abscess may, 
 however, occasion much local disturbance, according 
 to its location and size. In retro-pharyngeal abscess 
 dysphagia and suffocative attacks may be experi- 
 enced, and when it opens into the bronchi there is 
 an expectoration of pus, attended by extreme dysp- 
 noea and collapse. All the reported cases of rupture 
 into the peritoneum and large bloodvessels have 
 terminated fatally. Abscesses may remain station- 
 ary for a long time, and, especially in children, give 
 rise to very little disturbance of function or of the 
 general health. Occasionally they are, under care- 
 
POTT'S DISEASE. 141 
 
 ful mechanical treatment, absorbed ; but, as a rule, 
 they steadily increase in size and finally rupture. 
 
 Stage of Paraplegia. It so often happens in 
 disease of the lower cervical and upper dorsal region 
 that we meet with paraplegia of the lower extremi- 
 ties that, while it cannot perhaps be considered as 
 strictly a distinct stage of Pott's disease, it is still 
 of sufficient importance to demand separate descrip- 
 tion. This paraplegia, which generally involves 
 only the motor functions of the cord, has been 
 usually believed to be the result of a compression- 
 myelitis, and, while pathologically partaking rather 
 of the characteristics of a pachymeningitis or men- 
 ingo-myelitis, gives rise to such symptoms as would 
 ordinarily result from a myelitis due to pressure, 
 either from inflammatory products or abscess. Its 
 onset is marked by a gradual diminution in the 
 strength of the parts affected, until eventually there 
 is complete loss of power, but usually little disturb- 
 ance of sensation. All the reflexes are increased, 
 as indeed they are very early, and at times it is 
 possible to prognosticate the approach of the para- 
 plegic condition by this exaggeration of the patellar 
 tendon and other reflexes. Muscles which are the 
 seat of paraplegia become rigid and tense, and at 
 times marked clonus is easily produced, while at a 
 later period, where the paraplegia has existed for a 
 long time, permanent contracture may result. The 
 paraplegia of Pott's disease is a bilateral affection, 
 and, as before stated, usually involves the lower 
 extremities. In rare cases of dorsal caries, more 
 frequently of upper cervical, the upper extremities 
 
142 MEMOIR OF A. S. ROBERTS. 
 
 may be involved. The functions of the rectum and 
 bladder are rarely disturbed, and there is little inter- 
 ference with the general nutrition of the patient, 
 atrophy taking place only in the paraplegic parts. 
 Indeed, it not infrequently happens that many of 
 these patients gain flesh, probably from their forced 
 confinement in one position. Recovery is often 
 spontaneous, and seems to be the natural tendency 
 of this form of paraplegia. Recurring attacks are 
 not of unusual frequency, a case having been under 
 my personal observation where two attacks took 
 place with recovery, and other writers report similar 
 results. Cases have also been reported where re- 
 covery took place with marked sensory disturbance, 
 as in a case under the author's care, where both 
 sensation and motion were lost. As a rule, the 
 involvement of the sensory function would render 
 the prognosis less favorable than where there was 
 simple motor paraplegia, 
 
 DIAGNOSIS. 
 
 It may be stated as a general axiom that diag- 
 nosis is of value proportionately as it enables us to 
 give early and prompt treatment to the patient, and 
 in no disease is this more pertinent than in the one 
 under consideration. ISTo difficulty in diagnosis is 
 experienced where, as is, unfortunately, too often 
 the case, patients present a kyphosis and abscess 
 well marked, or a paraplegia in full progress. Here, 
 however, the opportunity for relief, certainly so far 
 as deformity is concerned, is reduced to the mini- 
 mum. Where we are brought into contact with a 
 
POTT'S DISEASE. 143 
 
 case in which we do not find this tell-tale deformity 
 or other marked symptoms — in other words, an 
 incipient case — the question of diagnosis becomes a 
 more difficult one, and will necessitate a most care- 
 ful inquiry into the symptoms, both subjective and 
 objective, before we are enabled to arrive at a proper 
 conclusion. 
 
 Examination of a patient presenting with symp- 
 toms which would indicate the existence of spinal 
 caries should be conducted in the following manner: 
 A history should be taken, according to a uniform 
 plan, and with especial reference to certain points. 
 The general condition, hereditary tendencies to dis- 
 eases, apparent cause, and mode of invasion should 
 first occupy our attention. Secondly, the subjec- 
 tive symptoms — pain, etc. — should be considered. 
 Thirdly, the attitude and aspect will often give 
 valuable held in diagnosis. 
 
 Most important is the physical examination of 
 the patient, and this should be conducted as follows : 
 The patient, after being stripped, is placed in a good 
 light, and the surgeon, standing at his back, observes 
 any inequalities of the spinous processes, or any 
 deviation from the normal contour of the spinal 
 column. In this way any marked irregularity will 
 be at once manifest. Spinal flexibility should next 
 receive attention. In order to have a correct per- 
 ception of the spinal rigidity due to reflex muscular 
 spasm, it is necessary that a knowledge of the 
 normal mobility of the spine should be obtained, 
 and this is tested best by the " Adams method," 
 as follows : The patient, standing erect, with arms 
 
144 MEMOIR OF A. S. ROBERTS. 
 
 at the side, should be directed to touch the toes 
 with the points of the fingers, the head being thrown 
 forward on the chest. If the spine be normal, no 
 difficulty will be experienced in performing this 
 simple manoeuvre ; should there be any rigidity, the 
 movement will be checked at a certain point. The 
 same test practically may be applied to young chil- 
 dren unable to stand, by placing them prone on a 
 hard couch, the surgeon grasping the heels and ele- 
 vating the whole lower segment of the body. If 
 the spine be normal, it will be surprising, to those 
 who have never used this test, to see what an 
 amount of mobility can be obtained in this manner. 
 As the thighs ascend, the spine bends, in some cases 
 enough to allow the heels to approach the occiput. 
 This motion would be checked at some point of the 
 normal arc were disease present, and the spine as- 
 sume such rigidity that the back would rise as a 
 whole. Lateral mobility, which in the normal spine 
 is considerable in extent, and of great value in diag- 
 nosis, is affected in a similar manner by the presence 
 of disease. Taken as a ivJiole, spinal rigidity is the 
 most constant and valuable symptom we jwssess for 
 diagnosis, and, in conjunction with pain and attitude, 
 often enables us to diagnosticate serious spinal caries 
 long before the appearance of deformity. 
 
 With these few preliminary remarks, we will 
 proceed to the study of regional diagnosis in Pott's 
 disease. 
 
 Cervical Caries. The different regions of 
 the spine affected with caries are characterized by 
 widely-differing symptoms, depending upon the 
 
POTT'S DISEASE. 
 
 145 
 
 mobility, nervous supply, and construction of the 
 vertebras forming the different segments. In the 
 cervical region we most often have disease at the 
 third, fourth, and fifth vertebrae, and the muscular 
 
 Fig. 34. 
 
 m 
 
 Cervical caries. 
 
 expression of disease at this point is quite charac 
 teristic. The patients hold the head rigidly in a 
 position either of flexion or extension, greater or 
 
 10 
 
146 MEMOIR OF A. S. ROBERTS. 
 
 less according to the amount of the disease. (Fig. 
 34.) On attempting to move the head, the surgeon 
 is resisted by marked reflex spasm in the direction 
 either of flexion or extension, yet mobility in rota- 
 tion will be found free. Herein lies a valuable 
 diagnostic point in differentiating disease of the 
 lower cervical from disease of the two upper cervical 
 vertebrae, as rotation is in the latter markedly and 
 invariably resisted. Pain is referred to the parts 
 immediately below the diseased area. Pains radiat- 
 ing down the arms and in some cases to the sides 
 of the neck, and even to the superior parts of the 
 thorax, are most often complained of, the pains fol- 
 lowing the general rule and finding their expression 
 at the periphery of the nerves. Jars and concus- 
 sions are badly borne, and we are often enabled to 
 observe a marked broadening of the neck. In the 
 attempt to hold the head in such a position that 
 concussion from jar is least liable to be felt, the 
 spinal column below the point of disease assumes a 
 compensatory curve, giving a hollow appearance to 
 the dorsal part between the shoulders, with a pro- 
 jection in the lumbar region. 
 
 In cervical disease it is sometimes possible to feel 
 the thickened vertebra3 through the mouth, especially 
 where the caries has advanced sufficiently to occa- 
 sion some breaking down of the bodies and bulging 
 forward of the post-pharyngeal wall, or, again, 
 where an abscess points in this region. Paraplegia 
 may be associated with disease of this part. 
 
 Less frequently than disease of the third, fourth, 
 and fifth, we meet with disease of the first and second 
 
POTT'S DISEASE. 147 
 
 cervical vertebrae, or atlo-axoid disease. Here rigid- 
 ity is quite expressive, and of itself furnishes a 
 diagnosis. In disease between the atlas and axis 
 all rotary movements are checked, and, while it is 
 very rare that we have uncomplicated disease of 
 these two vertebrae, a sufficient number of cases 
 occur to make this limitation of motion strongly 
 characteristic. It is in this region, although not 
 exclusively, that we meet with the torticollis de- 
 pendent on spinal caries, and this is sometimes 
 difficult to distinguish from wry-neck due to causes 
 independent of bone disease, but is always a valua- 
 ble aid to diagnosis. The characteristic of this 
 symptomatic torticollis is that in spinal caries the 
 head is rotated toward the contracted muscles, 
 whereas in the idiopathic form of wry-neck torsion 
 takes place away from it. Again, there is a spas- 
 modic feeling imparted to the muscles on movement, 
 and the posterior group are more commonly involved 
 than the sterno-mastoid in the contraction due to 
 reflex spasm. Ether abolishes the contraction com- 
 pletely. With atlo-axoid disease pain is found 
 early in the upper part of the neck and in the occip- 
 ital region, or, again, is complained of in the ears, 
 the sides of the neck, or the upper part of the chest, 
 and is neuralgic in character. This pain is increased 
 by pressure on the head or by any movements affect- 
 ing the upper part of the spinal column. Hilton 
 speaks of pain in atlo-axoid disease as being always 
 unilateral, and seems to think that this indicates the 
 side of the vertebrae affected. Swelling and broad- 
 ening of the neck also occur ; marked protrusion of 
 
148 MEMOIR OF A. S. ROBERTS. 
 
 the pharyngeal wall can sometimes be felt with the 
 finger in the mouth, the patient being subject to 
 attacks of dysphagia. Deformity appears at a 
 variable period, the patient having adopted a pecu- 
 liar attitude. The head may be flexed or extended 
 markedly, with rotation, but usually it is projected 
 forward, and supported in every possible position 
 by the patient, recumbency being the favorite pos- 
 ture. It has been supposed that deformity in this 
 region depends upon a forward luxation of the atlas 
 upon the vertebras beneath, and the spinous process 
 of the axis can often be felt or seen. 
 
 Abscesses are common in this region, and present 
 frequently as " post-pharyngeal " collections of pus, 
 giving rise to serious symptoms, which have re- 
 ceived detailed description in works on surgery. 
 Abscesses may appear also at the sides of the neck 
 posteriorly, and follow the course of other deep- 
 seated cervical abscesses. Nerve symptoms are 
 very often associated with atlo-axoid disease, vary- 
 ing greatly in extent, from paralysis of one arm to 
 a more general paralysis of the parts below the 
 neck. This is usually of the motor type, but at 
 times anaesthesia is noticed with loss of vesical and 
 rectal control. Cerebral symptoms meningeal in 
 character often occur, or sudden death may take 
 place from crushing of the spinal cord. 
 
 Differential Diagnosis (Cervical Region). 
 We have already spoken of torticollis as being at 
 limes a symptom of caries of the cervical region 
 easily mistaken for idiopathic wry-neck, and have 
 given a rule for its differentiation. Among other 
 
POTT'S DISEA SE. 149 
 
 diseases liable to be mistaken for this serious malady 
 are lateral curvature involving the upper part of the 
 spine, muscular rheumatism, simple abscess, aden- 
 itis, acute traumatic lesions, and hysterical simula- 
 tion of Pott's disease. Lateral curvature is rare in 
 this region, and is usually accompanied by rotation 
 and marked by absence of pain and reflex spasm. 
 It should be borne in mind, however, that a lateral 
 deviation of the spine may take place early in Pott's 
 disease, and in any region, but this disappears, as a 
 rule, rapidly with the advent of bony deformity and 
 other pronounced symptoms, and is entirely modi- 
 fied by treatment. Muscular rheumatism is marked 
 by tenderness of the muscles themselves and by the 
 entire absence of bone deformity, and is more apt 
 to take place at a later period of life. The move- 
 ments of the neck, while stiff and painful, give no 
 characteristic spastic sensation, and the transitory 
 and shifting character of the affection should leave 
 no doubt as to its nature. Simple abscesses are 
 usually acute in character, attended by high tem- 
 perature, and their history and superficial character 
 leave little room for doubt. Acute traumatic lesions 
 — dislocation and fracture — are diagnosticated by 
 the history, the sudden deformity, and the usual 
 signs of such injuries as met with in other parts of 
 the body. 
 
 Hysterical simulation is at times exceedingly 
 difficult to diagnosticate from true spondylitis, and 
 may be encountered in all parts of the spinal 
 column. In the simulated condition pain is the 
 most prominent symptom, and is always complained 
 
150 MEMOIR OF A. S. ROBERTS. 
 
 of at the supposed seat of the disease, differing 
 from that of true caries, which is generally reflected 
 to the anterior part of the body. It has all the 
 characteristics of an intense hyperesthesia, and 
 light pressure apparently gives rise to great suffer- 
 ing, such as is found in the so-called " spinal irrita- 
 tion." When attention is diverted, the pain on 
 pressure either disappears or a new locality is com- 
 plained of. There is no reflex spasm, voluntary 
 efforts being made to keep the spine quiet, and per- 
 sistent gentle f&rce usually overcomes the resistance 
 to motion. Care must be taken in estimating the 
 amount of motion present, our diagnosis depending 
 largely on the muscular expression accompanying 
 the disease. Whatever bulging of the vertebrae 
 occurs is immediately reduced by placing the pa- 
 tient in the prone position. Paralysis of hysterical 
 origin is very common, and at times is difficult to 
 distinguish from the paraplegia of Pott's disease. 
 It is, as a rule, sudden, differing from the gradual 
 loss of power found in the course of spondylitis, is 
 more often unilateral or confined to one extremity, 
 and frequently disappears as suddenly as it came. 
 
 Dorsal Caries. The attitude of a patient suf- 
 fering with caries of the upper dorsal region suggests 
 the attempt of one endeavoring to balance the head 
 on the shoulders. (Fig. 35.) The chin is elevated, 
 the spinal column below the seat of disease is 
 straightened, and at times curved forward and held 
 rigidly, and the gait and carriage of the patient are 
 those of extreme apprehension. When the bony 
 deformity is large, the head sinks between the ele- 
 
POTT'S DISEASE. 
 
 151 
 
 vated shoulders, giving a characteristic " turtle- 
 head " appearance. Pain in disease of this region 
 is referred to the chest and sides, and often there is 
 disturbance of the respiratory function, as mani- 
 fested by a peculiar " grunting," at times accom- 
 
 Fig. 35. 
 
 Dorsal caries. 
 
 panied by cough, dyspnoea, and partial cyanosis. 
 Interference of motion at this portion is detected 
 with some difficulty, owing to the fact that nor- 
 mally here is the most rigid and unyielding portion 
 of the spinal column. This, however, is sufficiently 
 
152 MEMOIR OF A. S. ROBERTS. 
 
 well marked and appreciated, especially when the 
 other symptoms present are taken into considera- 
 tion. Paraplegia is most often found in connection 
 with disease of the upper dorsal spine, and affects 
 chiefly the lower extremities. Reference to this has 
 already been made under the head of Symptom- 
 atology. 
 
 Mid-dorsal disease gives rise to the typical "hunch- 
 back," the most persistent deformity taking place in 
 this region. The progressive character of the lesion 
 is due to several reasons. It is in this locality, 
 especially the superior dorsal, that we contend with 
 the constant traumatism of respiration, and, having 
 a fixed projection in the middle of a flexible column, 
 the application of proper supports becomes a matter 
 of great difficulty. The attitude assumed by patients 
 with disease in this region is an exaggeration of the 
 one described under disease of the upper dorsal 
 spine. A marked rigidity in stooping or lifting 
 articles from the floor is noticed. The patient in 
 performing these movements lowers the body as a 
 whole, bending his knees and hips, and gradually 
 approaches the article he wishes to raise, resuming 
 the upright position with infinite care, never allow- 
 ing the spine to bend. Pain is marked, especially 
 on motion, and is referred most frequently to the 
 lower part of the thorax and stomach, giving the 
 " initial gastralgia " so often complained of, and at 
 times coming on very early in the course of the 
 disease, antedating even the appearance of the 
 deformity. It is of great importance to realize 
 distinctly the connection of this pain with spinal 
 
POTT'S DISEASE. 153 
 
 caries, as many children are treated during long 
 periods for many different diseases — indigestion, 
 worms, and other disorders of the digestive tract 
 being not infrequently assumed as the cause of the 
 pain. The pain is frequently accompanied by the 
 so-called " osteitic cry," and occurs most often at 
 night, this cry being in character very much like 
 that of acute hydrocephalus, and found in connec- 
 tion with disease of the bone in any part of the 
 spine or of the articulations. 
 
 Disease of the lower dorsal spine is so intimately 
 associated with lumbar caries that it will be best 
 considered in the description of that region. 
 
 Differential Diagnosis (Dorsal Region). 
 Before the appearance of deformity causing abnor- 
 mal curves to appear in the spine, aneurism of the 
 thoracic and abdominal aorta, eroding the vetebral 
 bodies, as evinced in two autopsies the author had 
 opportunities of making, may give rise to symptoms 
 similar to those of spinal caries. Diagnosis by 
 auscultation and the presence of other symptoms 
 usually establish the nature of this lesion before 
 the spine is much affected, and the extensive curve 
 and localized pain are sufficient to demonstrate the 
 existence of aneurism. 
 
 Malignant growths, cancer, etc., are rarely seen 
 in children. 
 
 Chronic pleurisy, with effusion or empyema, and 
 other inflammatory lung troubles, would be excluded 
 by physical signs. 
 
 Rhachitic curves are very common in the dorsal 
 region (Fig. 36), but are marked by their gradual 
 
154 
 
 MEMOIR OF A. S. ROBERTS. 
 
 character and extent, and are attended by the char- 
 acteristic large head, flattened epiphyses, general 
 tenderness, and inability to walk. Motion is rarely 
 limited, the curvature mostly disappearing in the 
 
 Fig. 36. 
 
 Functional spinal debility simulating caries. 
 
 prone position. Pain, when present, is local in 
 character, and the general listless appearance of the 
 patient serves to explain the functional curve. 
 
 Disease of the Lumbar Region. Disease of 
 the lower segment of the vertebral column, which 
 will here include the lower dorsal and lumbar ver- 
 tebrae, presents some especially important features 
 from the stand-point of diagnosis. It is here that 
 
POTTS DISEASE. 
 
 155 
 
 we have to deal with a portion of the spine largely 
 controlled by the psoas muscles, and the reflex limi- 
 tation of motion at this point gives us most valua- 
 ble indications concerning not only the condition of 
 the vertebrae, but also the presence and progress of 
 
 Fig. 37. 
 
 Lumbar caries. 
 
 abscess, which is more often encountered here than 
 in disease of any other part of the spine. Here, 
 again, a special attitude is assumed by the patient, 
 in most cases consisting of a " lordosis," or an ante- 
 rior curvature of the spine. This is nature's mode 
 
156 MEMOIR OF A. S. ROBERTS. 
 
 of protecting the diseased parts, there being a con- 
 servative attempt made to throw the weight of the 
 body from the diseased vertebral bodies on to the 
 articulating facets. The reflex muscular spasm is 
 best appreciated here by placing the patient in the 
 prone position and making the movement already 
 described in the general remarks on diagnosis. (See 
 Fig. 37.) As stated, the condition of the psoas 
 muscle furnishes us with excellent indications as to 
 the presence or absence of abscess in its sheath. 
 If, the patient being prone, the surgeon makes 
 pressure on the pelvis with one hand, holding it 
 firmly in one position, and, grasping the thigh with 
 the other hand, the knee having previously been 
 flexed, attempts to extend the thigh on the pelvis, 
 should contraction of the psoas exist he will be met 
 by a decided limitation in the extension of the thigh. 
 The application of this test, one of the utmost im- 
 portance, is easily learned, and, in conjunction with 
 palpation of the pelvic fossae and with the general 
 symptoms of pain, temperature, etc., will usually 
 show the presence or absence of an abscess. This 
 limited extension is generally found unilaterally, but 
 may be bilateral, and on the emergence of the 
 abscess from the pelvic cavity usually disappears. 
 Pain from caries of the dorso-lumbar spine is re- 
 ferred to the hypogastric region and the lower 
 extremities. 
 
 Paraplegia with this form of spondylitis is among 
 the rarest of complications, for well-known anatom- 
 ical reasons. Deformity, as in the cervical region, 
 rarely reaches the degree met with in the mid- 
 
POTT'S DISEASE. 157 
 
 dorsal spine, and in many cases where the disease 
 is confined exclusively to the lumbar vertebrae little 
 or no deformity is noticeable. 
 
 Differential Diagnosis (Lumbar Region). 
 Many diseases may occur at or about this part of 
 the vertebral column with spinal caries, and the 
 knowledge and experience of the surgeon will often 
 be severely tested in differentiating between them. 
 Disease of the last lumbar vertebra is often mis- 
 taken for hip-joint disease, the converse being also 
 true. 
 
 Sacro-iliac disease, perityphlitis and nephritis, 
 sciatica, lumbago, and other diseases may also 
 obscure the diagnosis ; but space forbids a detailed 
 account of the symptoms and methods used for 
 differential diagnosis, the reader being referred to 
 the articles on these subjects in other portions of 
 this work. 
 
 GENERAL PROGNOSIS. 
 
