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PRACTICAL NOTES 
 
 TREATMENT OF DEFORMITIES. 
 
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PRACTICAL NOTES 
 
 ON THE 
 
 TREATMENT OF DEFORMITIES. 
 
 HENRY F. BAKER, F.R.O.S. Edik., 
 
 ASSISTANT-SURGEON (LATE HOUSE SUUGEON) TO THE EOTAL OKTHOP^DIC HOSPITAL; 
 
 SUEGEON TO THE CRIPPLES* NTJESEET ; 
 
 FOKMEELT HOUSE SURGEON AND HOUSE PHTSICIAN TO ST. BARTHOLOMEW'S HOSPITAL. 
 
 LONDON: 
 EDWAED STANFOKD, 55, CHAEINa CROSS, S.W. 
 
 18 8 6. 
 
3/7 
 
PREFACE 
 
 Having lield the office of Resident House Surgeon 
 to the Royal Orthopaedic Hospital for ten years, and 
 having been also, during a great part of that time, 
 Assistant - Surgeon, I have enjoyed considerable 
 opportunities of studying practically the different 
 kinds of deformities that have passed through the 
 Hospital. It is not my object to repeat, with respect 
 to the pathology or causes of deformities, what has 
 been so well written in. other works on Orthopaedic 
 Surgery, but rather to state, in a short space, what 
 methods of treatment I have found from personal 
 experience to be best adapted for the relief or cure 
 of the more common forms ; pointing out where I 
 myself have found most difficulties, and what means 
 I have found best calculated to surmount them. 
 
 HENRY F. BAKER. 
 
 oOa, George Street, Hanover Square. 
 
CONTENTS. 
 
 Introductory 
 
 CHAPTER I. 
 
 PAGE 
 1 
 
 Anjesthetics 
 
 Club-foot 
 
 CHAPTEE II. 
 
 CHAPTEE III. 
 
 Tenotomy 
 
 CHAPTEE IV. 
 
 28 
 
 CHAPTEE V. 
 
 Kachitis 
 
 CHAPTEE VI 
 
 Contraction of Knee-joint .. 
 
 CHAPTEE VII 
 
 Contraction op Joints caused by Burns 
 
 36 
 
 44 
 
 48 
 
 CHAPTEE VIII. 
 
 Webbed Fingers 
 
 50 
 
Vlll CONTENTS. 
 
 CHAPTEE IX. 
 
 PAGE 
 
 COMTKACTED FlNGERS .. .. .. .. .. .. ..51 
 
 CHAPTEE X. 
 
 Contracted Toes .. .. .. .. .. .. .. 53 
 
 CHAPTEE XI. 
 
 Wryneck.. .. .. .. .. .. •• .. .. 56 
 
 CHAPTEE XII. 
 
 Caries of the Spine (Angular Curvature) .. .. ..58 
 
 CHAPTEE XIII. 
 
 Lateral Curvature of the Spine .. ,. .. .. ..65 
 
 CHAPTEE XIV. 
 
 Anterior and Posterior Curvature of the Spine .. .. 70 
 
PRACTICAL NOTES 
 
 TEEATMENT OF DEFOEMITIES. 
 
 CHAPTER I. 
 
 INTRODUCTORY. 
 
 In the treatment of deformities, the surgeon, in 
 order to obtain success, must carefully attend to 
 minute details, and must exercise an unlimited 
 amount of patience. For example : (1) In the opera- 
 tion of subcutaneous division of tendons, it is abso- 
 lutely necessary to be certain that the tendon has 
 been really severed ; as many cases prove that neglect 
 of this rule has been a fruitful source of failure and 
 of needless pain to the patient. If the sheath of a 
 tendon has been opened and the tendon not properly 
 divided, adhesions often form ; and when the tendon 
 is subsequently really severed at this spot, the ends 
 of the tendon cannot be drawn asunder, and from 
 this cause a relapsing case is usually much more 
 difficult to treat than any other. Forgetfulness of 
 this and similar facts has led to the mistaken idea 
 that many relapsing cases were originally incurable, 
 and this has caused subcutaneous tenotomy to be 
 
 B 
 
 > 
 
2 TREATMENT OF DEFORMITIES. 
 
 brought into undeserved disrepute ; and more severe 
 operations have in some cases been substituted for it 
 unnecessarily. 
 
 (2) Although the tendon or tendons which hold 
 the limb in its deformed position have been really 
 divided, it still may not be possible to correct the 
 deformity on account of the amount of stiffness 
 present in the joint itself and its surrounding text- 
 ures. For instance, in a case of Congenital Talipes 
 Equinus, when the tendo Achillis is divided, the 
 foot never goes suddenly up into its proper place 
 unless great force is used, and the ligaments, &c., 
 surrounding the joint are entirely broken through ; 
 while on the contrary, in a case of Paralytic Talipes 
 Equinus, after division of the same tendon, the foot 
 usually gives way at once, no force having been used. 
 Thus the treatment of these two cases is quite different. 
 In the first class of cases slight force may with advan- 
 tage be used in attempting to place the foot in its 
 proper place, although in my opinion it is a mistake 
 to attempt very much by this means. The foot should 
 be put up in the deformed position, and be brought 
 into perfect position by instruments after the 
 tenotomy puncture has healed. In the second class 
 of cases it is necessary to be extremely careful to 
 keep the foot in the position of Equinus a sufficiently 
 long time, lest after treatment it should be found 
 that the tendon is too greatly elongated, and the 
 result is a state of deformity the opposite to that from 
 which the patient originally suffered. 
 
 (3) A suitable, well-fitting instrument must be 
 provided, and in its application great care must be 
 taken lest it press unduly on any particular spot. It 
 
TREATMENT OP DEFORMITIES. O 
 
 must in all cases be made to fit the limb accurately 
 in its deformed state, and be constructed in such 
 a way that it can be made to draw the limb into 
 its natural position, and still to accommodate itself 
 exactly to it. Under each individual kind of defor- 
 mity the instrument which I have found most useful 
 in practice will be mentioned and explained. 
 
 (4) Let it be a rule in practice never to allow the 
 slightest sore to form upon the skin ; and in order to 
 carry this out, the sensations of the patient are the best 
 guide. If instruments cause much pain, either they 
 are not properly applied or they are too tight, and 
 it will be found that by loosening them much time 
 is really saved. If a slough is allowed to form, the 
 treatment of the case must be postponed until the 
 skin is quite sound again, and this will be found to 
 take so long a time that the limb will have relapsed 
 into its former state of deformity. This difficulty 
 can only be overcome in many cases by the use of 
 instruments so constructed that the necessary pressure 
 can be distributed, and changed from place to place 
 hj means 0^ movable pads, 
 
 1 do not propose to deal with the treatment of 
 deformities by any other methods than those which I 
 myself believe, and have found by practical experi- 
 ence, to be the best, and must refer my readers to 
 larger works on this subject, should they wish to 
 follow the arguments in favour of cure by other 
 means. 
 
 B 2 
 
TREATMENT OF DEFORMITIES. 
 
 CHAPTER II. 
 
 ON THE ADMINISTRATION OF AN ANESTHETIC DURING 
 THE OPERATION OP THE SUBCUTANEOUS DIVISION 
 OF TENDONS. 
 
 In tlie consideration of the question, whetlier it is 
 advisable to administer an anaesthetic during the 
 subcutaneous division of tendons and fascia, the 
 points to be attended to are these — 
 
 (1) The age and disposition of the patient. If it 
 be an infant to be operated upon, it is only, as a rule, 
 necessary to produce partial anaesthesia, as the pain 
 is but slight, and the operation over in a very short 
 time. An infant can also have no dread of the 
 operation, and forgets it immediately. In the case 
 of older children, the fear of taking chloroform is 
 often worse than the pain of the operation. If, how- 
 ever, the child be observed to be of a very nervous 
 and sensitive disposition, the administration of a 
 small quantity of some anaesthetic is good; but it 
 should not be carried to the stage of complete 
 relaxation. 
 
 (2) The structure of the contraction, that is, 
 whether it is a tendon to be divided, which being 
 attached to a muscle would be relaxed by the influence 
 of the anaesthetic, or whether it is a band of ligament 
 or fascia, which would not be affected by it. In the 
 first class of cases it is often better that no anaesthetic 
 
ADMINISTRATION OF ANESTHETICS. 
 
 should be given ; for the patient can sometimes give 
 valuable aid to the surgeon by voluntarily contracting 
 his muscle and making the tendon taut. This is well 
 seen in the case of the division of the biceps femoris, 
 when there is much more likelihood of dividing the 
 peroneal nerve when the tendon is perfectly relaxed. 
 During the division of ligament or fascia the patient, 
 if an adult, may generally be allowed to choose for 
 himself on this point. 
 
 (3) An anaesthetic should be administered when 
 important adjacent structures may be wounded, owing 
 to the struggles of the patient. A good example of 
 this is seen when it is necessary to divide the sterno- 
 mastoid for the cure of wryneck. When an anaesthetic 
 is given in a case such as this, it is essential that 
 the patient should be entirely under its influence, 
 lest he should give a sudden jerk at a critical 
 moment. 
 
TREATMENT OF DEFORMITIES. 
 
 CHAPTER III. 
 
 CLUB-FOOT, OR TALIPES. 
 
 The term Club-foot, or Talipes, signifies any 
 deformity of the foot caused by an unnatural con- 
 traction of muscle, tendon, fascia or ligament. It 
 may be either congenital, or it may first appear after 
 birth. 
 
 The causes of the congenital variety are very 
 obscure. The deformity is most probably due to 
 disordered nervous function reacting on the muscles 
 which draw the foot into its deformed position. 
 
 Non-congenital talipes is occasioned by various 
 means, chief amongst which are paralysis, spasmodic 
 contractions of muscles, rupture of tendon or muscle, 
 and the cicatrices following burns and other lesions ; 
 also from a too-long-continued malposition. 
 
 In cases of congenital club-foot, the bones of the 
 tarsus are somewhat altered in shape and size, and 
 are also displaced from their proper position. As, 
 however, in the great majority this does not in any 
 way afiect the treatment, it is unnecessary to enlarge 
 upon this part of the subject. 
 
 The Several Varieties op Olub-foot. 
 
 The varieties of club-foot are: — 1. Talipes EquinuSy 
 in which the heel is raised and cannot be brought to 
 
VARIETIES OF TALIPES. 7 
 
 tlie ground, and the patient walks on the toes and 
 the distal ends of the metatarsal bones. 2. Talipes 
 Calcaneus, the reverse of the last named variety, in 
 which the heel is depressed and the toes are raised, 
 so that the patient walks on the former. 3. Talipes 
 Varus, in which the inner edge of the foot is drawn 
 upwards, and the anterior two-thirds of the foot are 
 twisted inwards, and the outer edge rests on the 
 ground. 4. Talipes Valgus, the reverse of Talipes 
 Yarns, in which the outer edge of the foot is drawn 
 upwards, so that the patient rests on the inside of 
 his foot and inner ankle. 
 
 Also the combinations of these : — 1. Talipes 
 Equino- Varus, when the foot is twisted in and the 
 heel drawn up. 2. Talipes Equino- Valgus, when 
 the foot is turned out and the heel is drawn up. 
 3. Talipes Calcaneo- Varus, when the heel is depressed 
 and the foot turned out. 
 
 In the treatment of all the different forms of 
 talipes, the object of the surgeon must be to get the 
 foot into its natural position without danger to the 
 patient, and with the natural movements of the foot 
 as little impaired as possible. 
 
 The foot must be first of all carefully examined 
 to find out what it is that holds it in its deformed 
 position. In almost all cases this is a contracted 
 condition of muscle acting through its tendon, 
 and this is in many cases combined with stiffness of 
 the ankle-joint. The evident treatment then consists 
 in subcutaneously dividing the tendon of the con- 
 tracted muscle or muscles, and in gradually stretching 
 it to the required length, and when necessary in 
 forcibly extending the stiffened joint. 
 
8 
 
 TREATMENT OP DEFORMITIES. 
 
 Fig. 1. 
 
 The metliod in which each tendon is to be divided 
 will be explained in detail in the chapter on Tenotomy 
 (page 28). 
 
 Talipes Equinus. 
 
