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DEFORMITIES
TWO POST - GRADUATE LECTURES
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ARTES SCIENTIA VERITAS
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Dr John Ridlom
103 State Shuck
Chicago - Amrica
With the Authors kind regends -
POST-GRADUATE LECTURES Adams.
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ON THE
SURGICAL TREATMENT
OF
DEFORMITIES.
I.-ON THE PRINCIPLES OF SURGERY APPLICABLE TO
THE TREATMENT OF DEFORMITIES; AND ON SOME ?
RECENT DEPARTURES FROM THESE PRINCIPLES.
II.-ON THE SURGICAL TREATMENT OF DEFORMITIES
DUE TO PARALYSIS.
By WILLIAM ADAMS, F.R.C.S.,
CONSULTING SURGEON TO THE GREAT NORTHERN CENTRAL HOSPITAL; THE
NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEDȚIC; AND THE
T OF THE
Ex Libris
VEIAN
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Dr. H.Winnett Orr
› Cox,
AND.
4
Medical Library
RD
461
·A22
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11-26-58
Medical
Sift
9-41-58
PREFACE.
ALTHOUGH the two Post-Graduate Lectures,
published in their present form, have already
appeared in print, it has been thought that
they might gain a more permanent form, and
be more readily accessible if published in a
separate pamphlet.
I have the more willingly acceded to this
suggestion, because the subject matter has
reference to some recent and important changes
in practice, and therefore does not appear in my
larger works on Orthopedic Surgery.
HENRIETTA ST., CAVENDISH Square,
June, 1893.
•
LECTURE I.
On the Principles of Surgery applicable to the
Treatment of Deformities; and on some recent
departures from these principles. (a)
GENTLEMEN,-In the large public institution in
which we are assembled to-day-The Central London
Sick Asylum-containing as it does nearly 300 beds,—
under the care of Mr. John Hopkins, who has kindly
given me every assistance, cases may readily be found
to illustrate any medical or surgical subject, referring
especially to the chronic class of affections; and
amongst these I find many cases belonging to contrac-
tions and deformities which fall under the observation
of those who have more especially studied orthopedic
surgery. There are several cases for clinical illustra-
tion in the side room, which we may separately
examine after the Lecture.
The occasion seems to me, therefore, a fitting one
on which I might offer you a few general remarks on
the principles of surgery applicable to the treatment of
cases of contraction and deformity, more especially as
these principles have of late years been subject to
many important deviations and modifications in their
practical application.
I do not propose to-day to enter into a detailed
description of any particular class of contractions, as I
am sure with these you are sufficiently familiar. I
therefore desire to point out to you the general prin-
(a) Delivered at the Central London Sick Asylum, March 2nd, 1893.
6
ciples of surgery which are applicable to the various
classes of cases into which contractions with deformity
may be grouped, and also to advert to the new depar-
tures from the established principles of treatment
which some surgeons have endeavoured to make.
These general principles of Surgery I have arranged
in seven classes, and propose to make some observa-
tions on each class, viz. :
The First Principle.-Mechanical treatment.
The Second Principle.-Subcutaneous tenotomy and
gradual mechanical extension.
The Third Principle.-Subcutaneous osteotomy.
The Fourth Principle.-Forcible straightening of
bent limbs and contracted joints-"The Bone Setter's"
treatment.
The Fifth Principle.-Extension.
The Sixth Principle.-Recumbency.
The Seventh Principle.-Including massage often
combined with passive movements and galvanism.
No. I.-MECHANICAL TREATMENT.
The oldest principle adopted before the treatment
of contractions and deformities was brought within
the domain of surgery by the introduction of sub-
cutaneous tenotomy in the year 1831, by Stromeyer of
Hanover. The mechanical treatment in these early
days was necessarily of the simplest kind adopted by
a class of so-called mechanicians, and in accordance
with the imperfect knowledge of the day. I need only
mention the case of the celebrated Lord Byron who
was born with a club-foot, and whose sufferings under
the mechanical treatment adopted, are well described
in Moore's life of the poet, who died in the year 1824,
T
-J
at the age of thirty-six years. It is a matter of history
in the house of the mechanician whose business was
conducted in Leicester Square, that on one occasion,
in a fit of impetuous temper Lord Byron threw his
boot and iron through the window into Leicester
Square. The anatomical conditions of this deformity
had not then been described, and the mechanical
appliances were necessarily ill-adapted to the case.
The same defects necessarily accompanied the treat-
ment of all other contractions and deformities.
No. II. THE SECOND PRINCIPLE IS THAT OF SUB-
CUTANEOUS TENOTOMY FOLLOWED BY GRADUAL
MECHANICAL EXTENSION.
The scientific treatment of all contractions and
deformities, including both the congenital and the non-
congenital forms, when associated with muscular con-
traction, may be referred to the re-introduction of
subcutaneous tenotomy in its improved form by
Stromeyer of Hanover, in the year 1831, although
Delpech, of Montpelier, had in the year 1816, first
suggested the operation, and accurately laid down the
principle upon which it should be performed, viz.:
the complete exclusion of air, and the after treatment
by gradual mechanical extension in proportion to the
activity of the reparative process.
Delpech, however, only operated upon one case, and
as the result did not prove so successful as was antici-
pated he never repeated it, and thus sixteen years were
lost to the world until Stromeyer re-introduced the
operation with essential modifications and improve-
ments in the year 1831.
This improved operation might also have remained
8
for some time dormant in Germany had it not been for
the accidental circumstance of a distinguished member
of our profession, Dr. Little, then a student at the
London Hospital, and afflicted with a severe degree of
contraction of the right foot, going over to Hanover to
witness the results of the operation. The favourable
impression made upon his mind by the numerous cases
he saw, induced him to submit to the operation which
Stromeyer performed in 1836 with complete success.
On the 20th February, 1837, Dr. Little first divided
the Achilles tendon in London. It is right to say,
however, that in this country he had been anticipated
by a celebrated English surgeon, the late Mr. Whipple
of Plymouth, who divided the Achilles subcutaneously
in May, 1836. Mr. Whipple himself informed me that
when he first devised the operation he was not aware
of its having been performed by Stromeyer, and that
Sir Benjamin Brodie, to whom he wrote on the subject,
discountenanced it, but Liston sanctioned it on the
ground that the chances of benefit outweighed the
probability of the patient being injured by its per-
formance.
This is another illustration of the same discovery
being made independently in different countries, and
sometimes not far from the same date.
In the year 1838 the Royal Orthopedic Hospital
was founded by Dr. Little with the aid of rich and
grateful patients, more especially Mr. Quarles Harris,
whose daughter Dr. Little had cured. At the present
time three Orthopedic Hospitals exist in this me-
tropolis.
With the mode of performing the operation and its
beneficial results in overcoming all muscular contrac-
9
tions, whether in congenital or acquired club-foot, con-
tractions of the knee and hip-joint from myelitis and
other causes; contraction at the elbow-joint by division
of the biceps tendon; and in wry-neck by division of
the tendons of the sterno-mastoid muscle, you are I
am sure sufficiently familiar, and I would merely re-
mark that we always divide tendons by cutting from
below upwards towards the skin, whilst in Scotland
the Achilles tendon has always been divided by cutting
from above downwards; both Liston and Ferguson
advocated this method. I only make one exception to
this rule, viz.: when dividing the extensor tendons of
the toes and this I always do by cutting from above
downwards.
Another point I would advert to is the method of
making the cutaneous puncture not directly over the
tendon to be divided, but rather more than a quarter
of an inch from it, and then carry the knife flatwise
under the skin until the tendon is reached, when the
direction of the knife must be immediately altered,
and the point dipped below the tendon, towards which
the edge of the knife must be turned at the same time.
This forms an indirect route and more completely ex-
cludes the admission of air. When the cut is made
from above downwards it is only necessary to turn the
edge of the knife towards the structure to be divided,
whether tendon, ligament, or a band of fascia, as in
Dupuytren's finger contraction, &c.
•
After subcutaneous tenotomy all contractions and
deformities have been overcome by gradual mechanical
extension, generally by means of instruments adapted
either to the foot, knee, hip, elbow, or neck, and the
extension is regulated by one or more of the well-
!
10
known rack and pinion movements. This is the old,
safe, and successful orthopedic treatment, of the
results of which since the Royal Orthopaedic Hospital
was founded in 1838-more than fifty years—we may
be justly proud. My advice to you, gentlemen,
would be to keep to the bridge which has carried us
safely over. However, new improvements, and some
radical changes are being sought after, and I will make
a few observations on what I propose to call
THE NEW DEPARTURE from the principle of sub-
cutaneous tenotomy and gradual mechanical extension
which we are now considering.
This new departure is divided into two distinct
propositions :-
The first proposition is to do away with subcutaneous
surgery altogether, and to substitute for it a large open
wound with antiseptic precautions, so that the surgeon
may see and feel the structure he intends to divide.