 In general terms it may be stated that the prog- 
 nosis of Pott's disease depends largely on that 
 portion of the spinal column affected by the caries. 
 Thus, the best results of treatment are usually 
 obtained in the cervical and lumbar regions, at times 
 lasting many years, although so-called acute cases 
 have been reported. Much of the success achieved 
 in later times in the treatment of spondylitis may 
 be ascribed to a more correct interpretation of the 
 symptoms, to a better knowledge of the etiology 
 and of the mechanics of the parts, and, above all 
 to a better adaptation of the various supports used 
 
158 MEMOIR OF A. S. ROBERTS. 
 
 in the treatment of the diseased areas. Prognosis 
 will always be affected by the amount of personal 
 attention given by the surgeon, by the home care 
 of the patient, and by the detail with which the 
 mechanical treatment is carried out. During the 
 progress of a case the symptoms may be held in 
 abeyance for a long time, and the inexperienced 
 surgeon, judging from the cessation of pain, the 
 apparent arrest of deformity, and the non-appearance 
 of abscess, may remove the apparatus, thinking his 
 patient cured. Very soon, however, he is unde- 
 ceived ; the symptoms become more acute in char- 
 acter and assume an alarming aspect, the patient 
 having one of the exacerbations known to every one 
 familiar with these cases. The earlier the diagnosis 
 is made and the child placed under mechanical treat- 
 ment and good hygienic conditions, the better the 
 prognosis. Notwithstanding the fact that the 
 strumous or tubercular diathesis usually underlies 
 the lesion, many patients recover, with more or less 
 deformity, and sometimes live to advanced age. 
 The deformity when once present rarely disappears, 
 although it may be diminished at times by treatment. 
 Abscess was formerly regarded as a symptom of 
 the utmost gravity as affecting prognosis, but many 
 patients recover, with strong, though sharply-de- 
 formed backs, who have had one or more abscesses. 
 Ii is an undoubted fact that many abscesses form 
 and entirely disappear, protective treatment modify- 
 ing their course to a very large extent. Abscesses 
 which suppurate and discharge by fistulous openings 
 for a long time are necessarily of grave import in 
 
POTTS DISEASE. 159 
 
 making a prognosis, owing to the ultimate involve- 
 ment of internal organs, amyloid degenerations 
 oftentimes causing death from kidney and liver 
 complications. 
 
 Paraplegia, while a distressing complication and 
 alarming alike to the parents and the attendants, is, 
 as a rule, recovered from, often spontaneously, 
 although usually it lasts for a long time. An 
 exception to this is found in the paralysis attending 
 upper cervical disease, where sudden death may 
 take place from crushing of the cord or involvement 
 of the respiratory centre, or, again, where motion 
 and sensation are both involved, incurable paralysis 
 often remains. We have discussed this complica- 
 tion at some length in a former section. 
 
 Death often occurs from rupture of an abscess 
 internally, from intercurrent inflammations, such as 
 pneumonia and tubercular meningitis, or from ex- 
 haustion following long-continued discharges. The 
 acute exanthemata have a deleterious effect on the 
 progress of caries, and pertussis is a particularly 
 dangerous complication, especially in disease of the 
 thoracic vertebra, the affection of the spine advanc- 
 ing rapidly, the patient often dying in a paroxysm. 
 Hemorrhage from perforation of large bloodvessels, 
 and suffocation from discharge of abscesses into 
 the lungs, have also been reported as complications 
 with a fatal termination. 
 
 TREATMENT. 
 
 The modern treatment of Pott's disease has 
 attained a measure of excellence attested in a hio-h 
 
160 MEMOIR OF A. S. ROBERTS. 
 
 degree by the much less frequent sight of those 
 distressing deformities which were at one time so 
 common. Much of this is due to the improved 
 means not only of treatment but also of early diag- 
 nosis, and to American surgery is largely due the 
 advance in this formerly much neglected branch of 
 medicine. In commencing the treatment of caries 
 of the spine a consideration of the pathological 
 state that we have to deal with is of the utmost 
 importance. It must be remembered that there 
 exists in this condition a retrograde rather than a 
 reparative process, one which in its course is entirely 
 different from the process that follows an acute 
 traumatic lesion. Instead of its being a question 
 of days or weeks, months and sometimes even years 
 are necessary to effect a cure. 
 
 There being this long-continued drain on the 
 S3^stem, it is obvious that the care of the general 
 health should receive as much attention at our 
 hands as the local condition, which in most in- 
 stances is but the expression of a general constitu- 
 tional state. 
 
 The principles of treatment to be constantly held 
 in view should be those which aim at (1) improve- 
 ment of the general health and (2) proper rest to 
 the diseased parts, which embraces the question of 
 correct mechanical support. 
 
 Before mentioning those remedies which have 
 been found of service as general reconstructive 
 agents, we would insist, in every case where it is 
 possible, on the importance of fresh air and sun- 
 light, the influence of which has been recognized 
 
POTT'S DISEASE. 161 
 
 and has largely aided in bringing abont the good 
 results of modern treatment. We have ventured 
 to speak of these agents before mentioning the 
 more generally used medicines, feeling, as we do, 
 that if restricted to a choice, we should select these 
 hygienic means as against internal medication. All 
 such medicines as tend to "bone-building" are of 
 value in this disease, and the selection of one — 
 whether it be cod-liver oil, the compound syrup of 
 the hypophosphites, phosphorus, or any of the tonics, 
 mineral or vegetable — depends largely on the con- 
 dition of the individual case and the judgment of 
 the practitioner. 
 
 Under the second division all those means which 
 have for their object proper rest of the diseased 
 parts, and which include recumbency and splints 
 or braces, will be considered. The question of rest 
 encounters at present no dissent except from those 
 whose experience and clinical opportunities hardly 
 entitle them to speak with authority. On the 
 mode of giving proper support there is still much 
 difference of opinion. 
 
 The treatment by recumbency has had and still 
 has its advocates ; its chief merit consists in the 
 fact that in the recumbent position, whether prone 
 or supine, there is no superincumbent weight press- 
 ing upon the spine. Where other means are not at 
 hand, it is well that the recumbent posture should 
 be advised ; but the utter failure of simple recum- 
 bency is easily explained by the difficulty of keeping 
 a patient in bed, in one position, without other 
 means. It is often necessary, even with good me- 
 
 11 
 
162 MEMOIR OF A. S. ROBERTS. 
 
 chanical support, that a patient should be confined 
 to bed, especially where exacerbations occur or a 
 paraplegia is in progress. Thus recumbency be- 
 comes an aid rather than a mode of treatment, and 
 in this way has a legitimate place in our therapeu- 
 tics of Pott's disease. The effect of recumbency 
 on the general health, especially in strumous cases, 
 has been variously estimated. Many believe that, 
 by lessening the pain and irritation, the general 
 health has improved. Personally the results ob- 
 tained by us with other means have been, as a rule, 
 so favorable that we have not had occasion to test 
 its merits from this stand-point. 
 
 Extension and suspension are modes of treatment 
 which have been used for a long time, and which 
 have recently been brought into prominence. The 
 former has been used with advantage in cervical 
 disease, but here again the treatment by this method 
 necessitates the recumbent posture, and, unless 
 under exceptional circumstances, we prefer the use 
 of apparatus which allows fresh air and sunlight, 
 while the patient receives proper support at the 
 same time. 
 
 Suspension as a mode of treatment in caries of 
 the spine is now generally used simply to allow of 
 the application of plastic supports. As a remedial 
 agent it is of no value independent of support. The 
 idea formerly entertained, that by suspension path- 
 ological curves could be obliterated, no longer pre- 
 vails, it having been demonstrated that, while the 
 physiological curves may be altered or even obliter- 
 ated, the gibbous curvedoes not change its character. 
 
POTTS DISEASE. 163 
 
 Suspension should always be practised with the 
 greatest care, and always under the direction and 
 in the presence of the surgeon or an assistant. 
 
 Mechanical Treatment. The plan pursued 
 in the section on diagnosis — namely, the regional 
 one — will be continued in the consideration of treat- 
 ment. ^N"o attempt will be made to consider the 
 numberless mechanical devices used in the treat- 
 ment of Pott's disease, only those receiving atten- 
 tion which in the hands of the author have been 
 found to be most easy of adjustment and modifica- 
 tion, and which mechanically are capable of meeting 
 the indications in the greatest number of cases. 
 The principles underlying the question of all such 
 apparatus as are used in the treatment of Pott's 
 disease ought to be such as will enable us to secure 
 certain objects. Chief among these are, first, the 
 prevention of undue traumatism ; second, the avoid- 
 ance, as far as is practicable, of any movement of 
 the diseased parts ; and, last, the prevention, where 
 possible, of increase of pain and deformity. In the 
 present state of our knowledge, there is no appa- 
 ratus that will satisfactorily accomplish all these 
 indications, and we have already stated why this 
 lesion presents difficulties in the way of treatment, 
 from a pathological stand-point, entirely different 
 from those which present themselves in the treat- 
 ment of an acute traumatic trouble. Were the 
 anatomical opportunities present, as they are in 
 other articulations, for making proper traction on 
 the diseased parts, there could be no doubt as to the 
 superiority of this method ; but the application of 
 
164 MEMOIR OF A. S. ROBERTS. 
 
 continuous traction to certain localities of the spine, 
 the subject of carious inflammation, and the limita- 
 tion of such traction force, are not, in our opinion, 
 possible. 
 
 The treatment of Pott's disease by the plaster-of- 
 Paris jacket, as popularized by Prof. Say re, has of 
 late years received so many adherents and been so 
 universally accepted as an easy mode of treating 
 this disease that a few words concerning it and 
 similar plastic supports will not be out of place. 
 It is an undeniable fact that any apparatus which 
 gives protection from undue motion and traumatism 
 to certain diseased areas will afford relief, and for 
 giving us a ready means of treating such localities 
 Prof. Sayre's method is of the greatest value. This 
 is particularly true of the dorso-lumbar region, 
 which is the most easily controlled of any portion 
 of the spine. 
 
 There are, however, certain disadvantages con- 
 nected with the use of any plastic material, which 
 are of sufficient importance to receive attention. 
 The encircling the body in any solid support pre- 
 vents the surgeon from having the opportunity of 
 carefully watching the progress of the disease, and 
 of estimating the condition of the skin, so that it 
 shall receive proper care. Ulcerations or abscesses 
 may form without his knowledge, and no modifica- 
 tion of the apparatus is possible without removal 
 and renewal. The improvement which ensues on 
 the application of any apparatus giving immobility 
 is such that patients, as well as surgeons, are apt 
 to be deceived by the amelioration of the symptoms. 
 
POTTS DISEASE. 165 
 
 and hence escape the strict watch necessary in these 
 cases. Thus the plastic envelope may be borne for 
 months, the disease constantly advancing, and the 
 patient returning only at rare intervals, owing to 
 the absence of the acute manifestations. Among 
 the poor, while it has the advantage of cheapness, 
 the lack of cleanliness is a drawback to the use of 
 the plaster, which those in public practice cannot 
 have failed to notice. It is obvious, therefore, that, 
 while possessing the advantages of economy, of 
 needing less special experience than is required for 
 the application and modification of steel braces, and 
 of being entirely beyond the control of the patient, 
 these are offset by the disadvantages already men- 
 tioned. 
 
 It is not an easy thing to apply a proper jacket, 
 and it requires considerable experience to apply an 
 efficient one, its improper application being apt to 
 do great harm. A brief description of its mode of 
 application will suffice here ; for a fuller account the 
 reader is referred to Dr. Sayre's work on " Spinal 
 Disease and Curvature," London, 1877. 
 
 Suspension is obtained by securing the head in a 
 sling, which is attached to a strong cord playing in 
 a pulley and fastened to a staple driven into a firm 
 place above the patient's head. The patient having 
 previously had a tight-fitting, seamless undershirt 
 applied, suspension is begun. The cord attached 
 to the pulley is so pulled that the patient's heels are 
 raised from the floor. Freshly-prepared plaster, of 
 the best dental variety, having been rubbed into 
 cross-barred crinoline or other loose-meshed cloth, 
 
1(36 
 
 MEMOIR OF A. S. ROBERTS. 
 
 and rolled into bandages, is then applied. These 
 bandages should before application be placed in 
 water until bubbles cease to appear. The parts 
 
 I lor'8 modification of Davis's spinal assistant. (From Transac- 
 tion- oi the Americas Orthopedic Association, vol. i., 1889.) 
 
POTT'S DISEASE. 167 
 
 most liable to excoriation are carefully padded, and 
 over the abdomen a ' ; dinner-pad " is applied, which 
 is afterward removed, in order to prevent too great 
 pressure. In females the mammae are also padded. 
 The bandages should be put on smoothly, and as 
 high as possible, and there should be no inequalities 
 or differences in thickness between the front and 
 the back portion. After the plaster has hardened, 
 the patient is placed on a smooth soft surface, and 
 all rough edges are cut away, making the support 
 as comfortable as possible. Plastic supports of dif- 
 ferent materials may be applied without suspension. 
 
 Fixative Apparatus. Apparatus of different 
 constructions, and representing many principles, are 
 in use ; but we have personally had such excellent 
 results from the anteroposterior support as modi- 
 fied by C. F. Taylor, of New York, that in closing 
 the account of treatment we shall speak of this 
 alone. (Fig. 38.) 
 
 The antero-posterior splint acts upon the prin- 
 ciple of a lever, with its fulcrum at the point of 
 deformity. The apparatus is constructed as follows : 
 Two uprights made of the best annealed steel, al- 
 lowing of easy bending and modification of shape, 
 are connected above by a transverse bar, giving 
 attachment for the shoulder-pieces, and below by 
 a pelvic band. (Fig. 39.) At the location of de- 
 formity, and where we wish them to serve as a 
 fulcrum, are placed the pad-plates, which extend for 
 some distance above and below the deformity, and 
 should always be sufficiently long to include the 
 entire area of disease. These are pieces of steel 
 
168 
 
 MEMOIR OF A. S. ROBERTS. 
 
 slightly wider than the uprights, and are fastened 
 to the uprights by hinges allowing of easy removal 
 and modification. In some cases they may be 
 screwed to the upright without hinges. They are 
 
 Fig. 39. 
 
 Davis's spinal assistant. 
 
 padded with various materials, ground cork being 
 the best. The uprights should be so widely sepa- 
 rated that the pressure of the pad-plates will come 
 on the transverse process, and never on the spinous 
 ones. The uprights should extend high enough to 
 give sufficient leverage, and below to the anal com- 
 missure, and the pelvic band should be broad and 
 strong, extending from trochanter to trochanter. 
 Cross-pieces for the insertion of buckles which are 
 attached to the anterior support or apron are placed 
 at points corresponding to the upper border of the 
 
POTT'S DISEASE. 169 
 
 axillae and the lower angle of the scapulae, and are 
 attached to the uprights by screws. The anterior 
 part of the support consists of an apron made of 
 strong jean or other similar material, and this serves 
 to fasten the trunk to the apparatus. It reaches 
 from the upper border of the axillae in front to a 
 point just above the symphysis pubis. Webbing 
 straps are attached at different points for attach- 
 ment into the buckles of the cross-pieces and pelvic 
 band, and to the shoulder-pieces are attached padded 
 axillary straps. 
 
 The apparatus is applied as follows : The patient 
 is placed in the recumbent posture on a hard even 
 couch, with the apron applied to the anterior part of 
 the trunk. The brace, previously fitted to the con- 
 tour of the spine, is first secured by the pelvic band 
 and by axillary straps which pass to the lower cross- 
 piece. The upper strap of the apron is then attached 
 to the upper cross-piece. These are the important 
 and essential points of attachment, and should 
 always be made firm. Supplementary webbing 
 straps and buckles may be attached to the apron to 
 give more firmness to the support. 
 
 Principles of the Antero-posterior Support. The 
 antero-posterior support acts, as has already been 
 stated, on the principle of a lever with a fulcrum at 
 the location of the deformity (Fig. 40) and acting 
 through the transverse processes. The pelvis is 
 another point of pressure, forming the base of the 
 support, and the resistance is furnished anteriorly 
 by the superior thoracic wall and the traction of 
 the shoulder straps passing under the axillae. The 
 
170 
 
 MEMOIR OF A. S. ROBERTS. 
 
 power is maintained by the two uprights to support 
 the spine in the same position as is gained by the 
 recumbent posture. 
 
 Fig. 40. 
 
 Diagram showing the principle of Davis's support. 
 
 There are certain rules concerning the application 
 of the antero-posterior brace which should be care- 
 fully followed. It should always be put on in the 
 recumbent posture. The pressure should be en- 
 tirely equable over the transverse processes, as 
 made by the pad-plates, and the shoulder-pieces 
 should never press on the shoulders, it being well 
 to leave a small space between the lower surface of 
 the shoulder-pieces and the shoulders. The axillary 
 pads should run in such a direction that no constric- 
 tion will occur on the axillary vessels and nerves. 
 The brace should be worn day and night, unless 
 
POTTS DISEASE. 171 
 
 removed for some special reason or complication, 
 and in no case should a patient with a carious spine 
 be allowed to assume the upright position without 
 support. Bathing should be done by sponging the 
 body, the patient being recumbent. 
 
 For ease of application, for convenience of modi- 
 fication and inspection, for comfort and cleanliness 
 to the wearer, and for maintaining the proper press- 
 ure, we know of no apparatus which will compare 
 with the antero-posterior brace. With a little care 
 in adjusting the apparatus, it is within the province 
 of every surgeon to secure with it the most satis- 
 factory results. 
 
 Measurements for Ajjparatus. It is important 
 that the surgeon should be fully equipped not only 
 to measure for his apparatus, but also, when it is 
 sent to him in crude form, to be able to fit it and 
 modify it, so that nothing is left to the instrument- 
 maker but its manufacture. 
 
 It is measured for as follows : The patient is 
 placed on a hard surface in the prone position. A 
 strip of flexible lead or block-tin, which retains its 
 form, is laid over the spinous processes from the 
 neck to the anal commissure, and all the inequalities 
 are carefully moulded with the lead. This is then 
 placed on a stencil-board or ordinary pasteboard, 
 and the inner outline traced with great care. This 
 outline is then cut out with scissors, and marks 
 places on the pattern for the position of the pad- 
 plates, cross-pieces, and shoulder-pieces. The pelvic 
 measurement is taken from trochanter to trochanter. 
 The pattern serves a double purpose, being the 
 
172 
 
 MEMOIR OF A. S. ROBERTS. 
 
 guide for the instrument-maker, and also a record 
 of the deformity at the time of measurement, and 
 should be kept for future observation. 
 
 Treatment op Cervical Caries. Under this 
 head will be included the treatment of caries extend- 
 ing to the seventh dorsal vertebrae, as above this 
 point we have, in order to get efficient support, to 
 
 Fig. 41. 
 
 ipM 
 
 Spinal support, with chin-rest, for treatment of upper dorsal and 
 cervical caries. 
 
 extend the arm of the lever superiorly. This is 
 best done by means of Taylor's chin-piece, which 
 is secured to the uprights by means of a " keeper 
 and pivot." (Fig. 41.) A modification of this has 
 been devised by Dr. Shaffer, in the form of a ball- 
 and-socket joint (Fig. 42), which allows of motion 
 in all directions, which can be locked at any point, 
 
POTT'S DISEASE. 
 
 173 
 
 and in which the head can be treated in the position 
 of deformity, and so held and modified from time to 
 time. It is important that the chin-piece (Fig. 43) 
 surmounting the apparatus should not be too large, 
 and its measurement represents only the occipito- 
 mental diameter. 
 
 Fig. 42. 
 
 Ball-and-socket joint for accurate adaptation of chin-rest, 
 
 In this region, it must be remembered, we are 
 dealing with a rigid projection in the middle of a 
 flexible column. It is thus not easy to secure ade- 
 quate support, especially in the upper dorsal region, 
 and the addition of the superior lever by means of 
 the chin-piece is of great importance. 
 
 Fig. 43. 
 
 Chin-rest. 
 
 In the cervical region above the second dorsal 
 vertebrae, treatment, as a rule, is attended by excel- 
 
174 MEMOIR OF A. S. ROBERTS. 
 
 lent results. It is sometimes necessary still further 
 to supplement our chin-piece by the addition of 
 occipital uprights (Fig. 41), which increase the sup- 
 port. Traction-force is not attempted with the 
 chin-piece, immobility being the object primarily in 
 view. In some cases where the expense of a steel 
 brace is of moment, disease in this region may be 
 treated by means of a pedestal of plaster encircling 
 the trunk, into which the chin-piece with ball-and- 
 socket pivot can be adjusted. The advantages of 
 the chin-piece in the treatment of disease of the 
 upper portion of the spine are its lightness, firm- 
 ness, and inconspicuous appearance as compared 
 with the "jury mast" used in the treatment by 
 plaster-of-Paris for the same affection. 
 
 Treatment of Dorsal Disease. Disease of 
 the dorsal vertebra? extending from the seventh to 
 the twelfth is very common. The mechanical diffi- 
 culties here, as well as in the lumbar region, are 
 much more simple than those involved in the treat- 
 ment of the upper part of the spine. We have 
 here as a firm basis for our support the pelvis below, 
 while the thorax and axilla? afford excellent locations 
 for securing fixation. It is in dorsal disease that 
 the best results are often obtained, traumatism 
 being reduced to a minimum by the absence of 
 respiratory and other movements, which conflict 
 with proper support in the cervico-dorsal region. 
 In this region sufficient leverage can be obtained 
 by the use, of* the antero-posterior support without 
 the use of a chin-piece. It is necessary,, however, 
 that the anterior support or apron should be firm, 
 
POTT'S DISEASE. 175 
 
 and it is often beneficial to reinforce this by the 
 supplementary means of corsets, etc. 
 
 Treatment of Lumbar Disease. Here the 
 difficulties of treatment are reduced to a minimum, 
 for the same reasons as stated in speaking of lower 
 dorsal caries. The results in this region are usually 
 good, exception sometimes taking place in disease 
 of the last lumbar vertebra. At times, owing to 
 the form of the deformity, it is difficult to prevent 
 the apparatus from pushing or slipping upward. 
 This may be prevented by attaching perineal straps 
 to the apron, which pass between and are fastened 
 to buckles inserted in the pelvic band. It is espe- 
 cially in the lower region of the spine that any 
 apparatus, whether of steel or plaster, providing 
 proper fixation and support, gives real and at times 
 instantaneous relief to the symptoms. Care must 
 be taken here, as well as in the other localities af- 
 flicted with caries, not to remove the splint too early. 
 
 Treatment oe Complications. Abscess and 
 paraplegia are the two most common complications 
 of caries of the spine. Of the former, we would 
 simply say that for the surgical procedures neces- 
 sary for their relief the reader is referred to works 
 on surgery. There is, however, one point to which 
 we wish to call attention. Clinical experience has 
 taught orthopedic surgeons that the course, prog- 
 ress, and treatment of cold abscesses connected 
 with Pott's disease are materially affected by me- 
 chanical treatment. Where good support of the 
 diseased parts is given we are sure that the devel- 
 opment of abscesses is less common, their course is 
 
176 MEMOIR OF A. S. ROBERTS. 
 
 more benign, and in many instances they are entirely 
 absorbed. Abscesses of this nature should not be 
 opened too early, and, when opened, it is well to do 
 so in a position suitable for thorough drainage, and 
 under rigid antisepsis. 
 