 Talipes Equinus (in which the heel is raised and 
 cannot be brought to the ground, and the patient 
 walks on the toes). This form of talipes is hardly 
 ever congenital. On examining a case of simple 
 Talipes Equinus, the foot will be found to be in a 
 straight line with the leg, neither inverted nor 
 everted ; and on attempting to flex the foot on the 
 leg, the tendo Achillis can be felt as a rigid band 
 holding the heel in its raised position. (Fig. 1.) 
 In the majority of these cases 
 nothing else is at fault; but in 
 some, on further examination 
 being made, the arch of the 
 foot is found unduly flexed, and 
 the plantar fascia is to be felt 
 tightly contracted. In some rare 
 cases of an unusually severe na- 
 ture, the tendons of either the 
 posterior tibial, or of the peronei, 
 will be noticed preventing the 
 foot from being placed in its 
 natural position. In addition to 
 these causes of Talipes Equinus, in many cases there 
 is considerable stiffness of the ankle-joint, and a 
 contracted state of the ligaments around the joint. 
 This will be found to vary greatly in each case, 
 and in some to be entirely absent. 
 
 The treatment of Talipes Equinus consists in the 
 
TALIPES EQUINTJS. 9 
 
 subcutaneous division of the abnormally contracted 
 tendons and fascia (see page 29), and, after the 
 punctures made by the tenotome are healed, the 
 gradual extension of the foot by means of a Scarpa's 
 shoe. The amount of force to be used must depend 
 on the resistance caused by the adhesions in and 
 around the ankle-joint. In those cases in which, 
 after division of the contracted tendon, the foot can 
 at once be placed in the natural position, great care 
 must be taken to keep the divided ends of the tendo 
 Achillis in apposition until they are partially united; 
 and to extend with caution, lest the tendon become too 
 elongated, and the case be made into one of Talipes 
 Calcaneus. It must be observed, moreover, that 
 when the plantar fascia as well as the tendo 
 Achillis is contracted^ it must be divided first, as the 
 resistance offered by the contracted tendo Achillis 
 offers the necessary resistance that is required in 
 stretching it. After division of the tendo Achillis, 
 the patient should not be allowed to put the foot to 
 the ground for at least six weeks, lest the tendon 
 become unduly stretched. After the foot has been 
 brought to its natural position by the means 
 indicated, a boot with a " steel support " will in most 
 cases be required. 
 
 This support consists of a steel bar fixed to the 
 heel of the boot, and extending along the side of the 
 leg to the calf, and at this point is attached a leather 
 strap, which encircles the leg. Just opposite the 
 ankle a joint is introduced, so that the motion of the 
 ankle-joint is not impaired. In most cases the foot, 
 on being placed on the ground, will be observed to 
 have a tendency to rest on the inner or outer ^idiQ of 
 
10 TREATMENT OF DEFORMITIES. 
 
 the heel. In the former case, the iron support must 
 be on the inside of the ankle and leg ; in the latter, 
 on the outside. 
 
 In cases in which the ligaments on both sides of 
 the ankle are very weak, an " iron " on both sides is 
 necessary. 
 
 If the case be one of paralysis, and the patient has 
 not the power to flex the foot on the leg, a back-stop 
 must be fixed into the joint of the support, so as to 
 allow the foot to be bent up, but to prevent its falling 
 beyond a right angle with the leg ; and the patient 
 should wear an apparatus at night to retain the foot 
 in its proper position, as there is danger of a relapse 
 if this be not done. 
 
 Talipes Calcaneus. 
 
 Talipes Calcaneus (in which the heel is depressed 
 and the toes are raised, so that the patient walks on 
 the posterior end of the os calcis) may be conveniently 
 divided into two varieties. 1st, 
 ^'^- ^- True ; 2nd, False. The first kind 
 
 is well illustrated in congenital 
 cases, when the foot is fixed in 
 its deformed position, and the 
 tendons of the muscles which flex 
 the foot on the leg are found con- 
 tracted, and at the same time 
 the tendo Achillis is elongated. 
 (Fig. 2.) This variety may also 
 be produced by burns, which leave a cicatrix on the 
 anterior surface of the ankle-joint. 
 
 The false variety is by far the more common, and 
 
TALIPES CALCANEUS. 11 
 
 is the result of paralysis of the gastrocnemius muscle. 
 In these cases the tendo Achillis is much lengthened, 
 and the dorsum of the foot can be placed on the front 
 of the leg without any resistance being offered ; but 
 there is no contraction of the tendons in front of 
 the ankle joint. The plantar fascia is generally 
 much contracted. This state of deformity is some- 
 times produced after division of the tendo Achillis, 
 when sufiScient care has not been taken in the after- 
 treatment, and the tendon has consequently become 
 too much elongated. 
 
 In the congenital cases, a cure can usually be 
 effected without the division of tendons, by rubbing 
 the anterior surface of the ankle joint with some simple 
 oily liniment, and stretching the foot away from the 
 leg, and retaining it in position by means of a padded 
 flexible iron splint, bent at the required angle. 
 
 The treatment generally adopted for the relief of 
 the paralytic cases is to have a support fixed to the 
 boot, so that an elastic band may be placed at the 
 back of the ankle in order in some degree to compen- 
 sate for the loss of power in the gastrocnemius 
 muscle. When the plantar fascia is contracted, it 
 should be divided (see page 32), and the contraction 
 of the sole overcome by means of a Scarpa's shoe, 
 having a divided sole with a cog-wheel, and a strap 
 that can be fixed over the front of the foot. This is 
 necessary, as there is no contracted tendo Achillis 
 to work against, as in cases of ordinary Talipes 
 Equinus. 
 
 In the case of contracted cicatrix after a burn, 
 the treatment is the same as in the case of similar 
 cicatrices in other parts of the body (see page 48). 
 
12 treatment of deformities. 
 
 Talipes Varus. 
 
 Talipes Varus (in which the inner edge of the foot 
 is drawn upwards, and the anterior two-thirds of the 
 foot are twisted inwards, and the outer edge rests on 
 the ground) is so seldom met with apart from Talipes 
 Equinus, that, to save repetition, it will be con- 
 sidered under the heading of Talipes Equino-Yarus. 
 
 Talipes Yalgfs. 
 
 Talipes Valgus (in which the outer edge of the 
 
 foot is drawn upwards, so that the patient rests on 
 
 the inside of his foot and inner ankle) (Fig. 3) is 
 
 so 2:enerallv combined 
 Fig. 3. • r n f> " 1 • 
 
 with flat-foot, that it 
 
 will be most convenient 
 to consider them to- 
 gether. The congenital 
 form of Valgus is not 
 very common ; but 
 when it does occur it is 
 of a somewhat severe 
 type, the sole of the foot 
 being slightly convex, while the foot is held in its 
 deformed position by the peroneus longus and brevis. 
 The treatment of these congenital cases is to stretch 
 the foot towards the position of Talipes Varus, and 
 to retain it by means of a flexible splint, bandaged to 
 the inside of the foot and leg. If this is found not 
 sufScient to overcome the deformity, the tendons of 
 the peroneus longus and brevis must be divided. 
 When the child begins to walk, a steel sole-plate with 
 
TALIPES VALGUS. 13 
 
 an india-rubber pad fixed to it must be worn in the 
 boot to support the displaced bones of the tarsus, so 
 that in time the patient may regain the arch of the 
 instep. 
 
 Cases of Paralytic Valgus are sometimes met with 
 in which there is no flat-foot, and division of the 
 peroneal tendons may or may not be necessary, accord- 
 ing to whether they are tightly contracted. In either 
 case a boot with an iron support attached to the out- 
 side of the sole and with a band round the calf must 
 be worn, and a leather strap with two ends (T-strap) 
 must be fixed to the inside of the boot just below the 
 internal malleolus. The two ends are buckled round 
 the ankle, so as to include the iron support, and these 
 pull the foot into its natural position and retain it 
 there. 
 
 In addition to these cases of Talipes Valgus, either 
 congenital or caused by paralysis, many others of a 
 similar nature are met with in various degrees of 
 severity, from a slight sinking of the arch of the foot 
 to those in which there is even convexity of the inner 
 border of the sole, and in which the inner malleolus 
 nearly touches the ground. In these latter cases the 
 foot is firmly held in this deformed position by the 
 contracted tendons of the peroneus longus and brevis, 
 and in the very worst examples by the extensor 
 longus digitorum and the peroneus tertius. These 
 cases for the most part begin in growing youths and 
 girls, and are brought to the severe type by constant 
 standing or carrying heavy weights. 
 
 The treatment depends upon the stage in which 
 the deformity presents itself, and cases may be 
 placed under three heads : — 
 
14 TREATMENT OP DEFORMITIES. 
 
 (1) On the patient standing up, the whole of the 
 bottom of the foot will be seen to touch the ground, 
 but little or no valgus will be observed. On exami- 
 nation there will be found to be no stiffness in the 
 ankle joint, and the foot can be freely moved in all 
 directions. 
 
 The treatment consists in the use of a boot with a 
 wide and flat heel, into which is placed a steel plate 
 with a pad attached to its inner border to press up 
 the fallen arch when the patient stands upon it. 
 It is necessary that the pad should be fixed to a steel 
 plate, or it will be pushed inwards and become useless. 
 
 (2) In the second class, in addition to the 
 flatness of the foot, its outer side is drawn upwards 
 and the inner malleolus nearly touches the ground. 
 On manipulation , however, the foot can be inverted 
 without resistance. 
 
 In the treatment of this kind a sole-plate must be 
 worn, as in the first kind, but in addition two cross- 
 straps must be fixed to the inner side of the boot, one 
 passing over the ankle, and the other at the back of 
 the ankle and buckled over and just above the 
 external malleolus. 
 
 (3) In this, the most severe form of Talipes 
 Valgus, the foot will be found on examination to be 
 in the same position as that just described, but the 
 deformity will be somewhat more marked. The 
 chief difference between them, however, is that the 
 foot is firmly held in its deformed state ; so much so 
 that it is sometimes thought to be anchylosed at the 
 ankle joint, and severe pain is complained of around 
 this joint, especially after standing or walking. On 
 an attempt being made to draw the foot inwards, the 
 
TALIPES EQUINO-VARUS. 15 
 
 tendons of the peroneus longus and brevis, and in 
 some cases also the tendons of the extensor longus 
 digitorum and peroneus tertius, will be found rigidly 
 contracted. Although this is the most painful of all 
 cases of club-foot, it is perhaps the most satisfactory 
 to treat ; for after complete division of the contracted 
 tendons, the foot can be placed without difficulty in 
 its natural position, and with the use of good boots 
 and sole-plates, the patient is freed from all pain, 
 and able to return to his former occupation. After 
 the tendons mentioned above have been divided 
 (p. 31), the treatment requires the use of no special 
 instrument, as the necessary extension can be effi- 
 ciently carried out by means of a padded flexible 
 splint bandaged to the inner side of the leg and foot. 
 If the extensor longus digitorum has been divided, 
 the extension should not be too rapidly proceeded 
 with. The patient may be allowed to walk in six 
 weeks after the tenotomy, but it will be necessary 
 that he should wear, as well as a sole-plate, a steel 
 support on the outer side of the leg with a T-strap, 
 as explained above. 
 
 Talipes Equino-Yarus. 
 
 Talipes Equina- Varus is that variety of club-foot 
 in which the heel is raised, the inner border of the 
 foot being drawn upwards a ad the outer edge 
 resting on the ground. I propose to consider it in 
 detail, as it is the most complex, and requires much 
 care and attention in its treatment. 
 
 Congenital Talipes Equino- Varus in the infant 
 differs from that of the adult, in that it is less severe_, 
 
16 TREATMENT OF DEFORMITIES. 
 
 as the foot has not been walked on, and the tendons, 
 ligaments, and fascia have not become so greatly 
 developed and contracted in the deformed position. 
 It will therefore be best to consider the treatment 
 
 of the two separately, and to 
 take first of all the infantile 
 variety. (Fig. 4.) 
 
 The treatment must com- 
 mence with the cure of the 
 varus ; and it is necessary 
 that this should be com- 
 pletely accomplished before 
 anything else is attempted. 
 For it is evident that a 
 simple deformity is more easy to cure than a compound 
 one, and it will be found impossible to overcome 
 the equinus while the varus is still present ; for the 
 foot being turned inwards, and the tendo Achillis 
 being shifted towards the inner side of the leg, an 
 attempt to stretch it is made at a mechanical dis- 
 advantage, and cannot be satisfactorily accomplished. 
 On the other hand, attempts to stretch the tendons 
 and ligaments which hold the foot in the position of 
 varus are made more advantageously the more the 
 tendo Achillis is contracted ; and this is proved by 
 the much greater difficulty that is experienced in the 
 treatment of those cases in which the tendo Achillis 
 has been divided before the tibials, under the 
 mistaken idea that they can be afterwards sufficiently 
 stretched to accomplish a cure. Therefore it is better 
 to treat the varus first, and thus produce a case 
 of simple equinus, which can afterwards be readily 
 cured. 
 