It is contended that in the subcutaneous method the
surgeon is not certain that he divides the structures
he intends to divide, and that he runs considerable
risk of wounding arteries and large veins,-in fact that
the surgeon is operating under a condition of anato-
mical darkness.
The second proposition is to do away with the
ordinary mechanical appliances used in the after-treat-
ment so as to regulate the extension as it may appear
to be necessary, and to substitute for it the plan of
immediate extension, even when the foot, when this
method is applied to the foot, should require some
force to bring it into its natural position. The foot is
then to be retained in its improved position by plaster of
Paris bandage, or some other form of immobility splint.
Th
11
This new departure is of American origin, and first
carried out in its entirety, I believe, by Dr. A. M.
Paelps of New York, a few years ago. In England
Mr. Edmund Owen has for several years carried out
this open-wound method with immediate extension,
and expresses himself as "highly pleased with it."
Mr. Owen recently brought the subject prominently
before the profession in a paper which he read at the
Royal Medical and Chirurgical Society of London, on
the 22nd November, 1892, on "The Radical Treatment
of Severe Talipes Equino-varus in Children."
In this paper Mr. Owen remarks, "the operation re-
commended in this paper for adoption in severe cases
of club-foot is that introduced by Dr. A. M. Phelps of
New Vork; it consists in dividing every resisting
structure which is encountered in a free vertical in-
cision passing from the dorsum of the foot into the
depths of the sole, over the head of the astragalus, the
tendon of the Achilles having been first cut. The im-
proved position of the foot is thus obtained by
lengthening the inner border of the foot, rather than
by shortening the external border, as is usually ac-
complished in tarsectomy."
For this new American departure we are therefore
indebted to Dr. A. M. Phelps of New York, who must
take the responsibility of its results, whether for good
or evil, and I am sorry to say that I cannot speak of it
in any favourable terms.
With regard to the first proposition, the idea of
which is that antiseptic surgery has now superseded
subcutaneous surgery, I must observe that it is en-
tirely devoid of proof, and I cannot but regard it not
only as a retrograde step in surgery, but a very serious
159
12
one, as not being without danger to the patient. Sub-
cutaneous surgery has held its own for more than sixty
years-ie., since Stromeyer's operation in 1831. It is
based on a sound physiological principle, viz., the ex-
clusion of air, and in its freedom from inflammation,
leaves nothing to be desired. In some thousands of
tendons which I have divided in more than forty years
hospital and private practice, I have never seen in flam-
mation follow the operation, and it is not at all pro-
bable that antiseptic surgery with an open wound
could have given such a result.
In the larger operations surgeons are by no means
agreed as to the value of the antiseptic system. The
ovariotomists are by no means agreed, and in my own
experience of more than thirty years as surgeon to the
Great Northern Hospital, where we adopted Professor
Lister's antiseptic method as strictly as our house-
surgeons could carry it out, the results were by no
means uniformly successful in cases of amputation,
removal of breast and other tumours, hernia cases, &c.
In all these cases whilst we have had brilliant results
in a large number of cases, still a considerable per-
centage of failures resulted.
Antiseptic surgery, therefore, cannot be implicitly
relied upon, as subcutaneous surgery undoubtedly can,
and I am convinced that antiseptic surgery will never
supersede subcutaneous surgery where the latter can
be adopted. There are, moreover, some minor, but still
important, disadvantages in the method by an open
wound: first, the formation of adhesions which is sure
to occur, and must interfere with the free movement
of the tendons at the end of the treatment; and,
secondly, a scar will certainly remain, and it is perhaps
13
not sufficiently considered that all scars existing in
childhood continue to grow pari-passu with the growth
of the part over which they are placed-for example, I
exhibit to you the models of a case of congenital club-
foot which was operated upon by open wound in the
year 1851 by a surgeon of Bradford, in Yorkshire, who
dissected off the redundant skin on the convexity of
the foot, with the idea of obtaining contraction on the
outer side. When this child was brought to me in
October, 1852, he was nearly two years old, and the
scar on the convexity of each foot measured two
inches and a quarter in length, but it was of a linear
character. When he came a second time under my
care in May, 1859, in consequence of a slight degree of
relapse, it was found that each scar had grown fully an
inch in length during the six years and a-half. Casts
of the feet were taken on both occasions, and I ex-
hibited them to the Pathological Society on the 21st
February, 1860 (see vol. xi.).
The second case in which I had the opportunity of
watching the growth of a cicatrix occurred in a little
girl about a year old, and a cousin of my own, who was
the subject of a prominent and rapidly-growing nævus
situated between the clavicle and the right nipple,
rather nearer to the latter. My former master, Mr.
Jos. Henry Green was consulted by my father, and he
decided to remove it, remarking that as the incision
would only be about an inch and a-half in length, the
scar would be of no importance. Mr. Green performed
the operation at which I assisted, and, as he knew the
incision would be deep and he wished to avoid
hæmorrhage, he remarked when commencing the
incision, "Now then, quick is the word"; probably
14
this was the only occasion on which Mr. Green ever
used such an expression, as he was notoriously a very
slow operator.
This young lady grew up as a fine stout girl, and
with the general growth and expansion of the breast
the cicatrix not only grew in length but also in width,
so that at the age of eighteen years it measured three
inches in length, and varying from three quarters of
an inch to one and a half inches in width, and the thin
cicatricial tissue had a marked tendency to become
red, so that a low dress never could be worn. This
cicatrix was traced for me on silver paper by her sister,
and I exhibit it to you. I described this case in a
paper "On the Growth of Cicatrices in Childhood” I
read before the Medical Society of London, 17th Nov.,
1873. (a)
In the foot a cicatrix might not be considered to be
of any importance, though a gentleman in the position
of my first case regarded it with a good deal of dis-
favour, but in other situations it should be avoided in
children. This remark would especially apply to the
sterno-mastoid muscle which Mr. Owen has advised
should be divided by open wound in his Lettsomian
Lectures at the Medical Society of London, in January
and February, 1890. There can be no doubt that a
young lady of twenty years of age would not like to
see a large transverse scar across her neck, where the
sterno-mastoid muscle had been divided in childhood
for wry-neck.
Then with regard to the division of such articular
ligaments as are within reach of the surgeon, as for
(c) See "Proceedings of the Medical Society of London,” vol. i,
p. 105.
15
example the ligamentous bands passing between the
navicular bone and the astragalus on the inner side,
which can easily be reached after the anterior and
posterior tibial tendons have been divided—an opera-
tion first proposed by my friend Mr. Parker, which
certainly helps to liberate the navicular bone in severe
cases. Also the inner band of the deltoid ligament
can be easily reached and divided. The strong cal-
caneo-cuboid ligament can easily be divided by a punc-
ture on the outer side of the foot, and this operation I
have done for many years in cases now described by
my colleague, Mr. Fisher, as talipes arcuatus, i.e., when
the anterior portion of the foot is flexed from the trans-
verse tarsal joint so as to shorten the sole of the foot,
and raise the arch to an unnatural extent.
Nor can I at all agree with the remark made by Mr.
Owen that in subcutaneous operations the surgeon
operates "comparatively in anatomical darkness," so
that he cannot know for certain what structures he is
dividing. With the tendons nearly always super-
ficially placed, so that they can be either seen or felt,
and the landmarks for the division of the deeply seated
posterior tibial tendon and other structures clearly
laid down, it seems to me that a careful study of the
anatomical condition of the parts involved, together
with a little experience and a cultivated touch, always
necessary in subcutaneous operations, are all that is
required to enable any surgeon to perform these opera-
tions subcutaneously.
This, gentlemen, completes the objections I have to
raise against the first proposition involved in this new
departure from the long established rules of practice
and I will now proceed to make a few observations on
16
涩
​1
the second proposition, the idea of which is to do away
with the ordinary mechanical appliances used in the
treatment to regulate the extension, and to substitute
for it the plan of immediate extension and rectification
of the deformity. When applied to club-foot this
principle is recommended, even if the foot should re-
quire some force to bring it into its natural position.
The foot is then to be retained in the improved posi-
tion by plaster of Paris bandage, or some form of im-
mobility splint.
Of this proposition I can only say that it is very
unscientific as opposed to our knowledge of the repara-
tive process in tendons, and not without risk of serious
injury to the patient by interfering with the reunion
of the divided tendon. If this should occur in the
Achilles tendon, so that the uniting medium is thin,
elongated, and imperfect, the patient will be propor-
tionately damaged, and an opposite and incurable
deformity-Talipes calcaneus-is sometimes produced.
I exhibit to you a drawing of a case in which this
occurred in both feet of a young lady. I always watch
the reparative process in a divided tendon, and examine
it once or twice a week for three or four weeks, at
which time the divided extremities of a tendon
generally begin to form a junction with the new re-
parative material thrown out between the divided
extremities.