 Paraplegia, as has been already stated, has, when 
 caused by caries of the spine, a spontaneous dispo- 
 sition to recover. Its treatment is still somewhat a 
 vexed question. Absolute rest in the recumbent 
 posture, with efficient support, has seemed to us to 
 have been of most benefit. The affection being 
 spastic in its nature, the result usually of a direct 
 irritation of the cord, electricity in any form would 
 be strongly contraindicated. Suspension as a 
 means of treating the paraplegia of Pott's disease 
 has not, up to this date, been sufficiently tried or 
 recorded to give any idea of its status as a treat- 
 ment for this form of paralysis. 
 
 In conclusion, the question of cessation of treat- 
 ment is of practical importance. With the disap- 
 pearance of pain and the non-increase of deformity, 
 as evidenced by repeated measurement and compari- 
 son of the patterns, with the disappearance of reflex 
 spasm, allowing of free motion above and below the 
 deformity, and lastly with the general improvement 
 in the condition of the patient, it may be considered 
 that solidification has taken place and that the 
 carious process has been arrested. Relapses may 
 occur, or disease may appear in other parts of the 
 spine, and a careful watch should for a long period 
 of time be kept on patients who have been the 
 subjects of Pott's disease. 
 
THE SPINAL ARTHROPATHIES 
 
 12 
 
THE SPINAL APTHKOPATHIES. 
 
 A CLINICAL REPORT OF SIX CASES OE CHARCOT'S 
 
 JOINTS. 
 
 Case I. — M. K.., male, aged forty-one, referred to 
 the New York Orthopedic Dispensary from St. 
 Luke's Hospital on May 5, 1879. Hereditary his- 
 tory unusually good. He is a moderate drinker. 
 Health excellent until manifestation of present joint 
 trouble. Married, and the father of five healthy 
 children. 
 
 Condition at date of entry : A large nodular 
 tumor was found over the left hip-joint, oval in 
 shape, the long axis of which corresponds with line 
 of Poupart's ligament (Fig. 44). Transverse diam- 
 eter of normal limb over hip-joint, 22 inches ; of 
 affected limb at same point, 30J inches. No mus- 
 cular atrophy detected by measurements of circum- 
 ference. Left limb If inches shorter than its fellow; 
 measurements made from the umbilicus. External 
 iliac fossa of left side filled with osteophytes, which 
 add to bulk of tumor. The ligamentous structures 
 about the joint seem entirely destroyed ; motion of 
 the limb abnormally free in all directions. Head 
 of femur probably absorbed or greatly atrophied. 
 Limb abducted and rotated outward. What ap- 
 
180 
 
 MEMOIR OF A. S. ROBERTS. 
 
 pears as the head of the femur is anterior to its 
 normal position, lying under a "shed" of bone, 
 built out from the pelvis, which covers its atrophied 
 extremity like an umbrella. When the patient 
 
 Fig. 44. 
 
 flexes the limb, the upper extremity of the femur 
 glides forward until it catches under this " shed " of 
 provisional bone, which, acting as a fulcrum, allows 
 the patient to flex and rotate the limb with ease. 
 
TEE SPINAL AB THR OPATHIES. \ 81 
 
 A thorough examination of the patient for evi- 
 dence of a central lesion, revealed the absence of 
 numbness of limbs, of pain, or of constricting bands ; 
 sensation slightly impaired on left side. On right 
 side, reflex action increased on titillation of soles ; 
 none on left. No tendon reflex in either limb. 
 Sways with " closed eyes test." 
 
 Condition eighteen months later: The patient 
 presented all the marked symptoms of locomotor 
 ataxia. Two years from date upon which the above 
 notes were recorded (May 5, 1879), he is confined 
 to bed, with complete loss of muscular coordination. 
 
 Remarks. The case exhibits an arthropathy 
 existing four and a half years prior to the develop- 
 ment of active tabetic symptoms, and shows a 
 tendency, from early stages, to the formation of 
 osteophytes about the joint, with early atrophy of 
 the upper epiphysis of the femur. 
 
 At no time during the progress of the lesion were 
 there developed reflex neural symptoms that would 
 point to joint inflammation. 
 
 The joint lesion (swelling and tumefaction) dimin- 
 ished as the active symptoms of ataxia advanced. 
 Provisional callus was thrown out about the atro- 
 phied extremity of the femur as a substitute for the 
 destroyed acetabulum. 
 
 Case II. — O. P., male, aged forty-four. Regis- 
 tered as an out-patient in the New York Orthopedic 
 Dispensary on January 29, 1879. The following 
 notes were recorded : 
 
 Hereditary History. Parents living and 
 healthy ; one brother died of phthisis. Patient is 
 
182 
 
 MEMOIR OF A. S. ROBERTS. 
 
 married ; has three children, two in excellent health, 
 the third has an intrapelvic abscess (subsequently 
 died of amyloid degeneration of the kidneys). Pa- 
 tient has had to work very hard, with considerable 
 mental anxiety ; no other known cause for present 
 disease. 
 
 Fig. 45. * 
 
 The left knee and ankle (Fig. 45) are enlarged, 
 the latter more so relatively than the knee. The 
 patient states that seven years ago, while working, 
 a heavy box fell upon him, injuring the ankle. The 
 joint became swollen, and he was "laid up for two 
 months." lie recovered, and suffered no inconven- 
 ience for one year; the swelling again returned in 
 
THE SPINAL ARTHROPATHIES. 183 
 
 the same ankle and involved the entire leg. At 
 this time he was incapacitated from work for three 
 months ; recovered, and has had no active joint 
 symptoms since. Has never had an abscess about 
 the joint. 
 
 The urgent symptoms at present examination are 
 those of locomotor ataxia. He cannot walk with- 
 out staggering, and when attempting to do so in 
 the dark, or with closed eyes, falls. Suffers from 
 ataxic pains in the right leg and arm. Is uncertain 
 in guiding his finger to the tip of his nose, with eyes 
 closed, or in putting his heel on a designated spot. 
 Sensation impaired in right hand and arm ; has diffi- 
 culty in buttoning his coat with that hand. "When 
 standing or walking in his bare feet, he feels as 
 though he were on cushions ; vision unimpaired 
 (eye-ground not examined). 
 
 On February 4, 1879, Dr. Cloves Adams saw the 
 patient in consultation, and thought him to be suf- 
 fering from locomotor ataxia in the third stage, with 
 osseous changes in left ankle and synovitis of both 
 knees. 
 
 The patient returned to the dispensary in Sep- 
 tember of the same year, with a marked elastic 
 swelling of the right elbow-joint (Fig. 46). 
 
 A year later (November, 1880), he was referred 
 to the clinic of Dr. E. C. Seguin. He again applied 
 to the Orthopedic Dispensary on February 14, 1881. 
 The ataxic symptoms had advanced ; he walked 
 with extreme difficulty. The condition of the joints 
 remained about the same as when last examined, 
 now four months ago. 
 
184 
 
 MEMOIR OF A. S. ROBERTS. 
 
 During November (1881) the patient was criti- 
 cally examined by Dr. S. Weir Mitchell, and pro- 
 nounced to be in the third stasre of locomotor ataxia, 
 
 Fig. 46. 
 
 with spinal arthropathies of the right elbow and 
 left ankle-joints. It was noted that the circumfer- 
 ence of the elbow tumor had materially diminished 
 since the last measurements were recorded (decrease 
 of two and a half inches). 
 
THE SPINAL ARTHROPATHIES. 185 
 
 Remarks. The joint enlargements in this patient 
 presented three characteristic peripheral ataxic con- 
 ditions : 
 
 1. At the knee-joint synovial irritation, indicated 
 by the physical signs of a chronic synovitis, although 
 at no time during its course was there evidence of 
 inflammation. 
 
 2. A characteristic doughy, nodular, ataxic joint 
 tumor of the elbow, largely composed of osteophytes 
 and excessive synovial secretion. 
 
 3. Hypertrophy of the lower epiphyses of the 
 tibia and fibula, with but slight synovial irritation. 
 
 The peripheral manifestations at the knee and 
 ankle accompanied the earlier symptoms of ataxia ; 
 the elbow tumor entered abruptly upon the second 
 stage of the sclerosis. I am indebted to my friend 
 Dr. Newton M. Shaffer, of New York, for the 
 privilege of reporting the above notes. 
 
 Case III. — J. H., male, aged forty-five ; was 
 admitted to my wards in the Philadelphia Hospital 
 on April 3, 1883. The following notes were re- 
 corded : A vigorous, well- nourished man, with little 
 personal knowledge of his family or their history. 
 Knew his parents lived to advanced age, but 
 thought both of his brothers had died, and likewise 
 two sisters. Acknowledged to being strongly ad- 
 dicted to the use of alcohol. He thought that his 
 present trouble arose from a " dissipated life and 
 constitutional syphilis." 
 
 Two years ago, after a debauch, his attention 
 was directed to painful swelling of his right great 
 toe. This lasted a few days, and as the pain and 
 
186 MEMOIR OF A. S. ROBERTS. 
 
 swelling of the toe subsided, the right ankle-joint 
 enlarged. This swelling slowly and painlessly in- 
 creased, and three months from its onset, the same 
 condition appeared in the left ankle-joint. Without 
 especial discomfort to the patient, this joint enlarged. 
 He continued drinking to excess, and was admitted 
 to the hospital in a state of chronic alcoholism. 
 
 An examination two weeks after admission, when 
 all traces of alcoholism had subsided, gave evidence 
 by the following facts of a central lesion : He had 
 suffered from constricting pains about the abdomen, 
 and occasional darting pain in the region of the hips 
 and thighs for the past year. He also experiences 
 considerable difficulty in walking, especially at 
 night. At present he has a staggering gait. Ab- 
 sence of patellar reflex in both limbs ; sways and 
 falls with " closed eyes test," and has difficulty in 
 finding tip of nose with forefinger when eyes are 
 closed. 
 
 The metatarsophalangeal articulation of the right 
 great toe is anchylosed. Both ankle-joints are en- 
 larged, apparently by a diffuse hypertrophy of the 
 epiphyses of tibia and fibula. This increase has 
 almost doubled their normal circumference. The 
 subcutaneous tissues are slightly cedematous. The 
 capsules of ankle-joints are distended and elastic. 
 
 "When first admitted, the tissues about the ankles 
 and legs were swollen, presenting the appearance of 
 diffuse cellulitis. This subsided in a few days from 
 rest and local treatment. 
 
 My colleague, Dr. C. K. Mills, saw the patient 
 with me in consultation, and confirmed the diag- 
 
THE SPINA L AB THB OP A THIES. 187 
 
 nosis I had made — of posterior spinal sclerosis, with 
 accompanying arthropathies at ankle-joint. 
 
 Remarks. The joint hypertrophy had preceded 
 any active symptoms of ataxia. The character of 
 the joint enlargement was that of bony hypertrophy, 
 without a tendency to the formation of osteophytes 
 or to nodular irregularity of contour. 
 
 The possibility of rheumatism or malignant dis- 
 ease was considered and dismissed. A thorough 
 physical examination failed to detect any of the 
 characteristic reflex neural symptoms of epiphyseal 
 osteitis. 
 
 The history of the progress and course of the 
 ankle-joint hypertrophy, together with the evidence 
 of a central lesion and the negative physical signs 
 of local joint inflammation, all confirmed the diag- 
 nosis of an arthropathy of spinal origin. 
 
 Case TV. — Dr. A. A. Y., male, aged sixty-five, 
 resident of Hammonton, N". J. Examined the 
 patient with Dr. S. Weir Mitchell on January 16, 
 1885. For the substance of the following notes I 
 am indebted to Dr. Woodnut : 
 
 Hereditary history of patient excellent. He had 
 always been strong and healthy during youth and 
 up to 1865, though a hard-working farmer. An 
 army life, and three years of extreme exposure prior 
 to the close of the war, found him suffering in 1865 
 from sharp, wandering pains in the upper and lower 
 extremities ; never noticed, however, in the articu- 
 lations. Loss of power followed in the right leg. 
 Three years later suppurative arthritis attacked the 
 metatarso-phalangeal articulation of the right great 
 
188 MEMOIR OF A. S. ROBERTS. 
 
 toe, and last phalanx of left ring finger, sequestra 
 coming away in each instance. 
 
 During 1870 the patient first noticed an cedema- 
 tous swelling of the right elbow ; following shortly 
 upon this, the wrist-joint of the same arm gradually 
 
 Fig. 47. 
 
 and painlessly enlarged. Then a distention of the 
 capsule of the right knee-joint succeeded. The 
 enlargement of the latter articulation was more 
 rapid than either the wrist or elbow. Rheumatic 
 
THE SPINAL ARTHROPATHIES. 189 
 
 pains in the joints accompanied the swelling and 
 deformity. 
 
 The left limb has been comparatively exempt 
 from pain. Recently, however, the capsule of the 
 knee-joint has become distended and elastic. The 
 elbow-tumor has diminished somewhat in circum- 
 ference during the past four years. 
 
 During the past year the distal phalanx of the 
 right index finger has gradually atrophied without 
 inflammation, and is now entirely wanting. The nail 
 and finger end are normal, though somewhat short- 
 ened. Pain at present is chiefly in both feet, parox- 
 ysmal and erratic, often attacking corresponding 
 points on the legs. 
 
 At present the right elbow and knee-joint en- 
 largements (Fig. 47) exhibit an irregular nodulated 
 hypertrophy, bearing no resemblance to normal joint 
 outline, and consisting chiefly of osteophytes and 
 abnormal increase of synovial fluid. Motion is 
 preternaturally free in all directions ; structure of 
 joints apparently entirely destroyed. 
 
 Remarks. The joint lesions first appeared in 
 this patient after ataxia had become established. 
 The appearance of the affected elbow and knee is 
 that of an enormous nodular hypertrophied mass of 
 bone, doubling their normal circumference, asso- 
 ciated with synovial distention of the capsule. 
 Osteophytes readily movable within the capsule, 
 and varying in size from a pigeon's egg to that of 
 a turkey. 
 
 The atrophy of the distal phalanx of the right 
 index finger is especially to be noted. It is the first 
 
190 
 
 MEMOIR OF A. S. ROBERTS. 
 
 instance of complete absorption of the diaphysis of 
 bone that I have had an opportunity of observing. 
 
 Case V. — "W. H. McC, male, aged thirty-eight, 
 married. Admitted to the Orthopedic Dispensary 
 of the University Hospital in July, 1883. 
 
 Hereditary history excellent ; no evidence could 
 be obtained of articular disease, rheumatism, or 
 phthisis in any member of his family. He pre- 
 sented at the date of examination the appearance of 
 a healthy well-nourished man. Has always worked 
 
THE SPINA L AR THE OP A THIES. 191 
 
 industriously at his trade of plumber. A moderate 
 drinker. He had constitutional evidence of syphilis, 
 following a chancre contracted in 1863. 
 
 The patient attributes the present enlargement 
 of the right ankle-joint to an injury received while 
 working in a cramped position. Following this 
 strain the ankle became suddenly discolored and 
 swollen, bursting the buttons from his shoes. He 
 was incapacitated for work during the succeeding 
 four days ; at the end of a week the discoloration 
 and swelling had about disappeared. His attention 
 was then first directed to a bony enlargement of the 
 right ankle-joint. This slowly and painlessly in- 
 creased in size without any appreciable interference 
 in locomotion. At present examination the en- 
 largement resembles a simple hypertrophy of the 
 lower epiphyses of the tibia and fibula (Fig. 48). 
 The outline of the joint is globular, with slight 
 elasticity of capsule. No pain or reflex muscular 
 spasm. 
 
 Record of Spinal Symptoms. Complains of 
 darting pains about hips. Has difficulty in walking 
 at night. Sways with closed eyes. Complete 
 absence of patellar reflex on both sides. Dr. 
 Horatio C. Wood saw him with me in October of 
 1833, and pronounced him ataxic. 
 
 KemaPlKS. This case presents an arthropathy 
 that apparently followed a direct traumatism to the 
 affected joint. From careful interrogation, I deter- 
 mined that the acute swelling and ecchymosis 
 resulted from the rupture of a varicose vein, inas- 
 much as these were numerous and greatly engorged 
 
192 MEMOIR OF A. S. ROBERTS. 
 
 about the affected ankle. This first attracted his 
 attention to the ankle, the deeper bony growth 
 being detected when the active symptoms of sub- 
 cutaneous swelling had subsided. 
 
 The hypertrophy of the joint has increased the 
 circumference four and a half inches over its 
 fellow. 
 
 Case YI. — A specimen of shoulder-joint arthrop- 
 athy, lately removed at an autopsy held upon the 
 body of a well-marked ataxic, has been referred to 
 me by Dr. S. Weir Mitchell, to embody in this 
 report. The joint had become suddenly and pain- 
 lessly enlarged in the later stages of the central 
 lesion. It presented ante mortem all the char- 
 acteristic symptoms of a tabetic arthropathy : 
 distention of the capsule, abnormal mobility, and 
 the presence of osteophytes. The joint, upon ex- 
 amination, presented the following structural 
 changes : 
 
 1. Cartilage covering head of humerus eroded; 
 that upon glenoid cavity irregularly thickened. 
 
 2. Anterior margin of glenoid cavity worn away, 
 allowing the head of bone to rest in position of 
 forward dislocation. 
 
 3. Osteophytes abundant about junction of cap- 
 sule with anatomical neck. Marked relaxation of 
 ligamentous structures, and distention of capsule. 
 
 4. General hypertrophy of epiphysis, somewhat 
 nodular at margins. Evidences of hydrarthrosis. 
 
 The practical deductions to be drawn from a 
 clinical study of the above somewhat anomalous 
 cases, may be briefly summarized as follows : 
 
THE SPINAL ARTHROPATHIES. 193 
 
 Period of Development. 1. The tabetic ar- 
 thropathies may occur independently, or precede the 
 active symptoms of locomotor ataxia. 
 
 2. They occasionally develop suddenly, late in 
 the course of a posterior spinal sclerosis. 
 
 Nature of Lesions. The peripheral expression 
 of. central nerve irritation is characterized by the 
 following changes found in the structure of the 
 various articulations. 
 
 1. A chronic asthenic hyperemia of the synovial 
 membranes ; a hydrarthrosis. 
 
 2. An interstitial atrophy of the epiphyses. 
 
 3. A fungous or rarefying epiphyseal hypertrophy. 
 
 4. The formation of osteophytes and bony stalac- 
 tites. 
 
 These various joint lesions characteristic of the 
 spinal arthropathies may exist separately ; but are 
 usually combined in the same subject. 
 
 Differential Diagnosis. They may be readily 
 distinguished from the common inflammatory dis- 
 eases of the epiphyses by the total absence of the 
 reflex neural phenomena — i. e., of pain, both reflex 
 and local, the apprehensive state regarding joint 
 movements, and the reflex or tetanic spasm of the 
 muscles, always associated with joint osteitis. Ab- 
 scess is never directly associated with the arthrop- 
 athies, unless incident upon direct traumatism. 
 
 They are more difficult to differentiate from 
 malignant affections of the articulations ; but a 
 careful inquiry into the history and course of the 
 lesion, and the presence or absence of central dis- 
 turbance, are our most reliable guides. 
 
 13 
 
194 MEMOIR OF A. S. ROBERTS. 
 
 Course. The progress of the arthropathies is 
 essentially chronic. Occurring, not infrequently, 
 early in the history of the tabetic lesion, they slowly 
 increase, with occasional exacerbations, and years 
 elapse before fully matured. Their course is self- 
 limiting, though never reparative. 
 
THE ETIOLOGY, MORBID ANATOMY, VARIETIES, 
 AND TREATMENT 
 
 OF 
 
 CLUB-FOOT 
 
CLUB-FOOT. 
 
 LECTURE I. 
 
 Gentlemen : Every observant person, whether 
 within or without the profession of medicine, must 
 be impressed with the prevalence of various deform- 
 ities in individuals of the human family, and their 
 very existence must cause him to reflect upon the 
 nature of their being, their chronic and progressive 
 character, and the apparent difficulty of arresting 
 them. Much of this has been due to lack of knowl- 
 edge of the mechanical factors which enter into their 
 etiology, and the very general neglect the subject 
 of malformations has received, from an educational 
 stand-point, in our medical schools. Though twenty- 
 five years have elapsed since the establishment of 
 orthopedic surgery as a legitimate special branch of 
 surgical art, its science and practice, noticeably in 
 this city, are permitted to occupy a very subordi- 
 nate position, and its principles practically are 
 untaught. In this clinic, which will initiate the 
 course of lectures upon orthopedic surgery in the 
 Philadelphia Hospital, which it will be my privilege 
 to deliver before you this spring, no better subject 
 
 1 Clinical Lectures on Orthopedic Surgery, delivered at the Phila- 
 delphia Hospital. 
 
198 MEMOIR OF A. S. ROBERTS. 
 
 could be chosen than one descriptive of club-foot, a 
 condition which you will frequently meet in prac- 
 tice, and of which many examples may be constantly 
 observed in the nervous, obstetrical, and surgical 
 wards of this hospital. 
 
 We may define club-foot, or talipes, which latter 
 designation was first employed, about thirty years 
 ago, by William J. Little, of London, as a deform- 
 ity of the foot, caused by paralysis, permanent 
 spasm, or structural shortening of the muscles, con- 
 tractions of fasciae or ligaments, and resulting in 
 an alteration of the normal relations of the tibio- 
 astragaloid articulation, or between the bones of 
 the tarsus proper. Under the generic term club- 
 foot, or talipes, we include all deformities of the 
 foot which occur on an antero-posterior or trans- 
 verse plane, and which are characterized by flexion, 
 extension, inversion or eversion. 
 
 To obtain a clear conception of the deformities 
 under consideration, it is best to divide the foot 
 into an anterior and a posterior portion, the former, 
 the "^>es," or foot proper, and the latter, the " talus" 
 or ankle. These portions articulate at Chopart's 
 joint, which is formed by the astragalus and os 
 calcis behind, and the scaphoid and cuboid in 
 front. For purposes of clinical study, club-foot is 
 conveniently separated into two classes, composed 
 of the simple and the compound forms. Of the 
 former there are four varieties, two between the 
 tibia and foot, namely, equinus, in which the heel is 
 raised, the foot being held in the extended posi- 
 tion, the patient walking upon the ball of the foot; 
 
CLUB-FOOT. 
 
 199 
 
 and calcaneus, its opposite, in which the patient 
 walks upon the heel, the foot being drawn into the 
 position of flexion. There are also two lateral de- 
 formities : varus, in which the internal border of the 
 foot is elevated, the sole directed inward, and the 
 anterior portion of the foot adducted ; and valgus, 
 its opposite, in which the outer side of the foot is 
 raised and the sole everted. Any combination of 
 these simple varieties will present compound forms, 
 such as talipes equino-varus, equino-valgus, calcaneo- 
 valgus, etc. ; some authors have added others : for 
 instance, talipes cavus, in which the arch of the foot 
 is increased, and talipes planus, or spurious valgus, 
 in which the foot is flattened, the arch resting upon 
 the ground. Recently, Shaffer, of ]S"ew York, under 
 the title non-deforming club-foot, has described a 
 class of cases in which there is little or no deformity, 
 but which are very important on account of the 
 inconvenience they occasion the sufferer, and the 
 results to which they give rise, coupled with the 
 liability of being overlooked, unless care be taken 
 in the examination of the patient. 
 