TALIPES EQUINO- VARUS. 17 
 
 If in a case of Talipes Equino-Yarus an attempt be 
 made to evert the deformed foot on the leg, while the 
 fingers are placed on the inner side of the ankle joint, 
 the tendon of the tibialis anticus will be readily felt as 
 a tight cord holding the foot in its deformed position. 
 If still greater force be used, and the finger be placed 
 on the inner side of the leg, just behind the edge 
 of the tibia, about an inch above the tip of the 
 malleolus, a slight movement will be felt under the 
 finger, indicating the position of the tendon of the 
 tibialis posticus, more or less distinct, according to 
 the extent of the contraction and the amount of 
 subcutaneous fat. Lying very near this is the tendon 
 of the flexor longus digitorum; but this cannot be 
 felt. 
 
 The first stage of the operation for the cure of 
 Talipes Equino-Yarus consists in the division of these 
 tendons, and as a rule the best age to do this in the 
 case of infants is one month. This having been 
 done, as described in the chapter on Tenotomy 
 (page 30), after the foot has been kept at rest for four 
 days, and the punctures having healed, a flexible 
 iron splint, six inches long and one broad, and care- 
 fully padded, must be slightly bent so as to make 
 the padded side somewhat concave, and this is to be 
 applied to the outside of the foot and bandaged on, 
 so as to draw the foot into a rather straighter 
 position, but not to cause pain to the child. In 
 three or four days the splint is to be taken off, and 
 having been made somewhat straighter, again 
 applied. This is to be continued at about the same 
 interval until the foot can be placed quite straight, or, 
 better still, can be bent a little in the opposite 
 
 c 
 
18 TREATMENT OF DEFORMITIES. 
 
 direction to the original deformity. In ordinary- 
 cases this can be accomplished in three weeks. 
 
 In the more severe examples of this deformity, 
 however, it will be found that progress cannot be 
 made at such a quick rate. These are the cases in 
 which the heels will be noticed to be very small and 
 flat, and the foot to have a more rounded appearance 
 than common. In these cases stretching must be 
 carried out for a longer time, and the foot must 
 occasionally, at an interval of a few days, be suddenly 
 wrenched, either with or without chloroform. 
 
 When at last the foot has been placed quite 
 straight, it is advisable to keep it in that position for 
 a prolonged time — a month or six weeks — before the 
 treatment is proceeded with. 
 
 Having got so far with the case, the sole of the 
 foot should be carefully examined to see if there is 
 any undue contraction of the plantar fascia ; and if 
 such be found, the fascia must be divided (see page 
 32). In the less severe cases this will not be neces- 
 sary. In the case of an infant the tendo Achillis may 
 be divided at the same time (see page 29). 
 
 It is now necessary to decide upon the lorm of 
 instrument which is to be employed for the further 
 treatment of the case, as this must be measured for 
 and got ready for application four or five days after 
 the division of the tendo Achillis. If the deformity 
 is not unusually severe, a very simple instrument 
 may be adopted. (Fig. 5.) It is made of sheet-iron, 
 covered with wash-leather, and consists of a trough 
 for the leg, and a foot-piece at right angles with it, 
 with a leather ankle strap, A, to keep the heel down, 
 and two webbing straps. One of these, B, is fastened 
 
TALIPES EQUINO-VARUS. 
 
 19 
 
 Fig. 5. 
 
 o 
 
 round the leg, and the other, C, goes round the toes 
 and keeps the foot everted. There are no cog-wheels, 
 and this instrument is therefore cheap. 
 
 Supposing the case to be a simple one, on the 
 fourth or fifth day after the 
 tendo Achillis has been di- 
 vided, the foot having been 
 bandaged, the instrument is 
 to be applied by thrusting 
 the heel into it; and the 
 leather strap over the front 
 of the ankle being drawn 
 as tight as possible and 
 buckled, the other straps 
 are to be then fastened. If 
 the child should suffer much 
 
 at night, the ankle straps may be loosened by one hole 
 and fastened up again in the morning. This, how- 
 ever, is not often necessary, as leather straps always 
 stretch somewhat. Every two or three days the 
 splint must be removed ; when the foot will be found 
 to be improved in position, so that when the splint 
 is reapplied the ankle strap will be able to be 
 tightened by another hole. The heel will also be 
 found to go gradually into its place on the sole- 
 plate of the instrument as the use of this treatment 
 is continued. After about three weeks, the splint 
 should be removed every night and morning, and at 
 first the surgeon and then the nurse should gently 
 work the foot up and down, care being taken that- 
 sufficient force is not used to rupture the newly 
 formed tendon. After this has been done, the splint 
 must be at once replaced, and a thin pad may be 
 
 c 2 
 
20 TREATMENT OF DEFORMITIES. 
 
 placed under the metatarso-plialarigeal joints of the 
 toes, so that on tightening the heel strap the foot may 
 be further flexed on the leg. In two or three months 
 the foot will have assumed a natural shape, and will 
 move quite freely at the ankle-joint. It should now be 
 left out of the splint for a short time each day, to 
 allow the child to exercise its muscles ; and frictions 
 with a simple liniment may be made use of. It must 
 be remembered, however, that in all these cases there 
 is so much danger of relapse, that the patient must 
 be watched for the first symptoms of a return of 
 the stiffness. The child must go on in this way until 
 old enough to walk, and must then wear an iron 
 inside the ankle and leg. This iron must curve at 
 the upper part of the leg, from the inside to the out- 
 side of the limb, and then upwards to and around 
 the waist, a joint being introduced at the knee and 
 hip, extending round the waist. It is necessary to 
 make the supports extend to the waist, as there is 
 always rotation inwards at the knees, which cannot 
 be overcome by auy other means. 
 
 In the more severe cases of infantile Talipes 
 Equino- Varus, the treatment is the same as that of 
 the cases in which the deformity has been left un- 
 treated until after the child can walk. (See below.) 
 
 Congenital Talipes Equino- Varus, after the 
 PERIOD OF Infancy. 
 
 The treatment of Talipes Equino-varus, after the 
 period of infancy, may be conveniently divided 
 into three parts : — 1st. The cure of the simple 
 infantile varus occasioned only by the contraction of 
 
TALIPES EQUINO- VARUS. 21 
 
 the tibialis posticus, flexor longus digitorum, and the 
 tibialis anticus. 2nd. The cure of the remaining 
 acquired varus, caused by the contraction of the 
 abductor poUicis, plantar fascia, and the various 
 ligaments connected with the misshapen bones of 
 the tarsus. 3rd. The equinus, caused by the con- 
 tracted tendo Achillis. 
 
 With regard to the treatment of the first part, 
 the tendons of the tibialis posticus, flexor longus 
 digitorum, and the tibialis anticus must be divided 
 (see page 30) ; and after the tenotomy punctures are 
 healed, a wooden padded outside splint, extending 
 from the knee to the end of the toes, and with an 
 extra pad just above the external malleolus, must be 
 applied, and to this the foot is gradually drawn by 
 means of an ordinary bandage. Great care must be 
 taken lest a sore form on the outer side of the foot; 
 and if the skin on this part is observed to become 
 red and tender, all pressure must be removed, and 
 the splint be discontinued for a day or two. In 
 addition to the gradual stretching by these means, 
 it is well occasionally to forcibly twist the foot out- 
 wards, and so to rupture any tense fibres of ligament 
 that hold the foot in its deformed position. This 
 treatment must be persevered in until the foot is 
 perfectly straight and in a line with the leg, when 
 the second part may be proceeded with. This is, of 
 all, the most difficult to accomplish, even after com- 
 plete division of the abductor pollicis and the plantar 
 fascia, chiefly on account of the great danger of 
 producing sloughs by such an amount of pressure as 
 will suffice to correct the deformity, and also by the 
 difficulty that is experienced in preventing rotation of 
 
22 TREATMENT OF DEFORMITIES. 
 
 the foot. The common Scarpa^s shoe, useful as it is 
 in some forms of talipes, is quite useless here. 
 Scarpa, indeed, invented a special instrument for 
 the purpose, but it is almost impossible to use it 
 without causing sloughs. In more modern times, 
 also, many very clever instruments have been 
 devised with the same object in view, but in practice 
 they have proved only partially successful. 
 
 For the efficient application of force in overcoming 
 the resistance formed by the contracted tissues on 
 the concave aspect of the deformed tarsus, the 
 fulcrum must be placed on some part of its convexity, 
 and as near as possible to its most projecting point ; 
 the internal tubercle of the os calcis being made a 
 fixed point, and the power being represented by the 
 tension of a strap placed round the ball of the great 
 toe, to draw it outwards. The problem, therefore, 
 to be solved is : How can the fulcrum be applied in 
 this position for the required length of time without 
 causing sloughs ? The only method is by rendering 
 it a movable one, and so graduating the pressure on 
 this point, or shifting the pressure from it by 
 the introduction of pads in other parts of the 
 instrument. In other words, the pad which forms 
 the fulcrum, instead of being a fixed part of the 
 splint, should be unconnected with it, and thus 
 made capable of being shifted from point to point 
 along the outer edge of the tarsus and leg, as circum- 
 stances require. The instrument I have devised for 
 carrying this into execution was explained in the 
 'Lancet' of May 3rd, 1879, and is figured below. 
 (Fig. 6.) I have named it "The Movable Pad 
 Instrument," and the advantages I claim for it are 
 
TALIPES EQUINO-VARUS. 
 
 23 
 
 that it prevents rotation of the foot, without causing 
 sores from too great pressure. 
 
 Fig. 6 represents the instrument open, and it 
 will be seen to consist of a back-splint, connected 
 with a foot-piece by means of a cog-wheel, ^, at the 
 heel, and having hinged to it two wings, which 
 extend well below the foot-piece, and have a buckle 
 
 Fig. 6. 
 
 and strap, H, attached to their lower ends. A A are 
 two webbing straps introduced through slots to fix 
 the leg firmly. B is a leather ankle-strap, wide and 
 padded in the centre, to fix the heel immovably in its 
 position ; it is attached to a buckle at the back. D 
 is a plate attached to the external wing, hollowed 
 out and moulded to receive the pad C, or movable 
 fulcrum, which may be placed beneath it to press on 
 the projection at the outer side of the foot. I is a 
 rigid bar for carrying the toe-strap. S is a rectan- 
 
24 
 
 TREATMENT OF DEFORMITIES. 
 
 gular pad to be introduced beneatli the external 
 wing at M, when it is found necessary to diminisli the 
 pressure over the tarsus on the outer side of the foot, 
 even after the pad has been withdrawn. Fig. 7 
 represents the instrument in action. The leg is 
 
 firmly held to the back- 
 splint by the straps A A. 
 The heel is kept in place 
 by strap B, and the mov- 
 able pad C is adjusted. 
 The wings are brought 
 together, and firmly fixed 
 by the further action of 
 the straps A A and strap 
 H; and the toe-strap is 
 then tightened, and the 
 cog-wheel, k, screwed up. 
 By simply loosening the 
 toe-strap the pressure is 
 at once relieved, if this 
 should be found neces- 
 sary, as is frequently the 
 case at night, when the 
 foot becomes hot; and in a day or two, the wings 
 being thrown back, hut the foot not being disturbed^ the 
 pad C may be slightly shifted or removed, or the 
 rectangular pad S may be introduced at M for a 
 short time until the skin on the outer side of the 
 tarsus is again able to bear pressure. 
 
 The plantar fascia and the abductor pollicis 
 having been divided, as explained on page 32, and 
 the punctures having healed, the treatment by means 
 of " The Movable Pad Instrument " must be carried 
 
TALIPES EQUINO-VARUS. 25 
 
 out as described, and must be continued until 
 the contracted tarsus has been as far as possible 
 unfolded, when the third stage of the treatment may 
 be commenced by dividing the tendo Achillis (page 
 29). When the puncture from this operation is 
 healed, the foot is to be again placed in the same 
 instrument as before, and by means of the cog-wheel, 
 k, attached behind the heel, the equinus is to be 
 gradually overcome, and the foot drawn to less than 
 a right angle with the leg. If this part of the treat- 
 ment is retarded by stiffness of the ankle joint, the 
 foot is to be removed from the instrument occasionally 
 and worked up and down^ or in some cases it is 
 advisable that an anaesthetic should be administered, 
 and the foot suddenly wrenched up into its place. 
 When by these means the foot has been placed in its 
 natural position in relation to the leg, a boot must 
 be provided having an iron attached to it on the inner 
 side of the leg, and extending round the waist 
 (p. 20). 
 