The reparative process is sometimes rapid, especially
in young healthy children; sometimes it is sluggish
and imperfect in children of delicate constitution, and
at other times the new material thrown out between
the divided extremities of the old tendon is very thin
and attenuated, more especially in cases of contraction
17
due to paralysis, either infantile or adult. A few
weeks ago I took Mr. Noble Smith to see a young
lady, æt. 23, whose Achilles tendon I had divided more
than a month previously, for a severe contraction
following an attack of paralysis two or three years
ago. In this case about one and a half inches of new
material was required, but only an inch at the upper
part had formed. A gap of half an inch existed at
the lower part, and the lower fragment of the tendon
still presented a square and abrupt outline. This was
a case of retarded union, but it is now fairly perfect
and she has begun to walk with a stop-joint at the
ankle to prevent undue flexion.
Immediate extension applies only to the division of
fascia and ligaments, as we do not wish these struc-
tures to reunite; but it never should be applied to the
division of tendons, the reunion of which is one of the
chief points to be attended to in the after treatment.
These are my objections to the second proposition as
regards immediate extension and fixation in the new
departure.
Now, gentlemen, although only dealing with the
general principles of surgery applicable to the treat-
ment of contractions and deformities in the present
lecture, and avoiding details it may be worth while
calling your attention to one of the general rules of
practice in the treatment of club-foot to which I have
especially drawn attention and followed for many
years.
It has not been sufficiently considered that the foot
in all its deformities moves from two very distinct
centres of motion, viz., first from the transverse
tarsal joint which, partaking more or less of the ball-
18
and-socket type, controls the movements of inversion,
flexion, and rotation of the anterior two-thirds of the
foot in varus, and eversion in valgus; and secondly
from the ankle-joint which, belonging to the gingly-
moid type, admits only of flexion and extension by
the elevation or depression of the os calcis.
The rule of orthopedic practice has therefore long
been in severe cases to divide the treatment into two
stages, the object of the first stage being to overcome
the more complicated movements from the transverse-
tarsal joint, and when this has been accomplished and
the foot brought into a straight line with the leg;
then in a second stage to divide the Achilles tendon
and restore the flexion and extension movements at
the ankle-joint. In the first stage the fixation of the
os calcis by the contraction of the Achilles tendon is
found to be of the greatest advantage, and a sufficient
reason for delaying its division.
If I have been more successful than some surgeons
in the treatment of severe cases of club-foot, and cases
of relapsed club-foot after others have failed, it is only
because for more than thirty years I have rigidly
adhered to the above principle of treatment which I
laid down after dissecting a number of club-feet, and
more especially after studying the anatomical con-
ditions in a carefully dissected and dried specimen of
adult varus, which fortunately I was enabled to pur-
chase in the year 1853, and of which there are three
illustrations in my work on Club-foot, Figs. 34, 35, and
36. This specimen which at the time I believe was
the only reliable dissection of an adult club-foot in
this or any other country, is now in the museum of
the Royal College of Surgeons.
:
19
1
I was thus led to attach a much greater degree of
importance to the transverse-tarsal joint than it had
hitherto received; and it so happened that early in
1854 a case of severe adult varus in a gentleman,
æt. 26, came under my care, and I had a new instru-
ment, represented in Fig. 56 in my club-foot book,
especially constructed for him, and moulded upon the
dissected leg referred to. This instrument was radi-
cally opposed to all the instruments previously in use
but in about a year and a quarter the foot was com-
pletely restored to a natural position as shown in Figs.
94, 95, and 96 in my work referred to. The only draw-
back was a limited degree of mobility at the ankle-
joint which would be expected from the age of the
patient, but a gradual improvement in this respect
took place, and the result was extremely satisfactory.
I would, therefore, strongly recommend you to follow
the same principle of treatment, whether in infantile
or adult varus, and not to be led into the error of
dividing all the tendons at once and immediately
attempting to overcome the deformity by force, and
afterwards fixing the limb in an immobility splint.
There can be no doubt that this orthopedic treat-
ment is necessarily slow, tedious, and troublesome,
always taking seven or eight weeks in the infant and
as many months in the older children, and a year or
more in some cases of extreme severity, but it leads to
the foot being not only perfectly restored in form but
physiologically perfect as regards all the natural move-
ments from the two great centres of motion to which
I have directed attention. This may, therefore, very
justly be considered as one of the triumphs of modern
surgery.
20
1
I now pass on to the consideration of another
principle of surgery of modern origin, mentioned as the
third principle, especially applicable te the treatment
of many contractions and deformities :-
No. III.-OSTEOTOMY.
Next to the discovery of tenotomy with all its valu-
able, or I would rather say invaluable, results, came
more gradually the idea that the bone might be cut
through with advantage in many cases of deformity
and distortion, either by the subcutaneous method
or by open wound.
A solid approach to the true subcutaneous osteo-
tomy was made by the celebrated German surgeon
Langenbeck, (a) who during the Schleswig-Holstein
War of 1848 first introduced the use of a small-pointed
saw, with a point one-eighth of an inch wide, gradually
increasing to half-an-inch at the base, the interme-
diate cutting edge being four inches in length. With
this saw exposed portions of bone were removed in
suppurating wounds, and then Langenbeck remarks in
his work published in 1854, the idea of resection of
bones dawned upon him. Cases of bony anchylosis of
the knee-joint, and ricketty deformities were operated
upon, a drill in the shape of a gouge a quarter of an
inch in diameter being first used, and the pointed saw
then introduced.
Operations, generally for anchylosis of the knee-
joint, or ricketty deformities, were performed in this
country, in Germany, and in America, the gimlet or
small chisel being used to weaken the bone before for-
cibly breaking it.
(a) "Subcutane Osteotomie." Voa B. Langeubeck, M.D. Berlin.
1854.
21
A great impetus was given to subcutaneous osteotomy
in this country by the operation of the subcutaneous
division of the neck of the thigh bone, which I first
performed at the Great Northern Hospital on Dec. 1st,
1869. (a)
The patient, Luke Bristowe, æt. 24, was a gar-
dener, and seven years previously had suffered from
a severe attack of rheumatic fever. The right leg was
drawn up and the thigh flexed at a right angle with
the pelvis, and the limb abducted. He could only
walk with crutches or one crutch and a stick. All
attempts to break down adhesions by forcible exten-
sion by myself and colleagues failed, and the case was
considered to be one of bony anchylosis.
It occurred to me that a division through the neck
of the thigh bone was the only surgical procedure to
relieve such a severe contraction, and I thought this
might be done subcutaneously if I could only get a saw
small enough and strong enough for the purpose. To
obtain this saw was my only difficulty, and this after
many experiments on bones and hard woods was ac-
complished by my talented instrument-maker, Mr.
Blaise, of Savigny & Co., St. James's Street. A wide
double cutting edge, an inch and a half in length for
an adult, was found to be necessary, the blade, three-
eighths of an inch in width, gradually becoming thinner
towards the back, at the end of a slender shank. some-
what flattened and rounded, and measuring three
inches in length. This allowed for the saw being
carried to the requisite depth without interfering with
(a) "A New Operation for Bony Anchylosis of the Rip-joint with
Malposition of the Limb, by Subcutaneous Division of the Neck of
the Thigh Bone." By Wm. Adams, F.R.C.S. J. and A. Churchill.
London. 1871.
с
1
22
the cutaneous puncture made by an enlarged teno-
tomy knife three-eighths of an inch in width.
No difficulty was experienced at the operation; no
inflammation or deep suppuration followed. The
contracted muscles at the hip were divided at the time
of the operation, and the leg was bandaged in a straight
position to a long interrupted Liston splint. In a
fortnight I began to encourage motion, but all attempts
at movements were so painful, that I gave up the idea,
and the result was bony anchylosis in a straight posi-
tion with a good useful leg. Weight extension was
used when the straight splint was discontinued.
This operation has been repeated many times by my-
self and other surgeons in this country and America.
It is now a well-known and generally adopted opera-
tion. Saws of a smaller size with a cutting edge of one
inch and an inch and a quarter in length, are used for
younger people, and these I exhibit to you. Mr. T.
Bryant, of Guy's Hospital, successfully applied it to a
number of cases of fibrous anchylosis after hip-joint
disease arrested in an early stage, when the anchylosis
would not readily yield to a little force. Mr. P. Pick,
of St. George's Hospital, also followed the same course.
The selection of cases is no doubt a matter of import-
ance, the most favourable being those in which the
anchylosis has followed an attack of rheumatic fever,
as no destruction of bone occurs in this class; and the
most unfavourable are those in which the anchylosis
has resulted from hip-joint disease, with chronic sup-
puration, and more or less, destruction of the head and
neck of the bone. In these cases the division through
the neck should not be attempted. Fortunately an
admirable suggestion was made by my friend, Mr. F.
23
1
J. Gant, to divide through the shaft of the femur just
below the small trochanter, and I was present when
he first performed this operation on the 10th December,
1872. No difficulty was experienced, and the case did
remarkably well. I have applied this subcutaneous
osteotomy to the division of the shafts of the long
bones in many cases, generally of badly united frac-
tures with malposition, or of severe ricketty curvatures.
The results have been extremely favourable.