 The varieties of club-foot may be classified as 
 follows : 
 
 Table No. I. 
 
 ' Simple. 
 
 Varieties . \ Compound 
 
 f Anteroposterior 
 
 J Equinus. 
 j Calcaneus 
 
 ( Lateral 
 
 f Varus. 
 j Valgus. 
 
 f Equino- 
 
 f Varus. 
 I Valgus. 
 
 ( Calcaneo- . 
 
 f Varus. 
 { Valgus. 
 
 ( Cavus. 
 (_ Other forms. < Planus. 
 
 Non-deformins:. 
 
200 
 
 MEMOIR OF A. S. ROBERTS. 
 
 As previously mentioned, these simple forms, or 
 their combinations, constitute the deformities which 
 you will meet with, and a knowledge of their rela- 
 tive frequency is of interest and importance. Much 
 difficulty is experienced in the investigation of this 
 subject, owing to the difference in nomenclature 
 employed by various authors, similar conditions 
 being spoken of under different names. Duval has 
 recorded 1000 cases, of which 574 were congenital ; 
 364 of these were in males, and 210 in females. His 
 statistics as to relative frequency are valuable, and 
 are as follows : 
 
 Table No. II. 
 
 
 
 Cases. 
 
 Boys. 
 
 Girls 
 
 Equinus and equino-varus . 417 
 
 215 
 
 202 
 
 Varus 532 
 
 302 
 
 230 
 
 Valgus 22 
 
 14 
 
 8 
 
 Calcaneus .... 9 
 
 6 
 
 3 
 
 Extreme calcaneus ... 20 
 
 13 
 
 7 
 
 Totals .... 1000 
 
 550 
 
 450 
 
 I have compiled the following statistics, shown in 
 Table No. III., from the records of the New York 
 Orthopedic Hospital, and the Orthopedic Dispen- 
 sary of the University of Pennsylvania : 
 
 Table No. 
 
 in. 
 
 
 
 Congenital. 
 
 Acquired 
 
 Equinus 5 
 
 87 
 
 Calcaneus . 
 
 
 
 3 
 
 31 
 
 Varus 
 
 
 
 73 
 
 66 
 
 Valgus 
 
 
 
 29 
 
 236 
 
 Equino-varus 
 
 
 
 95 
 
 68 
 
 Equino-valgus . 
 
 
 
 3 
 
 9 
 
 Calcaneo-varus . 
 
 
 
 (i 
 
 2 
 
 Calcaneo-valgus . 
 
 
 
 5 
 
 34 
 
 Totals .... 
 
 
 
 213 
 
 533 
 
CLUB-FOOT. 
 
 201 
 
 Lannelongue has collected the statistics of the 
 Maternity Hospital (Paris), covering a period of 
 ten years, from 1858 to 1867, inclusive. In 15,229 
 births, 8 children were born with club-foot, a pro- 
 portion of about 1 case in 1963 births. 
 
 The condition may be present as a congenital or 
 an acquired deformity, and the relative frequency 
 of the two forms may be seen by reference to Table 
 No. III., from the cases treated in the ~New York 
 Orthopedic Hospital, and the Orthopedic Dispen- 
 sary of the University of Pennsylvania, in which 
 are recorded 746 cases, of which 213 were congeni- 
 tal, and 533 acquired. Tamplin's deductions, shown 
 in Table ~No. IV., covering 764 cases of congenital 
 talipes, show the relative frequency to be as follows : 
 
 
 Table No. IV. 
 
 
 
 
 Congenital. 
 
 
 Talipes 
 
 varus 
 
 
 688 cases 
 
 « 
 
 valgus 
 
 
 42 " 
 
 u 
 
 calcaneus 
 
 
 19 " 
 
 (1 
 
 varus of one 
 
 foot and valgus of the 
 
 
 
 other . 
 
 
 15 " 
 
 
 Total 
 
 Acquired. 
 
 764 " 
 
 Talipes 
 
 equinus . 
 
 
 401 cases 
 
 a 
 
 valgus 
 
 
 181 " 
 
 a 
 
 equino-varus 
 
 
 162 " 
 
 i( 
 
 calcaneus and calcaneo-valgus 
 
 110 " 
 
 (< 
 
 equino-valgus .... 
 
 80 " 
 
 11 
 
 varus 
 
 
 60 " 
 
 a 
 
 varus of one 
 
 foot and valgus of the 
 
 
 
 other . 
 
 Total 
 
 . 
 
 5 " 
 999 " 
 
202 MEMOIR OF A. S. ROBERTS. 
 
 Adams states the proportion between the con- 
 genital and acquired forms to be as 2 : 3, and the 
 tables already referred to show the large prepon- 
 derance of cases in which the deformity has been 
 acquired. Giving due weight to the statistics which 
 have been alluded to, we may conclude that club-foot 
 occurs more frequently in males than in females; 
 that cases in which inversion and adduction of the 
 foot, either accompanied or not by elevation of the 
 heel, or the varus types, are oftener met with, and 
 that the right foot is more frequently deformed than 
 the left, but that many more cases of double club- 
 foot occur than of single ; and that the primitive 
 forms, pure equinus, calcaneus, varus or valgus, 
 are rare. 
 
 The etiology of congenital talipes is veiled in 
 obscurity. The difficulty of studying pathological 
 changes occurring; during intra-uterine life is self- 
 evident, as the foetus cannot be subjected to any 
 direct scientific method of investigation. Compara- 
 tive physiology, embryology, and the changes and 
 diseases which occur subsequently to birth, give us 
 data of comparative value, but all such investiga- 
 tions have resulted in much speculation, many 
 theories, and but few facts. The theory that dis- 
 eases which produce the acquired forms have their 
 prototypes during intra-uterine existence has its sup- 
 porters, notably Little. But microscopical research 
 has not yet shown the existence of changes in the 
 foetal brain and spinal cord analogous to those found 
 in cases of the acquired paralytic forms. Volun- 
 tary muscular control is retained in congenital 
 
CLUB-FOOT. 203 
 
 cases, while it is lost in the acquired varieties re- 
 ferred to, and the electrical reactions are markedly 
 different ; so that this theory has no foundation to 
 rest upon, except the similarity in the appearance of 
 the deformities. 
 
 Hereditary influence, with its transmission of 
 peculiarities of face and form, of various tendencies, 
 of traits of character, etc., has some weight as an 
 etiological factor. 
 
 Another theory of causation is that of arrest of 
 development, and, although cases occur in which 
 coexisting deformities, such as spina bifida, hare- 
 lip, cleft palate, etc., are also present, the feet show 
 no evidence of arrest of development, the only alter- 
 ation being that of the direction of the planes of 
 the feet which is characteristic of the deformity. 
 Adams and Hiiter, it is true, have described changes 
 in the bones involved, consisting of alteration of 
 form and relative position of articulating facets, 
 but these changes are by no means constant, and 
 whether they be causative or secondary to the 
 altered relation of the bones is a matter regarding: 
 which there is much difference of opinion. Person- 
 ally, I incline to the latter view, although the theory 
 has many eminent supporters, including A. Liicke. 
 
 The theory which has, perhaps, the greatest num- 
 ber of votaries is that which ascribes to abnormal 
 intra-uterine pressure, and deficiency of amniotic 
 fluid, the influence productive of club-foot, the 
 foot being permanently fixed in the abnormal posi- 
 tion during intra-uterine life. Although numbering 
 among its supporters such names as Volkmann, 
 
204 MEMOIR OF A. S. ROBERTS. 
 
 Kocher, Bauga, and Parker, I do not think the 
 assumption tenable, for the following reasons : 
 AVere this deformity the result of pressure, it is 
 reasonable to believe that in many cases deformity 
 of other members would coexist, having been ex- 
 posed to the same pressure-influence ; such, how- 
 ever, is not the case, combinations of this kind 
 being of rare occurrence. Again, in children who 
 have been born with club-foot, and in which the 
 mother had previously given birth to several health}^ 
 children, no appreciable difference in the quantity 
 of amniotic fluid discharged during the various 
 labors can be made out. Further, I have recently 
 seen a case of double equino-varus in a twin, the 
 other child showing no deformity whatever. 
 
 Dr. H. W. Berg, of New York, in a series of 
 investigations which are commendable for their 
 originality, ascribes congenital equino-varus to a 
 failure of rotation during intra-uterine existence. 
 In his studies at the New York Hospital and 
 Wood's Museum at Bellevue Hospital, he has fol- 
 lowed the changes which occur in the position of 
 the lower extremities at different periods of foetal 
 life. At first, the entire leg is rotated outward, and 
 the feet are in a position of marked varus, and, 
 subsequently, of equino-varus. Later, rotation in- 
 ward takes place, gradually diminishing the amount 
 of varus ; but even after this rotation has been 
 completed some varus remains, and, in a very slight 
 degree, is the normal position of the foot in the 
 new-born. Dr. Berg found, in some instances, 
 equinus to be present in foetuses of two, three, and 
 
CLUB-FOOT. 205 
 
 four months, the condition disappearing in the pro- 
 cess of normal growth, and he reaches the conclu- 
 sion that in early foetal life equino-varus or varus 
 is physiological, and that its disappearance is coin- 
 cident and keeps pace with the normal rotation of 
 the limb. When, from any cause, rotation is re- 
 tarded or arrested, club-foot results. 
 
 To summarize the theories to which I have 
 alluded, and which constitute the principal ones 
 advanced in explanation of the causes of congenital 
 talipes, I have reduced them to the following : that 
 which would ascribe club-foot to pathological 
 changes occurring in the foetus, similar to post- 
 natal diseases ; that which assumes, as a cause, the 
 action of mechanical forces upon the child in utero ; 
 then the theory of heredity, with its influences but 
 little understood ; the theory of arrest of develop- 
 ment ; and, lastly, the theory promulgated by Dr. 
 Berg, which would make club-foot dependent upon 
 the absence or retardation of rotation. The last 
 mentioned possesses the merit of being demonstra- 
 ble by embryological research, and in the present 
 state of our knowledge it has, in my opinion, greater 
 claims to recognition than those which are based 
 upon similarity of post-natal conditions, or those 
 which rest upon even a more fanciful basis. 
 
 Turning our attention now to the consideration 
 of the etiology of acquired talipes, we do not find 
 the path of investigation beset with the difficulties 
 we met with in the study of the causation of the 
 congenital types. We may divide the causes into 
 six groups : 1. Infantile spinal paralysis. 2. Spastic 
 
206 MEMOIR OF A. S. ROBERTS. 
 
 contractions due to an irritative lesion of the spinal 
 cord. 3. Contraction of aponeuroses. 4. Trauma- 
 tism. 5. Rhachitis. 6. Hysteria. 
 
 By far the greater number of cases of acquired 
 talipes are due to infantile spinal paralysis — " polio- 
 myelitis anterior."' This is essentially a disease of 
 childhood, usually occurring at the period of denti- 
 tion, its invasion being, as a rule, sudden, marked 
 by fever, gastro-intestinal disturbance, sometimes 
 ushered in by a convulsion, and immediately fol- 
 lowed by muscular paralysis, more or less extensive. 
 Recovery follows rapidly in many of the muscles 
 affected, but is rarely, if ever, complete, a certain 
 amount of residual paralysis remaining permanently, 
 in one or both of the lower extremities. Atrophic 
 changes now take place, and are characterized by 
 wasting of the muscles of the limb, loss of electro- 
 contractility, especially to the faradic current; later 
 by reaction, when stimulated by galvanism, charac- 
 teristic of degenerative change, and deformity, of 
 which the most frequent is club-foot. 
 
 It has been thought that the deformity in these 
 cases was due to the loss of equilibrium between 
 the muscles of the limb ; one set being paralyzed, 
 their antagonists drawing the foot into the deformed 
 position; but Hitter has shown that the weight of 
 the limb, in the position assumed in paralysis, is the 
 cause of contractions, and that these were due to 
 atrophy and arrest of growth, and were not in any 
 sense muscular. In some cases, resulting from 
 poliomyelitis, the deformity is due entirely to the 
 force of gravity, the foot dropping into the position 
 
CLUB-FOOT. 207 
 
 of equinus, and the anterior portion being adducted 
 by its own weight. In these cases there is little, if 
 any, contraction, and the deformity is readily reduced 
 by manual pressure, but, of course, returns imme- 
 diately upon the removal of the hand. Volkmann, 
 also, has directed attention to the fact that, owing 
 to the weight of the body, the limb assumes an 
 abnormal position, which eventually becomes per- 
 manent, being due, not to contraction, but to 
 abnormal growth. 
 
 The " spastic paralysis " of Erb is also produc- 
 tive of club-foot. This condition has been called 
 by Adams, "paralysis with rigid muscles," and by 
 Seguin, " tetanoid paraplegia." It is well illustrated 
 by the case I now present. 
 
 Case I. Tetanoid paraplegia, producing double 
 talipes equino-varus. — Barney, aged six years. ]S T o 
 record or information could be obtained regarding 
 previous history. Having stripped him, it will be 
 noticed that the thighs are adducted and slightly 
 flexed upon the pelvis. The legs are held firmly 
 at a moderate degree of flexion at the knee-joint. 
 The feet are extended and inverted in the position 
 of pronounced equino-varus. All muscular groups 
 of the lower limbs are in a condition of spasmodic 
 rigidity. You will notice these contractions may 
 be temporarily overcome by firm and continuous 
 pressure, but immediately reappear upon the re- 
 moval of the opposing force. Locomotion, with 
 assistance, is accomplished, with difficulty, by a 
 swinging, discordant gait, typical of the disease, 
 the patient walking only upon the ball of the feet 
 
208 MEMOIR OF A. S. ROBERTS. 
 
 and toes, the weight of his body not being sufficient 
 to overcome the contraction and bring the heels to 
 the floor. The other symptoms characteristic of 
 the central lesion — deficient intelligence, strabismus, 
 exaggerated muscular reflexes, and general rigidity 
 and spasm of the muscular system, are all present. 
 As I propose to operate upon this patient, I will 
 defer a further consideration of his feet until my 
 next clinic. The condition appears to be due, in 
 some instances, to retarded development in the 
 motor tract of the brain ; in others, to a lesion in 
 the same position, followed by secondary changes 
 in the lateral columns of the cord. The researches 
 of Rupprecht, of Dresden, not only show that 
 tenotomy is followed in some of these cases by 
 improvement in the position of the feet, but that 
 the mental state is also appreciably benefited hy the 
 operation. His article has been published in "Volk- 
 mann's series of clinical lectures, and constitutes an 
 important and valuable contribution to our knowl- 
 edge of this interesting class of cases. Various 
 spinal diseases, acute compression, syphilis, tumors, 
 caries, etc., are frequently productive of a similar 
 condition. Other diseases of the nervous system 
 should be mentioned as causes of club-foot. In 
 rare cases, pseudo-hypertrophic muscular paralysis 
 and post-hcmiplegic contractions produce the de- 
 formity, but neuromimetic conditions, which of late 
 years have attracted much attention, are more fre- 
 quently the cause of it. A careful elimination of 
 other possible etiological factors in a given case, 
 coupled with a proper appreciation of the general 
 
CLUB-FOOT. 209 
 
 condition, will usually lead to correct conclusions 
 in the cases of the latter kind. 
 
 Sayre has advocated the view that paralysis due 
 to reflex irritation is, in many instances, productive 
 of talipes, and has reported cases in which he claims 
 that functional disturbance of the nervous system 
 can cause spasm of muscles, which, if sufficiently 
 prolonged, while healthy growth continues in their 
 antagonists, becomes the cause of a permanent 
 deformity. Much discussion has taken place con- 
 cerning this condition as a cause of club-foot, but 
 I do not consider Dr. Say re's theory as in any way 
 tenable. 
 
 Talipes equinus sometimes occurs as a concomi- 
 tant of the paraplegia of Pott's disease of the spine, 
 but disappears upon recovery from the paralysis ; 
 joint diseases of the lower extremity are also potent 
 factors in the production of club-foot. In ankle- 
 joint disease the deformity may follow osteitis of 
 the articulation, and remain as a permanent condi- 
 tion, due to anchylosis of the joint in the position 
 of extension. In hip-joint disease, it would be 
 due to prolonged malposition during the period of 
 growth. I have lately seen a case of this disease 
 in which the limb upon the affected side was short- 
 ened but one inch, and in which there was a marked 
 equinus accompanied by contraction of the plantar 
 fascia. Occupations requiring long-continued stand- 
 ing in one position can be also considered causative 
 agents ; printers, bakers, blacksmiths, and those 
 engaged in kindred trades may be mentioned as the 
 principal sufferers. The enforced position and the 
 
 14 
 
210 MEMOIR OF A. S. ROBERTS. 
 
 weight of the body are the factors in the production 
 of this variety of the deformity, which is most 
 commonly a valgus. The same remarks will apply 
 to the valgus of adolescence, due probably to rapid 
 growth and increased weight of the body, without, 
 however, a corresponding development of the mus- 
 cles, aponeuroses, and ligaments of the feet. The 
 influence of long-continued decubitus is further 
 shown by the case reported by Yolkmann, in which 
 an equinus was found, after prolonged typhoid 
 fever, so resistant that it required a year's treatment 
 to restore the feet to their normal position. As to 
 traumatism, it will be only necessary to allude to 
 the possibility of wounds, burns, rupture of tendons, 
 etc. The former may result in the production of 
 deep cicatrices, which, by their contraction, tend to 
 draw the foot into a deformed position. Spurious 
 valgus, or splay-foot, is frequently the result of 
 rhachitis, although, as before mentioned, occupa- 
 tion is often an important factor in its causation. 
 All these forms may be simulated by hysteria, 
 and this class of cases frequently taxes the knowl- 
 edge and ingenuity of the surgeon; their recog- 
 nition lies in a thorough understanding of general 
 morbid conditions and a careful diagnosis by ex- 
 clusion. 
 
 Before closing, I desire to call your attention to 
 the morbid anatomy of club-foot. I shall, however, 
 touch upon it only sufficiently to give you an idea 
 of the muscles involved in the production of the 
 various deformities, and will illustrate my remarks 
 by reference to the following classification : 
 
CLUB-FOOT. 211 
 
 Table No. V. 
 
 Extension (equinus) 
 
 f Gastrocnemius. 
 J Soleus. 
 | Plantaris. 
 I Peroneus longus. 
 
 Tibialis anticus. 
 Flexion (calcaneus) . . \ Peroneus tertius. 
 
 Extensor longus digitorum. 
 
 Tibialis anticus. 
 Adduction (varus) . . -I Tibialis posticus. 
 
 Flexor longus digitorum. 
 
 Peroneus longus. 
 Abduction (valgus) . . -J Peroneus brevis. 
 
 Peroneus tertius. 
 
 Dividing the muscles into three groups, which 
 move the foot in four directions, as shown in Table 
 No. V., we have a posterior group, the calf muscles, 
 the gastrocnemius, and the soleus, and two anterior 
 groups, the tibial and the peroneal. In the normal 
 condition, an equilibrium is maintained between 
 these muscles, and the correct anatomical relation 
 of the parts is preserved; but should spasmodic 
 contraction or paralysis of one or more of these 
 groups occur, the balance is destroyed, and deform- 
 ity takes places. As has been remarked, the purely 
 primitive forms of club-foot are extremely rare, 
 and this statement will apply to these deformities, 
 whether they be congenital or acquired. A brief 
 consideration of them, however, is necessary in 
 order that a clear understanding of the compound 
 forms which are encountered most frequently in 
 practice may be obtained. They are equinus, cal- 
 caneus, varus, and valgus; the two former being 
 
212 MEMOIR OF A. S. ROBERTS. 
 
 anteroposterior deformities ; the two latter occur- 
 ring upon a transverse plane. 
 
 In tali-pes equinus the heel is raised, the patient 
 walking upon the ball of the foot. Here we find 
 the posterior group of muscles, consisting of the 
 gastrocnemius and soleus, contracted and shortened, 
 the tendo Achillis being felt as a tense band. In 
 the opposite condition, talipes calcaneus, the anterior 
 groups of muscles, tibialis anticus, posticus, and 
 peronei, are at fault, and, being shortened, maintain 
 the foot in the position of flexion, the patient walk- 
 ing upon the heel. Talipes varus manifests itself 
 by inversion and adduction of the foot, the deform- 
 ity taking place anterior to Chopart's joint ; in it 
 the sole is turned inward and raised, and the anterior 
 portion of the foot adducted, the tibailis anticus and 
 posticus and flexor longus digitorum being con- 
 tracted. In valgus, on the contrary, the sole is 
 turned outward, and its outer border raised, the 
 peronei being the muscles at fault. In this de- 
 formity, however, the plantar fascia is involved, 
 the arch of the foot being diminished by its relaxa- 
 tion. 
 
 In all these varieties, changes occur, not only in 
 the muscles, but also in the ligaments, fascia?, and 
 in the bones themselves, Avhether as causes or 
 effects ; but we shall defer the study of them until 
 our next meeting, my object in briefly mentioning 
 the primitive deformities now being merely to im- 
 press upon you the character of the changed relation 
 of the parts from an anatomical rather than a patho- 
 logical stand-point, which latter condition can be 
 
CLUB-FOOT. 213 
 
 best considered when we come to speak of the most 
 frequent of all the forms of club-foot, namely, 
 talipes equino-varus. 
 
 LECTURE II. 
 
 Gentlemen : Our last meeting closed with a 
 brief description of the primitive forms of club-foot. 
 We now pass to the consideration of the treatment 
 of talipes in general, such modifications as may be 
 necessary to correct the deformity in any special 
 case which may come before us being deferred until 
 we discuss the compound forms. Properly to cope 
 with these conditions, it is essential that you should 
 thoroughly comprehend the factors, pathological 
 and mechanical, which produce them. Because of 
 the lack of exact knowledge upon the subject by 
 the profession, many cases of deformity remain 
 uncured, and scores of children who could other- 
 wise be relieved are left to the care of inconsiderate 
 instrument makers. It is only by the intelligent 
 application of measures fitted exactly to the case 
 that success can be achieved ; and the knowledge 
 requisite to do this is not possessed by the mechani- 
 cian in any greater degree than is the knowledge 
 necessary properly to care for a medical case a part 
 of the education of the apothecary. Nor has the 
 training of the general practitioner been such as to 
 make him an adept in this branch of surgery, and 
 when it is considered how few are his opportunities 
 
214 MEMOIR OF A. S. ROBERTS. 
 
 of seeing many such cases, it is not strange that 
 extreme deformities are frequent, and that their 
 existence and progression should be an opprobrium. 
 It is only by the dissemination of knowledge by 
 clinical teaching, and the establishment of institu- 
 tions dedicated to the care of these special cases, 
 that a better state of things may be hoped for, and 
 the importance of such measures cannot be over- 
 estimated. 
 