 Talipes Equixo-Yarus caused by Paralysis, etc. 
 
 Although the amount of deformity in cases of 
 Paralytic Talipes will be found to vary greatly, from 
 the slightest deviation from the normal state to a 
 condition as severe as in a congenital case, the treat- 
 ment of these two varieties of club-foot is in many 
 respects identical. Each patient must be carefully 
 examined to determine what are the tendons or fascia 
 that keep the foot in its deformed position. This is done 
 by trying to force the foot into its natural position. 
 In some cases this can be accomplished without any 
 
26 TREATMENT OF DEFORMITIES. 
 
 resistance being offered ; and then it is only neces- 
 sary that the patient should wear an inside iron and 
 strap. In other cases, the same tendons and fascia 
 that it is necessary to divide in a congenital case 
 must be operated on. It should be remembered that 
 the posterior tibial tendon, when contracted, causes 
 equinus as well as varus, and in many cases this 
 deformity cannot be overcome unless it is properly 
 divided. 
 
 In some examples of this deformity, after division 
 of the tendo A chillis, the foot hangs quite loose at 
 the ankle joint, and with the slightest amount of 
 pressure goes up to the position of calcaneus. When 
 this happens, no special instrument is required for 
 the treatment, but the foot must be kept a sufficiently 
 long time in the position of equinus until the tendon 
 unites, when it must be stretched with great care. 
 This can be done by means of a flexible splint and 
 bandage. The splint is bent at an angle correspond- 
 ing to the deformity, and bandaged to the dorsum of 
 the foot. After three or four weeks, when the divided 
 tendon is felt to be uniting, the splint is to be bent at 
 a less obtuse angle and bandaged on as before. The 
 foot can in this way be brought to any required 
 position . 
 
 In severe cases the details of the treatment are the 
 same as those required for congenital cases, and the 
 same instrument must be used. Also when the 
 patient is allowed to walk, the same kind of boot 
 and " support " is necessary. As the foot on walking 
 drops, causing the toes to touch the ground before 
 the heel, and the patient has not the power to flex 
 the foot on the leg, a stop must be fixed in the 
 
TALIPES CALCANEO-VALGUS. 27 
 
 joint of the iron at the ankle in such a way as to 
 allow the foot to be flexed on the leg, but to prevent 
 it from dropping below a right angle. 
 
 Talipes Equino-Yalgus. 
 
 Talipes Equino- Valgus (in which the foot is turned 
 out and the heel drawn up) is rarely if ever met 
 with as a congenital deformity. In several instances, 
 however, of Talipes Equinus caused by paralysis, the 
 foot will be observed, after division of the tendo 
 Achillis, to have a tendency to turn out. This can 
 generally be sufficiently treated by placing an iron on 
 the outside of the foot and leg, with a strap, attached 
 to the inside of the boot, passing round it. 
 
 It must be remembered that the peroneus longus 
 and brevis when contracted can cause equinus as 
 well as valgus ; and in some cases it is necessary 
 to divide them. 
 
 Talipes Calcaneo-Yarus. 
 
 Talipes Calcaneo- Varus (in which the heel is 
 depressed and the foot turned in) is a very rare 
 deformity, and requires no separate description. 
 
 Talipes Calcaneo- Yalgus. 
 
 Talipes Calcaneo- Valgus (in which the heel is 
 depressed and the foot turned out). In nearly all 
 cases of Talipes Calcaneus the foot is more or less 
 turned out. The treatment is generally the same as 
 that recommended for Talipes Calcaneus. The steel 
 support attached to the boot must be on the outside 
 of the leg ; a leather strap being attached to it as in 
 the case of Talipes Yalgus. 
 
28 TREATMENT OF DEFORMITIES. 
 
 CHAPTER lY. 
 
 TENOTOMY. 
 
 Tenotomy signifies the subcutaneous division of 
 tendon or fascia. 
 
 A narrow-bladed knife, called a tenotome, is 
 introduced a short distance from the tendon to be 
 operated on, and made to divide it ; the forefinger 
 or thumb of the other hand being employed as a 
 guide to the situation of the blade. On its with- 
 drawal, a piece of folded lint, with a strip of soap- 
 plaster across it, to fix it, is placed on the puncture, 
 and by the application of a splint and bandage the 
 part is kept at rest for four or five days until 
 the puncture is healed. When the operation has 
 been properly performed, the result is almost in- 
 variably the same as if no wound of the skin at all 
 had been made, and as if no communication had 
 ever existed between the severed tendon and the 
 external air. 
 
 It has been shown on dissection and proved by 
 experience that the ends of a divided tendon become 
 perfectly united by an intervening substance, which 
 after a time becomes indistinguishable from the rest 
 of the tendon, and that the lengthening of the 
 tendon by these means can be regulated by the extent 
 to which the divided ends are kept apart during the 
 first few weeks after tenotomy. 
 
TENOTOMY — TENDO ACHILLIS. 29 
 
 In the performance of tenotomy, care must be 
 taken to keep the knife close to the tendon to be 
 divided, so that no artery or nerve may be injured. 
 
 As in almost all cases requiring this operation the 
 tendon or fascia is unnaturally prominent, on account 
 of its contracted condition, there is not the 
 same difficulty that there would be in the normal 
 state, nor is there the same danger of wounding 
 adjacent structures. 
 
 The chief tendons and fasciae that may require 
 division are : — The tendo Achillis, the tibialis posti- 
 cus, the tibialis anticus, the peroneus longus and 
 brevis, the plantar and the palmar fascia, the exten- 
 sor longus digitorum with the peroneus brevis, the 
 biceps femoris, the semitendinosus and the semimem- 
 branosus, the stern o-mastoid. There are some others 
 that may require division, but these require no 
 separate description. The method in which the 
 tendons mentioned above are operated upon is as 
 follows : — 
 
 The Tendo Achillis. 
 
 The operator sits at the end of a table with 
 the assistant on his left. The patient lies on his 
 face on the table with his foot slightly overhang- 
 ing the end. The assistant then grasps the 
 calf of the leg with his left hand, and the anterior 
 part of the foot with his right, and flexes it slightly, 
 thus bringing the tendon prominently forward. 
 The operator puts his left thumb on the tendon, 
 and introduces a sharp-pointed tenotome flatwise 
 beneath it ; he then turns the knife, at this moment 
 the assistant making further extension, and divides 
 
30 TREATMENT OF DEFORMITIES. 
 
 the tendon from below upwards. When the assistant 
 feels the tendon give way, he relaxes the extension. 
 This is important ; for if it be not done, there is some 
 danger of the knife cutting through the skin. In this 
 operation the knife may be introduced either on the 
 inner or outer side of the tendon, but in the latter 
 case it must be remembered that the posterior tibial 
 artery is not far from the point of the knife, which 
 should not be thrust in too far. With ordinary care 
 there is no danger of wounding the vessel. 
 
 The Tibialis Posticus. 
 
 The operator sits at the foot of a table with 
 the assistant on his left. The patient lies on the 
 same side as the deformed foot, and the other 
 foot being held out of the way, the assistant 
 grasps the leg firmly, just below the knee, with his 
 left hand, and with his right holds the foot well 
 flexed in the deformed position. The operator then 
 feels for the inner edge of the tibia, and just over 
 this, and about an inch (two inches in an adult) 
 above the tip of the malleolus, makes a puncture 
 with a sharp-pointed tenotome, passing it down 
 to the edge of the tibia, and guided by this, opens 
 the sheath of the posterior tibial tendon. The sharp- 
 pointed knife is then withdrawn, the assistant beiug 
 careful to keep the foot in exactly the same position. 
 The operator, holding a blunt-pointed tenotome like 
 a pen, now introduces it into the opening, and 
 insinuates the blade flatwise between the tendon and 
 the bone. Indicating to the assistant to evert 
 the foot, he turns the edge of the knife towards the 
 
TENOTOMY — PERONEUS LONGUS AXD BREYIS. 31 
 
 tendon, and supinating his wrist, divides it, and also 
 the subjacent tendon of the flexor longus digitoriim. 
 A snap is felt or heard at the moment of the division 
 of the tendon. 
 
 The Tibialis Anticus. 
 
 The patient lies on his back, and the operator 
 and his assistant place themselves as before. 
 The operator works the foot from side to side, 
 and feels with his forefinger for the tendon of 
 the tibialis anticus. Keeping his finger over the 
 tendon, he introduces a sharp-pointed tenotome, with 
 its edge towards it, between it and the tendon of the 
 extensor proprius pollicis, and the assistant making 
 at this moment forcible extension, he divides it. 
 
 The Peroneus Longus and Brevis. 
 
 The patient lies on the opposite side to the 
 deformed foot, and a cushion is placed under the 
 lower part of the leg with the foot extending 
 over it. The operator sits at the foot of the 
 table, with the assistant on his left. The assistant 
 grasps the leg with his left hand and with his 
 right holds the foot up, so as to slacken the 
 tendons as much as possible. The operator, placing 
 his left forefinger on the tendons, introduces a strong 
 sharp-pointed tenotome, flatwise, in an oblique direc- 
 tion, between the fibula and the tendons, two inches 
 (in an adult) above the end of the malleolus, and 
 having turned the edge towards the tendons, the 
 assistant making extensiqfi, divides them. 
 
32 treatment of deformities. 
 
 The Extensor Long us Digitorum and the 
 Peroneus Tertius. 
 
 The patient lies on his back. The operator sits 
 at the foot of the table with the assistant on his left. 
 The assistant grasps the leg with his left hand, and 
 the foot with his right. The operator, keeping the 
 fingers of the left hand on the tendons, introduces a 
 sharp-pointed tenotome between the tendons of the 
 extensor proprius pollicis and the tendon to be 
 divided, and guiding the blade beneath these tendons 
 he divides them. Care must be taken not to dip the 
 point of the knife deeper than necessary, or the 
 anterior tibial artery may be divided. The duty of 
 the assistant will be rather to prevent the foot from 
 suddenly falling than to make extension. 
 
 The foregoing descriptions apply to a surgeon 
 operating with his right hand on the tibialis anticus 
 and posticus of the left foot, or on the peronei or ex- 
 tensors of the right foot. If, however, the contracted 
 tendons are situated on the opposite limb, and the 
 operator cannot use his left hand, he must stand 
 facing the foot of the table, which is on his right. 
 
 The Plantar Fascia. 
 
 The patient lies on his back if it is a right 
 foot to be operated on; on his face if a left 
 one. The operator sits at the foot of the table, 
 with the assistant on his left. The assistant holds 
 the foot at the ankle, and places his thumb at the 
 bottom of the heel, and th* other hand under the ball 
 of the great toe, and extends as much as possible. 
 
TENOTOMY — THE PALMAR FASCIA. 33 
 
 The operator then feels for the spot at which the 
 fascia is most prominent, and introduces a sharp- 
 pointed tenotome at its inner border, and keeping his 
 left thumb on the fascia, just over the point of the 
 knife, cuts or nicks the fascia bit bj bit, being careful 
 at the same time not to dip the point more deeply 
 than is necessary. If, after this has been accomplished 
 as thoroughly as possible, some fibres of fascia be felt, 
 at another part of the sole of the foot, another punc- 
 ture may be made to divide them, for the object 
 of the surgeon should be to divide every portion of 
 it as efficiently as possible, and to retain the divided 
 ends as much apart as possible. 
 
 The Palmar Fascia. 
 