A very bold, and decidedly the most ingenious appli-
cation of the subcutaneous saw, was made by Professor
Alexander Ogston, of Aberdeen, who proposed in cases
of severe knock-knee to introduce the saw just above
the inner condyle of the femur through a tenotomy
puncture, opening the capsular ligament, and then
carry the point obliquely downwards towards the
median line, between the condyles. By the use of the
saw the inner condyle can now be readily detached,
the bone between the condyles being very thin. The
detached inner condyle is then to be pushed upwards
by a lateral movement of the head of the tibia, and a
straight splint applied. Passive motion should be
commenced at the end of the third week; occasionally
at the end of five or six weeks some bands of adhesion
may have to be broken through, but under the subcu-
taneous system no inflammation of the joints seems to
occur. I adopted this operation some years ago at the
Great Northern Hospital in a severe case of knock-
knee in a young adult, æt. 23, and the result was ex-
tremely favourable, the deformity being cured without
the free motion of the joint being at all interfered with.
I doubt whether this operation is generally applicable
to children, but after the completion of growth it may
be recommended.
24
;
Professor Ogston's operation seems, however,
gradually to have given way to the operation adopted
by Professor Macewen, of Glasgow, who, in cases of
knock-knee, divides the femur a little above the knee-
joint with a chisel, and in his hands this instrument
has been extremely successful, but still it always
appears to me that the subcutaneous saw is much more
reliable as an instrument of precision, and more
manageable, without the risk of accidents.
Osteotomy performed by open wound is an operation
of much older date, and the American surgeons led
the way in operating on cases of anchylosis of the hip-
joint with the object, not only of correcting deformity,
but of obtaining motion by the formation, more or less,
of a new socket. In the year 1826, Rhea Barton, of
Philadelphia, successfully divided the femur trans-
versely by a fine saw, just above the trochanter minor,
through an incision, made over the great trochanter,
seven inches in length, and five inches in a horizontal
direction. It is said that useful motion was obtained,
but that seven years afterwards anchylosis took
place. (a)
In the year 1862 Professor Sayre, of New York,
revived this operation with some modifications, and
operated upon two cases. The operation consisted in
the removal of a transverse section of the femur, with
a convex upper surface, just above the trochanter
minor, by means of a chain saw, an incision of about
six inches in length being made over the trochanter
major.
(a) "On the Treatment of Anchylosis by the Formation of Artificial
Joints," in the North American and Surgical Journal, April, 1827;
with further remarks in the American Journal of Medical Sciences,
vol. xxi.
25
The first case, a man, æt. 26, did very well, and
obtained a good, useful limb, but whether motion was
retained is not stated. The second case was less
favourable. The patient was a girl, æt. 24, and deep
suppuration occurred, with the escape of a little
necrosed bone; pneumonia and pleurisy also occurred,
and she died six months afterwards. Tubercular
deposits were found in the lungs, and a large abscess
in the left lung. The formation of an artificial joint
is stated to have been proceeding very favourably, the
articulating surfaces being tipped with cartilages. I
am not aware of any other operation of this nature
having been performed with the object of obtaining
free motion by the establishment of an artificial joint
in which articular cartilage and synovial membrane are
reproduced.
In the class of cases we are now describing exci-
sional surgery, sometimes applied to the treatment of
deformities, as well as cases of progressing disease,
must hold a place. Many years ago I excised the head
of the humerus, at the Queen's Square Hospital, in an
old unreduced dorsal dislocation, and restored free
motion with a useful arm. In the year 1882 (a) I also
excised the head of the femur, at the Great Northern
Hospital, in an unreduced dislocation of long standing,
after repeated attempts at reduction by the ordinary
means had failed. The dislocation occurred spon-
taneously during fever; and in this case also I restored
free motion with a useful leg. The head of the bone
is preserved in the Museum of the Royal College of
Surgeons. This operation was first performed by Dr.
(a) Proceedings of the Royal Medical and Chirurgical Society, Oct.
28th, 1834.
26
H. G. Rawdon, of Liverpool, in the year 1881, (a) and
both the children, æt. about 11 or 12, were exhibited
at the Medico-Chirurgical Society, on the 28th Oct.,
1884.
Excision of the knee-joint for bony anchylosis with
malposition of the leg, I have also performed, and
operations of this class have been done by many sur-
geons.
In the treatment of severe cases of congenital club-
foot, especially in cases of talipes varus occasionally
seen in young adults, and in relapsed cases at younger
ages, osteotomy by open wound has been frequently
performed with considerable success. The foot has
been brought into a fairly natural position, and re-
stored to usefulness, but I need hardly say far short
of physiological perfection, the motion at the ankle-
joint generally remaining very limited. The best re-
sult I have seen was obtained by Mr. Lund, of Man-
chester, after excision of the astragalus.
S
Excision of the cuboid bone was first suggested by
Dr. Little, but the operation was first performed by
the late Mr. Samuel Solly, of St. Thomas' Hospital on
the 26th June, 1854, and by whose invitation I was
present, but was not consulted regarding it. Dr. Little
and several surgeons were also present. The opera-
tion was performed by making a free incision over the
convexity and the outer margin of the foot, exposing
the cuboid bone, which was then removed piece-meal
by the gouge, but portions of other bones were also
cut away.
The object was to remove a large wedge
from the convexity of the foot. The immediate
(a) The Liverpool Medico-Chirurgical Journal, Jan. 2nd, 1832.
F
27
effect of the operation was to produce some improve-
ment in the position of the foot when this was forcibly
everted, but the after treatment was troublesome, and
the result of the case less successful than anticipated
by Mr. Solly. The patient was a young gentleman,
æt. 21, who came to this country to be cured of severe
congenital varus.
This operation has been frequently performed during
the last ten years or more, by my friend, Mr. Richard
Davy, of the Westminster Hospital, with some modifi-
cations; and also by Mr. H. L. Ewens, of Clifton.
The cases selected have been extremely severe, and
the results on the whole very satisfactory. I have
never had occasion to perform this operation in pri-
vate practice having always succeeded in curing these
cases up to 26 years of age; and in the Orthopedic
Hospital, when these severe cases are admitted, suffi-
cient time-say a year is allowed for the more
gradual method which I have described. I think,
however, the ultimate result would be improved in
these cases of osteotomy, if the treatment were di-
vided into two stages, the osteotomy being limited to
the first stage, as a rapid means of everting and un-
folding the foot which should be brought into a
straight line with the leg. Then in the second stage
the Achilles tendon might be divided and the foot up-
lifted by the use of the simplest form of Scarpa's
shoe.
Add
I have now, gentlemen, to say a few words upon
another principle in General Surgery especially applic-
able to the treatment of many cases of contractions
and deformity-the fourth of my series, viz. :-
28
No. IV.-FORCIBLE STRAIGHTENING OF BENT LIMBS
AND CONTRACTED JOINTS; AND FORCIBLE MOVE-
MENT IN THE TREATMENT OF STIFF JOINTS.
Badly united fractures in the long bones have always
been forcibly rebroken and set by the "bone-setters,"
and hence the general term applied to this method of
treatment is bone-setting" or the bone-setter's
treatment, but the introduction of subcutaneous oste-
otomy has rendered this practice obsolete.
"L
Many years ago I saw M. Guérin, of the Hotel Dieu
in Paris, forcibly straighten a rather severe case of
knock-knee in a patient of my late colleague, Mr. John
Gay, at the Great Northern Hospital. More force had
to be employed than I had ever seen used, the surgeon's
knee being placed on the inner side of the knee-joint
to act as a fulcrum, and with one hand on the femur,
and the other on the leg, all the force the surgeon was
capable of using had to be employed before an audible
snap took place. The object was to obtain a partial
separation of the epiphysis of the thigh bone. The leg
was immediately straightened and a straight splint
applied. The case did well.
In the year 1861, it occurred to me that this principle
of forcibly straightening, or re-breaking badly united
fractures might be applied to broken noses which
occasionally came under the notice of the surgeon.
On the 12th July, 1861, a young gentleman, L. L.,
æt. 16, who had sustained an injury to the nose from
a cricket-ball at Eton a month previously, was brought
to me by his father, in consequence of opinions which
had been given by the local surgeon at Eton and two
London consultants, that no surgical measures could
improve the condition of the nose; and if improved, it
29
could not be maintained. The late Sir Prescott Hewitt,
who generally attended the family, advised that nothing
should be done, and in this the other surgeons agreed.
The external deformity was slight, consisting of a
depression a little above the tip of the nose, from the
junction of the cartilage with the bone, with a lateral
inclination of the anterior portion. Since the accident,
however, the voice had become completely altered,
and assumed a most disagreeable nasal twang, and the
breathing through the right nostril was obstructed.
This was the cause of great anxiety in the family as
the father very quietly observed we think very little
of the deformity as all our noses and little fingers are
crooked," but the loss of voice to a man destined to
hold a public position was a serious matter.
On examination I found the right nostril obstructed,
or I might say completely occluded, by the cartilagin-
ous septum which had been bent, and probably broken,
by the blow from the cricket ball, and now projected
into the cavity of the right nostril, so that a probe
could not be made to pass through it, nor could air be
made to pass by efforts at inspiration or expiration.