 The object of treatment in club-foot is not only 
 to remove the existing deformity, but to restore to 
 the foot its functions ; and to do this many proced- 
 ures have been resorted to which have been in turn 
 discarded. We may consider the methods now in 
 use as mechanical and operative. First among the 
 former is manipulation, applied so as to stretch 
 the contracted tissues, passive motion, massage, 
 shampooing, and electricity being used the while, 
 to aid in the restoration of function. The hand, if 
 pressure and traction to the contracted tissues could 
 be continuously applied by it, would, no doubt, con- 
 stitute the best instrument for the relief of club-foot ; 
 the apparatus which is best adapted to take its place 
 is that which should be relied upon in the mechani- 
 cal treatment of the deformity. 
 
 Massage and electricity serve, in paralytic cases, 
 to restore, as far as possible, the functional activity 
 of the paretic muscles, and should always be em- 
 ployed as adjuvants in such cases. 
 
 Tenotomy, for the division of contracted tendons, 
 called .iponcurotomy when performed upon fasciae 
 and aponeuroses, was resorted to first by Delpech, 
 
CLUB-FOOT. 215 
 
 of Montpellier, France. It was not, however, gen- 
 erally employed nntil Stromeyer, of Hanover, ren- 
 dered it popular. Little introduced the operation 
 into England, and Dickson, of South Carolina, first 
 performed it in America. To Deltmold, of New 
 York, and Mutter, of this city, however, is due 
 much of the credit of making the operation popular 
 in this country. Opinions differ as to the indica- 
 tions for tenotomy and the proper time for its 
 performance ; whether, for instance, in cases of con- 
 genital talipes, it should be done prior to the time 
 at which the child is able to walk, or subsequently. 
 'No difference of opinion can exist as to the advisa- 
 bility of early operation in cases in which the nature 
 or extent of the deformity renders correction by 
 mechanical means alone impossible ; but as experi- 
 ence is the only guide to discrimination, mechanical 
 appliances should always be granted a fair trial 
 before resorting to operation. Rigidity, or the 
 reflex spasm caused by point pressure mentioned 
 by Sayre, is not in itself a safe criterion, nor does 
 excessive deformity, taken alone, furnish a reliable 
 indication. 
 
 Retentive dressings, such as splints of silicate of 
 coda or plaster of Paris, are used, either alone or 
 after tenotomy, serving to retain the foot in the 
 position acquired after manipulation or operation. 
 The rubber muscle advocated by Richard Barwell, 
 of London, and extensively used by Sayre, may be 
 employed to take the place of paralyzed muscles ; 
 or Scarpa's shoe, as variously modified, may be 
 applied to fix the foot and exert traction. 
 
216 MEMOIR OF A. S. ROBERTS. 
 
 As I mentioned to you at our last meeting, the 
 type of club-foot with which you will most fre- 
 quently meet is talipes equino-varus. The princi- 
 ples of treatment appropriate to the mechanical 
 conditions present can be applied to any of the other 
 forms. This deformity is well illustrated by the 
 case I now show you. 
 
 Case II. Congenital double talijjes eauino-varus ; 
 mechanical extension y recovery. — Richard C, aged 
 four months, referred to my care from the Obstet- 
 rical Department of this hospital. The deformity, 
 which in this case affects both feet, takes place upon 
 an anteroposterior and a transverse plane, combin- 
 ing elevation of the heel, equinus, and inversion of 
 the foot, with elevation of the internal border of the 
 sole, varus. The os calcis is drawn upward by the 
 contraction of the gastrocnemius and soleus, and 
 rotated in such a manner that its posterior border 
 is turned outward and its anterior border inward. 
 The bones of the tarsus, following the direction of 
 the os calcis, are inverted, and the inner sole raised 
 by the action of the tibialis anticus. The altered 
 relation of the bones of the tarsus leads to change 
 in form, especially of the articular facets ; and some 
 have considered these alterations as causative. This 
 is by far the most frequent of the congenital forms 
 of club-foot, and it has been argued that arrest of 
 development in bones and muscles is the principal 
 etiological factor. As the various theories on the 
 subject were discussed in our former clinic, they 
 need not detain us here. 
 
 The lateral deflection of the anterior portion of 
 
CLUB-FOOT. 
 
 217 
 
 the foot, as compared to that of the normal imprint, 
 is well shown in the following cuts. The outline 
 tracings are from impressions of the feet of patients 
 suffering from various deformities, obtained after 
 the method advocated by Rohmer ("Les Variations 
 de Forme Normales et Pathologiques de la Plante 
 du Pied," These, Nancy, 1879), consisting of first 
 
 Fig. 50. 
 
 covering the plantar surface of the foot with lamp- 
 black, which leaves a correct impression of the sole 
 upon white paper, on which the patients are then 
 requested to walk. To obtain a correct basis of 
 measurement, and still further to carry out Rohmer's 
 researches as a guide to treatment, I selected the 
 medio-tarsal joint as a base line of measurement ; 
 erecting upon it a perpendicular corresponding to 
 the long axis of the os calcis. As they are com- 
 paratively stable structures in all deflections from 
 the normal condition of the foot, the position and 
 
218 
 
 MEMOIR OF A. S. ROBERTS. 
 
 character of deformity could be readily determined 
 by a comparison of the degrees of variation. 
 
 In the thirty-two normal feet measured, I have 
 found the angle of deflection, which is represented 
 by an imaginary line passing through the head of 
 the metatarsal bone of the great toe, to range be- 
 tween 26 and 37 degrees (average, 20 males, 34.8 
 degrees ; 12 females, 31.5 degrees) ; typical exam- 
 ples may be seen in Figs. 49 and 50, males, and 
 Figs. 51 and 52, females. 
 
 Fig. 51. 
 
 Fig. 52. 
 
 In valgus, on the contrary, the angle of internal 
 deflection is reduced to from 12 degrees in moderate 
 cases, to 5 degrees in extreme ones, illustrated by 
 Figs. 53 and 54, which represent the imprint of 
 patient's feet suffering from acquired "flat-foot," 
 of rhachitic origin. From an examination of seven 
 cases I have ascertained the average deviation from 
 the perpendicular to be about 8.2 degrees. 
 
 The adduction of varus has in two instances 
 
CLUB-FOOT. 
 
 219 
 
 reached an internal rotation of 63 degrees. I con- 
 sider all feet that have an internal deviation in 
 excess of 40 degrees as abnormal. An examina- 
 tion of fourteen cases of varus yields an average of 
 
 51 degrees. 
 
 Fig. 53. 
 
 Fig. 54. 
 
 This method of measurement I believe to be of 
 importance, as furnishing us with an excellent and 
 accurate guide to the amount of deformity, as well 
 as affording an opportunity of determining the 
 improvement that may follow any plan of treatment 
 instituted. 
 
 In the correction of equino-varus, as in that of 
 the other compound forms, it is best to divide the 
 process of rectification into two stages, the object 
 being to overcome one of the factors of the deform- 
 ity before attacking the other. The reason for this 
 will be sufficiently obvious when it is considered 
 that the altered relations of the tissues of the foot 
 
220 
 
 MEMOIR OF A. S. ROBERTS. 
 
 take place upon two planes at right angles to each 
 other. Our endeavor, then, should be directed first 
 to the lateral or varus element of the deformity. 
 Manipulation should be systematically used, and, 
 while sufficient in very mild cases, is of great ser- 
 vice as an adjuvant in severe ones. It should be 
 applied several times daily, and in the following 
 manner : The heel is firmly grasped by one hand, 
 while with the other the anterior portion of the foot 
 is gradually and steadily brought into a position of 
 valgus, and held there for a few moments, then 
 allowed to return to its abnormal position. After 
 
 Fig. 55. 
 
 the manipulation has been repeated several times at 
 short intervals the foot may be placed in any light 
 dressing. This splint will retain the foot in its cor- 
 rected position, and may be modified from time to 
 time to suit the lessened amount of varus. It may 
 consist of material suited to the case. In the milder 
 degrees of the deformity, adhesive plaster wound 
 around the foot and attached to the fibular aspect 
 of the leg answers the purpose, but when greater 
 Btrength is required splints made of leather, gutta 
 
CLUB-FOOT. 
 
 221 
 
 percha, or hatters' felt may be moulded to the parts, 
 and secured by a roller bandage. These have the 
 advantage over fixed dressings of plaster of Paris 
 in allowing inspection as frequently as may be 
 desired, together with the application of massage, 
 electricity, etc. 
 
 Fig. 57. 
 
 But the majority of cases of varus cannot be 
 cured by such simple means. As in this case, 
 which is typical of congenital equino-varus, we 
 have absolute deformity to overcome ; tendons and 
 muscles are shortened, and the tissues structurally 
 
222 
 
 MEMOIR OF A. S. ROBERTS. 
 
 altered. The so-called " mild measures " will not 
 avail, and time occupied in their trial is wasted. 
 Nothing will be of benefit except the application of 
 instruments which by their accuracy of construc- 
 tion and power will appropriately stretch the tissues 
 involved, or, after a fair trial of these, operations 
 which will divide the resisting structures. 
 
 In such cases the shoe which I now show you 
 (Fig. 57) is of the greatest service. It is a modifi- 
 cation of Taylor's ankle support, and in its original 
 form was devised by Shaffer, of New York. To 
 this brace I have given more power by substituting 
 in the sole plate, for his extension bar a triple thread 
 screw worked by a key at b, and by throwing the 
 
CLUB-FOOT. 
 
 223 
 
 centre of motion further to the outer side of the sole 
 at A (Fig. 58). The instrument consists of a steel 
 trough fitted to the inner side of the leg, extending 
 from the upper part of the tibia to the internal 
 malleolus. A hinge at o (Fig. 57), the direction of 
 which is such as to allow pressure exerted upon it 
 at right angles to operate upon the anterior or 
 lateral deformity, connects this trough with a con- 
 
 tinuation, or foot portion, which is joined by a plate 
 to receive the foot by an antero-posterior joint, so 
 that the shoe may be accurately adjusted to the 
 " equinus " element of the deformity. The endless 
 
224 
 
 MEMOIR OF A. S. ROBERTS. 
 
 screw which I show you at A (Fig. 57) is operated 
 by a key, and acts through this hinge upon the 
 anterior portion of the foot. The sole is divided 
 opposite the medio-tarsal joint, and by means of the 
 screw b (Figs. 58, 59) acting upon the centre of 
 motion at a allows of extreme and powerful abduc- 
 tion of the anterior part of the foot. The apparatus 
 
 Fig. 60. 
 
 having been applied to fit the deformity, and se- 
 cured by a bandage (f, f), the foot is thrown into 
 a position of valgus by means of the screw A (Fig. 
 57) acting upon the hinge c, and this is supple- 
 mented by applying the force of the screw in the sole 
 plate b (Fig. 58), which still further acts upon the 
 anterior deformity. It is better to use the apparatus 
 by stretching the tissues several times in succession, 
 
CLUB-FOOT. 225 
 
 and, after allowing them to relax, to adjust the brace 
 to the corrected position. Having by this method 
 overcome the lateral deformity, as illustrated in 
 Fig. 60, our attention must be directed to the 
 anteroposterior or equinus element. 
 
 To correct this deformity by mechanical means 
 it is necessary to apply an instrument which, 
 through the tendo Achillis, will elongate the con- 
 tracted posterior muscles of the calf. To accom- 
 plish this many modifications of Scarpa's shoe have 
 been devised. They consist of two steel uprights 
 extending from the upper part of the tibia to the 
 ankle-joint, and are attached to a heel-cup and sole, 
 to hold the foot, the heel being strapped in its place 
 by means of a band of webbing, a bandage, or sim- 
 ilar material passing over the instep. The sole may, 
 or may not, be divided opposite the medio-tarsal 
 junction. At first sight, such an apparatus would 
 seem to fulfil the indication of applying a force 
 sufficient to flex the foot and stretch the tendo 
 Achillis, but in practice we find that as the neces- 
 sary power is exerted, the centre of motion in the 
 instrument being opposite the ankle-joint, the heel- 
 cup slips away from the os calcis, and the posterior 
 border of the foot is found resting upon the top of 
 the heel-cup. To obviate this, Shaffer has in his 
 extension shoe, which I now proceed to apply to 
 this patient (Fig. 61), divided the sole of the brace 
 opposite Chopart's joint, and attached to the ante- 
 rior portion or sole an extension bar which is worked 
 by a key which is introduced beneath the heel-cup 
 at b. The shoe having been applied extended to an 
 
 15 
 
226 
 
 MEMOIR OF A. S. ROBERTS. 
 
 angle corresjjonding to the angle of deformity, and 
 the heel secured in its place by a strap passing over 
 the instep, e, the os calcis is further secured by a 
 strap, d, passing around it posteriorly and attached 
 to the buckles upon either side of the anterior por- 
 tion of the sole plate. When flexion is made by the 
 
 Fig. 61. 
 
 key at a, which acts upon the endless screw oppo- 
 site the ankle-joint, c, the tendency of the heel, as 
 you see in Fig. 62, is to slip away and rest upon 
 the upper border of the heel-cup, and the degree of 
 flexion of the foot does not correspond to that of the 
 brace. If now we insert the key below the heel- 
 cup at b, and throw the anterior portion of the sole 
 
CLUB-FOOT. 
 
 227 
 
 forward, the os calcis is dragged upon by the strap 
 passing over it at d, and the centre of motion is 
 transferred from a point opposite the ankle-joint, to 
 a point represented by the centre of the strap, e^ 
 which passes over the instep, and the heel descends 
 until it rests upon the extension bar. The tendo 
 
 Fig. 62. 
 
 Achillis is thus thoroughly put upon the stretch,, 
 and may be felt as a tense band (see Fig. 63). The 
 operation is repeated several times at each sitting,. 
 and the amount of flexion thus gained is held by 
 readjustment of the brace in the acquired position. 
 No danger need be apprehended from interference 
 
228 
 
 MEMOIR OF A. S. ROBERTS. 
 
 with the circulation, if proper precautions be ob- 
 served ; the pressure is not continuous, being rather 
 a momentary overstretching, followed by relaxation. 
 The foot should be inspected daily. After the treat- 
 ment has resulted in bringing the foot to a right 
 angle with the leg, a retention-shoe with stop-joint 
 
 Fig. 63. 
 
 should be worn, to keep the foot in the corrected 
 position, and a similar apparatus must be applied 
 during the night throughout the treatment. Here 
 let me remark that a cure is not effected when the 
 amount of possible flexion of the foot forms a right 
 anerle with the tibia. 
 
CLUB-FOOT. 
 
 229 
 
 Referring to the diagram (Fig. 64), you will 
 observe that the normal foot in extreme flexion 
 forms with the leg an angle of about 70 degrees, 
 and at the ankle-joint motion is possible, in the 
 normal condition, through an arc of which the 
 extremes are represented by 135 degrees of exten- 
 
 Fig. 64. 
 
 r**^^ 
 
 sion and 70 degrees of flexion. Our endeavor in 
 the treatment of talipes equinus should be to make 
 the acquired flexion reach this amount as nearly as 
 possible. In connection with this subject, I wish 
 to call attention to the existence of cases of incom- 
 plete equinus, designated "non-deforming club-foot." 
 
230 MEMOIR OF A. S. ROBERTS. 
 
 In this condition flexion is impossible beyond 90 
 degrees, and the deformity is amenable to the treat- 
 ment just described. 
 
 Case III. Acquired double talipes equino-varus 
 from tetanoid paraplegia ; tenotomy of each tendo 
 Aclnllis. — You will recollect the case presented at 
 our last meeting, which comes before us now for 
 operation. In performing tenotomy, much of its 
 success is due to attention to detail. Two teno- 
 tomes are necessary ; one sharp-pointed, with which 
 to puncture the skin, and the other probe-pointed, 
 which is introduced through the puncture and be- 
 neath the tendon or fascia to be divided. The parts 
 having been rendered aseptic by cleansing with a 
 solution of 1 : 2000 of bichloride of mercury, and 
 put upon the stretch by flexing the foot, the punc- 
 ture in the integument is made over the central 
 portion of the tendon in such a manner that the 
 incision in the skin and that of the deeper tissues 
 shall not correspond after relaxation of the parts. 
 Through this puncture the probe-pointed tenotome 
 is introduced flatwise beneath the tendon and as 
 close to its deep surface as possible. The cutting 
 edge being now turned toward it, the tendon is 
 divided by a sawing motion of the knife. An 
 assistant keeps the tissues upon the stretch until 
 the operation is almost completed, but relaxes his 
 hold before the tendon is thoroughly divided, to 
 preclude the possibility of the instrument cutting 
 its way through the skin. The tenotome is again 
 turned upon its side, and withdrawn through the 
 puncture, the operator placing his finger over its 
 
CLUB-FOOT. 231 
 
 point of exit, dusting with iodoform, and sealing 
 with a pledget of cotton saturated with compound 
 tincture of benzoin, which forms a pellicle and pre- 
 vents the entrance of air. After the operation the 
 foot is placed in the extension brace, in order that 
 its degree of flexion may be controlled. This pos- 
 sesses the great advantage over fixed plaster-of- 
 Paris dressings of allowing frequent inspection of 
 the parts. 
 
 I shall only mention the operations of myotomy, 
 or division of muscles; tarsotomy, or osteotomy of 
 the tarsal bones ; tarsectomy, or the removal of a 
 wedge-shaped piece of bone ; open incision, as advo- 
 cated by Phelps and Hingston, instead of subcu- 
 taneous tenotomy ; and amputation as a last resort. 
 These are so rarely performed and so little neces- 
 sary, that it is only essential that you should know 
 that such procedures have been devised. 
 
 The next case I have to show you is one of 
 acquired talipes calcaneus. 
 
 Case IV. Acquired single talipes calcaneus from 
 infantile spinal paralysis ; application of BarweWs 
 rubber muscle ; improvement. — Maggie B., aged ten, 
 first presented for treatment in the Orthopedic Dis- 
 pensary of the University of Pennsylvania. She 
 has kindly consented to appear before you to-day. 
 You will notice the characteristic deformity, the 
 foot being flexed by the action of the anterior 
 groups of muscles, the patient walking upon the 
 heel. In this condition, no treatment does so well 
 as the application of elastic force, advocated by 
 Bar well. The rubber supplies the place of the 
 
232 MEMOIR OF A. S. ROBERTS. 
 
 paralyzed gastrocnemius and soleus, and should be 
 applied as you see in this case. To the shoe are 
 attached two uprights with an anteroposterior joint 
 opposite the ankle. It is important that this joint 
 should be so arranged that, while it will permit 
 flexion to any degree, it will stop extension at a 
 right angle. The posterior rubber muscle is at- 
 tached above to a band which passes around the 
 upper part of the calf and below to the heel of the 
 shoe. Should there be much contraction of the 
 anterior muscles, their tendons may be divided in 
 the manner described, before the application of the 
 apparatus. An operation has been devised for 
 exsection of a portion of the tendo Achillis for the 
 radical cure of this condition, and consists in the 
 removal of a portion of the tendon and the stitching 
 together of the divided ends. 
 
 The next case I have to exhibit illustrates a very 
 important principle in treatment. 
 
 Case V. Acquired single talipes equino-varus ; 
 mechanical extension, ajwneurotomy ; recovery. — 
 Joseph F., aged ten years, applied to the Ortho- 
 pedic Dispensary of the University Hospital for 
 relief from a congenital talipes equino-varus with 
 pronounced cavus. The case was treated by me- 
 chanical extension, as described when speaking of 
 talipes equino-varus, and resulted in the perfect 
 reduction of the equinus and varus. There remained, 
 however, marked cavus caused by contraction of 
 the plantar fascia. The extension-shoe was applied 
 with the hope of relieving this condition, but with- 
 out result, when aponeurotomy was resorted to. 
 
CLUB-FOOT. 233 
 
 Several operations were performed, the knife being 
 entered beneath the plantar fascia, and the resisting 
 tissues nicked, and the extent of the division was 
 regulated by the degree of relaxation of the plantar 
 arch resulting from each operation. As you see, 
 the boy has made a perfect recovery. 
 
 I wish to draw your attention especially to the 
 inefficacy of mechanical means in cases of cavus 
 with marked contraction of the plantar fascia, and 
 the reason will be readily understood if we consider 
 the structure and function of the arch of the foot. 
 In those forms of talipes which depend upon contrac- 
 tion of muscles, mechanical force applied through 
 the tendon will act upon muscular tissue and elon- 
 gate it. The plantar arch, on the contrary, is con- 
 structed with the view of supporting the weight of 
 the body, the tissues entering into its formation are 
 of the most unyielding character, i. e., plantar 
 fascia, and no amount of mechanical power which 
 can be safely applied will suffice in cases in which 
 it is markedly contracted. Aponeurotomy is neces- 
 sary, and performed tentatively, nicking a little, 
 and repeated as often as necessary, yields the best 
 results. 
 
 The last patient to which I shall call your atten- 
 tion to-day illustrates a condition the opposite of 
 cavus, the essential element being relaxation of the 
 plantar tissues. 
 
 Case VI. Acquired double talipes planus ("flat- 
 foot"} from rhachitis; plantar springs; improve- 
 ment. — John B., aged thirteen years. This case 
 shows the deformity in a marked degree, the plantar 
 
234 MEMOIR OF A. S. ROBERTS. 
 
 arch being relaxed and flattened, the internal border 
 of the foot resting upon the ground. These cases, 
 in which there is much pain, have received the 
 appellation of "inflammatory valgus." Besides 
 rhachitis, the other causes of this deformity are 
 paralysis, ankle-joint disease, and rheumatism. It 
 also occurs in growing children, and in those whose 
 occupation necessitates long standing in one posi- 
 tion. In mild cases the most efficient means at 
 our disposal for its relief are the plantar springs, 
 which have been applied in this case, with the 
 resulting improvement which you notice. They 
 are made as follows : 
 
 A tempered steel spring is placed inside the 
 shank of the shoe, moulded in such a manner as to 
 support the relaxed tissues of the arch and over- 
 come the tendency of the foot to e version. In cases 
 of greater severity it should be supplemented by 
 an ankle support having a pad which will make 
 pressure upon the internal malleolus. 
 
 All forms of club-foot may be simulated by the 
 neuromimetic or hysterical conditions. In cases of 
 this kind the pedal deformity may be accompanied 
 by contractions in other regions, or it may be the 
 only symptom outside the general condition, and 
 the dependence of the local trouble upon the neu- 
 rotic state may be very difficult to discover. Here, 
 as in neuromimetic affections in other regions, con- 
 tractions and contractures may so counterfeit their 
 organic prototypes as to render positive differentia- 
 tion well-nigh impossible. In making a diagnosis, 
 the general condition and surroundings of the pa- 
 
CLUB-FOOT. 235 
 
 tient, the hereditary history, together with any fact 
 as to previous mimicry or simulative tendency, 
 should be carefully weighed. The local condition 
 alone is not a reliable guide : the contractions are 
 often as unyielding as in the real deformity ; the 
 muscles do not relax during sleep, and the condition 
 may be very persistent. It is only by a careful 
 consideration of each case, and a diagnosis by exclu- 
 sion, that a correct opinion can be formed. 
 