 It is advisable that during this operation the 
 patient should be placed under the influence of 
 an aucesthetic. The hand should be placed with 
 its back on a table, while the assistant with 
 one hand grasps the wrist and with the other 
 attempts to straighten the contracted fingers ; this 
 brings the fascia prominently forward and close 
 beneath the skin. The operator selects the part in 
 which the fascia is most tense, and introduces a very 
 narrow tenotome and divides it. It is a question 
 somewhat difficult to decide whether it is better to 
 sever the fascia by placing the blade of the knife 
 under it and cutting up, or introducing it between 
 the fascia and the skin and cutting down. I believe 
 it depends on the peculiarities of each individual case. 
 If the first method be adopted, care must be taken 
 not to let the knife slip through the skin, and if the 
 
34 TREATMENT OF DEFORMITIES. 
 
 second, not to let the point of the knife jerk down 
 so as to wound the arteries in the palm of the hand. 
 If after division of the fascia in one place, on 
 stretching the contracted fingers, other parts of the 
 fascia be felt tense and prominent, other punctures 
 must be made and the contracted fibres divided. 
 
 Biceps Femoris. 
 
 The patient lies on his face. The surgeon places 
 himself on the same side of the table as the leg to be 
 operated on. An assistant supports the leg in the 
 flexed position. If possible this operation should be 
 performed without the previous administration of 
 an anaesthetic. The patient should attempt to flex 
 the knee-joint, the assistant holding the leg firmly 
 at the same time. This will bring the tendon 
 prominently forward. The operator then introduces 
 a strong sharp-pointed tenotome on the inner side 
 of the tendon and then somewhat under it, keeping 
 the blade close to the tendon. The knife now 
 lies between the tendon and the peroneal nerve, 
 and on cutting outwards and upwards the tendon is 
 divided and the nerve is not injured. On the knife 
 being carefully withdrawn, the nerve will be 
 observed to come more prominently forward than 
 before, and care must be taken not to mistake this 
 for part of the tendon. 
 
 The Semitendinosus and Semimembranosus. 
 
 The knife should be introduced on the outer side 
 of these tendons, i.e, between the tendons and the 
 
TENOTOMY — THE STERNO-MASTOID. 35 
 
 popliteal vessels, and care must of course be taken 
 not to dip the point deeper than necessary owing to 
 the position of the popliteal artery. 
 
 The Sterno-Mastoid. 
 
 Either the sternal or the clavicular portion ot the 
 sterno-mastoid may require division. If it be 
 necessary to operate on both portions, a separate 
 puncture must be made for each. The patient lies 
 on a table and the operator stands on the same side 
 as the muscle to be divided. A puncture is made on 
 the inner margin of either the sternal or clavicular 
 portion of the muscle in its lower third. A blunt- 
 pointed tenotome is then carefully introduced, on the 
 flat, through the opening, and being guided closely 
 round the border of the muscle, is passed behind it. 
 The sharp edge of the knife is then turned towards 
 the muscle and made to divide it from within 
 outwards. The assistant during the operation holds 
 the head firmly and keeps the muscle tense. In 
 dividing the clavicular portion, care must be taken 
 to avoid the external jugular vein, which runs near 
 the posterior border of the muscle. 
 
 D 2 
 
36 TREATMENT OP DEFORMITIES. 
 
 CHAPTER Y. 
 
 ON DEFORMITIES CAUSED BY RICKETS. 
 
 Of all the different varieties of deformity that come 
 tinder the notice of the surgeon, the most common 
 are those curvatures of bones which take place during 
 the progress of rickets. It will be observed that 
 while the child is suffering from this disease, the 
 bones are soft, and can be readily bent, by continued 
 pressure, in any direction ; but as the child recovers 
 from this affection, the bones become even harder 
 than in the natural state. It follows from this, that 
 if the deformity is treated early by means of proper 
 instruments, the bones can be straightened and kept 
 in their natural position until, by the help of suitable 
 medicinal treatment, the disease is cured. If, on the 
 other hand, the deformity is left to take its course 
 until the bones have become thoroughly hardened, 
 nothing can of course be of service except osteotomy. 
 If these views be correct, it is evident that the 
 necessity for osteotomy for the cure of rickety 
 deformity must be looked upon as a proof of neglect 
 of proper treatment at an earlier stage of the 
 disease. Although all the bones are liable to 
 become bent during rickets, those of the lower 
 extremities generally give way first, and are most 
 severely deformed, because in walking the weight of 
 the body is sustained by them. As the deformity thus 
 
ON DEFORMITIES CAUSED BY RICKETS. 
 
 37 
 
 caused is more amenable to treatment than that of 
 the bones of the trunk, the surgeon is oftener called 
 upon to rectify it. These deformities of the legs 
 may be divided into two classes — 1st, Bow-legs, 
 occasioned by bending outwards and sometimes 
 forwards of the tibia and fibula, and combined in 
 some rather rare cases with a bowing outwards at 
 the knee-joints (genu extrorsum) ; 2nd, Knock-knees 
 (genu valgum), or bending inward of the legs at 
 the knee-joints. This deformity is sometimes caused 
 in part by a curvature of the femur, but this is a 
 comparative rarity. Frequently outward curvature 
 of the tibia and knock-knees are present in the same 
 limb. 
 
 Bow-Ugs. — This deformity is almost always found 
 to be a simple bending outward of the tibia and 
 fibula ; and when this is the case the treatment consists 
 in applying a wooden splint, ex- 
 tending from the sole of the boot 
 to half-an-inch above the knee- 
 joint on the inner side of the leg, 
 and fixing it by means of straps 
 and buckles. (Fig. 8.) The straps 
 should be loosened at night, and 
 the splints are to be removed 
 every morning, and a salt bath 
 administered — cold in summer, but 
 tepid in winter. The nurse then 
 applies the splints again as tightly 
 as the child can conveniently bear 
 them, and the child must also be 
 kept almost entirely off its feet. If any undue pressure 
 occur on the inner malleolus, a pad may be inserted 
 
 Fig. 8. 
 
38 TREATMENT OF DEFORMITIES. 
 
 just below it, or the splints may be left off for a day 
 or two occasionally, so that the skin may become 
 gradually accustomed to them. This treatment must 
 be continued until the legs are quite straight, and 
 until the child has recovered from the rickets, and 
 the bones have become hardened. 
 
 In those more severe cases in which there is a 
 curvature of the bones forward, a special instrument 
 is required. It consists of an inside iron fixed to the 
 sole of the boot, and extending to just above the 
 knee ; to this, one end of a strong wire is attached 
 a little below the knee-joint, which, passing round 
 at the back of the leg, runs down the outer side of it, 
 and passing behind the ankle-joint, the other end is 
 attached to the inside iron. Webbing straps are 
 fastened to the wire on the outside of the leg, and 
 then pass in front of the curved bone, and being 
 buckled to the inside iron, cause a continued pressure 
 from before directly backwards. In those somewhat 
 rare cases in which, combined with the bowing out- 
 wards of the tibia, the knee-joints bend outwards 
 (genu extrorsum), it is necessary to apply outside 
 splints extending from ankle to hip, in addition 
 to the inside ones, in the way explained below in 
 the treatment of knock-knees combined with bow- 
 legs. 
 
 Knoch-knee^ or Genu Valgum. — In the great 
 majority of cases that come before the surgeon this 
 deformity is not of a severe nature ; and on the knees 
 being placed in the extended position and allowed to 
 touch each other, the distance between the inner 
 malleoli will be found not to exceed three or four 
 inches. When this is the case, all that is required 
 
ON DEFORMITIES CAUSED BY RICKETS. 
 
 39 
 
 for the cure of the deformity is the application of 
 wooden outside splints, extending from the hips to 
 the feet. A strap is attached to the upper ends of 
 the splints, which passing behind the pelvis keeps 
 them back in their place ; other straps and buckles are 
 attached along the splints from the ankles to above 
 the knees, by means of which the knee-joints can be 
 gradually drawn outwards towards the splints. 
 (Fig. 9). These splints must be removed every 
 
 Fig. 9. 
 
 morning for the child to have a salt bath, and re- 
 applied. The child must be kept almost entirely off 
 its feet. In those cases which are more severe, with 
 four to seven inches between the malleoli, a special in- 
 strument is necessary, and division of the biceps 
 
40 TREATMENT OF DEFORMITIES. 
 
 femoris (see page 34) or a part of the external lateral 
 ligament may be required. With reference to the 
 decision as to the necessity of tenotomy, an exami- 
 nation should be made of the deformed limb, and an 
 attempt be made to straighten it. While this is being 
 done, the structures above mentioned should be felt 
 for ; and if little or no contraction can be detected, 
 the case is one for treatment by gradual extension 
 without operation. If, on the other hand, either the 
 tendon of the biceps or a band of ligament can 
 be felt holding the limb in its deformed position and 
 preventing its being straightened, one or both must 
 be divided, according to the severity of the deformity. 
 
 To carry out the treatment by an instrument 
 satisfactorily, it is absolutely essential that the 
 patient be kept off his feet; and the important 
 points to attain in the construction of a proper in- 
 strument are that it should keep the knee in 
 the extended position, and prevent the leg from 
 rotating, at the same time that, by its means, the 
 knee-joint can be acted upon in the lateral direction, 
 with sufficient force to gradually overcome the de- 
 formity. No instrument fitted to a boot and used 
 while the patient walks about can do this. 
 
 The instrument figured below, which carries out 
 these conditions efficiently, was shown by me at a 
 meeting of the Medical Society of London in February 
 1880, and a description of it was published in the 
 'British Medical Journal,' May 22nd, 1880. (Fig. 
 10.) It will be seen to consist of a trough (A) for 
 the thigh, which takes its bearing on the great 
 trochanter of the femur, and is connected with the 
 leg-splint by a stem on the outer side of the leg. 
 
ON DEFORMITIES CAUSED BY RICKETS. 
 
 41 
 
 which is provided with a cog-wheel, B, opposite the 
 knee-joint. A band, C, encircles the knee. The 
 special points in which it differs from the trough- 
 instruments in common use are^ that it has a wing 
 
 Fig. 10. 
 
 hinged to the back part of the leg-splint, on the 
 inner side of the leg and ankle, which, together with 
 an ankle-strap, D, and an inside toe-strap, H, keeps the 
 heel and leg from rotating inwards, a pad, I, being 
 introduced within the wing at F, to press on the 
 internal tubercle of the os calcis, and the wing being 
 kept in its place by the straps M and N. There 
 
42 
 
 TREATMENT OF DEFORMITIES. 
 
 Fig. 11. 
 
 is a rigid bar, K, at the back of the knee, which 
 keeps the joint in a perfectly extended position, 
 whatever amount of force is used laterally. To this 
 bar is attached a carefully made leather strap, C, 
 formed in such a way as to cause the least possible 
 amount of pressure on the patella, and also to 
 
 diffuse the pressure over the 
 inner condyle, when the cog- 
 wheel, B, at the knee is acted 
 upon. The instrument is also 
 made in such a manner that, in 
 drawing the limb straight, it 
 adapts itself to its altered posi- 
 tion, and fits the straightened 
 limb as well as it before fitted 
 the deformed one. Fig. 11 
 shows the apparatus applied. 
 
 Before the application of 
 the instrument, a soft woollen 
 stocking should be put on the 
 deformed limb, and a bandage 
 carefully applied over it from 
 the foot upwards. The instru- 
 ment having been made to cor- 
 respond exactly to the angle of 
 the deformed leg by means of 
 the screw B at the knee-joint, is 
 to be then applied and the straps adjusted, and the 
 wing and pad fixed in their place. The cog-wheel B, 
 opposite the knee-joint, is then acted on so as to 
 slightly straighten the leg until pain is complained of, 
 when the screw must be a little reversed, and the 
 patient made quite easy. In this manner, the leg 
 
ox DEFORMITIES CAUSED BY RICKETS. 43 
 
 must be slightly stretched every day ; when the resis- 
 tance will he found to gradually give way, and the 
 limh will be brought into the straight position. 
 Great caution must be used in the application of pres- 
 sure ; for, if a sore be allowed to form on the skin 
 over the inner condyle of the femur, all treatment 
 must for a time be abandoned, and much time will he 
 lost. 
 
 It is advisable that the instrument should be re- 
 moved occasionally, and more frequently at first, 
 before the skin has become accustomed to its pressure ; 
 and the leg should then be washed and powdered, and 
 the knee flexed and extended to prevent its becoming 
 stiff. This treatment must be continued until the 
 limb is quite straight ; and, as there is danger of re- 
 lapse in this, as in other deformities, it is necessary 
 that when the patient begins to walk, steel supports, 
 fixed to the boots and extending to the hips, should 
 be worn during the day. 
 