The cavity of the left nostril was much enlarged by
the depression and bending of the cartilaginous septum
into the right nostril. No fracture of the nasal bones
could be detected, though a little bending at the free
border might exist; there was no depression or lateral
displacement of the nasal bones.
Considering all the circumstances of the case, I
advised that an attempt should be made to straighten
the septum, and retain it in the improved position by
some mechanical appliance; and consent being at once
given by the father I directed Mr. Blaise, of Savigny's
30
in St. James's Street, to prepare the strong flat-bladed
forceps, the clamp and ivory plugs.
On the 16th July, 1861, the first attempt to straighten
the septum was made, with only partial success, in con-
sequence of the patient not being allowed by his father
to take chloroform, and the pain and sneezing rendered
it impossible to proceed. The clamp was, however,
worn for three days and three nights, and afterwards
the ivory plugs were used. This did not cause much
pain or inconvenience, and the improvement was very
decided, although incomplete. Consent to the ad-
ministration of chloroform was now obtained, and on
the 30th July I repeated the operation, the chloroform
being administered by Dr. Allan, the medical attendant
of the family. I now completely straightened the
septum, and all the obstruction of the right nostril was
removed, so that the forceps, with the blades closed,
could readily be passed through it. The retentive ap-
paratus was used as before, the ivory plugs being worn
at night for several weeks. It was not necessary to
repeat the operation; the external deformity was re-
moved, and the voice was completely restored. At the
present time (1893) this gentleman's voice is clear, and
distinctly to be heard in any large assembly. (a)
I have given this case somewhat in detail because it
was the first in which any such operation had been
performed, but now it has become an established sur-
gical procedure, described in every text-book, and the
instruments used are generally figured. I exhibit to
you to-day all the latest alterations and improvements
in the clamp, and the plugs, and also the narrow
(a) Brit. Med. Jour., Oct. 2nd, 1875, and "Proceedings of Medical
Society of London,” vol. ii (1874 and 1875).
31
curved forceps to raise the nasal bones and straighten
the central plate of the ethmoid bone. There is also
another form of retentive apparatus which I have
found necessary in severe cases, when the nasal bones
are fractured, depressed, and displaced sideways. It
is described as a nose truss, and consists of a steel
band passing round the forehead, with a steel plate in
front, to which two movable levers with felt pads are
attached—one long and one short lever; the short
lever is intended to support the convexity of the curve
after the fractured and displaced nasal bones have
been raised, and the long lever acts as a counter-
pressure lower down. I first employed this instru-
ment in a very severe case upon which I operated on
the 9th June, 1871, and have frequently used it since.
As a part of the principle of forcibly straightening
bent limbs and contracted joints, I would make a few
remarks with reference to the application of this prin-
ciple in cases of contracted joints and also in cases of
stiff joints.
1st. The cases of a traumatic origin are the most
favourable for this treatment.
2nd. Cases of a rheumatic origin are also very
favourable.
3rd. Cases of a strumous origin are the most un-
favourable.
4th. Cases of muscular contraction, such as infantile
or adult forms of paralysis are very unfavourable, and
always yield to tenotomy and gradual mechanical ex-
tension.
5th. Cases of deformity such as talipes varus and
valgus have been treated upon this principle, but
nothing can be more unscientific than to tear through,
32
or attempt to tear through the normal articular liga-
ments of any joint, as they will all yield to gradual
mechanical extension. (a)
The next general principle in surgery, the fifth of
my series, to which I would direct your attention as
especially applicable to the treatment of deformities
and contractions is
No. V.-THE PRINCIPLE OF EXTENSION.
This is undoubtedly one of the most important
principles of modern surgery, and for it we are in-
debted to the genius and practical ability of the
American surgeons.
It was first discovered in connection with the treat-
ment of hip-joint disease in about the year 1850 by
Dr. Henry G. Davis, of New York, who found that ex-
tension by the weight-and-pulley apparatus relieved
the pain and overcame the contraction in hip-joint
disease. As a remedy for the acute pain met with in
some cases of hip-joint disease in the early stage, I
need hardly say that this was an invaluable discovery,
and it applies equally to the knee and the ankle-joint.
It also led to the explanation of the pain being due
to a mechanical cause, i.e., articular pressure caused
by the contraction, and not to the acuteness of the
inflammation as formerly supposed, all active anti-
phlogistic treatment therefore being done away with.
Dr. Henry Davis continued his observations, and in
(a) This principle in surgery was fully discussed in the Section of
Surgery at the Annual Meeting of the British Medical Association in
Worcester, on the 9th August, 1382, under the head of "Bone-setting."
The very able introductory address by Mr. Howard Marsh, followed
by a paper by Mr. Adams "On the Selection of Cases," are reported
in the British Medical Journal, 7th October, 1832.
33
the year 1855 (a) invented a hip-joint instrument by
which the patient, when the acute stage had subsided,
was enabled to walk whilst the extension was still
maintained. Thus extension with locomotion was
another great advance in treatment.
About the same period Dr. Louis Sayre, of New
York, also directed his attention to the influence of
extension in relieving pain and overcoming contraction
in disease both of the hip and knee-joint. With the
object of combining extension with locomotion, Dr.
Sayre invented an instrument in a greatly improved
form, now well known as "the American hip-joint
instrument."
In the year 1860 Dr. Gurdon Buck, of New York,
applied the weight extension principle to the treat-
ment of fractures of the femur and of the leg. Dr.
Joseph Pancoast, of Philadelphia, and Dr. Grosse also
advocated this system which English surgeons have
adopted for many years.
Extension by the head and arms with the patient
in a standing position has been used by Dr. L. Sayre
in the treatment of lateral curvature of the spine as a
preliminary to the application of the plaster of Paris
jacket which is intended to preserve the improved
position gained by extension.
Dr. Sayre also adopted the same plan in the treat-
ment of Pott's disease of the spine, sometimes suspend-
ing from the head only as a preliminary to the appli-
cation of plaster of Paris jacket.
In these cases, however, I prefer absolute recum-
(a) "Conservative Surgery," by H. G. Davis, of New York. Appleton
& Co., New York, 1867.
34
bency for about two years, with the application of a
poro-plastic felt jacket for support and immobility.
Extension by the head only, combined with absolute
recumbency I have found to be very valuable in cases
of Pott's disease in the cervical and upper dorsal re-
gions, especially when associated with more or less
paralysis. The paralysis begins to improve in a few
days and disappears in a few weeks. The patient
must be on a movable plane, to which a rack and
pinion movement is attached for regulating the exten-
sion, and in the day-time it can be placed in a spinal
carriage, so that the patient may pass as much time as
possible in the open air.
Extension applied to both legs with counter-exten-
sion by the head and arms I have found to be very
useful in some cases of fractured spine in which the
displacement of the vertebræ is not sufficient to cause
complete paralysis. A very successful case of this
kind occurred in my practice at the Great Northern
Hospital many years ago. A plumber fell about
twenty or thirty feet from a ladder and fractured his
spine. When he was admitted partial paralysis existed in
both legs, and an angular projection of the twelfth dorsal
or first lumbar spine was very distinct. I commenced
the extension treatment, the patient being kept on a
fracture-bed covered by a thin mattress. The paralysis
diminished somewhat rapidly at first, and then com-
pletely, so that the extension was discontinued in
about three months. The recumbency was continued
for two or three months longer, and in about six
months from the accident he was discharged, wearing
a steel spinal support. He gradually resumed work
and came to see me at the hospital, but he wore the
spinal support for more than a year.
35
Extension applied to both legs, with counter-exten-
sion from the pelvis, applied to cases of congenital dis-
placement of the hip-joint, generally, but erroneously
described as "congenital dislocation," of the hip-joint.
The last application of the extension principle was
made by a distinguished American surgeon, Dr. Buck-
minster Brown of Boston, in the year 1882. (a) In April,
1882, a little girl, four years of age, was taken to Dr.
Brown who at once recognised the case as
one of
double displacement of the hip-joint. From his ex-
perience he advised against all active treatment, and
Dr. Brown had studied this affection in Paris as early
as 1845 and 6, in the wards of M. Guérin in the
"Hôpital des Enfants Malades." The parents, how-
ever, urged Dr. Brown to try some means of relief,
and he decided upon a long course of extension upon
the weight-and-pulley system which was commenced
on the 30th December, 1882. On the 14th January,
1884, the little girl sat up in bed for a short time, and
soon after this attempts at walking in a go-cart were
commenced. On the 2nd January, 1885, [the report
says "the child walks well without canes." The
photographs, taken two years and three months after
the commencement of treatment, show an improve-
ment far beyond anything that could have been an-
ticipated.
When this case was published I saw at once the
value of this principle of treatment, but endeavoured
to modify the apparatus by making the extension on a
movable plane so that the patient could be moved
about easily and taken into the open air in a spinal
(a) " Double Displacement of the Hip." By Dr. Buckminster Prown,
Boston, U.S. Cupples, Upman & Co. 1885.