 The care of this condition taxes the patience and 
 ingenuity of the surgeon to the utmost. In few 
 words, the treatment is that of the general neurotic 
 state, coupled with the absolute avoidance of all 
 local manipulations and mechanical contrivances 
 suited to similar organic deformities, and which 
 would here direct the attention of the patient to the 
 affected member. Despite the most careful general 
 treatment, the deformity may persist for months, as 
 shown by Dr. S. Weir Mitchell, 1 of this city. In this 
 case, hysterical single talipes equinus in a young 
 lady of fifteen had continued for two years, notwith- 
 standing the fact that treatment had removed all 
 the more general symptoms of the hysterical state; 
 and it was not until division of the tendo Achillis, 
 which I performed after consultation with Dr. Mit- 
 chell, that the deformity finally disappeared. 
 
 1 Lectures on Diseases of the Nervous System, especially in 
 Women. By S. Weir Mitchell, M.D., p. 129. Philadelphia: Lea 
 Bros. & Co., 1885. 
 
KNOCK-KNEE AND BOW-LEGS, 
 
 WITH REMARKS ON 
 
 EHACHITIS 
 
KNOCK-KNEE AND BOW-LEGS, 
 
 WITH REMARKS ON 
 
 RHACHITIS. 
 
 LECTURE I. 
 
 Gentlemen: As Macewen, of Glasgow, and 
 others have, by the revival of the operation of oste- 
 otomy for the cure of knock-knee and bow-legs, 
 renewed the interest in these deformities, and placed 
 themselves on record as being ardent advocates of 
 operative procedures for their radical relief, it will 
 be my endeavor to call your attention especially to 
 these important malformations ; and I purpose to 
 inquire how far operations are a necessity for their 
 correction, and what proportion and class of cases 
 can be best treated by such means, and, also? 
 whether mechanical methods of treatment are not 
 fully as important as those of a more radical nature. 
 
 Mechanically considered, knock-knee and bow- 
 legs result from an alteration in the plane of the 
 articulating surfaces of the bones entering into the 
 formation of the knee-joint, with or without a curv- 
 
 1 Clinical Lectures on Orthopedic Surgery, delivered at the Phila- 
 delphia Hospital. 
 
240 MEMOIR OF A. S. ROBERTS. 
 
 ing of the shaft of the femur or tibia, whereby the 
 knee is thrown either inside or outside a perpendic- 
 ular line let fall from the head of the femur to a 
 point midway betAveen the two malleoli. Should 
 the knee fall inside this line, the resulting deformity 
 is known as knock-knee or genu valgum, the oppo- 
 site condition, that in which the knee is without the 
 perpendicular, being called bow-legs or genu varum, 
 and the causes producing these results may be 
 summarized as : 1. Rhachitis. 2. Ligamentous 
 relaxation. 3. Central disturbances destroying the 
 equilibrium of muscular action, or aifecting the 
 nutrition of the epiphyses. 
 
 By far the most frequent and important cause is 
 the one first mentioned, namely rhachitis, which 
 favors the production of deformity by the softening 
 of bone and the relaxation of ligaments which 
 occurs during its progress, whereby we have an 
 alteration of the normal development of the cartilage 
 and periosteum from increased cell proliferation, the 
 resulting cartilaginous and osseous tissues being 
 less completely matured, and much more retarded 
 in their development than in the normal course of 
 bone growth. Moreover, the rapidly proliferated 
 cells are not supplied with a sufficient quantity of 
 inorganic elements, and, therefore, a relative excess 
 of organic material with a corresponding deficiency 
 of lime salts occurs. In other words, the cells 
 which are deposited are immature, half ripe in char- 
 acter, and the dyscrasia interferes with their normal 
 progression toward maturity. When the disease 
 finds expression in the epiphyses, it occurs at the 
 
KNOCK-KNEE AND BOW-LEGS. 241 
 
 epiphyseal juncture, at which point we find the 
 cartilage filled with young cells which are neither 
 mature cartilage cells nor true bone cells, but have 
 a character which partakes of both. In consequence 
 of this abnormal cell deposit we find the thickness 
 of the cartilage is increased, and the structure has 
 not the resisting quality so marked in health ; on 
 the contrary, the aggregation of cells forms a soft, 
 non-resisting material which breaks down and gives 
 way under pressure, and if this pressure be une- 
 qually distributed, bending of the bones and altera- 
 tion of the plane of the joints result. 
 
 Rhachitis is, primarily, a constitutional disorder, 
 whose local manifestations fall with greatest force 
 and frequency upon the organs of locomotion and 
 support, the bones, the epiphyses, articular surfaces 
 of the joints, the ligaments, and muscles. The 
 osseous changes found are due to increased vascu- 
 larity of the periosteum and other nutritive centres, 
 the epiphyses, and medullary substance. Rhachitis 
 is a disease of early childhood. Cases in which it 
 is congenital have been reported, and knock-knee 
 and bow-legs have been observed in the new-born. 
 The disease most usually begins about the period 
 of dentition, and is attended by disturbances in the 
 alimentary tract, vomiting and chronic diarrhoea 
 being frequent. The patients suffer also from 
 sweating of the head, face, and neck, and prefer to 
 lie quietly, resisting attempts to move or handle 
 them. With this, notable weakness and marked 
 tenderness are observed, and this weakness, notice- 
 able chiefly in the muscles, sometimes gives rise to 
 
 16 
 
242 MEMOIR OF A. S. ROBERTS. 
 
 a condition which has been mistaken for infantile 
 paralysis, although no palsy exists. While some 
 children suffering from rhachitis appear fairly well 
 nourished, the majority have a large belly, and a 
 puffy, flabby condition of flesh, easily distinguished 
 from the firm, resistant feeling of healthy tissues. 
 They are also peculiarly liable to convulsive affec- 
 tions, as before mentioned, and chronic hydroceph- 
 alus occurs frequently. Thirst is at times urgent ; 
 the patients sit or lie about ; are silent or drowsy, 
 and at night often rest upon their hands and knees, 
 with their heads buried in their pillows, or toss rest- 
 lessly from side to side. 
 
 While these symptoms are progressing, notable 
 changes are going on in the bones, muscles, and 
 ligaments. I have already alluded to these changes 
 in my general remarks on pathology, and have 
 shown you how their chief expressions are found in 
 the epiphyses and shafts of the bones. Clinically, 
 it is not, however, alone in the long bones that the 
 changes take place. The skull, with its thin and 
 softened envelope and thickened sutures ; the thorax, 
 as shown principally in the beaded ribs, chicken- 
 breast, and curved vertebras, and the flattened, 
 distorted pelvis, all bear evidences of the disease. 
 Not all the cases, however, exhibit these universal 
 effects of the general condition. Indeed, I have 
 seen undoubted evidences of localized rhachitis 
 where the disease, so to speak, had expended itself 
 upon one locality. Thus, it is not unusual to see 
 deformities which are unilateral in character, and 
 one-sided cases of bow-legs and knock-knee are not 
 
KNOCK-KNEE AND BOW-LEGS. 243 
 
 uncommon. We have already spoken of the causes 
 which produce this condition, and will only add 
 that, although it is found more frequently among 
 the poorer classes, the wealthy are by no means 
 exempt from it. Poor sanitary surroundings, insuffi- 
 cient nourishment, lack of air and sunlight, and the 
 crowding together of many people, frequent preg- 
 nancies, and the bringing up of children " by hand," 
 all add their quota as active agents in its produc- 
 tion. Locality and climate also have their influence 
 as causative factors. Thus, it is by no means a 
 common disease among American children, but is 
 very frequent in Southern races, the negro being 
 peculiarly liable to it ; and its frequency in England 
 has caused the Germans to give to it the appellation 
 of '" Englische Kranlclieit" 
 
 I have dwelt at length upon the general manifes- 
 tations of rhachitis as it is in this stage, before 
 local symptoms have developed, that general treat- 
 ment may prevent deformity. In beginning the 
 treatment, great care should be exercised in the 
 selection of appropriate diet, and all errors in this 
 and the surroundings of the patient should be cor- 
 rected. The child should be regularly taken out in 
 the open air, and "sun-baths" given. Attention 
 should be especially directed to the proper bathing 
 of the child, and the skin kept in good condition by 
 these means. The diet should be digestible and 
 nutritious, and all approved methods having for 
 their object the proper hygienic care of the patient 
 should be persistently and systematically employed. 
 As to drugs, those which are directed to checking 
 
244 MEMOIR OF A. S. ROBERTS. 
 
 the diarrhoea after the bowels have been emptied 
 of irritating matter are first indicated. The time- 
 honored " rhubarb-and-soda " mixture will best 
 accomplish the latter purpose, while drop doses of 
 tincture of opium, with the addition of an alkali, 
 have best succeeded in my hands in checking the 
 diarrhoea. To improve the general condition of the 
 child, cod-liver oil may be given, and by many it is 
 considered a specific ; but there are many objections 
 to its use ; it is apt to increase the digestive trouble, 
 and many children cannot be induced to take it, no 
 matter how disguised. Good, fresh butter answers 
 admirably as a substitute, and fulfils all the indi- 
 cations of the oil. The compound syrup of the 
 hypophosphites is another excellent remedy, and is 
 readily administered for a long time. Iron is an 
 efficient tonic, especially the syrup of the hypophos- 
 phite or the iodide. Phosphorus also has given 
 excellent results in this as well as other wasting 
 diseases of the bones. Such is a brief outline of 
 the medicinal treatment of rhachitis, important in 
 all cases of the disease, but most important in cases 
 prior to the occurrence of deformity, in addition to 
 which mechanical supports should frecruently be 
 used as a prophylactic measure. The case I now 
 show you will illustrate this principle. 
 
 Case I. Softening of the bones from rhachitis; 
 retention braces ; improvement. — J. M., aged twenty- 
 six months. The hereditary history in this case is 
 good, as to bone, joint, or lung troubles; she was 
 apparently healthy until her eighth month, when 
 her mother was obliged to leave her to the care of 
 
KNOCK-KNEE AND BOW-LEGS. 245 
 
 strangers. At this time it was noticed that she 
 was not as lively as usual, had frequent diarrhoea, 
 was peevish and restless at night, sweating freely, 
 frequently soaking the pillow. She has never at- 
 tempted to walk, but can hold herself erect by the 
 aid of chairs. You will notice the flabby condition 
 of the muscles, although she is apparently fairly 
 nourished, and, although presenting all the char- 
 acteristic symptoms of rhachitis — the large head, 
 protuberant belly, and flattened epiphyses indicate 
 rhachitis — there is, as yet, no evidence of deformity 
 of the lower extremities, for the child has not yet 
 walked, and nature has evidently acted in a con- 
 servative manner, by depriving the muscles of their 
 proper tone, thereby making it impossible for the 
 child to throw the weight of the body upon the 
 lower extremities, and we have happily the power 
 to prevent, by mechanical means, the occurrence of 
 deviations which would surely follow were the soft- 
 ened osseous tissues allowed to bear unaided the 
 superincumbent weight of the body. 
 
 In this case the object has been accomplished by 
 the application of retention braces, consisting of 
 two steel uprights fastened to the shoe, and extend- 
 ing above the knee, with joints corresponding to 
 the articulation of the knee and ankle. These allow 
 free motion, but at the same time remove the super- 
 incumbent weight. To one point I wish especially 
 to call your attention : when I grasp the thigh and 
 leg of the patient, and move the knee-joint from 
 side to side, you can easily distinguish the preter- 
 natural lateral mobility of the articulation, a com- 
 
246 MEMOIR OF A. S. ROBERTS. 
 
 mon condition in rhachitic subjects. This is due to 
 ligamentous relaxation, and opinions vary as to the 
 ligaments involved and their action in the produc- 
 tion of the deformities, it being considered by some 
 that primary relation of the internal lateral ligament 
 results in a separation between the articular surfaces 
 of the knee-joint upon the inner side, allowing 
 increased growth of the internal condyle downward 
 and inward in the gap between its lower surfaces at 
 the head of the tibia, while others are of the opinion 
 that shortening of the external lateral ligament, by 
 permitting pressure to be exerted upon the external 
 condyle, prevents its normal growth, the internal 
 condyle, at the same time, completing its develop- 
 ment. "While some cases occur in which ligament- 
 ous relaxation seems to be the only apparent cause 
 of the deformity, they are extremely rare, and I 
 think that the relaxation, as a rule, is secondary to 
 and symptomatic of the bony changes. While 
 much attention has been given to the external liga- 
 ments of the knee-joint as factors in the causation 
 of knock-knee, I am sure that the internal ligaments 
 of the joint, principally the crucial, are largely con- 
 cerned in the deformity; but as to the mechanism 
 of these ligaments as causative agents, I cannot, 
 for want of time, speak. In the small class of cases 
 which exhibit no evidence of rhachitis, but which 
 suffer from relaxation of ligaments, the term atonic 
 can best be applied. They are similar to the class 
 of lateral spinal curvatures known as habitual or 
 functional ; but, as before stated, in the majority of 
 cases the ligamentous changes are secondary to the 
 
KNOCK-KNEE AND BOW-LEGS. 247 
 
 osseous ones, and depend upon the general condition, 
 i. e., rliacliitis. 
 
 The changes which occur in the bones, and which 
 lead to the deformity, may be divided into three 
 stages : 
 
 1. Tlie stage of vascularity, or invasion. 
 
 2. Tlie stage of softening, or deformity. 
 
 3. The stage of consolidation, or sclerosis. 
 
 It is important that these stages should be recog- 
 nized, as giving important indications for treatment. 
 The second stage is well illustrated in the case 
 before us : when I grasp the limbs and attempt to 
 bend the bones, a characteristic springy sensation is 
 imparted to the hands, showing that the stage of 
 softening is still in progress, and indicating that 
 constitutional and mechanical treatment are suffi- 
 cient. 
 
 When softening has further progressed, and de- 
 formity has begun from the weight of the body 
 upon the diseased tissues, mechanical support may 
 still suffice; but when hardening or sclerosis has 
 once occurred, and the bones are in a deformed 
 position, nothing but operative measures will re- 
 store the limb to its normal position. To determine 
 this stage in doubtful cases I use an instrument 
 which I look upon as an important aid to correct 
 diagnosis, *". e., the ordinary bone drill, preferably, 
 the cog-wheel drill of Colin, of Paris ; the proced- 
 ure is analogous to exploratory incision prior to 
 other surgical operations. Where the drill encoun- 
 ters no obstacle to its entrance into the bone, and 
 imparts to the hand the sensation indicative of soft 
 
248 MEMOIR OF A. S. ROBERTS. 
 
 tissue, operative procedures are not necessary; but, 
 should the characteristic resistance of the sclerotic 
 stage, as if the drill were being bored through 
 ivory, be met, mechanical measures will be futile, 
 and operation is necessary. 
 
 I have an opportunity of showing you another 
 case illustrative of the stage of softening with 
 beginning deformity. 
 
 Case II. Bow-legs from rhachitis; mechanical 
 support; improvement. — This patient, Mary "W., is 
 three years old; gives all the evidences of having 
 had rhachitis, and still shows symptoms of what 
 may be called the subacute stage. You notice 
 many of the conditions to which I called your 
 attention in speaking of the child who has just 
 passed out ; but, in addition to these, you are at 
 once struck with the peculiar waddling gait, and 
 the tendency of the feet to a varus position when 
 the child attempts to walk. This varus is not con- 
 stant, as in some cases of bow-legs there may be a 
 valgoid position of the feet. Here you again see 
 the unusual lateral mobility of the knee-joints. In 
 the present instance the deformity, which is quite 
 marked, is produced by curvatures affecting both 
 the femur and the tibia ; that is to say, the rhachitic 
 process has involved the diaphyses above and below 
 the knee-joint. This is not, by far, as common as 
 those cases where the tibia is alone affected,, in 
 which case the deformity usually takes place at 
 about the middle of the tibia, although the same 
 condition, greatly magnifying the distortion, may 
 occur at the lower third, or an anterior curvature 
 
KNOCK-KNEE AND BOW-LEGS. 249 
 
 of the tibia may be observed. When I grasp the 
 bones firmly I at once get a peculiar springy 
 response, and this serves as a guide to my treat- 
 ment in this stage. In answer to inquiry concerning 
 the increase of the deformity, the mother states that 
 the bowing has increased very rapidly during the 
 last four or five months ; that before this it was not 
 at all marked, and she has experienced no fear of a 
 permanent deformity, having been told by a practi- 
 tioner that the child would surely grow out of it. 
 This is a popular fallacy, and cannot be too strongly 
 condemned. The indications for mechanical treat- 
 ment are therefore very plain. In order to counteract 
 the effect of the superincumbent weight which falls 
 on the lower extremities during the day in the act 
 of walking, it becomes necessary to have something 
 which shall relieve this, and for this purpose I use 
 the conventional apparatus which I briefly described 
 in speaking of the first case. This brace will allow 
 your patient to go about at the minimum risk of 
 increasing the deformity, and also give him an 
 opportunity to get sunlight and fresh air, very im- 
 portant adjuncts toward improvement of his general 
 condition. In cases in which deformity is present, 
 this serves merely as a retention splint, and some- 
 thing more powerful must be used to overcome the 
 deformity. 
 
 The brace which I have advised for the applica- 
 tion of elastic traction has, in my hands, in private 
 and hospital practice, accomplished excellent results. 
 It consists of a piece of straight tempered steel, its 
 upper extremity terminating in a semicircular steel 
 
250 
 
 MEMOIR OF A. S. ROBERTS. 
 
 band to extend half-way around the limb ; below, 
 and jointed to it opposite the ankle, is a steel foot- 
 piece with heel-cup, which is secured to the foot by 
 a strap passing over the instep, and a light leather 
 shoe-piece laced over the foot. The length of the 
 upright is regulated by the position of the curva- 
 
 Fig. 65. 
 
 ture in the bones ; in bow-legs where this occurs in 
 the tibia, the upright should, therefore, extend only 
 to its upper border. The brace is adjusted by 
 securing it to the internal aspect of the limb, and 
 the elastic element of the brace brought into play 
 by strapping the steel upright to the leg at the 
 
KNOCK-KNEE AND BOW-LEGS. 251 
 
 point of the greatest convexity (Fig. 65). It 
 should be thus applied at night, and it is readily 
 seen that its constant effort to return to the straight 
 line d c exerts a continuous elastic force in a direc- 
 tion calculated to reduce the deformity. 
 
 LECTURE II. 
 
 Case III. Knock-knee; application of elastic 
 traction brace. — Frances G. is two and a half years 
 old, and has, as the father states, always been a 
 weak, nervous child, and subject to croup. During 
 the period of dentition she was much troubled with 
 diarrhoea, and very thirsty ; also perspired a great 
 deal, and was restless and peevish. The ribs have 
 the " beaded " feel ; there is quite a prominent 
 sternum, and all the epiphyses are flattened. The 
 skull also shows evidences of rhachitis. On placing 
 the child on her feet, the deformity of the lower 
 extremities, consisting principally of the in-knee 
 deviation, is at once perceived. There is the usual 
 extensive lateral motion at the knee-joints which is 
 also manifested in the other articulations. When I 
 flex the legs on the thighs the deformity disappears ; 
 there is marked projection at the inner side of the 
 knees, due to the hypertrophied internal condyle of 
 the femur. The first thing that attracts attention 
 to these cases is the peculiar gait when the children 
 begin to walk, which they do not attempt, as a rule, 
 until quite late, and, with this, much fatigue is com- 
 plained of. Pain is not a frequent or urgent symp- 
 
252 
 
 MEMOIR OF A. S. ROBERTS. 
 
 torn, and, when it occurs, is referred to the inner side 
 of the knee. 
 
 In the treatment of this case the same rules 
 should be followed as are applicable to the cure of 
 bow-legs; and as sclerosis has not as yet occurred, 
 
 Fig. 66. 
 
 I shall use, in addition to the retention braces to be 
 worn throughout the day, an elastic traction brace 
 at night. (Fig. 66.) 
 
 It is applied to the external aspect of the limb, 
 and the upright extends well up to the thigh, and is 
 secured at two points, just above and just below 
 
KNOCK-KNEE AND BOW-LEGS. 253 
 
 the knee-joint, so that, in its efforts to right itself, 
 it will produce continuous elastic pressure upon the 
 foypeiiropliied internal condyle. It would be impos- 
 sible in a clinical lecture for me to describe exten- 
 sively the various forms of apparatus devised for 
 the relief of this deformity, but among others used 
 for removing it are those which aim at this result 
 by the use of exaggerated interarticular pressure 
 directed against the already hypertrophied internal 
 condyle, thus attempting to produce absorption at 
 this point. This also involves the use of intermit- 
 tent rather than constant pressure. I am of the 
 opinion that, while intermittent traction through soft 
 tissues is of infinite value in the relief of certain 
 deformities, this does not hold concerning intermit- 
 tent pressure. Apart from the fact that these 
 instruments are complicated and expensive, difficult 
 of adjustment, and liable to constant malposition by 
 slipping, etc., they must depend largely for their 
 efficacy on the constant personal supervision of the 
 surgeon or attendant. Again, the fallacy of attempt- 
 ing to produce absorption by intermittent pressure 
 from without is clearly shown by Sir James Paget, 
 in his " Lectures on Pathology," who, in speaking 
 of atrophy as manifested in the Chinese foot, and 
 also in stumps after amputation, says : " These 
 examples, then, may suffice to show, as I have said, 
 that constant pressure on a part produces absorp- 
 tion; occasional pressure, especially if combined 
 with friction, produces thickening or hypertrophy, 
 and that these result whatever be the direction of 
 the pressure." 
 
254 
 
 MEMOIR OF A. S. ROBERTS. 
 
 The positive atrophy and absorption of tissues 
 from elastic pressure, on the contrary, are remark- 
 ably shown in the destruction and removal of large 
 areas of bone, which frequently occur in aneurism 
 of the aorta, and this brace is constantly exerting a 
 similar influence upon the internal condyle. 
 
 Case IV. Unilateral genu valgum; osteotomy ; 
 cure. — The next case is one upon which I operated 
 
 Fig. 67. 
 
 at the clinic a few weeks ago, and is the first oste- 
 otomy for genu valgum performed at this hospital. 
 
KNOCK-KNEE AND BOW-LEGS. 
 
 255 
 
 Frank D., aged five, colored, an inmate of the 
 children's ward, presented the following character- 
 istic rhachitic deformities : The vertebrae are rotated 
 upon their axis, and laterally deflected into the 
 deformity of rotary lateral curvature and rhachitis, 
 the primary curve existing in the lumbar region. 
 