 In extreme cases of genu valgum in adults, osteo- 
 tomy may be necessary. In cases of genu valgum 
 combined with outward curvature of the tibia, inside 
 splints must be applied as before explained, and in 
 addition to these, outside splints must be placed, in 
 the same way as in a case of ordinary genu val- 
 gum. The child must be kept off its feet, and in 
 this way both deformities will be relieved at the 
 same time. Children are occasionally seen suffering 
 from knock-knee in one limb, and bow-leg in the 
 other. The treatment for this variety of deformity 
 is by the application of splints in the same way as 
 in cases of genu valgum with bow-legs. 
 
44 TREATMENT OF DEFORMITIES. 
 
 CHAPTER YI. 
 
 CONTRACTION OF THE KNEE-JOINT. 
 
 Contraction of the knee-joint may be occasioned 
 by a simple sliortening of the hamstring muscles, 
 as when the extensor muscles are paralysed, or by 
 spasm ; or it may be the result of any of the various 
 diseases to which this joint is liable and which cause 
 these tendons to be secondarily contracted ; or it 
 may arise from the cicatrices of burns, or it may 
 be only a temporary condition, as in hysteria. If 
 there is any difficulty in diagnosis, the patient should 
 be placed under the influence of an auEesthetic. 
 If after a careful examination it is decided that this 
 deformed condition is maintained by contraction 
 of the hamstring tendons, they must be divided 
 (see page 34) before any attempt is made to 
 straighten the limb. For if this be not done there is 
 great danger, in forcing the joint straight, of the 
 hamstring muscles drawing the head of the tibia 
 backwards. Unnecessary pain is also caused to the 
 patient. It is also a fact that although many cases 
 are capable of considerable improvement by extension 
 without division of tendons, it often happens that 
 the limb cannot be quite straightened, and thus when 
 the patient begins to walk, the line of pressure 
 from the weight of the body does not fall directly 
 from the femur to the tibia. A very slight bending 
 
CONTRACTION OF THE KNEE-JOINT. 45 
 
 at the knee-joint is sufficient to interfere materially 
 with the application of an instrument intended to 
 give support in walking ; and the weight of the body 
 being borne by the instrument, and not directly 
 through the limb, the former will be either bent out 
 of its proper shape or broken. In many cases there 
 is also combined with the contraction of the tendons 
 some amount of fibrous anchylosis; this latter con- 
 dition, however, can usually be gradually overcome, 
 after the tendons have been divided, by means of 
 a suitable instrument. In those cases which arise 
 from disease of the joint, it is necessary, as a rule, 
 before attempting the cure of the deformity, that the 
 disease should have entirely subsided, and all pain 
 and inflammation have ceased. 
 
 The treatment of the cicatricial bands caused by 
 burns will be spoken of hereafter (see page 48). 
 
 Before the operation of tenotomy is performed, the 
 extension instrument to be used in the after treat- 
 ment must be got ready. This instrument consists 
 of a trough to hold the thigh, and another to hold 
 the calf of the leg ; these are connected together by 
 two stems, one on each side of the knee. On a level 
 with the joint there is a cog-wheel, which acts on a 
 knee-cap. This instrument is fitted to a Scarpa's 
 shoe, which keeps it in its place. 
 
 The hamstring tendons having been divided as 
 explained in the chapter on Tenotomy, page 28, at 
 the end of six or seven days the punctures will have 
 healed. The limb having been carefully bandaged, 
 the instrument, after being unscrewed to an angle 
 to correspond with the contracted condition of the 
 knee, is to be then applied, and the straps are to be 
 
46 TREATMENT OP DEFORMITIES. 
 
 adjusted. The key is now to be applied to the rack 
 at the knee, and the instrument by this means is 
 to be slightly straightened until the patient begins to 
 complain of pain. The rack is then to be a little re- 
 versed, so that the patient may be quite comfortable. 
 Slight extension is to be made in the same way from 
 day to day, care being taken that the patient suffers 
 little or no pain, but only a feeling of stretching. 
 Any attempt to make more rapid progress, by 
 making a greater amount of daily extension than 
 is consistent with comfort on the part of the patient, 
 will fail, and in the end time will be lost. The 
 instrument should be removed every week or ten 
 days and, the limb having been washed and 
 powdered and rebandaged, then reapplied. After 
 the knee has been made quite straight, it must be 
 still kept in the instrument for two or three weeks, 
 as at first there will be a great tendency to relapse. 
 
 If the case is one of simple contraction of the 
 tendons, and the joint itself has not been affected by 
 disease, the cure is now complete ; but in cases of 
 paralysis of the extensor muscles of the joint, it is 
 necessary that an instrument should be worn by the 
 patient, fixed to the boot and extending to the hip, 
 and with a joint at the knee made in such a way 
 that although the patient is allowed to bend the 
 joint while sitting, it can be fixed on walking, and 
 thus prevent the knee from giving way under him. 
 
 If, on the other hand, the case is one of old joint 
 disease, the leg, although straight, will most probably 
 be found to be quite stiff in this position, and a 
 serious question will arise as to the advisability of 
 attempting to obtain a movable joint by breaking 
 
CONTRACTION OF THE KNEE-JOINT. 47 
 
 down the adhesions in the joint while the patient is 
 under an ansesthetic. With regard to this question, 
 each case must be judged on its own merits, and 
 especially with regard to the extent to which the 
 disease has advanced, and how much of the interior 
 of the joint has been destroyed by it. It must be 
 remembered that a stiff straight leg is strong and 
 useful, and that it is quite possible that it may be 
 weakened by attempts to obtain motion in it. In 
 those cases in which it is decided to try to regain 
 movement, it is generally safest to bend the joint a 
 little at a time, and to do this frequently, keeping up 
 the movement thus obtained by rubbing and sham- 
 pooing, as in this way there is less danger of setting 
 up fresh inflammation in the joint. 
 
48 TREATMENT OP DEFORMITIES. 
 
 CHAPTER YII. 
 
 CONTRACTION OF JOINTS CAUSED BY BURNS. 
 
 All the joints of tlie extremities are liable to be 
 kept in the position of permanent flexion by the 
 cicatrices following burns. When an attempt is 
 made to extend a joint affected in this manner, a 
 web of cicatrised tissue is observed preventing its 
 extension beyond a certain point. 
 
 In slight cases this deformity may be overcome 
 by stretching, carried out by means of an instrument 
 with a cog-wheel opposite the joint affected ; and 
 the web, having been daily well lubricated with oil, 
 may disappear under this treatment. The use of 
 the instrument must be continued at night for a 
 considerable time, in order to prevent a relapse. If, 
 however, this does not succeed, the web must be got 
 rid of. The first part of the process by which this is 
 accomplished is analogous to the piercing of the lobe 
 of the ear previous to the wearing of ear-rings, and 
 consists in simply putting a ring of silver through 
 the base of the web, care being taken that no important 
 vessel or nerve is included. This ring must be left 
 in until the tissues have healed around it. The 
 length of time necessary for this to take place 
 depends upon the thickness of the web, but it is 
 better to wait too long than to hurry over the treat- 
 ment, as the whole success of the case depends on 
 
CONTRACTION OF JOINTS CAUSED BY BURNS. 49 
 
 the healing process being complete. Usually the 
 time during which the ring should be kept in situ is 
 from two to six months. When this has been accom- 
 plished, the web must be cut through down to the 
 ring, and a strip of oiled lint is placed between the 
 raw edges. The extension instrument before men- 
 tioned is to be now applied, and the joint gradually- 
 extended and retained ,in the position of extension 
 until the wounds are quite healed. When this has 
 taken place, the limb may be brought into use during 
 the day and the joint worked regularly backwards 
 and forwards, but the instrument must be worn at 
 night until all symptoms of relapse have disappeared. 
 In those cases in which the wound, caused by cutting 
 through the web, is extensive, the healing process 
 may be greatly aided by the grafting of small bits of 
 skin after M. Reverdin's method. 
 
 Into the subject of plastic operations, which are 
 required for many of the more severe cases, I do not 
 propose to enter, as their consideration belongs rather 
 to a treatise on general surgery. 
 
50 TREATMENT OF DEFORMITIES. 
 
 CHAPTER YIII. 
 
 WEBBED FINGERS. 
 
 In this deformity, the fingers, or the fingers and 
 thumb, are united together by a web of skin. This 
 may be either a congenital aJBfection or it may be the 
 result of a burn. The treatment is similar to that 
 described in the last chapter for the removal of 
 cicatrices causing contraction of joints. The ring is 
 introduced through the web at the point at which 
 the fingers affected should naturally separate, and 
 when the tissues around the ring have healed, the 
 web is to be slit up, and great care must be taken to 
 keep the fingers separated from each other until the 
 raw surfaces are quite healed. 
 
 The failure, in many cases, of this treatment is due 
 to the ring not being retained for a sufficient length 
 of time before the division of the web. 
 
( ^1 ) 
 
 CHAPTER IX. 
 
 CONTRACTED FIXaERS. 
 
 Contraction" of the joints of the fingers may be con- 
 veniently divided into two varieties — (1) That which 
 arises from the same causes that affect other joints, 
 such as inflammatory disease of the joint affected, 
 shortening of tendons as the result of paralysis or 
 spasm, congenital contraction, those caused from in- 
 flammation outside the joint as in thecal abscess, and 
 also from burns. (2) Contraction of the palmar fascia. 
 
 It is very important that a correct diagnosis should 
 be made in these cases, and that contraction of the 
 palmar fascia should not be mistaken for contraction 
 of the flexor tendons of the fingers. As a rule it is 
 not difficult to distinguish between them. In a case 
 of contraction of the fingers, occasioned by shortening 
 of the palmar fascia, the skin of the palm of the 
 hand corresponding to the carpo-metacarpal joints 
 will be found to be puckered and knotted, and 
 a rigid strong cord will be felt lying quite super- 
 ficially beneath the skin, evidently preventing the 
 finger or fingers affected from being straightened. 
 The appearance and feel of this condition are very 
 characteristic. 
 
 In the case of contraction of the flexor tendons, on 
 the other hand, this peculiar appearance is never met 
 with ; for as the tendons are securely held down by a 
 
 E 2 
 
52 TREATMENT OF DEFORMITIES. 
 
 fibrous sheath formed by the palmar fascia, they are 
 not to be felt, even when contracted, immediately 
 beneath the skin, as the fascia is, and the skin is not 
 bound down and rigid in the same way. 
 
 Treatment. 
 
 The treatment of contraction of the fingers depends 
 on the cause. In those cases which are caused by the 
 cicatrix of a burn the treatment is the same as that 
 described on page 48. When the flexor tendons are 
 in fault, the treatment must consist in manipulations 
 and extension by means of an instrument made like 
 that to be used after division of the fascia, and ex- 
 plained below. As a rule the tendons of the fingers 
 must not be divided, as this would most probably 
 cause an impairment of the power of flexion, and the 
 condition of the patient would be made worse than 
 before the operation. 
 
 (2) In the second class of cases the treatment 
 consists, in the first place, in the subcutaneous divi- 
 sion of the contracted fascia as explained on page 33, 
 and subsequently the finger or fingers affected must 
 be extended by means of an instrument, which is 
 fixed to the hand and to the back of which stems 
 are attached, which extend along the back of the 
 fingers affected, and which have joints with cog- 
 wheels to correspond with each joint of the fingers. 
 This instrument can be adjusted to the deformed 
 finger, and by actiug on the cog-wheels the fingers 
 can be brought gradually into the natural position. 
 When by these means the deformity has been over- 
 come, the fingers must be brought into use and 
 shampooed, and the instrument must be worn at 
 night, as there is danger of relapse. 
 
( 53 ) 
 
 CHAPTER X. 
 
 CONTRACTION OP THE TOES. 
 
 Deformities of the toes are matters of great import- 
 ance on account of the pain they occasion when the 
 patient walks about, thus preventing him from 
 taking a proper amount of exercise, or in some cases 
 from following his usual occupation. 
 
 The cause of these deformities in a large proportion 
 of instances is due to badly shaped boots and shoes, 
 and sometimes the toes are injuriously pressed 
 together by tight and inelastic stockings. The boots 
 in common use are not only made so narrow that 
 they cramp the toes, but they are also provided with 
 high heels, which have the effect of driving the foot 
 forward into the narrow toe of the boot when the 
 weight of the body is on the foot. 
 
 If the uncovered foot be placed on the ground, and 
 if it be made to sustain the weight of the body, it 
 will be observed to increase in length, and the toes 
 will separate a little from each other. A properly 
 made boot, at the same time that it holds the foot 
 firmly, should allow of these natural movements, and 
 if this were always carried out, the number of 
 deformed feet and toes would be materially 
 diminished. 
 