1
36
carriage. This Mr. Ernst very ably contrived for me
by attaching the extension and counter-extension
straps to the movable plane. I have carried out this
treatment in a number of cases, and the results have
been very satisfactory. They will shortly be published.
Two papers of mine on this subject have already
appeared in print. (a) (b)
The next general principle in surgery, the sixth in
my series, on which I have only a few remarks to make
is that of recumbency.
NO. VI.-RECUMBENCY.
The older surgeons used to rely upon recumbency to
a much greater extent than is adopted at the present
day. In the treatment of lateral curvature of the spine
the order was frequently given for young ladies to lie
down for two years; and in Pott's disease of the spine
a similar order was generally given. In the latter
affection I still adhere to absolute recumbency, but in
lateral curvature partial recumbency at an angle of 45°
for four or six hours a day is sufficient, in combination
with gymnastics and the patient wearing a light spinal
support. In the treatment of congenital displacement
at the hip-joint, to which I have just referred, I always
order absolute recumbency for at least two years, and
in children I have never known the health suffer.
Before concluding, I must refer to another, and the
last principle of treatment, the seventh in my series,
applicable to many cases of contraction and deformity,
viz. :
(a) The British Medical Journal, April 23rd, 1857.
(b) Ibid., Feb. 22nd, 1890.
37
No. VII.-Massage ofteN COMBINED WITH PASSIVE
MOVEMENTS AND GALVANISM.
I need hardly say that this treatment now holds a
high position, owing to the influence of many well-
known authorities who have devoted their attention to
these subjects, and to no one are we more indebted
than to our friend Dr. J. Fletcher Little, the able
secretary of this "Post-Graduate Course." Through
Dr. Little's teaching a sound and reliable knowledge of
these subjects is rapidly becoming more generally
known. In cases of infantile paralysis and of muscular
wasting I am constantly seeing great advantages from
this method of treatment; generally massage and gal-
vanism in combination, and frequently also with the
addition of passive movements.
Now, Gentlemen, I have brought before you seven
well recognised principles in surgery which are especi-
ally applicable to the treatment of contractions and
deformities, and in so doing have alluded to the serious
consequences which may result when these well-estab-
lished fixed principles are departed from by those who
run after novelty.
Each principle, with its history and illustrations,
might well form the subject of a separate lecture in a
course of orthopedic lectures, but to-day I have
endeavoured to sketch the general principles in outline,
and mention the cases to which each principle is especi-
ally applicable, and in this general survey I trust that
some of you will find the materials for extending the
work.
D
LECTURE II.
ON
!
THE SURGICAL TREATMENT
OF
DEFORMITIES DUE TO PARALYSIS.(a)
GENTLEMEN,—At this hospital, especially devoted to
the treatment of patients suffering from epilepsy and
paralysis, unusual opportunities are afforded for study-
ing these affections in all their varieties. These cases
are generally presented to you in their medical aspect,
and the great advances both in diagnosis and treatment
made by my distinguished medical colleagues have been
well recognised by the profession. But there is also a
surgical aspect presented by many of these cases, some
of which can be relieved by such operations as tre-
phining the skull and removing any tumour or morbid
growth from the substance of the brain which had been
diagnosed, and also the operation of trephining the
spine, either for the relief from pressure produced by
fracture, causing paralysis, or the removal of any
(a) Delivered at the National Hospital for the Paralysed and Epilep-
tic, on June 12th, 1890.
39
morbid growth. These large operations, performed
with strict attention to the rules of antiseptic surgery,
have been the special study of my colleague, Mr.
Victor Horsley, and the results obtained stand
out prominently amongst the advances made in modern
surgery.
But besides these large operations, there yet remain
a considerable number of cases of paralysis in which
we have to deal surgically with the late effects—more
especially with contracted joints and distortion of
limbs, and the treatment of these cases falls more or
less under the observation of those who have gained
some knowledge of orthopedic surgery.
It is this class to which I desire to direct your atten-
tion to-day, as the surgical treatment of these cases
presents some points of special interest. As a general
law, all paralytic affections of the upper and lower
extremities, whether infantile or adult, have a tendency
to pass into a state of contraction, with some malposi-
tion or deformity at the joint or joints involved;
whether the hip, knee, ankle, or transverse tarsal joint
in the lower extremity; or shoulder, elbow, orwrist in
the upper extremity. The muscular affection of the
eyes, in cases of paralysis producing strabismus, need
hardly be alluded to by me, as they fall especially
under the observation of the ophthalmic surgeon
attached to the hospital.
The contractions met with in the upper and lower
extremities naturally arise as the result of the loss of
the balance of muscular power, as we know that in
many of these affections, especially in the Infantile
class, either individual muscles or groups of muscles
are chiefly affected. We also know that the recovery
J
40
of muscular power proceeds at very unequal rates in
different muscles, or groups of muscles; for example,
the deltoid muscle is always very slow to recover, and
often fails to do so, leaving a permanent inability to
uplift the arm or raise the elbow. The rectus muscle
of the thigh is also a very unfavourable one for recovery,
leaving a permanent inability to extend the leg upon
the thigh, and rendering necessary a mechanical sup-
port to compensate for this inability. The muscles
surrounding the hip-joint generally make a very favour-
able recovery, and those most useful muscles in pro-
gression, the psoas and iliacus, are seldom lost. In the
leg, the muscles of the calf-the gastrocnemius and
soleus-are always very slow to recover, and frequently
fail to do so, thus causing a troublesome and incurable
deformity of the foot-talipes calcaneus. In the leg it
sometimes happens that all the muscles make a fair
recovery, except the tibialis anticus, which alone
remains paralysed, giving rise to an everted condition
of the foot-talipes valgus.
As a general result, it seems that contraction at some
of the joints involved almost invariably occurs; we
are therefore obliged to admit that whilst nature is a
very good physician and does her best to aid in the
recovery of muscular power, she is unmistakeably a bad
surgeon, and does her worst in the production of
various contractions and deformities. If this law were
more generally known many contractions and deformi-
ties at the joints might be avoided. Cases are fre-
quently brought to me in which the patients are mak-
ing an excellent recovery from some paralytic affection,
but little attention has been paid to the early stage of
contraction which quickly attracts my attention. This
4
41
most frequently occurs at the ankle-joint from contrac-
tion of the Achilles tendon, as we generally describe it,
although we know the structural changes really occur
in the muscles of the calf. The effect of this contrac-
tion is to limit the power of flexing the foot at the
ankle-joint, and if allowed to progress, the heel will
become elevated and a condition of talipes equinus
produced, with all its inconvenience in walking, if one
foot only is affected.
If both feet should be affected, then the patient will
be unable to stand until after tenotomy has been per-
formed. If the contraction is detected in the early
stage, I generally find it can be effectually overcome
by a well-regulated course of massage, accompanied
with passive movements; these movements, however,
require more special attention than is generally given
to them. The reason of this contraction being over-
looked in the early stage is, that there is nothing parti-
cular to direct attention to it, and also that the method
of testing the flexion power of the foot at the ankle-
joint is perhaps hardly studied with sufficient care.
This should be done in the following manner. First,
the leg must be placed in a fully extended position,
and the knee-joint lightly held either by the patient or
surgeon to prevent any flexion at this joint, as I need
hardly say this would destroy the test by relaxing the
heads of the gastrocnemius muscle attached to the con-
dyles of the femur. I prefer the patient to be sitting
on a chair, and resting the foot on another chair
placed opposite, and of the same height. Then the
surgeon, lightly grasping the knee with the left hand
so as to keep the leg fully extended, may with his
right hand try to flex the foot at the ankle-joint. In-
42
stead of using the hand, however, it is a good plan to
place a piece of wood or a book against the sole of the
foot, and by a little pressure try to flex the foot.
In slight cases it will be found that the foot can be
flexed barely up to a right angle with the leg, and then
the Achilles tendon becomes very tense. This is com-
monly spoken of as a right-angled contraction of the
Achilles tendon, and gives rise to more inconvenience
in walking, and in active exercise, than might be sup-
posed, but it can generally be overcome by massage
and passive movement. In a more severe case it will
be found that the foot cannot be flexed up to, or nearly
so far as, the right angle - probably 10° or more short
of the right angle, the foot forming an obtuse angle
with the leg at 100°. In such a case I should at once
advise tenotomy, as there is no probability of over-
coming this degree of contraction by massage and
passive movements.
The only alternative is the tedious and uncertain pro-
cess of gradual mechanical extension, carried out by
means of a Scarpa's shoe, with rack-and-pinion move-
ment at the ankle-joint, to be worn night and day, for
many months-at least six-the patient using crutches,
and not allowed to touch the ground with his foot during
the whole time. The treatment by tenotomy would
average from six to eight weeks, and from its certainty is
in every way to be preferred. Naturally the foot should
be capable of being flexed upon the leg from the ankle-
joint to 18° over the right angle, ¿.e., to an angle of 72°,
this degree of flexion being necessary for good walking
purposes, and in young people this will, as a rule, be
found to exist. In adults also it generally exists,
especially in ladies. Less than 15° of flexion beyond
43
the right angle, or 75°, will not suffice for good walking
purposes in the adult, and with a limited degree of
flexion movement various troubles arise, but these are
not connected with our present subject.