 Fig. 
 
 The deformity of the lower extremity presented as 
 a unilateral genu valgum of the left limb. The 
 femur is markedly curved in an anterior and lateral 
 direction, the internal condyle being depressed below 
 the normal plane of the joint, producing a decided 
 
256 MEMOIR OF A. S. ROBERTS. 
 
 in-knee deviation, as seen in Fig. 67, taken from a 
 photograph prior to the operation. The duration 
 and pronounced character of the deformity appar- 
 ently render this patient a fit subject for the opera- 
 tion of osteotomy or subcutaneous fracture of the 
 bone for restoration of the limb to a normal position. 
 Yet in order to be perfectly sure that the stage of 
 softening had passed, and that nothing more was to 
 be expected from conservative mechanical treat- 
 ment, I made use of the bone-drill spoken of, before 
 operating, and finding all the indications of sclerosis 
 present, I performed the operation of osteotomy, 
 and am happy to show you the correction of the 
 deformity as seen by these photographs, made prior 
 and subsequent to the operation. (See Figs. 67 
 and 68.) 
 
 Before proceeding to my next case, I think it will 
 be well briefly to call your attention to the different 
 surgical procedures now in vogue for the relief of 
 these deformities, and also to a short historical 
 account of them. These may be placed under three 
 heads, as follows : 
 
 1. Forcible straightening. 
 
 2. Osteoclasis. 
 
 3. Osteotomy. 
 
 Of the first two mentioned methods, I will not 
 enter into detail. They are approved by many sur- 
 geons, especially the French, and successful cases 
 have been reported as having been brought about 
 by these means ; Delore, of Lyons, and Tillaux 
 being their principal advocates. Excellent osteo- 
 clasis havo also been devised by Colin and Robin. 
 
KNOCK-KNEE AND BOW-LEGS. 257 
 
 The brilliant results attained by osteotomy have, 
 however, given this operation the palm, and most 
 surgeons now perform this in preference to osteo- 
 clasis. 
 
 Although osteotomy for an anchylosed hip-joint 
 had been performed by Khea Barton, of this city, 
 as early as 1826, it was not until 1852 that Mayer, 
 of Hamburg, first operated for knock-knee. He 
 opened the joint in his operation, and one of his 
 cases died of tetanus. In the same year Langen- 
 beck proposed osteotomy in cases of anchylosed 
 knee. Following this many osteotomies of different 
 articulations were performed, and American sur- 
 geons, Pancoast, Sayre, and Brainard, were among 
 the first to practise them. As applied to the de- 
 formity genu valgum, the first operator in England 
 was Annandale, who virtually excised a part of the 
 condyles of the femur for knock-knee, the operation 
 being done under antiseptic precautions. Anti- 
 septic osteotomy was introduced by Volkmann, of 
 Halle, in 1875, the same year that Annandale ope- 
 rated. In 1876, Ogston performed the operation, 
 using the saw, and was followed by Schede, of 
 Berlin. The objection to all these operations was 
 the fact that the knee-joint was opened, exposing 
 the patient to even a greater danger than the origi- 
 nal deformity. In 1877 Chiene cut through the 
 condyle with a chisel, removing a wedge-shaped 
 piece. In 1878 Barwell performed his "simul- 
 taneous multiple osteotomy," which consisted in a 
 division of both femur and tibia. In 1878 Mac- 
 ewen introduced his supra-condyloid osteotomy, 
 
 17 
 
258 
 
 MEMOIR OF A. S. ROBERTS. 
 
 and this, involving no possible danger to the knee- 
 joint, has been popularly adopted. In 1S79 Keeves 
 modified Ogston's operation so that the danger of 
 opening the articulation was reduced to the mini- 
 mum, the object being, at the same time, to replace 
 the displaced condyle. The following diagram 
 (Fig. 69) will illustrate the various points of elec- 
 tion for the performance of osteotomy. 
 
 Fig. 69. 
 
 1. Mayer, Billroth, Schede. 2. Annandale. 3. Ogston, Reeves, 
 Chiene. 4. Maceweu. 5. Taylor. 
 
 Of all the operations mentioned, I give my per- 
 sonal preference to that of Macewen, and in the 
 case which I now present to you, propose to perform 
 the operation. 
 
KNOCK-KNEE AND BOW-LEGS. 
 
 259 
 
 Case \. Bilateral knock-knee; double osteotomy 
 by Maceweri's method; recovery. — The history in 
 brief is as follows : Lottie H., aged five, colored, 
 was admitted into the Philadelphia Hospital in 
 1881, suffering from severe bilateral knock-knee. 
 No record could be obtained of her previous history 
 
 Fig. 70. 
 
 or the time at which the deformity first appeared. 
 You will notice, however, that a marked curvature 
 or in-knee deviation exists in both lower extremities 
 (Fig. 70). The femora have an anterior bend in 
 their lower third, as well as a lateral deviation. 
 
260 MEMOIR OF A. S. ROBERTS. 
 
 Curves of similar character are present in the tibia. 
 On measurement, I find, when the internal condyles 
 of the femur are approximated, the malleoli at the 
 ankle-joint are separated nine and a half inches, as 
 shown in Fig. 70, from a photograph. On account 
 of the long-standing and pronounced character of 
 the deformity, having satisfied myself by the drill 
 that sclerosis has taken place, I propose to do a 
 double supra-condyloid osteotomy, after the plan 
 recommended by Macewen, of Glasgow. 
 
 The patient being anaesthetized, and having 
 cleansed the limbs and rendered them aseptic at 
 the point of election for the introduction of the 
 osteotome, the elastic roller of Esmarch is applied, 
 and the limbs rendered bloodless. After securing 
 the vessels by a few turns of rubber tubing, the 
 bandages are removed, and the limbs are ready for 
 puncture, which is made at a point two fingers' 
 breadth above the internal condyle. The osteotome 
 is now introduced down to the bone, and turned 
 transversely to the long axis of the shaft. By a 
 few blows of a heavy wooden mallet, the instru- 
 ment is driven through the bone, and then with- 
 drawn from the wound, a little force being now 
 required to complete the fracture. Now loosen the 
 turns of the rubber tubing, to ascertain if any 
 hemorrhage has taken place, and, as you see, this is 
 very slight and mostly venous. The punctures are 
 dusted with iodoform, and covered with pledgets of 
 lint that have been previously soaked in compound 
 tincture of benzoin, which quickly dries, forming 
 an excellent artificial seal. The next step is to 
 
KNOCK-KNEE AND BOW-LEGS. 
 
 261 
 
 envelop the limbs in a flanner roller, and place over 
 all the plaster-of-Paris bandage from the toes to the 
 upper third of the thigh. It is well always to have 
 the plaster thoroughly dried in an oven overnight, 
 
 Fig. 71. 
 
 From a photograph taken six months after operation, showing 
 correction of deformity. 
 
 as it facilitates its setting and makes a much stiffer 
 and more durable splint; while the plaster is setting, 
 the limbs are "over-straightened," and the knees 
 brought in a position of slight genu varum, by 
 
262 MEMOIR OF A. S. ROBERTS. 
 
 placing a roller bandage between them, and bring- 
 in gs the malleoli together. Three days from the 
 date of operation I shall cut a small fenestrum in 
 the dressing opposite the point of puncture, and 
 examine the wound. Should no unfavorable symp- 
 toms intervene — i. e., suppuration or retarded union 
 — the dressing will be removed at the end of six 
 weeks, and the patient placed upon her feet with 
 light steel retention-braces, jointed at the knee and 
 ankle, to allow of motion. 
 
 Before closing, I desire to say a few words upon 
 the other causes of knock-knee and bow-legs men- 
 tioned in the early part of this lecture. Disturbance 
 of trophic centres acting either upon muscular tissue, 
 destroying equilibrium, or upon the nutrition of the 
 epiphyses, has been assigned as a cause of knock- 
 knee and bow-legs. The most direct results of 
 central disturbance are seen in connection with 
 poliomyelitis anterior (infantile spinal paralysis), 
 and in tetanoid or spastic paraplegia. Here de- 
 formity is induced directly by the lack of supporting 
 power in the muscles, as well as the loss of tone in 
 the ligaments, and cannot be explained by the old 
 antagonistic theory of loss of power in one set of 
 muscles, with preponderating action in others. The 
 same conditions obtain which Volkmann had shown 
 to exist in the production of club-foot, the deformity 
 not resulting from loss of muscular antagonism, but 
 rather from growth while the part remains in an 
 abnormal position. It is also probable that in these 
 paralytic cases the changes brought about in nutri- 
 tion affect the bone to a large extent, as it has been 
 
KNOCK-KNEE AND BOW-LEGS. 263 
 
 shown that they are much thinner, more curved, 
 and softer than normal. Here we cannot say that 
 rhachitis enters as an etiological factor, owing to 
 the absence of its characteristic symptoms. 
 
 The fact that cases of unilateral in-knee deviation 
 are often observed without the association of symp- 
 toms denoting the presence of rhachitis has given 
 rise to the idea that there is a condition which 
 affects the nutrition of the epiphyses in such a 
 manner as to produce knock-knee, and that this is 
 a probable result of central changes having their 
 expression in the epiphyseal cartilages of the knee- 
 joint. This is purely theoretical, though not an 
 entirely groundless idea. 
 
 I have thus endeavored to give you concisely the 
 principal points in the pathology and treatment of 
 bow-legs and knock-knee, and hope that, with the 
 general indications I have attempted to impress, 
 you will be enabled to cope successfully with these 
 deformities. 
 
FLAT-FOOT: 
 
 A NEW PLANTAR SPRING FOR ITS RELIEF. 
 
FLAT-FOOT : 
 A NEW PLANTAR SPRING FOR ITS RELIEF. 
 
 Amoistg- the most distressing and painful deform- 
 ities of the lower extremity which the orthopedic 
 surgeon is called upon to treat, cases of flat-foot 
 stand foremost. I should not have ventured to 
 speak of this very common deformity did I not 
 think that its importance is often overlooked, and 
 that in many instances it is a source of much con- 
 fusion regarding its etiology, diagnosis, and treat- 
 ment, to those who have not had many opportunities 
 for studying the disease. 
 
 As a rule, the ordinary forms of club-foot are 
 unattended with pain ; this sympton entering only 
 secondarily, either as a result of pressure from 
 walking in the deformed position, or from the faulty 
 mechanical appliances used to correct the deformity. 
 In the form of talipes under consideration, however, 
 pain plays an important part, and with this the dis- 
 ability produced is often so extreme as to render 
 the patient unable to pursue his ordinary occupa- 
 tion. Thus, in addition to the usual end to be 
 attained in the treatment of deformities of the feet, 
 namely, the restoration to the normal form of the 
 
268 MEMOIR OF A. S. ROBERTS. 
 
 foot, we have another and more practical object de- 
 manding onr utmost attention and study, and that 
 is the preservation of the means of livelihood to 
 those who are unfortunately afflicted with flat-foot. 
 
 Like other forms of talipes, flat-foot, or talipes 
 valgus, may be a congenital or an acquired malfor- 
 mation, but it is very rarely found at birth to such 
 an extent as to be considered pathological. On the 
 other hand, the acquired forms of valgus, taking all 
 the varieties collectively — whether occurring as 
 simple flattening of the arch, as secondary to rha- 
 chitis, as the result of infantile spinal paralysis, or 
 those of the inflammatory type — talipes valgus 
 probably occurs most frequently of all the distor- 
 tions of the feet. 
 
 It may be well, in this connection, before proceed- 
 ing to an account of the etiology of talipes valgus, 
 to give a brief account of the normal mechanism of 
 the foot and of the plantar arch. All of that portion 
 of the lower extremity situated below the tibio-tarsal 
 articulation enters into the construction of the foot, 
 and in the adult has the form of an arch, with its 
 convexity or dorsal surface above and its concavity 
 or plantar surface below. At the highest point of 
 this arch, which is formed by the astragalus, the 
 weight of the body is received and transmitted ; 
 receiving the weight on its trochlear surface from 
 the tibia, and transmitting it through the so-called 
 pillars of the arch. Of these there are two, the 
 anterior one, composed of the scaphoid, three cunei- 
 form and the three inner metatarsal bones, being 
 the longer, less oblique, and more elastic. The 
 
■FLAT-FOOT. 269 
 
 posterior pillar, formed by the os calcis, is shorter 
 and thicker, its concavity being directed inward, 
 and it is less elastic than the anterior one. The 
 astragalus, therefore, may be regarded as the key- 
 stone of the arch ; but it differs in certain respects 
 from the keystone of the ordinary arch. While its 
 anterior surface, by its apposition to the concave 
 posterior surface of the scaphoid, fulfils this re- 
 quirement, posteriorly it rests upon and overrides 
 the os calcis. Hence, this weak point in the arch 
 has to be supplemented, so to speak, and this is 
 accomplished by the soft parts, the interosseous 
 ligaments passing between and binding together 
 the bones, the calcaneo-scaphoid ligaments arising 
 from the inferior surface and forepart of the os 
 calcis, and passing to the posterior and under part 
 of the scaphoid bone, thus giving direct support to 
 the head of the astragalus. Again, we have a 
 secondary arch supporting the primary one. This 
 is formed by the outer part of the os calcis, the 
 cuboid, and the two outer metatarsal bones, this sup- 
 plementary arch being supported by the calcaneo- 
 cuboid ligaments, while the strong plantar fascia 
 extends between and acts as a brace to the pillars 
 of the arch. It must not be forgotten that, while 
 an arch has ordinarily to receive weight only in one 
 direction, in the case of the foot the direction of 
 the weight is continually changed by the various 
 positions assumed by the bod} r in its movements. 
 Thus, while in the standing position the weight 
 would fall chiefly on the astragalus and be directly 
 transmitted to the two pillars of the arch, in walk- 
 
270 MEMOIR OF A. S. ROBERTS. 
 
 ing, running, dancing, etc., involving, as these move- 
 ments do, the different parts of the foot, the weight 
 is constantly shifted, and consequently the liga- 
 ments and muscles of the foot are called upon to 
 reinforce the arch by their action. Added to this 
 there is the mobility of the tarsus, and this mobility 
 is the greatest just where the greatest strain falls, 
 namely, between the astragalus and scaphoid. The 
 muscle principally called upon in this connection is 
 the tibialis posticus, while the inner part of the 
 calcaneo-scaphoid ligament is chiefly engaged in 
 resisting all extra strain. 
 
 It will be easily understood then, that, associated 
 with the different complex movements alluded to, 
 involving as they do the raising (flexion) and 
 placing of the foot on the ground (extension), on 
 the resistance offered by the tibialis posticus and 
 calcaneo-scaphoid ligament, and upon the help thus 
 given to the arch, depend the conservation of the 
 form of the foot. Again, the normal curves of the 
 foot give a certain amount of mechanical advantage 
 in the distribution of the superincumbent body 
 weight. Thus, in flexion the two curves of the 
 foot — the larger, with its concavity downward, and 
 a lesser one along the inner side of the foot, with 
 its concavity outward — are increased. On the other 
 hand, in extension, as when the foot is firmly 
 planted on the ground, both these curves are dimin- 
 ished and the foot is flattened. It is evident, there- 
 fore, that any cause operating to weaken those 
 tissues which, by their aid, serve to strengthen the 
 arch, will cause a permanent extension of the foot, 
 
FLAT-FOOT. 271 
 
 with obliteration of the natural curves. Thus, in 
 occupations requiring continued standing or walk- 
 ing, or the maintenance of a given position for a 
 long time, these structures become overtaxed, and, 
 as a consequence, do not afford the proper accessory 
 support to the arch ; there exists a condition of per- 
 manent extension of the foot, and sooner or later, 
 depending on the constitution of the individual, 
 flat-foot follows as a consequence of this abnormal 
 strain. 
 
 The morbid anatomy of flat-foot, or spurious 
 valgus, shows differences according to the etiology 
 of the given cases. Thus, in the congenital variety 
 very few pathological changes are noticeable. The 
 external appearance of the foot shows a decided 
 lowering or flattening of the normal arch, with the 
 inner margin of the foot depressed and closer to the 
 ground, while the outer border is raised, and the 
 anterior part of the foot everted. Sometimes in 
 these congenital cases there is a marked degree of 
 equinus associated with the valgus, and when this 
 occurs there is decided contraction of the calf 
 muscles. In the congenital form of valgus there is 
 not much displacement of the bones of the foot, the 
 principal changes consisting of the elevation of the 
 tuberosity of the os calcis, while the astragalus is 
 pushed downward and forward, and is seen as a 
 prominence on the inner side of the foot, with the 
 rotated scaphoid bone, which is also prominent. 
 There is a slight rotation outward of the cuboid 
 bone, and the malleoli are depressed, being found 
 on a lower plane than normal. The weight of the 
 
272 MEMOIR OF A. S. ROBERTS. 
 
 body coming on these disturbed relations is not 
 properly received and transmitted, and, as a conse- 
 quence, the strain becoming too severe on those 
 tissues which serve to assist the arch, there is a 
 resulting stretching of the ligaments on the plantar 
 and inner side of the foot. Thus the calcaneo- 
 scaphoid ligament especially, which bears the brunt 
 of resistance to displacement, and is constantly 
 called upon in this connection, becomes relaxed. In 
 the congenital form, although the muscles show few 
 changes, with the continuance of the affection there 
 often ensues a marked contraction of the peronei 
 and calf muscles, the foot then taking the form of 
 an equino-valgus. With this there is often found 
 a contraction of the extensor longus digitorum, the 
 extensor pollicis, and the abductor minimi digiti, 
 with slight alterations in the relations of all the 
 tendons of these muscles. 
 
 The forms of flat-foot which deserve most of our 
 attention will come under those found in the ac- 
 quired variety, and these are the cases which, from 
 the unusual suffering and disability they occasion, 
 constitute a large and important class. They have 
 been variously called " splay-foot," " spurious val- 
 gus," " inflammatory flat-foot," " the tarsalgia of 
 adolescents," etc. In children the acquired form of 
 valgus usually met with is the result of a poliomye- 
 litis anterior, and in this condition the anterior tibial 
 and adductor muscles are usually the paralyzed 
 ones. At times, as in the congenital form, there is 
 a coincident contraction of the calf muscles, render- 
 ing the; deformity a compound one, and we have a 
 
FLAT-FOOT. 273 
 
 talipes equino-valgus. It is also found very often 
 associated with knock-knee and bow-legs, as a 
 mechanical result of these deformities, especially in 
 rhachitic subjects. Rhachitis itself is a very pro- 
 lific source of this deformity, while as a symptom- 
 atic condition in ankle-joint disease, after injuries 
 and burns of the foot, and following rheumatism, 
 flat-foot is of frequent occurrence. 
 
 Each one of these causes must be made out and 
 its relations to the deformity closely studied, but 
 the limit of this paper is too short to give an 
 extensive account of each variety. It is the condi- 
 tion variously named, as already stated, that I wish 
 to emphasize particularly. 
 
 While to the experienced orthopedist flat-foot is 
 not especially difficult of detection, to one who has 
 not seen many cases it frequently presents puzzling 
 symptoms. Thus, it is frequently mistaken for 
 neuralgia, rheumatism, and even for chronic osteitis 
 of the tarsal bones, and I have had patients who 
 have been treated for all these conditions before 
 the real cause was diagnosticated. They are met 
 with generally at the period of adolescence, although 
 I have had several cases in which the patients were 
 between forty and sixty years of age. In occupa- 
 tions necessitating long continuance of one position, 
 as is the case in bakers, machinists, clerks, waiters, 
 weavers, or in those vocations which compel con- 
 stant and fatiguing motion, as in soldiers, the de- 
 formity happens frequently. Growing boys and 
 girls, especially those of a languid disposition with 
 a tendency to the accumulation of adipose tissue, 
 
 18 
 
274 MEMOIR OF A. S. ROBERTS. 
 
 are more liable to this painful trouble. Certain 
 races seem prone to this affliction, namely, the 
 neoro and the Jewish races. 
 
 The gait and attitude of patients suffering with 
 this trouble are characteristic and easily recognized. 
 They have a heavy, dragging gait, the knees being 
 bent, and the feet are placed in a careful, gingerly 
 way on the ground, so that all the weight possible 
 shall be kept from the tender part. When such 
 patients step on an uneven surface the pain com- 
 plained of is of an excruciating nature, and walking 
 or standing is avoided as much as possible. The 
 patients are easily tired, and .have an anxious 
 expression of countenance, the general condition 
 sympathizing to such an extent with the local 
 trouble that, in certain instances, the nutrition of 
 the patient suffers very markedly. This is not diffi- 
 cult to understand when we reflect that, occurring 
 as it does in young people generally active, and at 
 a time of life when the desire for exercise and enjoy- 
 ment is at its height, the enforcement of compara- 
 tive idleness by the pain experienced prevents the 
 proper completion of those functions which give the 
 system at large its elasticity and tone. 
 
 The morbid changes found in the acquired form 
 of flat-foot are those which are found associated 
 with the special etiological factors entering into the 
 production of the deformity. For a long time it 
 was supposed that the painful variety, in which we 
 are especially interested, was due to an osteitis, but 
 no absolute evidence of an inflammatory lesion, 
 such, for instance, as that seen in the head of the 
 
FLAT-FOOT. 275 
 
 femur in morbus coxarius, has been found. Still, I 
 have seen cases in which, on rotation of the tarsus, 
 marked reflex spasm of the abduction muscles was 
 occasioned. If any osteitis be present, it would 
 seem to me to be of the nature of dry, or caries 
 sicca. In none of the cases that I have seen have 
 there been evidences of suppuration, the local 
 symptoms at times showing swelling, especially 
 below the malleoli, with a semi-fluctuating feeling ; 
 but heat is generally absent. On the contrary, the 
 feet of flat-footed people are, as a rule, cold, and 
 have a peculiar, dark-blue look, as though the 
 venous circulation was badly accomplished. The 
 appearances of the bones are such that pressure 
 in the deformed position would amply account for 
 them. They are not especially altered in their rela- 
 tive positions, although, with the gradual falling of 
 the arch, the astragalus becomes slightly displaced 
 downward, the scaphoid and internal cuneiform 
 bones being brought to a lower plane than normal 
 and nearer the ground. It is at the inner side of 
 the foot where the astragalus and scaphoid show 
 prominently, that, as a rule, the greatest amount of 
 pain is experienced ; but the location of the pain is 
 by no means constant, the transverse tarsal joint, 
 the metatarsophalangeal articulation, and even the 
 calcaneum being at times the seat. With the con- 
 tinuance of the abnormal pressure and the bony 
 changes due to it, there is seen a gradual destruc- 
 tion of the normal arch. The abductor muscles 
 begin to contract strongly, while the adductors are 
 in a condition of functional paresis, and thus, added 
 
276 MEMOIR OF A. S. ROBERTS. 
 
 to the flattening of the foot, we have abduction and 
 a constant condition of extension ; and if the con- 
 traction of the abductor muscles be maintained, the 
 outer edge of the foot is raised and does not touch 
 the ground. In the extreme degrees of the affection 
 the instep becomes totally obliterated through the 
 loss of the convexity of the arch, and the internal 
 malleolus especially becomes more and more promi- 
 nent, and is seen with the protuberant astragalus 
 and scaphoid bones as a prominence on the inner 
 side of the foot. 
 