 A very common deformity affecting the great toe 
 is often combined with bunion, and is indeed one of 
 
54 TREATMENT OF DEFORMITIES. 
 
 its chief causes. It consists in the turning outwards 
 of this toe under the second and third toes, and the 
 bunion cannot be successfully treated until this 
 malformation has been rectified. 
 
 In the majority of instances the toe affected can 
 without difficulty be drawn into its natural position, 
 and the only difficulty is to retain it there. This is 
 best done by having the stocking made with a 
 separate division for the great toe (like a glove), 
 and having a plate fitted into the boot, provided 
 with a vertical ridge to go between the great and 
 second toes, which will prevent the former from 
 bending outwards. In very severe cases, division of 
 the tendon of the adductor pollicis may be necessary. 
 
 Hammer Toe, in the true sense of the term, is 
 always a deformity of the second toe, and is not 
 caused by badly shaped boots. It consists of a per- 
 manent flexion of the second phalanx on the first at 
 a right angle, which causes the patient when standing 
 to rest on the tip of the toe, producing at this point 
 a painful corn as well as another corn over the 
 contraction. The treatment consists in the subcu- 
 taneous division of the flexor tendon, as well as the 
 bands of fascia that can be felt holding the toe in its 
 deformed position, and the subsequent application of 
 a splint to the sole of the foot and along the lower 
 surface of the toe. A narrow bandage passes over 
 the toe, and draws it down to the splint. After the 
 toe has been straightened by these means, the patient 
 must for some weeks wear a sandal inside the boot, 
 and the stocking must have a separate division for 
 the affected toe, like a glove. This sandal is provided 
 with two slots, made to correspond with each side of 
 
CONTRACTION OP THE TOES. 55 
 
 the affected toe, and a ribbon is threaded through 
 these in a loop within which the toe lies, the loop of 
 ribbon is then to be tightened and tied so as to keep 
 the toe in its straightened position. 
 
 In cases of paralysis it is not uncommon to find 
 all the toes deformed ; but in these cases, the extensor 
 tendons are usually contracted, and in the more 
 severe instances they may require division. 
 
56 TREATMENT OF DEFORMITIES. 
 
 CHAPTER XI. 
 
 WRYNECK. 
 
 The neck may be distorted in various ways, and the 
 head drawn in divers directions, as the result of either 
 caries of the cervical vertebrae, or by the contracted 
 cicatrix of ulceration arising from burns or other 
 causes. Grenuine wryneck, however^ depends on the 
 undue contraction of the whole or a part of one sterno- 
 mastoid muscle, and this condition may be produced 
 by either rheumatic inflammation of the muscle itself, 
 or by spasm, or by the paralysis of the corresponding 
 muscle on the other side. When this condition first 
 comes on, it is of course desirable to treat the 
 disease, which is causing the deformity, by ordinary 
 means ; but if, after everything has been done, de- 
 formity still continues, the patient must be carefully 
 examined in order to determine whether the muscles 
 on both sides of the neck have still the power of 
 moving the head from side to side or not. If it be 
 found that the patient has voluntary power over both 
 muscles, but that the sternal or clavicular portion, or 
 in some cases both portions of the muscle are simply 
 causing deformity by reason of their being abnormally 
 shortened, the case is a suitable one for tenotomy, and 
 one or both parts of the contracted muscle should be 
 divided, as explained on page 35. For four or five 
 days after the operation the patient should be kept in 
 
WRYNECK. 57 
 
 bed with the head resting in the deformed position, 
 and be further steadied by means of a bandage fixed 
 round the head, and passing under the arm on the 
 same side as the operation. In this way rest will be 
 obtained, the puncture will be enabled to heal, and 
 any danger of suppuration will be prevented. The 
 patient may now be allowed to get up, and the 
 bandage must be reapplied round the head as before, 
 but passing under the arm on the opposite side to 
 the operation, and the head will by this means be 
 gradually drawn into its natural position and retained 
 there. 
 
 After two or three weeks, the bandage having been 
 removed, the surgeon, by placing one hand imder the 
 angle of the jaw and the other on the shoulder, may 
 stretch the contracted parts, and this may be repeated 
 every other day and the bandage reapplied. The 
 patient also, if old enough, may help the cure by 
 keeping the head inclined in the opposite direction to 
 the deformed state. 
 
 In some few of the more severe cases a specially 
 made instrument is necessary. This instrument 
 must be made in such a way that being fixed to the 
 trunk it extends to and holds the head firmly, and it 
 is also provided with cog-wheels, so placed that the 
 surgeon by their means can turn and retain the 
 head in any required position. 
 
58 TREATMENT OF DEFORMITIES. 
 
 CHAPTER XII. 
 
 CARIES OF THE VERTEBRA FOLLOWED BY DEFORMITY. 
 
 In speaking of the various affections of the spine, 
 there is a tendency to mix up simple curvatures with 
 deformities which are the result of disease of the 
 bodies of the vertebrae. This is an error that should 
 be carefully guarded against, as there is in fact no 
 similarity between them in their pathology, and 
 therefore should be no similarity in their treatment. 
 It would be just as reasonable to talk of caries of 
 the tarsus as a variety of club-foot, and to suggest a 
 like treatment in both cases. 
 
 In speaking of angular curvature of the spine, in 
 the first place it is necessary to bear in mind that it 
 differs in all respects from every other kind of cur- 
 vature in its cause, its pathology, symptoms, prognosis, 
 and treatment, as well as in its being occasionally 
 followed by abscess and sometimes by paralysis. 
 This being the case, it would be well if the term 
 angular curvature could be abolished, and that the 
 name given to it should draw attention rather to the 
 disease that is destroying the bodies of the vertebras, 
 than to the deformity which is occasioned by it if it 
 is not arrested in an early stage of its progress. 
 
 " This curvature, which is always from within 
 outwards, is caused by the erosion or destruction of 
 
CARIES OF THE VERTEBRA. 59 
 
 part of the body or bodies of one or more of tlie 
 vertebras ; by which means that immediately above 
 the distemper, and that immediately below it, are 
 brought nearer to each other than they should be, 
 the body of the patient bends forward, the spine is 
 curved from within outward, and the tuberosity 
 appears behind, occasioned by the protrusion of the 
 spinal processes of the distempered vertebrse. That 
 according to the degree of carious erosion, and ac- 
 cording to the number of vertebree affected, the curve 
 must be less or greater. . . . Although there can be 
 no curve without caries, yet there is, and not un- 
 frequently, caries without curve." — (Pott). It is very 
 important, that this disease should be diagnosed at its 
 commencement. This, however, is somewhat difficult, 
 and the symptoms are sometimes attributed to dis- 
 eases of other parts ; if in the dorsal region, to the 
 lungs or to indigestion; if in the lumbar, to inci- 
 pient hip-disease. A very careful examination of the 
 patient should be always made to prevent a mistake 
 in diagnosis. When, however, on examination of the 
 spine there is found to be the least circumscribed pro- 
 jection, and this does not disappear when the patient 
 lies on the face, and when to this is added a feeling 
 of pain or discomfort, on concussion either directly 
 applied or by the patient jumping or raising himself 
 on the toes and suddenly letting himself down on the 
 heels, the diagnosis is certain. The serious nature of 
 the case should be pointed out to the friends of the 
 patient, in order that they may be induced to carry 
 out the tedious course of treatment which is neces- 
 sary, and which alone can arrest the disease and 
 prevent a further increase of the deformity. 
 
60 TREATMENT OP DEFORMITIES. 
 
 In order to accomplish this, it is allowed by most 
 surgeons that as perfect a state of rest as possible 
 must be enjoined ; but a great difference of opinion 
 exists as to the best mode of effecting this. Some, 
 for instance, have faith in being able to obtain rest 
 for the diseased spine in the upright position, and 
 while the patient walks about, by Dr. Sayre's mode 
 of treatment, by means of the plaster jacket. I 
 endeavoured to show in a paper read before the 
 International Medical Congress in 1881 that this 
 was impossible, and I believe that since that date 
 this method of treatment has to a great extent been 
 discontinued. Several different kinds of apparatus 
 have also been extolled at various times, with the 
 same end in view. The fact, however, remains that 
 although some of these undoubtedly give temporary 
 relief to some of the symptoms, they do not prevent 
 the continuance of the disease or the increase of 
 deformity, and as they are depended upon to the 
 neglect of recumbency, they do positive harm. 
 This, then^ being in my opinion an indisputable fact, I 
 believe we must fall back on the very old-fashioned, 
 but as experience shows, the very efficient treatment 
 by complete recumbency, and with this may be com- 
 bined Vv^ith advantage the use of a back-splint, which 
 helps to keep the spine still further at rest. 
 
 It is often stated that this treatment of rest in bed 
 is injurious to the general health of the patient. 
 This is, according to my experience, a fallacy. I 
 have found that the contrary is the case, as the 
 patient rapidly loses his pain, and, as a consequence, 
 becomes happy and comfortable, and his general 
 health improves. It is, moreover, easier to keep a 
 
CARIES OF THE VERTEBRJ^. 61 
 
 child always in bed than to insist on an occasional 
 rest on a sofa. 
 
 The splint which should be used while the patient 
 is recumbent is made of leather, moulded to the back, 
 and lightly padded and covered with wash-leather. 
 In cases of caries in the dorsal or lumbar region, it 
 extends in length from the seventh cervical to the 
 last lumbar vertebra, and in breadth to the angles 
 of the ribs on each side. The upper corners 
 must be cut oft" and rounded at the armpits, and 
 steel crutches, covered with wash-leather, must be 
 fixed at these parts, the ends of which should be 
 long enough to bend over in front of the shoulders 
 as far as the clavicles. These crutches, it must be 
 understood, are not intended to take the weight of the 
 shoulders from the spine, as it is both impossible and 
 unnecessary that they should do so, while the patient 
 is in the recumbent position ; but they are very 
 useful in keeping the patient from turning about, 
 and in this way they help materially in keeping the 
 spine in a state of rest. The splint is also kept in 
 place by straps attached to its sides and passing across 
 the chest. These should, however, be kept quite 
 loose, so as not in any degree to compress the thorax. 
 
 In those cases in which the disease is situated in 
 the cervical region, in addition to keeping the patient 
 in the recumbent position, it is necessary to keep 
 the head in a state of rest. This is best effected by 
 fixing to the back-splint already described a head- 
 piece, consisting of a band of steel to encircle and 
 clasp the head, and connected to two stems which are 
 screwed to the back of the splint. Straps pass over 
 the forehead and under the chin. 
 
62 TREATMENT OF DEFORMITIES. 
 
 A tightly fitting vest should be worn next the 
 skin under the splint, and at first the back must be 
 examined daily to ascertain that the splint does not 
 cause any undue pressure. The general health of 
 the patient must be attended to ; cod-liver oil and 
 steel wine being administered in addition to a 
 generous diet. 
 
 The frame of the bed and the mattress on which the 
 patient is placed should be a movable one, so that he 
 may be carried upon it into the open air, or to a 
 carriage, or to a perambulator with a board placed 
 across it. In the great majority of cases^ if this plan 
 of treatment be rigidly carried out, it will be found 
 that all the pain which was formerly suffered will be 
 speedily removed, and that the general health will 
 improve and the deformity will decrease, and in 
 slight cases may entirely disappear. This course of 
 treatment hy perfect recumbency must be continued 
 until the disease is quite cured, and until anchylosis 
 has taken place. To know when this has happened 
 is extremely difficult, but it is of the greatest import- 
 ance that it should be recognised. It is Letter to 
 err on the side of caution and allow the spine too 
 much rest than too little. 
 
 Before the patient is allowed to get up and walk 
 about, the whole of the pains that he formerly com- 
 plained of must have ceased, even when a slight blow 
 is made on the heels, causing concussion at the affected 
 part. Another sign of the disappearance of the 
 disease is the gradual passing away of the puffiness 
 around the projection which is so obvious a symptom 
 in the early stage of the disease ; while with this 
 disappearance of the puffiness there is also a drawing 
 
CARIES OF THE VERTEBRJ^. 63 
 
 in of the parts, causing the curvature to assume a 
 more pointed aspect. 
 
 The length of time during which it is necessary to 
 keep the patient in the recumbent posture varies in 
 different cases, and depends on the duration of the 
 disease, as well as on the care and patience with 
 which the treatment has been carried out. 
 