For the purpose of measuring accurately the angle
of flexion, I use an instrument well known as the
"engineer's rule," with a water-level on the lever held
horizontally, and the degrees through half a circle
marked off in 5° and 10°. (a) For rough use I employ
a measure fixed at 72°, which at once shows the patient
how much short of the natural angle of flexion the foot
may be.
The measure should be taken along the
outer border of the foot, as this is a tolerably straight
line, whilst the arched border on the inner side renders
the measure less apparent.
The contractions resulting from paralysis we are
called upon to treat surgically, most frequently occur
in the lower extremities, and the great majority result
from infantile paralysis, affecting either one, or both
legs-i.e., in the form of hemiplegia or paraplegia.
In infantile paralysis we have two distinct classes—
viz., those characterised by rigidity of the muscles, and
those in which the muscles are flaccid. These two
classes differ widely in their pathological and clinical
history, and equally therefore in their prognosis and
treatment. In their medical aspect they have been
fully described by my able colleague, Dr. Gowers, in
the lectures delivered by him in this hospital.
A few surgical points in reference to these, however,
I shall here allude to. When one leg only is affected,
and the foot contracted, although the awkwardness, and
(a) In an improved form this has been made for me by Elliott Bros.,
of St. Martin's Lane.
44
inconvenience in walking may be considerable, I have
known surgical interference to be strongly opposed on
the ground that the contracted foot is a firmer sup-
port and more useful, the contraction possibly com-
pensating for some degree of shortening, than it would
be after tenotomy, and the use of a raised boot. But I
believe it to be better for the patient not to be allowed
to walk on the toes with a raised heel, and to have the
sole of the foot brought firmly in contact with the
ground by tenotomy, even if a boot raised half an inch
or more should be required.
When both legs are affected and the feet contracted,
the patient is totally unable either to stand or walk,
and objection is at the present time seldom raised to
the combination of surgical and mechanical treatment
by which these patients are generally enabled to walk
fairly well. In bygone times I have known the
strongest opposition raised to any surgical treatment
in these cases, on the ground of the paralytic origin of
the affection and the persistence of the central lesion in
the spinal cord, or at the base of the brain, which would
prevent any permanent benefit resulting from the
operation, and certainly lead to recontraction of the
divided tendons. Those who hold this view would
continue to attack the central lesion by counter-irrita-
tion to the spine externally, and by saturating the
patients with powerful drugs, such as mercury, arsenic,
iodide of potassium, &c.
There is no doubt as to the persistence of the spinal
cord lesion in these cases, but when this is no longer
in an active stage of increase, and has remained so for
some months or years, the late effects are entirely
beyond the influence of the central lesion, which may
45
be considered not only to be in a stage of arrest, but
also in a stage of repair; and the indication of the
reparative stage is to be found in the partial, or in some
cases complete, return of voluntary muscular power.
My experience is that operative and mechanical
treatment is of the greatest advantage in these cases,
as we are enabled to make patients walk with ease and
comfort who have not walked for many years; though
necessarily with a restricted gait, and generally with
some mechanical assistance.
With regard to the liability to recontraction in the
divided tendons, this undoubtedly exists in the con-
genital, and in all the other forms of contraction, and
is probably somewhat greater in the paralytic class,
but with attention to massage, passive movements, and
galvanism, this recontraction may generally be pre-
vented; if it should occur, a second operation may be
resorted to with every prospect of success.
The belief that dividing tendons must still further
weaken the limbs is also frequently urged against any
operative treatment in cases of paralytic origin. The
fact that contracted muscles are strengthened by divi-
sion of their tendons was never recognised by the older
surgeons, and indeed is not universally recognised at
the present time; but the explanation will be obvious
when I mention that by the increased length of the
tendon gained by the insertion of new tendon, varying
from half an inch to an inch and a half, as it may be
required between the divided extremities of the old
tendon, movement at the joint involved-say, the ankle-
joint—is at once permitted; whilst in the contracted
condition of the muscles no movement at the joint could
take place. The effect of the joint movement is to
1
46
increase muscular development, and except in extreme
cases of complete degeneration of the muscular fibres,
the muscular structure always perceptibly increases in
bulk. A good illustration of this fact is seen by com-
paring the leg of an adult born club-footed and never
operated upon, with the leg of an adult born club-
footed who had been operated upon and well cured in
childhood.
I now exhibit to you plaster-of-Paris casts of two
such cases, and it will be seen that the calves in the
case which had been operated upon and cured, measure
two inches more in circumference than the calf of the
club-footed adult who had not been operated upon.
These cases are given in detail in my work on Club-
foot, second edition.
"
CASE 13.-Severe case of congenital talipes varus of
the right foot in the adult, which had not been operated
on, or otherwise treated.-Mr. B.
B— æt. 26, a
tall and very muscular man. The leg on the affected
side, below knee, appeared to be very small—a
withered limb, as it might be described, and the calf
measured only 11½ inches in circumference, and was
much higher than natural. I operated upon this
gentleman on May 29th, 1854, and the deformity was
cured in little more than a year, but the movement at
the ankle-joint remained very limited. The last report
published was on May 29th, 1856, when improvement
in every respect was maintained, and it is also stated
that the calf had increased lain. in circumference.
CASE 14.—Severe case of relapsed congenital varus of
both feet after two operations.-Master H. A.—
æt. 10. I operated on this patient on Aug. 12th,
1852 but the measurement of the calves at that time
47
}
is not stated. On Jan. 15th, 1855, nearly two years
and a half after the operation, the calves are stated to
have measured 10 in. in circumference, no doubt a
considerable increase since the operation. On June
6th, 1860, I had the opportunity of examining this
patient again. He was then over eighteen years of
age. The feet remained perfect in form, with free
motion at the ankle-joints, and the calves in circum-
ference measured 13½ in.—¿.e., 2 in. more than the calf
of the gentleman aged twenty-six years, who had not
been operated upon. From this illustration, and many
more might be given, there can be no doubt that con-
tracted muscles are strengthened, and the muscular
development increased by division of their tendons.
We are not, therefore, to be deterred from dividing
tendons, even in paralytic deformities, and we know
that some of the most brilliant results have been
obtained in cases of paraplegia, either infantile or
adult, in which the patients have been unable to stand
or walk for many years. Several good illustrations of
the advantages derived from treatment in these cases
are to be seen amongst the patients waiting for
examination in the adjoining room. In cases of severe
and long-standing paralysis, however, extra care is
required to obtain a strong union of the divided tendon,
and sufficient without excessive elongation.
All the contractions which occur during the progress
of paralytic affections towards recovery are to be
treated surgically on the same general principles-viz.:
(1) By the subcutaneous division of all the contracted
tendons; (2) by gradual mechanical extension, in order
to ensure the formation of a sufficient length of new
tendon between the divided extremities of the old
48
t
tendon, and at the same time guard against excessive
elongation; and also to stretch the deep ligaments and
other structures that cannot be divided; (3) by phy-
siological means to promote the restoration of muscular
power—viz., massage and passive movements, together
with galvanism to special muscles when required; (4)
by mechanical supports adapted to the requirements
of the case, so that by compensating for the paralysis,
more or less complete, of particular muscles or groups
of muscles, the patient may be enabled to walk, a great
gain to those who have been allowed to reach adult
life without having walked from childhood. In
reference to these different principles I have but few
remarks to make in their application to the particular
class of cases we are now considering.
With regard to tenotomy, in dividing the Achilles
tendon we always enter the point of the knife obliquely
downwards, a quarter of an inch from the margin of
the tendon, and divide from within outwards towards
the skin; but in one class of paralytic deformities—
viz., those with rigid muscles (" spasmodic rigidity" or
"spastic contraction" as it is called)—there is a special
danger in this operation of a large open wound being
made, instead of a subcutaneous puncture. The
assistant who has charge of the foot should be aware
that in these cases the anterior muscles are sometimes
thrown into violent spasmodic contractions as soon as
the tendon is divided, and if he does not control this
violent flexion of the foot, the tenotomy knife must
pass through and completely divide the skin, especially
if the Achilles tendon should be prominent and thinly
covered, as it generally is in these cases. Before the
tendon is completely divided the assistant should begin
•
49
to relax the tension, and instantaneously, as the divi-
sion is completed, extend the foot and approximate
the divided extremities of the tendon. In this position
the foot should then be bandaged, and a flexible metal
splint applied.
This accident happened once in my practice, when
dividing the Achilles tendon in a young lady with
spastic contraction, although I had especially cautioned
the surgeon assisting me as to its liability in this case.
Fortunately, however, the case did well. In another
case a colleague of mine had the greatest difficulty in
preventing it whilst I was operating, so strong was the
spasmodic action of the anterior muscles. The liability
to this accident should be borne in mind.