 In this condition, I have found, taking the medio- 
 tarsal joint as a base line of measurement, and 
 erecting upon this a perpendicular corresponding to 
 the long axis of the os calcis, that the angle of 
 internal deflection is reduced from twelve degrees 
 in moderate cases to five degrees in severe ones. 
 From an examination of severe cases, I have ascer- 
 tained the average deviation from the perpendicular 
 to be about eight and two-tenths degrees. 
 
 The prognosis in cases of flat-foot depends in a 
 larsfe degree on the causes which occasion the de- 
 formity, the surroundings of the patient, and the 
 time when he comes under treatment. In the con- 
 genital form of the disease, when it is not of great 
 severity, the prognosis is usually a favorable one, 
 but the severer cases, and those which have been 
 allowed to go on for a long time, are usually more 
 resistant, and often necessitate protracted treatment. 
 In the acquired form, occurring as it usually does 
 in the poorer classes, although the wealthy are by 
 no means exempt, and being mostly met with in 
 
FLAT-FOOT. 277 
 
 those who are dependent for their support on their 
 vocation, the prognosis is not so favorable, many 
 of these cases not coming under treatment until 
 the pain becomes excessive and the deformity far 
 advanced. Still, where the hygienic and other sur- 
 roundings can be improved and the patients placed 
 under favorable conditions, and when the disease is 
 not the result of incurable paralysis or of chronic 
 joint lesions, I know of no disease in which so much 
 can be done for the relief of pain, and in which such 
 gratifying results can be accomplished, although 
 much time and patience may be necessary for the 
 removal of the deformity. 
 
 Concerning the treatment of flat-foot very little 
 need be said regarding the congenital type of the 
 deformity. When seen shortly after birth the 
 patients may be successfully treated by manipula- 
 tions alone, these having for their object the carry- 
 ing of the foot to a more inverted position. To 
 retain the advantage gained by these movements 
 moleskin adhesive plaster (Maws, London), with a 
 roller bandage, may be employed to draw the foot 
 into the varus position. When the deformity is 
 more severe, and the child older, external splints of 
 a simple character, composed of tin, gutta percha, 
 or hatters' felt, may be employed. These are 
 moulded to the part, and a gradual inversion of 
 the foot accomplished. Should contractions occur 
 which cannot be overcome by the use of the 
 simple means mentioned, tenotomy of the peronei 
 and extensor longus digitorum becomes necessary. 
 Should the tendo Achillis be contracted, this will 
 
278 MEMOIR OF A. S. ROBERTS. 
 
 also have to be cut. These operations, however, 
 are best divided into two stages, the peronei and 
 extensor longus being tenotomized first, and the 
 tendo Achillis subsequently. Massage and elec- 
 tricity to the weakened tibial muscle may also be 
 resorted to with the greatest advantage. When 
 the child is old enough to walk, a simple support, 
 consisting of two lateral uprights, connected with 
 a band to encircle the calf, and with an inner pad 
 corresponding to the axis of the astragalo-scaphoid 
 articulation, and attached to the bottom of the 
 shoe, may be used. 
 
 The forms of flat-foot which we shall be called 
 upon to treat frequently are those which belong to 
 the acquired variety. Here our treatment will, of 
 course, be governed by the cause producing the 
 deformity and by the amount of pain and de- 
 formity. 
 
 I have already, in discussing the etiology of 
 the disease, given a brief account of the different 
 causes operating to produce flat-foot, and will not 
 dwell at length on the differentiation of these 
 causes, but simply remark here that any consti- 
 tutional causes or diatheses — whether strumous, 
 rhachitic, or tubercular — should receive careful at- 
 tention. Neither will it come into the province of 
 this paper to discuss those extreme instances of 
 valgus which, having been neglected for years, pre- 
 sent so much deformity that nothing but exsections 
 of the displaced tarsus will suffice for a restoration 
 to a useful foot. The symptomatic valgus seen in 
 the course of ankle-joint disease or osteitis of the 
 
FLAT-FOOT. 279 
 
 tarsus, generally yields to the treatment employed 
 for the primary lesion. 
 
 It is on the inflammatory form, so called, that I 
 will place especial stress in the matter of treatment. 
 I have already alluded to the difficulty of obtaining 
 rest for these cases, owing to the fact that they for 
 the most part occur in the working classes, where 
 daily labor is necessary for their support. Where 
 it can be done, the removal of the patient from all 
 employment suffices, especially in beginning cases, 
 to pi'omote a rapid cure; but even in these cases 
 some support to the weakened arch is called for. 
 This has been accomplished in several ways — 
 by inserting pieces of leather, pads of different 
 material and construction, or tempered steel bars 
 and springs on the plantar surface of the foot. 
 
 While relief can undoubtedly be afforded by these 
 means, there are objections to their use, chief among 
 these being the expense of especially constructed 
 shoes and the introduction of these various contriv- 
 ances. Of all those mentioned, however, I have 
 had the best results from the use of tempered 
 springs so made that the convexity of the spring 
 shall be at that point where the arch of the foot is 
 most flattened. These I have had made to extend 
 from the middle of the os calcis to the base of the 
 metatarso-phalangeal articulation, and their object 
 is to supply an artificial arch for the foot. They 
 have, however, to be inserted as a shank into the 
 shoe, and this necessitates the construction of a 
 special boot and oftentimes the making of a special 
 last for the patient. Again, being very narrow, 
 
280 
 
 MEMOIR OF A. S. ROBERTS. 
 
 they do not, when there is extreme flattening, give 
 the desired amount of support, patients often feel- 
 ing the necessity for more pressure than can be 
 given by them. I am indebted to Mr. Arthur H. 
 Lea, of Philadelphia, for an improvement on this 
 spring, and it gives, undoubtedly, the best support 
 of all the contrivances I have used or am acquainted 
 with. 
 
 Fig. 72. 
 
 Upper surface of spring. 
 Fig. 73. 
 
 Under surface of spring. 
 
 The artificial arch illustrated in the cut is made 
 of tempered steel. An outline of the patient's foot 
 is first taken on stencil -board, the tracing being 
 extended upward on the inner side of the foot. The 
 elevated portion, corresponding to the depressed 
 arch of the foot, can be tempered to the extent 
 required by the particular case. The lateral press- 
 ure brought to bear by the elevated flanges is such 
 
FLAT-FOOT. 281 
 
 that, while giving support to the arch to a certain 
 extent, the artificial arch also prevents further dis- 
 placement of the astragalus and scaphoid. Again, 
 in place of giving only a limited amount of support 
 to the inner side of the foot, this appliance supports 
 the foot as a whole. The objection urged against 
 the narrow spring is entirely avoided by the use of 
 this one. It can be placed in any shoe and changed 
 at pleasure. In most of the cases in which I have 
 used it the spring is simply inserted into the shoe 
 without any fastening whatsoever. The transition 
 from absolute disability to comparative freedom 
 from pain which the use of this simple contrivance 
 affords is surprising, and it is all the more grati- 
 fying from its simplicity and easy adaptability. 
 Where the disease has lasted for a long time I 
 sometimes combine with it the ankle support men- 
 tioned, and it often serves as a valuable adjuvant 
 in cases in which the muscles and ligaments are 
 fatigued from long use in the deformed position. 
 
 I cannot close these remarks without enjoining 
 the necessity of proper massage and electricity to 
 the weakened parts. Much good, also, may be done 
 at times by the use of rubber bands, especially in 
 those cases in which the tibialis anticus is in a 
 paretic condition. Concerning the use of plaster 
 of Paris for the redressement of the foot, I would 
 simply say, that the chief objection against its use 
 lies in the fact of its compelling the patient to keep 
 his bed, and so depriving him of the benefit of fresh 
 air and sunlight — both good adjuvants to the other 
 treatment recommended. 
 
CHRONIC ARTICULAR OSTEITIS 
 OF THE KNEE-JOINT: 
 
 WITH A DESCRIPTION OF 
 
 A NEW MECHANICAL SPLINT 
 
CHRONIC ARTICULAR OSTEITIS OF 
 THE KNEE-JOINT. 
 
 I have chosen the term chronic articular osteitis 
 as the one best expressing the pathological condition 
 found in those lesions of the epiphyses of the knee- 
 joint that have usually been described by the older 
 writers under the caption "tumor albus." My 
 reason for so doing has been by proper classification 
 to refer directly to inflammation of the cancellous 
 structure of bone, thereby avoiding the confusion 
 that usually exists if the more general terms arthritis 
 and knee-joint disease be employed. 
 
 Before considering the main feature of the paper, 
 viz., to bring before your notice a new mechanical 
 splint, designed for the treatment of chronic articular 
 osteitis of the knee-joint, it may be profitable to 
 review hastily the etiology and pathology of the 
 affection, the latter especially in reference to its 
 clinical expression, a thorough appreciation of which 
 aids so materially in deciding upon an intelligent 
 method of treatment. 
 
 From an analysis of many hundred cases of 
 articular osteitis, I feel safe in asserting that two 
 structures only are responsible for the development 
 of chronic osteitis. 
 
 1. The cancellous structure of the epiphyses. 
 
286 MEMOIR OF A. S. ROBERTS. 
 
 2. The synovial membrane. 
 
 Frequently the two are combined, and disease of 
 either may develop from the other ; it is not, how- 
 ever, until the cartilages and ligaments have been 
 invaded by the inflammatory process that we are 
 justified in using the term arthritis. 
 
 The pathological changes that give rise to the 
 more familiar clinical symptoms may be classified 
 in the following order: 
 
 A simple non-suppurative osteitis interna, the 
 primary lesion in the more formidable osteitis in- 
 terna fungiosa, caseosa, or necrotica, accompanying 
 which suppuration or the formation of inflamma- 
 tory neoplasia frequently adds serious complications 
 to the process of cicatrization. 
 
 Of these and the many other subdivisions of 
 chronic articular lesions designated by different 
 pathologists, only two demand special consideration 
 — the fungoid and suppurative, to which we may 
 add the non-humid variety of old age, the " caries 
 sicca " of Billroth. 
 
 In all save the necrotic variety the process of 
 destruction is by molecular death and absorption, 
 or suppuration ; the character of the discharge fre- 
 quently marking the atonic form of the lesion. 
 
 The fungous proliferations of a chronic synovitis 
 may, from pressure, eat their way through the car- 
 tilage and produce by contiguity an osteitis super- 
 ficialis; traumatism, by direct injury to the articular 
 surfaces, may produce the same inflammatory pro- 
 cess; seldom, however, without a predisposition to 
 the strumous, tuberculous, or rheumatic diathesis. 
 
CHRONIC ARTICULAR OSTEITIS OF KNEE JOINT. 287 
 
 Any of these inflammatory conditions when exist- 
 ing in the epiphyses may give rise to certain neural 
 disturbances that aid materially in their recognition. 
 I refer to the ever-present symptom of rigidity of 
 the joint due to a reflex spasm of the muscles that 
 control it. This interference with normal joint- 
 motion is due to an inflammatory irritation of the 
 nerves distributed through the epiphyses, reflected 
 by their centripetal fibres to the multipolar cells, 
 thence to the great nerve-centres, causing the appre- 
 hensive condition of pain and the reflex spasm and 
 consequent atrophy of the muscles controlling the 
 articulation. It is to this involuntary muscular 
 spasm that we are indebted alike for a means of 
 differentiating true osteitis from many of the dis- 
 eases that simulate it, as well as the insidiously 
 progressive character of the deformity, i. e. 9 flexion 
 of the limb and the frequent subluxation of the head 
 of the tibia into the popliteal space. Accept what 
 definition we may of the lesions found in post- 
 mortem examinations of the joints, the progressive 
 character of the disease, the tendency it presents to 
 frequent exacerbations after long periods of rejDOse, 
 the difficulty in controlling deformity and of reliev- 
 ing pain, the frequent formation of cold abscesses, 
 all class their treatment among the most difficult 
 problems that may fall to the lot of a general sur- 
 geon. To meet the universally recognized prin- 
 ciples of treatment, i. e., fixation of the joint and 
 extension, I have designed the splint that I now 
 feel justified, from the success that has attended its 
 use, in presenting to the profession. 
 
288 
 
 MEMOIR OF A. S. ROBERTS. 
 
 It consists of two light padded steel troughs 
 (a, a) that are firmly secured to the limb by encir- 
 cling bands of surgical webbing, affording absolute 
 fixation to the joint when the extending rods are 
 locked after adjustment. Three ratchet extension 
 
 Fig. 74. 
 
 bars arranged in the form of a triangle are placed 
 posteriorly, corresponding to the long axis of the 
 limb, placing within the control of the surgeon a 
 power that will overcome the flexion and the ten- 
 dency to the production of deformity, and at the 
 same time produce extension. It will be noticed, 
 
CHRONIC ARTICULAR OSTEITIS OF KNEE-JOINT. 289 
 
 in referring to Fig. 74, that the extension rod, b, 
 acts directly upon the head of the tibia and parallel 
 with the line of contraction of the flexor group of 
 muscles, obviating thereby the error in the mechan- 
 ical arrangement of the popular Stromeyer's splint, 
 or in all where the power is applied low down on 
 the tibia to overcome the flexion. Reference to 
 Fig. 75 will illustrate diagrammatically the point at 
 issue, i. e. 9 how to overcome the flexion and sub- 
 luxation without establishing a fulcrum, f, at the 
 
 surface of the diseased joint, which would be the 
 case should we apply our force at p, a distance be- 
 low the insertion, k, of the resisting flexor tendons. 
 In the splint under consideration the long exten- 
 sion rod, c, is used only as a compensating bar, 
 adjusting the angle of the splint to the angle of the 
 flexion of the limb. The power for restoring the 
 head of the tibia and overcoming the spasmodic 
 contraction of the flexor muscles is applied directly 
 in the axis of their contraction. Through the 
 extension bar, b (Fig. 74), the head of the bone 
 
 19 
 
290 MEMOIR OF A. S. ROBERTS. 
 
 describes in its restoration the arc of a circle, a b 
 (Fig. 75). The compensating bar in correcting the 
 angle or flexion carries the limb through the arc 
 c d, having a centre in the end of the femur. 
 Mechanically this arrangement of force corrects the 
 deformity and relieves, by extension, the reflex 
 spasm of the flexor muscles, without crowding 
 together the diseased joint-surfaces or aiding in 
 subluxating the head of the tibia, as would be the 
 case should the limb proper be used as the long 
 arm of our lever, with the insertion of the hamstring 
 tendons, instead of the normal centre of motion of 
 the joint, as the centre of motion of the splint. Sup- 
 plementing the direct extension upon the contracted 
 muscles, another bar, d, has been added to aid in 
 steadying the joint and relieving interarticular 
 pressure. Its action upon the limb is produced 
 tli rough adhesive plaster applied above and below 
 the joint, to which surgical webbing has been at- 
 tached. This is firmly secured to the counter- 
 extending band, f, and to the extension rod, g, 
 affording a means of direct extension always corre- 
 sponding to the angle of flexion. The extension 
 bars are controlled by a key-and-ratchet movement 
 held in place after adjustment by a small ring and 
 pin. I have found that this method of securing 
 fixation with extension by a portable appliance 
 enables the patient to enjoy, by means of crutches, 
 all the hygienic advantages of open air and exer- 
 cise, facilitating thereby a better result than would 
 otherwise be obtained. 
 
DEFORMITY OF THE FOREARM 
 AND HAND: 
 
 WITH AN 
 
 UNUSUAL HISTORY OF HEREDITARY 
 CONGENITAL DEFICIENCY. 
 
DEFORMITY OF FOREARM AND HAND. 
 
 Aaron MacIntyee, aged seventy-three years, 
 six feet four inches in height, a peddler by trade, 
 and a native of New Hampshire, was admitted to 
 the Philadelphia Hospital on March 7, 1885. His 
 forearm and hands exhibited the following congen- 
 ital deformity : 
 
 On the right side (see Fig. 76) the humerus is 
 normal except that its inferior extremity is rounded 
 
 Fig. 76. 
 
 so that the condyloid notch is scarcely perceptible. 
 In the forearm the ulna is absent, the radius form- 
 ing with the outer condyle of the humerus an 
 articulation which admits of limited motion in all 
 directions, but which does not admit of either com- 
 
294 MEMOIR OF A. S. ROBERTS. 
 
 plete extension or flexion. The carpal bones present 
 are those which articulate with the radius, and the 
 first two metacarpal bones. The pisiform, cunei- 
 form, and unciform bones are absent. Of the 
 metacarpal bones, only the first and second are 
 present. The thumb and index finger are present 
 and normal, except that the first phalangeal articu- 
 lation of the latter is anchylosed and the finger is, 
 as a whole, slightly curved toward the thumb. The 
 third, fourth, and fifth digits are wanting. 
 
 Fig. 77. 
 
 On the left side (see Fig. 77) no deformity is 
 noticed until we reach the metacarpal bones, except 
 that the olecranon process of the ulna is markedly 
 curved toward the inner condyle of the humerus. 
 Of the metacarpal bones the third is absent. The 
 first and second each have a thumb, the two thumbs 
 being united by connective tissue and skin, the 
 thumb nails being contiguous, and each complete 
 in itself. The metaearpo-phalangeal joints are en- 
 larged. The index finger is somewhat curved on 
 itself. The middle and ring fingers are absent. 
 This leaves a fissure between the index and little 
 fingers which extends to the wrist, as shown in 
 
DEFORMITY OF FOREARM AND HAND. 
 
 295 
 
 Fig. 78. The patient has considerable power in his 
 hands, with full use of the parts present. 
 
 Fig. 78. 
 
 The following history of similar deformities in 
 his family is interesting, and there is no reason for 
 doubting the veracity of the patient's statement. 
 His grandmother on his mother's side had one index 
 finger sthT. Two uncles on his mother's side had 
 each a stiff little finger. One sister had a hand 
 deformed like the patient's left hand. She had a 
 perfect child. Another sister's child had a hand 
 deformed like his right hand. The patient has been 
 married twice, and is the father of seven children. 
 The two by his first wife were perfect. Of the five 
 children by his second wife, two were perfect and 
 three were deformed with malformations similar in 
 character to his own. 
 
 Although many cases somewhat similar to or 
 resembling the one abo^e described have been re- 
 ported, principally by Annandale, 1 to whom the 
 
 1 The Malformations, Diseases, and Injuries of the Fingers and 
 Toes. Thomas Annandale, F.R.C.S., Jacksonian Prize Essay, 1864. 
 Philadelphia, J. B. Lippincott & Co., 1866. 
 
296 MEMOIR OF A. S. ROBERTS. 
 
 reader is referred for a further study of these affec- 
 tions, the unusual heredity observed in the present 
 instance was deemed worthy of more than passing 
 notice. Here heredity seems to have assumed 
 unusual prominence, several generations having 
 reproduced at one time or another malformations, 
 which, although not absolutely similar, have been 
 markedly so in the type and locality of the deform- 
 ity. In studying the etiology of congenital mal- 
 formations we find the subject surrounded by much 
 that is mysterious and confusing, owing to the 
 varying importance attached by authors to the 
 influence of physical and psychical conditions of 
 the patients upon the child in utero. I will not 
 attempt to deal here with the very extensive ques- 
 tion of predisposition to or inheritance of disease in 
 general, but only briefly consider malformations, 
 and especially those due to arrested development. 
 
 Hereditary similarities have been observed alike 
 in the most extensive and most minute forms. 
 These may vary from the shape of a particular part 
 of the body, or of a special organ, such as the nose 
 or ear, to the small pigment stain known as a 
 "mother's mark." Accompanying these physical 
 marks, similar mental tendencies and physical car- 
 riage can be observed for successive generations, 
 giving to races and persons their marked indi- 
 viduality, in the same way that organs perfectly 
 normal, but characteristic, are reproduced and phys- 
 ical defects and abnormalities are transmitted from 
 parent to child. Most congenital malformations, 
 especially those due to arrested development, have 
 
DEFORMITY OF FOREARM AND HAND. 297 
 
 been referred to pathological changes affecting the 
 child in utero. It being granted that the foetus has 
 its own circulation and nutrition, and that, conse- 
 quently, disease of a part may take place, resulting 
 in effusions, exudations, atrophies, and hypertro- 
 phies, with consequent marked nutritive changes, 
 this will not account for all the malformations met 
 with. For whilst these lesions undoubtedly cause 
 certain deformities, it has been found experiment- 
 ally, according to Wagner, 1 that malformations may 
 be produced by wounding the ovum, and thus pre- 
 venting the development of the part implicated. 
 
 Thus the action of mechanical agencies, such as 
 blows and falls at an early period of gestation, have 
 a claim as causative agents in the production of 
 anomalous development. The question of maternal 
 impressions, through the influence of fright, shock, 
 etc., is also to be considered, and their possibility 
 as factors cannot be entirely denied on a "priori 
 grounds, the literature of the subject abounding in 
 many instances where the relation of cause and 
 effect is seemingly very clear. The result of the 
 most recent investigations, however, would tend to 
 show that the effects apparently brought about by 
 these are the results of foetal disease or spontaneous 
 amputations. Simpson 2 and Montgomery 3 have 
 described cases where portions of the digits and 
 extremities have been so amputated, and Simpson 
 
 1 Manual of General Pathology. Translation by Seguin and Van 
 Duyn. New York, 1876. 
 
 2 Simpson's Obstetrics, vol. ii. p. 375. 
 
 3 Todd's Encyclopaedia of Anatomy and Physiology, " Foetus." 
 
 20 
 
298 MEMOIR OF A. S. ROBERTS. 
 
 has called attention to certain rudimentary digits 
 sprouting out from the end of the stumps. These 
 effects have also been demonstrated by prepara- 
 tions, where it is shown that by the encircling of 
 the extremities by turns of the umbilical cord, or 
 by bands of false membranes, spontaneous intra- 
 uterine amputations have resulted. Lastly, slight 
 lesions in undeveloped foetal organs can cause great 
 disturbances by preventing proper nutrition of the 
 parts, and thus, the progress, size, and quality of the 
 organ being interfered with, the resulting adult 
 development is either defective or entirely wanting. 
 These in brief are the causes of congenital mal- 
 formations, and, while many of the questions in 
 reo-ard to this class of cases are still in doubt, suffi- 
 cient etiological explanation can be deduced in the 
 reasons already stated for most of the cases met 
 with without resorting to apparent coincidences or 
 fanciful theories. 
 
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