 When it has been decided by the surgeon that 
 firm anchylosis has taken place between the affected 
 vertebrae, the patient may be allowed to sit up, and 
 by degrees to stand and walk. There will be 
 of course, for some considerable time, great weak- 
 ness of the back after the caries and accompanying 
 inflammatory conditions have disappeared, so that 
 it will be advisable that an instrument should be 
 worn, to assist the patient in holding himself erect, 
 and to support the projection resulting from the 
 diseased action. For the majority of cases, the most 
 efficient instrument for this purpose consists of a 
 pelvic band, to the back part of which is attached, 
 by means of an upright steel, a padded plate, to 
 exercise an amount of pressure on the projecting 
 part of the spine, which can be accurately regulated 
 by the surgeon by means of a rack. There are also 
 crutches affixed to it, the anterior ends of which 
 keep the shoulders well back, and tend in a great 
 measure to improve the figure and expand the chest. 
 
 When this mode of treatment has been rigidly 
 carried out, the formation of an abscess is a com- 
 paratively rare occurrence. When, however, it does 
 take place, it adds very greatly to the severity of the 
 case. These abscesses may point in the back, con- 
 stituting lumbar abscess ; or the pus may make its 
 
64 TREATMENT OF DEFORMITIES. 
 
 way between the abdominal muscles and point in the 
 abdomen. Sometimes, again, it may enter the sheath 
 of the psoas muscle, and point below Poupart's liga- 
 ment, or through the sacro-sciatic notch to the nates, 
 and it has been known to discharge itself through 
 the bladder and rectum. The best treatment for an 
 abscess of this description is either to leave it to 
 burst by itself, or to draw off the pus by means of an 
 aspirator, and to bandage a piece of folded lint over 
 the puncture and allow it to heal, and to repeat the 
 aspiration in case the abscess cavity refills. 
 
 It sometimes happens that during the progress of 
 these cases of caries of the vertebrse the patient 
 suddenly loses power over the lower extremities, and 
 on examination the feet will be found to be spas- 
 modically drawn into the position of equinus. The 
 treatment necessary in this form of paralysis is to 
 continue the recumbency, and to make use of 
 counter-irritation on each side of the spinous pro- 
 cesses of the diseased vertebrse. If this is carried 
 out, the power in the legs may return. If the case 
 should not, however, terminate in this way, and the 
 paralysis become permanent, causing contraction of 
 the limbs, the deformity must be treated on the same 
 principles as those laid down in former chapters on 
 paralytic deformities of the lower extremities. 
 
( 65 ) 
 
 CHAPTER XIII. 
 
 LATERAL CURVATURE OP THE SPINE. 
 
 Lateral curvature of the spine is due to a variety 
 of causes. It will be most convenient to consider it 
 under three chief heads : (1) That which is caused 
 by some alteration in the contents of the thorax, 
 which interferes with the relation naturally existing 
 between the organs contained in each side of the 
 chest ; (2) That which is caused mechanically by the 
 loss of equilibrium in the parts outside the chest 
 waUs, by which the spine is either dragged to one 
 side by the unequal power of the muscles on the 
 two sides, or tilted on one side by an inequality in 
 the length of the lower limbs ; (3) That which takes 
 place as the result of simple weakness of the muscles 
 and ligaments. This condition allows the spine to 
 deviate from the straight line, and the patient not 
 being able to exert sufficient muscular power to 
 overcome the deformity, it becomes permanent. 
 
 (1) and (2) The cases comprising the first set 
 are generally the result of bronchitis, which causes 
 the lung on one side of the chest to partially collapse, 
 on account of the plugging of one or more bronchial 
 tubes, or to pleurisy, after which the lung may be 
 bound down by adhesions, and be unable to expand. 
 The affected side will then shrink, and become smaller 
 than the other. Lateral curvature of the spine 
 
 F 
 
66 TKEATMENT OF DEFORMITIES. 
 
 caused in this way is of course an incurable deformity, 
 and the surgeon can only hope to alleviate the 
 symptoms by a properly fitting mechanical support. 
 The particular kind of apparatus most suitable for 
 each patient will depend on the severity of the case, 
 and what amount of pressure the patient is able to 
 bear. In a severe case, and when much pressure is 
 not advisable, a poroplastic felt corset is useful, and 
 in the less severe cases a steel instrument is best. 
 These remarks are applicable also to those cases 
 which are occasioned by loss of power in the 
 muscles on one side only of the chest, as in paralysis, 
 or after amputation of one arm. 
 
 When the curvature is owing to tilting of the 
 pelvis by an unequal length of the legs, the obvious 
 treatment is to make the limbs symmetrical again by 
 means of an artificial leg or cork boot. If, however, 
 before this is done the curvature has become perma- 
 nent, and does not disappear when the pelvis has 
 been made level, the spine must be treated in the 
 same way as the cases of the third class. 
 
 By far the largest number of cases of lateral cur- 
 vature of the spine belong to the third class. It is 
 probable that nearly all patients who suffer from this 
 deformity are predisposed to it, either from heredi- 
 tary causes or from a special constitutional debility. 
 This predisposition is intensified in the case of girls 
 at about the period of puberty. 
 
 The first event leading to the production of the 
 curvature is a general laxity of the ligaments, not 
 only of the spine, but of other parts, and as in 
 standing the ligaments of the ankles and knees are 
 naturally most acted upon, it is not uncommon to 
 
LATERAL CURVATURE OF THE SPINE. 67 
 
 find flat-foot or slight knock-knee as an early accom- 
 panying- symptom. In addition to this, there is a 
 marked want of tone in all the muscles of the body. 
 What might be expected to follow from this really 
 happens ; the patient, finding it extremely irksome or 
 perhaps impossible to keep upright, gradually sinks 
 to one side, usually standing on one leg only. As 
 the result of this, the spine adjusts itself to this 
 unnatural position and rotates. In this way the 
 ligaments of the outer part of the curve become 
 slightly elongated. The patient having over in- 
 dulged in this position, feels constrained to do so 
 again on the next occasion of feeling fatigued. 
 
 On examining the spine in this the first stage of 
 lateral curvature, although at first a distinct varia- 
 tion from the straight line is observable, yet the 
 patient is able, by making an effort, to rectify the 
 malposition, although on the attention being with- 
 drawn, the spine returns again to its deformed con- 
 dition. The extent to which this takes place differs 
 in each case. 
 
 The treatment of this condition of incipient lateral 
 curvature consists, in addition to suitable medicinal 
 management, of exercises and drilling, short of 
 fatigue, followed by rest in the recumbent position ; 
 and the patient must be prevented, as far as possible, 
 from assuming awkward positions, while the muscles 
 should be strengthened by shampooing, and in some 
 cases by galvanism. The success attending this 
 course of treatment will depend on how thoroughly 
 it is carried out. "When the patients are compelled 
 to work to obtain a livelihood, there are great 
 difficulties in the way. 
 
68 TREATMENT OF DEFORMITIES. 
 
 If the progress of the case continue unchecked, 
 the intervertebral catilages become compressed on the 
 side corresponding to the concavity of the curve, and 
 there is more and more tendency for the spinal 
 column to bend over. Subsequently a compensatory 
 curve is formed, and it is now impossible for the 
 patient to voluntarily overcome the deformity and 
 place the spine straight. If, however, by any means 
 the spinal column can be gradually and forcibly 
 made to retrace its movements and be retained in 
 its natural position, the cartilages may regain their 
 normal shape, and the muscles being strengthened 
 by frictions and exercises, and the patient having 
 recovered in regard to her general health, the cure or 
 improvement may become permanent. The question 
 to be answered then is, How is this to be done ? If 
 the surgeon places the palms of his hands one on 
 each side of the spine, on and a little below the 
 curves, he can by pressure improve the deformity 
 somewhat ; and if this pressure could be kept up, 
 the improvement would continue and increase. As 
 this cannot be done, we must try to imitate this 
 action as nearly as possible by means of an instru- 
 ment. Of late years the use of jackets made of 
 various materials, after having been laid aside for a 
 very long time, has again been advocated as a cure of 
 these cases. It must, however, be borne in mind 
 that although a jacket may keep the spine in a 
 straighter position than before it was applied, and be 
 useful in cases where there is no hope of improve- 
 ment, it cannot keep up a continued advancing 
 pressure ; its action is therefore very limited. The 
 instrument most suitable for obtaining the object in 
 
LATERAL CURVATURE OF THE SPINE. 69 
 
 view must be made of strong steel, and must be pro- 
 vided with two plates to act as the hands in clasping 
 the ribs and spine. The plates are acted upon by 
 cog-wheels, so that they can be made to exert a 
 constant pressure on the two curves ; and this pres- 
 sure can be regulated by the surgeon. As there is 
 no tendency for the curvature to increase when the 
 patient is recumbent, it is not necessary that the 
 instrument should be worn at night, and this being 
 so, the skin which has during the day been compressed 
 by the plates has an opportunity of recovering itself, 
 and so is prevented from becoming sore. During 
 the time the instrument is being used, care must be 
 taken to exercise the muscles of the back so that 
 when the patient leaves off the support they may be 
 in a condition to retain the spinal column in its 
 improved condition. 
 
 Instruments of the description mentioned above 
 can be obtained of any surgical mechanician, but in 
 practice many of these will be found to be practically 
 useless, unless the surgeon attending the case assures 
 himself, by personal inspection, that the pressure is 
 really applied in such a manner as to effect the 
 purpose intended. 
 
70 TREATMENT OP DEFORMITIES. 
 
 CHAPTER XIY. 
 
 ANTERIOR AND POSTERIOR CURVATURE OF THE SPINE. 
 
 The spinal column is the subject not only of angular 
 curvature from disease of the vertebra, and of lateral 
 curvature from weakness of the muscles and liga- 
 ments, but it may also be unnaturally flexed either 
 forward (anterior curvature or lordosis), or backward 
 (posterior curvature or cyphosis). 
 
 Anterior curvature of the spine is generally the 
 result of contraction of the hip-joint, or displacement 
 of the head of the femur. Attention is generally 
 called to it in the case of a child by the very peculiar 
 gait of the patient. When he walks, the spine is 
 observed to be strongly curved with the convexity 
 forwards, and with a corresponding protuberance of 
 the abdomen. 
 
 If the patient be laid on a couch, in the recumbent 
 posture, and the limb affected be allowed to assume 
 at the hip-joint a flexed position, the spine will be 
 placed perfectly straight ; the deformity, however, 
 at once recurs on an attempt being made to straighten 
 the leg-. 
 
 The treatment must be directed to the cause, and 
 if it be possible by any means to rectify this, the 
 resulting curvature of the spine will disappear. 
 
 In the first place, therefore, it is necessary to find 
 out to what the contraction of the hip is due, and a 
 
ANTERIOR AND POSTERIOR CURVATURE. 71 
 
 careful examination must be made to determine this 
 point. Most of the cases are the result of hip-joint 
 disease, and on examination some amount of anchy- 
 losis will be detected in the joint itself. Great care 
 and caution are required to decide upon the proper 
 treatment for each individual case. If the disease be 
 recent, extension by means of a weight attached to 
 the leg and suspended over the foot of the bed is 
 useful. If the case, on the other hand, be of long 
 duration, and it is found that fibrous anchylosis keeps 
 the leg in its deformed position, the adhesions may 
 be broken down while the patient is under the in- 
 fluence of an angesthetic. In those cases in which 
 bony anchylosis is present, nothing can improve the 
 deformity except osteotomy. 
 
 Anterior curvature of the spine is sometimes a 
 natural result of obesity, and in these cases an ab- 
 dominal belt is useful. 
 
 Posterior curvature of the whole spine is common 
 in weakly and rickety infants, and of the dorsal spine 
 in the young of both sexes (round shoulders). The 
 best form of treatment in the case of infants is to 
 keep them reclining as much as possible, and to im- 
 prove their general health by proper diet and suitable 
 medicine, such as cod-liver oil, steel wine, &c. 
 
 In the case of round shoulders in young girls and 
 
 youths, the shoulders must be kept back by means of 
 
 shoulder-straps, and exercises must be insisted upon, 
 
 in which the arms are thrown backwards, the ex- 
 
 * . .... 
 
 ercises being followed by rest in a reclining position. 
 
 The sitting position should be, as much as possible, 
 
 avoided. 
 
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