The tendo Achillis is recommended by some surgeons
to be divided by passing the knife flatways between
the tendon and skin, and then cutting through the
tendon from behind forwards. The Edinburgh school
generally adopt this method, and it has been recom-
mended by Liston, Syme, and Sir William Fergusson;
but in this method of operating the posterior tibial
artery may be punctured by the point of the knife
dipping too suddenly and too deeply after the tendon
has given way, an accident I once saw occur in a boy
twelve years of age, but the hemorrhage was controlled
by pressure, and the case did well.
After-treatment.-I need hardly remind you that
within the last few months there has been a good deal
of discussion as to the rate of extension after tenotomy
-.e., whether it should be immediate, rapid, or
gradual. In the particular class of cases we are now
speaking of-i.e., paralytic deformities-I would
strongly advise you against immediate extension, or
50
what is described as immediate reduction of the defor-
mity. No doubt some successful cases have occurred,
but I have seen many unsuccessful i.e., cases of
elongated and very feeble union, practically amounting
almost to non-union, and the patients damaged for
life, as excessive elongation produces the incurable con-
dition of talipes calcaneus.
The object of gradual extension is not to elongate or
stretch the new material, uniting the divided extremi-
ties of the tendon, as is generally supposed; but to
regulate the length of new material, or, as it may be
called, the new tendon, whilst we have the opportunity
of so doing, and the rate at which this is to be accom-
plished must have reference to the activity of the
reparative process, and to the length of new tendon
required. (a) In the Achilles tendon this can be
easily observed, and I always examine it carefully twice
a week. In well-nourished infants the full length
required in the divided Achilles tendon should, accord-
ing to my observation, be obtained in a fortnight, if
practicable; in a well-nourished leg in an adult it
should be obtained in from three to four weeks; but
in atrophied paralytic limbs it should not be obtained
in less than from four to six weeks. The extension
described as rapid—i.e., gaining the length required at
intervals of a week-is more rational, the foot being
put up either in a plaster-of-Paris bandage or any im-
mobility splint, provided this is removed at least once
a week, or at intervals of four days, during the first
three or four weeks; but I prefer the gradual exten-
(a) This subject is well illustrated in the plates in my work “On
the Reparative Process in Human Tendons." London: Churchill.
1860. And also in my book on "Club-foot," 2 Ed. Churchill. 1873.
;
51
i
sion by means of my varus splint for infants, or a
Scarpa's shoe with rack-and-pinion movements, which
can be regulated as frequently as may be required.
In contractions of the knee- and hip-joints the exten-
sion can often be made satisfactorily by means of the
ordinary weight extension apparatus. With regard to
the third principle of treatment—i.e., by physiological
means to promote the restoration of muscular power,
—there can be no doubt that the improved system of
massage, now so ably taught in some schools of instruc-
tion, and by professors who have established this
system upon a scientific basis, is of the utmost value;
and in many cases this may be still further assisted by
a well-regulated course of galvanic treatment. In
reference to the fourth principle of treatment-viz.,
the employment of mechanical supports, so constructed
as to compensate for the more or less complete paralysis
of certain muscles, which in severe cases often remain
as a permanent defect, there can be no doubt as to the
necessity of employing such mechanical assistance, and
the instruments now in use are constructed upon the
most scientific principles, with various ingenious con-
trivances adapted to the special requirements of each
case, and a variety of these appliances I now exhibit
to you.
There can be no doubt that by a combination of
these different principles of treatment results are
now obtained in the class of paralytic deformities
which were totally unknown to, and not within the
reach of our predecessors.
Before leaving the subject of tenotomy and its
results I would refer to one point which has
long attracted my attention-viz., the fact that
52
after tenotomy in cases of paralysis in which the feet
are always cold and cannot be warmed by artificial
means, a very marked increase of temperature rapidly
follows the operation of tenotomy, and the feet remain
warm.
The mother of a boy, æt. 12, upon whom I operated
six weeks ago at 9 a.m.-dividing the Achilles tendon
for paralytic contraction of the foot,-told me that she
observed an increase of temperature the same evening ;
and this has been maintained. Only yesterday I
operated upon the other foot, which was also paralysed
and contracted, and a marked difference in the
temperature of the two feet was observable, the one
about to be operated upon having remained cold. It is
of common occurrence at the Orthopedic Hospital for
the mother of a child which had been recently operated
upon for paralytic contraction to draw attention to the
fact that the child's foot became and has remained
warm since the operation, whilst she had been unable
to keep the foot warm by any extra clothing or other
means before the operation.
As to the explanation of this increase of temperature
after tenotomy, it seemed to me that it might be due
to a certain amount of muscular action taking place in
the muscles not contracted, after the tendons of the
contracted muscles had been divided. But Dr. Brown-
Séquard, to whom I mentioned the occurrence of this
event at the time he was connected with this hospital
as one of the physicians, said that he believed it to be
due to a direct reflex action of the spinal cord, and
that a local increase of temperature probably followed
all surgical operations, but it would be most observable
in cases of paralysis.
53
A
In the surgical treatment of contractions occurring
in cases of paralysis, it is necessary to bear in mind
that these are essentially of muscular origin, and are
due either to active muscular contraction, or adapted
shortening of an atrophic and passive character. There
are no adhesions, either intra-capsular or extra-capsu-
lar, in paralytic contractions. The deep ligaments and
bands of fascia are, however, subject to adapted
structural shortening, in those cases in which the
limb has been long retained in a contracted position;
whilst an atrophic and elongated condition of the
capsular ligament of the shoulder or hip-joint con-
stantly occurs in other cases. If there is any law
firmly established by long experience in the surgical
treatment of contracted joints in deformities due to
paralysis, it is, never attempt to overcome muscular
contraction by forcible extension. By subcutaneous
tenotomy we can at once remove all, or nearly all, the
muscular contraction without the least possible risk,
and gradual mechanical extension will overcome the
other obstacles.
I wish more especially to draw your attention to this
law, as I have frequently seen cases in which serious
injury has resulted, such as fracture of the femur, or
separation of the lower epiphysis in a case of knee-
joint contraction; laceration of the skin when this is
in an atrophic condition, as in the so-called glossy
skin occasionally met with in some cases of paralysis ;
a liability to dislocation of the hip, &c., when the sur-
geon has employed forcible extension, instead of
tenotomy and gradual extension.
In addition to the contractions and deformities
chiefly affecting the lower extremities in paralytic
E
54
cases which we have been considering, there are other
deformities affecting the spine and the pelvis, as well
as also the occasional displacement from ligamentous
relaxation, and in some cases the complete dislocation
of the head of the femur on the dorsum ilii. These
results occur only in one class of cases-viz., the most
severe form of infantile paralysis, in which both legs,
both arms, and the muscles of the trunk are affected.
The natural recovery in these cases, which we have not
time to discuss in the present lecture, is very slow,
partial, and incomplete, the permanent defect remain-
ing through life, being considerable; and, moreover,
the complications of severe spinal curvature, pelvic
tilting, and partial or complete luxation of the hip-
joint seriously interfere with any advantage gained by
surgical or mechanical treatment.
In one case of this extremely severe form of infantile
paralysis, the complete luxation of the head of the
femur was verified by a post-mortem examination, the
head of the femur being found displaced upwards and
backwards. The patient, a young lady, æt. 18., when
she came under my care, had never walked since child-
hood, and had only been able to get about the room
with assistance. In addition to contractions at both
hip-joints, both knees, and both feet, luxation of the
hip-joint was found to have occurred, the head of the
femur being displaced upwards, and backwards. After
treatment, she was enabled to walk fairly well with a
raised boot and steel support, as well as a leather
pelvic belt with straps to retain the femur in position,
but there had been for many years great difficulty in
feeding her, the stomach frequently rejecting food, and
she died suddenly from syncope.
·
55
At the post-mortem examination, the stomach was
found to be enormously dilated, and its walls extremely
thin and atrophied. This condition, I have no doubt,
frequently exists in these cases.
I have known two other deaths take place under
similar circumstances. In one of these, a young gen-
tlemen, æt. 20, with contractions at both hips, knees,
and feet, who had not walked from childhood, my
colleague, Mr. Lockwood, carefully examined with me.
There was no doubt as to the complete dorsal luxation
of the head of the femur, due to an elongated and
atrophied condition of the capsular ligaments. The
head of the femur could be easily restored to the
acetabulum by the ordinary movement of manipula-
tion, but it quickly become luxated again. He died
suddenly from syncope during one of my visits. No
post-mortem examination was allowed, but there had
been great difficulty in feeding him for some years,
and the dilated and atrophic condition of the stomach
probably existed.
This class of cases is especially worthy of our con-
sideration, as treatment at an early period, so as to
permit locomotion, even with the assistance of
mechanical supports, would materially assist in main-
taining the general health. The treatment of cases
of contraction and deformity due to paralysis,
whether in its infantile or adult form, should receive
more attention than has generally been given to this
class of cases.
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